Published data indicate that 15% of healthy women have never had an orgasm, while as many as 46% of women experience difficulty in reaching orgasm.1 Other research found that 50% of married couples experience sexual “dysfunction.”1

TIMES HAVE CHANGED—BUT NOT FOR EVERYONE

Sexual attitudes have improved, but many women still experience frustration and sadness. Limited information, poor partner technique, strife, and shyness are common causes of primary anorgasmia. Those who lack verbal skills are unable to discuss their needs with partners. Some women may be reluctantly having sex at the end of a long day, with little time or privacy. Medications and pelvic pathology are occasionally problematic.2

WHERE TO START?

Your discussion will model how the patient talks with her partner. Answer specific questions in a calm, straightforward way. Tailor your approach to your patient's age, culture, education, and level of comfort.

You might start with a psychosocial approach: What concerns you most about not having orgasms? Her partner may not enjoy making love without simultaneous orgasm. She may fear abandonment or partner rage.

You might be pragmatic: Do you know where your clitoris is? Do you get aroused? Do you have discomfort? You will need to ascertain if the woman achieves orgasm at times other than during vaginal intercourse. You will need to evaluate for depression and anxiety and explore issues of abuse or religious misinformation.

TREATMENT, FOLLOW-UP, AND REFERRAL

Frank discussion and a brief review of anatomy are important. Because women often wait until the end of the appointment (when they feel comfortable with their provider) to mention this problem, you may wish to invite the patient to return for a physical examination. At that visit you can point out her anatomy if she has not discovered it on her own and teach her Kegel exercises.

If there is time, you can discuss the issue further at this visit. Explain the importance of foreplay. Emphasize that most women need direct clitoral stimulation to achieve orgasm.3 Normalize safe activities, eg, different positions, and make specific suggestions, such as use of lubricants and removing the TV from the bedroom. Discuss use of adjuncts and options for referral and counseling.

Debunk myths about masturbation. Woody Allen famously observed that self-stimulation is “sex with someone you love.” With no one else to consider, no performance anxiety, and easier timing, your patient may welcome permission to discover orgasm on her own.

Many women who ask about how to have an orgasm are poorly educated and unable to read at the level of most sex manuals or articles. Some may not know what an orgasm is. Tell them that orgasm has been described as intense physical pleasure, like an overwhelming tickle or a strong wave flooding the whole body. There is a massive release of muscle tension,4 and some say it is like nearly passing out. Sometimes the only recourse to education is a movie, in which case you should direct the patient to a responsible and careful organization that produces videos especially for women.

Follow-up is very important. For intractable or concerning physical problems, refer the patient to a gynecologist or urologist.5 JAAPA

Margaret Allen practices at Ravenswood Family Health Center in East Palo Alto, California, and is a volunteer lecturer for the Stanford Primary Care Associate Program. She has indicated no relationships to disclose relating to the content of this article.

REFERENCES

1. Lentz G. Emotional aspects of gynecology. In: Katz VL, Gershenson D, Lobo RA, Lentz G, eds. Comprehensive Gynecology. 5th ed. Philadelphia, PA: Mosby Elsevier; 2007:chap 9.

2. McPhee SJ, Tierney LM, Papadakis MA, eds. Current Medical Diagnosis and Treatment. New York, NY: McGraw-Hill; 2008:908.

3. Kingsberg S, Janata J. Female sexual disorders. Urol Clin North Am. 2007;34(4):497-506, v-vi.

4. Masters WH, Johnson VE. Human Sexual Response. Boston, MA: Little, Brown; 1966.

5. Goldstein I. Urologic management of women with sexual health concerns. In: Wein AJ, Kavoussi LR, Peters CA, et al. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Saunders Elsevier; 2007:chap 28.