The Orgasm Gap

Q: Several of my heterosexual female clients have reported difficulty orgasming with a partner. I’m not a sex therapist, but I’d like to help them. Where do I start?

A: Women having difficulty with orgasm is a common, though underdiscussed, experience—and it happens most often within heterosexual relationships.

Statistically, women have higher rates of orgasm during sexual experiences that don’t involve men, including alone and with other women. A recent study found that 92 percent of women reported “usually” or “always” orgasming when masturbating, while only 57 percent said they experienced orgasms during sexual experiences with men. Studies also consistently find that women orgasm less often with male partners than with female partners.

But the difficulty many women have with orgasming during partner sex with men isn’t due to biology or something inherently wrong with men. In most cases, women’s problems with orgasm are due to the cultural messages we receive about heterosexual sexual encounters. The good news is that clinicians—even those who aren’t sex therapists—can help their clients overcome these faulty messages in surprisingly simple ways.

My own foray into sexual issues began about 15 years into my practice. After hearing many stories from female friends and clients about the loss of sexual desire—and experiencing it personally—I immersed myself in the sexual health field. Today, I teach therapists and physicians about treating sexual issues, and I’ve written two books about female desire, including A Tired Woman’s Guide to Passionate Sex and Becoming Cliterate: Why Orgasm Equality Matters—And How To Get It. My goal has been to help women become more orgasmic, aroused, and sexually satisfied, but also to help them improve their body image, increase their feelings of entitlement to pleasure, and experience less sexual pain. But my message isn’t just for women: men who become more well-versed in women’s pleasure and sexual communication have more satisfying sex as well.

Asking About Orgasms

How do we begin talking about orgasms, especially with the women who come to us feeling numb, ashamed, depressed, or broken because they’re struggling to orgasm?

Orgasm intensity varies between women. For one, it might feel like an earthquake; for another, like a sneeze. Since there’s no objective marker of the female orgasm, many women will say they don’t know if they’ve had one or not. The general thinking is if someone doesn’t know if they’ve had one, they probably haven’t.

The first step in helping your clients to experience orgasms more often or at all is simply to ask about them. Surveys report that almost half of clinicians avoid talking about sex with their clients, whether due to cultural or religious thinking around sex, mistakenly believing it’s too private, creepy, or unethical to bring up—or because they’re struggling with their own unresolved sexual issues. Regardless, avoiding the topic of sex is a disservice to our clients, since sexual satisfaction is highly related to both relationship and life satisfaction. And research shows that clients usually won’t bring up sexual issues unless asked to or given a signal that their therapist is open to discussing them.

You can send those signals early on in your work by asking about sex on your intake form or in your initial interview in a nonjudgmental, normalizing way. I might say something like, “More than 50 percent of people have problems with sex, and these problems are related to their overall well-being. Is there anything about your sex life that’s bothering you that you’d like to discuss?” Alternatively, you can ask about sex in the context of the client’s presenting concern. For example, you might say something like, “Many women with anxiety have difficulty calming their mind enough to enjoy sexual experiences. Is this something that’s bothering you?”

Even if you’re already deep into working with a client, you can still broach the subject by saying something like, “I recently read an article about the importance of sexual satisfaction to overall life and relationship satisfaction, and it made me realize that this is something I’ve never asked you about. Is there anything about your sex life that you think is important for me to know to best help you?”

If a client reports no sexual concerns, leave the door open. You might say, “I’m glad to hear this is an area of your life that isn’t problematic for you. But if this changes or if something occurs to you, please bring it up! Sex is something I’m comfortable discussing.”

Seven Strategies That Can Help

Let’s say your client does want to discuss their sexual issues. There are seven empirically supported techniques to help them orgasm (and they rhyme!): educate, meditate, masturbate, lubricate, vibrate, communicate, alternate. For women who’ve never had an orgasm, these steps can be applied roughly in this order. For those who can orgasm alone but not with a partner, they can skip some of these steps depending on why self-pleasure isn’t transferring to partner-pleasure. For example, if it’s due to fear about guiding a romantic partner to touch a certain way, communication training will be key; whereas if the client can’t quiet her thoughts enough during sex to reach orgasm, focusing on mindfulness will be key.

Before we jump into the seven strategies, be sure to rule out any underlying medical causes that may be inhibiting orgasm. Some medicines, especially SSRI’s, inhibit orgasm, as do some medical issues like vulvar skin diseases and clitoral adhesions. Many women experience decreased genital sensitivity and have difficulty orgasming during menopause. So the first step in any treatment is to send your client to a physician for assessment. Some off-label medications have been found to enhance orgasm, and a doctor may find that your client is a good candidate for them. Keep in mind that, unfortunately, most physicians—even gynecologists—aren’t trained in assessing and treating sexual disorders, so make sure you’re referring to a knowledgeable medical provider. You can find these on the websites for the International Society for the Study of Women’s Sexual Health and the National American Menopause Society.

