"What is normal? What is OK?" These are questions you may have asked yourself about your sex life. If you and your partner are comfortable with your sexual relationship, you should not attempt to make any changes. On the other hand, if either or both of you have questions, these should be addressed. Sex problems are more frequent than commonly recognized.
What is normal sexual function?
Understanding “the science” behind sex can help improve sexual function. A number of years ago the team of Masters and Johnson described a sexual function cycle for both men and women. Since then, others have expanded the description of the sexual function cycle.
- Neutrality is the state in which we spend most of our time.
- Excitement can be divided into desire and arousal.
- Desire begins prior to actual sexual contact and continues until orgasm. Desire has several components including:
- Arousal begins with foreplay. In both women and men blood flow increases to the sexual organs causing congestion of blood in the labia, vagina and uterus in women and erection of the penis in men. Women also experience vaginal lubrication during this initial phase. Another important result of arousal in the female is that the top of the vagina balloons out and lengthens. Penetration without adequate foreplay can result in pain on deep penetration. As a generalization, the arousal phase takes more time in women than in their male counterparts.
- The plateau phase lasts varying lengths of time depending on the length of time devoted to foreplay prior to orgasm. During plateau the level of arousal is maintained but not increased.
- Orgasm or climax results in ejaculation in the male with fairly rapid loss of erection of the penis. Subsequent orgasm can only occur during another separate arousal cycle. Women have the ability to have one orgasm or multiple orgasms with episodes of heightened arousal. Women can also stay on the plateau phase and be sexually satisfied without having orgasm. In fact some studies show women have an orgasm about one third of the time.
- Resolution follows orgasm and lasts for varying lengths of time. During this phase arousal is not possible in the male.
All of this sounds very scientific but is not meant to take away from the very personal and private nature of a sexual relationship. Factual information can enhance your relationship. We have learned some of the basic differences between sexual function in females and males. Why is this important? Medical studies show that up to 50% of all women have concerns regarding their sexual function. Recent scientific evidence suggests that libido or sex drive in males is spontaneous and in females is more responsive (see below).
What are some of the common sexual function problems experienced by women? (It should be noted that men can also encounter a number of sexual function problems, but the purpose of this is to address issues related to women.)
Vaginismus is one of the most commonly seen sexual function problems in women. Just inside the vagina between the lining-tissue of the vagina and the rectum is a group of muscles called the levator ani. If these muscles go into spasm, pain in the area of the muscles results, making sexual intercourse very uncomfortable, especially on initial penetration. In its worst form, vaginismus will make penetration impossible. Similar pain may be experienced during pelvic examination, especially if the exam is unnecessarily rough. If you experience this type of pain, it is critical that penetration not be attempted until you are well lubricated. You should also carefully guide your partner’s penis into your vagina to minimize the likelihood of muscle spasm. If you still have pain with penetration, discuss treatment of this with your physician. The most successful and perhaps the easiest therapy is a conditioning exercise using vaginal dilators. A series of four progressively larger dilators are used to allow the levator muscles to become used to something applying pressure but without causing pain.
Inadequate lubrication can result from something as simple as a vaginal infection. Other causes include not taking enough time with foreplay, previous pain with intercourse or estrogen deficiency as seen with the menopause. It is best to determine the specific cause and treat this. If external lubrication is needed, avoid oil-based products such as petroleum jelly since they may promote the development of vaginal infections. Water-based products are preferable. Other choices includeproducts that actually provide moisture to the vaginal wall in addition to providing lubrication.
Pain with intercourse (other than that associated with vaginismus or inadequate lubrication) is frequently described as feeling as though "he is hitting something," which in reality is exactly what is happening. If the uterus (womb) is tilted back, deep penetration may cause some discomfort. Simple change in position with intercourse usually eliminates this problem. Adequate foreplay is critical to minimize the chance of pain with penetration. As noted above, arousal resulting from adequate foreplay causes the top of the vagina to balloon out and lengthen, decreasing the chance of pain with penetration. It should be noted that many women with a "tilted uterus" have no pain at all. Other more significant causes of pelvic pain on deep thrust (deep-thrust dyspareunia) include pelvic infection, ovarian cysts and endometriosis. If you experience this kind of pain, consult your physician.
Enlarged labia can cause pain with intercourse or personal embarrassment. The labia minora (inner lips) are commonly different in size. Occasionally, one or both labia minora are enlarged enough to cause embarrassment when having sex or even avoidance of sex all together. In reality most partners do not notice the size of the labia minora. Enlarged labia may become congested with blood with activity such as exercise or sex or just standing on your feet – this can result in discomfort or pain. The treatment involves surgically reducing the size of one or both labia.