Educate. With most clients who have difficulty achieving orgasm, I like to begin by doing a little education around orgasms. As I mentioned earlier, women have more orgasms when alone and with other women than with men. With men, they have more orgasms in long-term relationships than in casual hookups. In all situations in which women have more orgasms, they’re receiving more external genital stimulation, referred to in most writings as “clitoral stimulation.”

How many women need clitoral stimulation to orgasm? Most studies say 85 to 96 percent. In research I’ve conducted with thousands of women, only four percent have said their most reliable route to orgasm is penetration alone. These women who orgasm from penetration usually aren’t the ones who come to us struggling with orgasm concerns.

The first step in helping a woman who’s either never had an orgasm or is having difficulty orgasming with a partner is to assess the type of stimulation she’s getting. This assessment goes together with education about genital anatomy, the need for clitoral stimulation, and our culture’s faulty messages about women’s sexual pleasure.

Assessment for orgasm concerns must be explicit and direct. Asking a client if they pleasure themselves, what they do, and if they orgasm is important. Likewise, asking a client to describe a typical sexual encounter with their current partner and whether external clitoral stimulation is involved is critical.

Take my client, Andrea, for example, a 33-year-old woman who told me she’d never had an orgasm with her husband of two years. Steve and Andrea had waited to “consummate the marriage,” and when Andrea didn’t have the orgasm she’d seen in movies the first time they had penetrative sex, she began to fear that her “vagina was broken.”  When asked directly, Andrea revealed that she did orgasm during self-pleasure. However, with Steve, they usually kissed a bit during foreplay, he’d caress her breasts, and then they’d have intercourse. Andrea told me she felt that she “should” orgasm this way, and that because she couldn’t, she felt “abnormal.”

I proceeded by educating Andrea on her genital anatomy and normalized the way she masturbated. She told me she was very relieved when I informed her that less than two percent of women masturbate by just putting something in their vagina, and that the rest use external stimulation, alone or coupled with penetration. “Wow, so you mean I’m not a total weirdo?” asked Andrea. “Of course not!” I replied.

To educate clients on genital anatomy, I’ll usually use either a vulva puppet or a drawing of the vulva—the anatomically correct word for the external genitals, including the external portion of the clitoris (the hood and glans) and the inner lips. The glans of the clitoris evolves from the same embryonic tissue as the head of the penis, while the clitoral hood evolves from the same tissue as the foreskin of the penis. The inner lips are equivalent to the shaft of the penis. All these parts contain abundant touch-sensitive nerve endings, as well as corpuscles that respond specifically to vibration. They also contain the erectile tissue that’s central to orgasm.

The vaginal canal itself has only touch-sensitive nerve endings within the first third. There are pressure sensitive nerve endings on the rest, which is why something inside the vagina feels wonderful to many women when aroused. When a woman is aroused, her vagina lubricates (although many women still need external lubricant). Then, the cervix pulls up and out of the way. But if penetration occurs before such changes, it can be painful. Having penetrative sex before being fully aroused and/or not using lubricant is a common cause of sexual pain for women, which can be a driving force behind sexual problems, including the inability to orgasm. Sex should never be painful, despite the cultural message given to women that this is normal or to be expected.

Another insidious culturally instilled belief that female clients often need help eradicating is that their pleasure is secondary to their partner’s pleasure. Such beliefs are reflected and perpetuated in the language our culture uses for sex. We use the word vagina to describe women’s entire genitals, thereby linguistically erasing the clitoris and calling women’s genitals by the name that is most sexually useful to men. We refer to intercourse—the way most men reliably orgasm—as “sex,” and we refer to clitoral stimulation—the way most women reliably orgasm—as “foreplay,” implying that the latter is just a lead-up to the main event. I talk about these linguistic mishaps with my clients, and tell them that moving forward, I’ll be using specific language, like oral sex and intercourse, and that when I say sex, I mean the entire sexual encounter.

For many clients, this is an aha moment. From there, I help them internalize that they’re entitled to pleasure, that clitoral stimulation is just as much sex as penetration, and that their orgasm is just as central to the encounter as their partner’s orgasm. Research shows that women who hold these beliefs have more orgasms.

Meditate. Teaching clients to be mindful during sex is an essential part of treatment for orgasm concerns. Women often have trouble orgasming, particularly with partners, because they’re focused on their thoughts rather than on their bodily sensations. When they’re with partners, they often worry about how they look or smell, if they’re “doing it right,” or if their partner is having a good time. If orgasming has been difficult or elusive in the past, thoughts like Am I going to come? may preoccupy a woman’s mind. But to have an orgasm requires not thinking. It requires being fully focused on the sensations in your body.

When I’m working with clients struggling with orgasm issues, I’ll often have them first practice mindfulness in daily life, and then apply it to solo and partner sex. Mindfulness practices outside of the bedroom can include guided meditations like breath work and body scans. Yoga can also be helpful, as it’s been shown to improve orgasm due to the mindful body focus it teaches. Clients can also practice being focused on sensations during daily tasks like brushing their teeth or washing their hands, during which time they can learn to notice when their mind wanders and bring their focus back to sensation.