"I am so grateful for the surgery Dr. Biggerstaff performed to treat my enlarged labia. I am 42 and have had pain for as long as I can remember. Dr. Biggerstaff was so easy to talk with. I can’t say enough good things about my experience in his office." C.H.
Preorgasmia implies no orgasm or climax, or at least infrequent orgasm. Some women are orgasmic but do not realize it. Orgasm may vary from a "slight rush" to something that includes the Star Spangled Banner and fireworks, along with a sensation of absolute ecstasy. Either, or any variation of, is "ok." Also as noted above, for many women orgasm occurs approximately one third of the time with sexual intercourse. For most women, vaginal penetration alone does not cause orgasm. One way or another there needs to be some stimulation of the clitoris (the small organ located just in front of the vaginal opening and urethra leading from the bladder). If you do not think you have had an orgasm, most women will be orgasmic with direct clitoral stimulation. More about this in the next section.
What is ok with sex and what is not?
As long as there is no physical or emotional harm, whatever you and your partner are comfortable with is ok. Most of us find doing the exact same thing, time after time, whether it is at work or in the bedroom is boring. Whether it is the time of the day when you have sex, the place, the position(s) you enjoy or other aspects of sex, change can promote a long healthy sex life and loving relationship. The following are commonly addressed topics regarding sexual function.
- Literally millions of women use vibrators on a regular basis either during self-stimulation or with sexual intercourse with a partner. Direct stimulation of the clitoris with a vibrator in a calm relaxed environment will result in orgasm for most women. If you question whether or not you are having orgasm, using a vibrator may save a visit to a sexual counseling therapist. Vibrators come in all shapes and sizes. If you use a vibrator or any other device during intercourse, make sure it is cleansed after each use to minimize the chance of vaginitis or pelvic infection.
- Many women practice self-stimulation or masturbation, with or without the use of a vibrator. Having "me-time", that is time on a regular basis that is yours is important for all-around wellness and health. Whether you choose to read a good book or to indulge yourself with sexual self-stimulation is your choice.
- Many couples practice oral sex (or cunilinguis) on a regular basis. A word of caution is appropriate since it is possible to transmit certain sexual diseases with this practice. Some cases of genital herpes have been contracted when her partner had oral herpes or genital warts have occurred in the mouth after oral sex.
- Anal sex presents an increased risk of transmission of sexually transmitted disease because the lining tissues are delicate and susceptible to damage and infection. This explains the higher rate of transmission of AIDS through homosexual male intercourse.
What causes a low libido or sex drive?
As noted above, female libido is more responsive than that in the male (which is felt to be spontaneous). Responsive libido in the female means her sex drive will usually be higher with a warm, loving relationship in an environment that is conducive to romance (candlelight, roses, and soft music). It is very important to realize that diminished sex drive is only a problem if one or both partners see it as a problem. If one partner has a low sex drive and the other a high sex drive, many couples simply find a happy median that works for both. What factors affect libido?
- Hormones may or may not affect libido. Many women who have gone through the menopause (the change) and have low hormone levels have very normal libidos. Some post-menopausal women feel more sexual when on hormone replacement therapy with estrogen, progesterone, and/or testosterone. There are many medical considerations that should be discussed with your physician.
- One of the most common causes of decreased sex drive is stress. Difficulty sleeping during times of stress is also very common. If you cannot make the stress go away, healthy eating and regular aerobic exercise can help reduce the stress. Chronic illness similarly can cause diminished libido.
- Your relationship with your partner has a major impact on your libido and sexuality in general. This goes back to the fact that you respond to the situation. If you are in a very caring, loving relationship, you are much more likely to have a good sex drive than if you are not.
- Body image may play an important role in your sex drive. If you feel and look physically fit, your libido will be much better.
- Medications commonly affect sex drive. The most well known group of medications that decreases sex drive is a group of antidepressants (Prozac®, Zoloft®, Paxil®, etc.). In this instance, ginseng can counter this effect on libido. You should check with your physician before taking ginseng, and you should not discontinue your antidepressant without consulting your physician. Many other medications can also affect libido.
- Diabetes and many other illnesses can decrease sex drive, in both women and men. Obtaining appropriate treatment can improve sex drive.
- Alcohol and street drugs frequently decrease libido.
As you can see, sexuality and sexual function is not as simple as it may first appear. Taking a pill may help in certain instances, but living a healthy lifestyle and being in a warm, loving relationship will result in a healthier sex life for most couples. If a woman wakes up in the morning and says “this is a great day,” she is much more likely to “be sexual” than her neighbor who has trouble getting out of bed and is “dragging” most of the day. Healthy lifestyle contributes to “the great day.”