Once a client understands what it feels like to focus on sensation, practicing mindful masturbation is an excellent next step, since during self-pleasure there’s no partner to worry about. The final step, of course, is a mindful focus during partner sex. Encourage your client to notice what they feel, smell, see, hear, and taste during sex. For example, some of my clients love their partner’s scent, so they’ll focus on it during sex when their mind wanders. Another one of my clients simply homes in on her own bodily sensations and couples this with breath work.

Masturbate, Lubricate, Vibrate. Many clients present with the inability to orgasm under any circumstances. For these women, sending them home with encouragement and instructions to pleasure themselves is a central part of treatment. This is called directed masturbation, and it’s the most empirically supported technique for anorgasmia. Two of my favorite books I recommend to help women with this are Betty Dodson’s Sex for One and Lonnie Barbach’s For Yourself.

With my client Sandra, who’d never had an orgasm, I explained the research backing guided masturbation and asked if this was something she was ready to try. “Yes, but not yet,” she replied. As a preliminary step, I suggested Sandra touch herself more erotically when getting dressed and in the shower. I also directed her to the educational website omgyes.com to learn about the ways other women masturbate. I told her to buy some lubricant, as vulvas are not supposed to be touched dry, and asked her to simply enjoy applying it to herself and touching herself in various ways, simply exploring what felt good. Finally, I suggested she set aside 30 minutes to mindfully touch herself, emphasizing that the goal was to be immersed in her sensations and not focus on the goal of orgasm, since trying to have an orgasm makes having one less likely.

Sandra reported back that while she’d enjoyed herself, she hadn’t orgasmed. I encouraged her to try other things like reading, watching, or listening to erotica, fantasizing, and switching up her self-pleasure method by adding penetration when aroused and pleasuring herself when lying face-down instead of face-up. As I do with almost all clients, I also suggested she purchase a clitoral vibrator. I explained to Sandra that many women don’t orgasm until they use a vibrator—the biological basis for this being that there are special corpuscles in the vulva that respond to vibration. Sandra bought a vibrator, which I reminded her to use with lube and a mindful focus, and the next session, she came in beaming. She’d had her first orgasm!

But her joy soon turned to worry. How would she be able to do this with a partner? she wondered. I assured her that this would involve communication, a skill she could easily master.

Communicate. I proceeded with Sandra by telling her she now had to follow the most essential (but underutilized) advice for having an orgasm with a partner: she needed to get the same type of stimulation with a partner that she was getting alone. To do this, women must be equipped with the confidence and skills to tell their partners about the clitoral stimulation they need to orgasm. Clients in committed relationships can bring partners to therapy or suggest reading material like the chapter in Becoming Cliterate (written for men!) or Ian Kerner’s outstanding book She Comes First. Kerner provides a fantastic pep talk for male readers about how focusing on clitoral stimulation benefits them by taking pressure off of lasting long and thrusting hard. Along with educating partners about clitoral stimulation, clients will need skills and guidance to talk about sex with partners more generally, including outside of the bedroom, and before, during, and after encounters. The research is clear: those who communicate about sex have better sex.

Take, for example, my client Valerie, a high-powered attorney with excellent communication skills—just not with her partner when it came to sex. She’d never told him about the stimulation she needed or really communicated during sex, she told me, because she’d never seen this modeled in the movies. After learning to communicate sexually, including during sex, she told me it had been “life changing.” There are some great books and websites to help women with sexual communication, including Sex Talks by Vanessa Marin. Having couples view and discuss the videos on the website omgyes.com is also incredibly useful.

Alternate. Something couples should talk about—and most often change—is their sexual routine.  One of the biggest contributors to women not having orgasms during heterosexual sexual encounters is the routine in which intercourse is considered the main event and ends when the man orgasms. One reason women who have sex with women have more orgasms than those who have sex with men is that instead of the encounter revolving around a main event—penetration—partners take turns pleasuring each other.

Turn-taking can be easily applied to heterosexual sexual encounters. For example, a woman might orgasm from oral sex while her partner orgasms from intercourse. Or they can take turns pleasuring each other with oral or manual stimulation. Or they might have intercourse during which the man orgasms and then after, the woman uses a vibrator on herself while her partner kisses and caresses her until she orgasms. The possibilities are limitless. Orgasmic partner sex requires each person to allow themselves the space to focus fully on their own sensations, and turn-taking provides this.

For those couples who want to orgasm during the same act—intercourse—a scientifically supported technique is the woman touching herself with a hand or vibrator during penetrative sex. In this case, it’s paramount to tell the client that it is no less sex if she touches herself, and that this is the only way many women can orgasm.

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Orgasm is considered the pinnacle of a sexual encounter. While not all sexual encounters need to include orgasm for both partners, the gendered orgasm gap tells us that we have a cultural problem that’s playing out in our clients’ bedrooms. To help our female clients experience orgasms, we need to empower them with knowledge, strategies, and tools. A client who’s never had an orgasm will likely need all of these interventions, while one who can orgasm alone but not with a partner may only need a few. Regardless, I’m confident that by following these suggestions, you’ll find helping your clients experience pleasure to be one of the great joys of your work.