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Sex and Your Psyche

Sexual dysfunction is a problem for many. Here's what you can do about it.

You know the cliche: a woman is so uninterested in sex that she makes a shopping list while making love. Jennifer and Laura Berman see such women all the time, and it's frustration—not boredom—that brings them to the Bermans' new clinic at UCLA.

"I was talking to a woman earlier today about her low libido, which was a result of the fact that she can't reach orgasm," says psychologist Laura Berman, Ph.D., who with her sister, urologist Jennifer Berman, M.D., is a founder and codirector of the Center for Women's Urology and Sexual Medicine clinic. "Because she can't reach orgasm, sex is frustrating. She feels a hopeless, fatalistic complacency about her sex life. When she's having sex, her partner picks up on that and feels rejected and angry, or notices she's withdrawing. Then intimacy starts to break down. Her partner feels less intimate because there's less sex, and she feels less sexual because there's less intimacy. The whole thing starts to break down."

Acknowledgement of sexual dysfunction in America is booming. But with all the attention on Viagra and prostate problems in men, most people would probably never guess that more women than men suffer from sexual dysfunction. According to an article in the Journal of the American Medical Association, as many as 43 percent of women have some form of difficulty in their sexual function, as opposed to 31 percent of men.

And yet female sexuality has taken a back seat to the penis. Before Viagra, medicine was doing everything from penile injections to wire and balloon implants to raise flagging erections, while female sexual dysfunction was almost exclusively treated as a mental problem. "Women were often told it was all in their head, and they just needed to relax," says Laura.

The Bermans want to change that. They are at the forefront of forging a mind-body perspective of female sexuality. The Bermans want the medical community and the public to recognize that female sexual dysfunction (FSD) is a problem that may have physical as well as emotional components. To spread their message, they have appeared twice on Oprah, have made numerous appearances on Good Morning America and have written a book, For Women Only.

"Female sexual dysfunction is a problem that can affect your sense of well-being," explains Jennifer. "And for years people have been working in a vacuum in the sex and psychotherapy realms and the medical community. Now we are putting it all together."

No single problem makes up female sexual dysfunction. A recent article in the Journal of Urology defined FSD as including such varied troubles as a lack of sexual desire so great that it causes personal distress, an inability of the genitals to become adequately lubricated, difficulty in reaching orgasm even after sufficient stimulation and a persistent genital pain associated with intercourse. "We see women ranging from their early twenties to their mid-seventies with all types of problems," Laura says, "most of which have both medical and emotional bases to them." The physical causes of FSD can range from having too little testosterone or estrogen in the blood to severed nerves as a result of pelvic surgery to taking such medications as antihistamines or serotonin reuptake inhibitors, such as Prozac and Zoloft. The psychological factors, Laura says, can include sexual history issues, relationship problems and depression.

The Bermans codirected the Women's Sexual Health Clinic at Boston University Medical Center for three years before starting the UCLA clinic this year. At present, they can see only eight patients a day, but each one receives a full consultation the first day. Laura gives an extensive evaluation to assess the psychological component of each woman's sexuality.

"Basically, it's a sex history," Laura says. "We talk about the presenting problem, its history, what she's done to address it in her relationship, how she's coped with it, how it has impacted the way she feels about herself. We also address earlier sexual development, unresolved sexual abuse or trauma, values around sexuality, body image, self-stimulation, whether the problem is situational or across the board, whether it's lifelong or acquired." After the evaluation, Laura recommends possible solutions. "There is some psycho-education in there, where I'll work with her around vibrators or videos or things to try, and talk about addressing sex therapy."

Afterward, the patient is given a physiological evaluation. Different probes are used to determine vaginal pH balance, the degree of clitoral and labial sensation and the amount of vaginal elasticity. "Then we give the patient a pair of 3-D goggles with surround sound and a vibrator and ask them to watch an erotic video and stimulate themselves to measure lubrication and pelvic blood flow," Jennifer says.

The identification of FSD has been called everything from the final frontier of the women's movement to an attempt by the patriarchy to shackle women's sexuality. But given the success that drugs such as Viagra have had in reversing male sexual dysfunction, the Bermans found an unexpected amount of criticism from their peers. "The resistance we got from the rest of the medical community early on was surprising to us," Laura says, explaining that the urological field in particular has been dominated by men.

Clearly, the Bermans will need hard data to win over their critics. Their UCLA facility is enabling the Bermans to conduct some of the first systematic psychological and physiological research on the factors that inhibit female sexual function. One of their first studies suggests that the pharmaco-sexual revolution that helped some men overcome their sexual dysfunction may prove less effective for women. Their initial study of the effects of Viagra on women found that Viagra did increase blood flow to genitalia and thereby facilitate sex, but women who took the drug said it provided little in the way of arousal. In short, subjects' bodies might have been ready, but their minds were not.

"Viagra worked half as often in the women with an unresolved sexual abuse history as in those without it," Laura says. "So it's just not going to work alone. Women experience sexuality in a context, and no amount of medication is going to mask psychologically rooted, or emotionally or relationally rooted sexual problems." Laura believes the results of the Viagra study counter those who contend that FSD is simply a tool of pharmaceutical companies to "medicalize" female sexuality.

"I'm less concerned about it, because I'm aware that it won't work," she says. "And in some respects, pharmaceutical companies are closing the divide between the mind and body camps of FSD. Clinical trials of new drugs for FSD are requiring psychologists to screen participants, and that is an acknowledgement that an accurate assessment of a drug's efficacy requires a consideration of the test subjects' feelings about sex. So these physicians who may not be motivated to bring on a sex therapist are now motivated to participate in a clinical trial, and then that model becomes the norm."

Currently, the sisters are working on MRI studies of the brain's response to sexual arousal, the place where mind and body meet. And although there is a lot more research to be done on FSD, identifying it as a problem has already made a significant impact on how women perceive their sexuality. "Women now feel more comfortable going to their doctors, and they're not taking no for an answer, not being told to just go home and have a glass of wine," explains Laura. "They feel more entitled to their sexual function."

His & Hers: How To Have Them

Hers: a female orgasm can be frustratingly evasive. While about 85 to 90 percent of women are capable of having an orgasm, according to Beverly Whipple, Ph.D., vice president of the World Association for Sexology, only about one-third have had one during intercourse. That said, it's important to remember that orgasm should never be the goal.

"In goal-oriented sexual interactions, each step leads to the top step, or the big "O"—orgasm," says Whipple. "Goal-oriented people who don't reach the top step don't feel very good about the process that has occurred. Whereas for people who are pleasure oriented, any activity can be an end in itself; it doesn't have to lead to something else. Sometimes, we're very satisfied holding hands or cuddling. There would be a lot more pleasure in this world if people would just focus on the process."

Whipple also points out that the psychological ramifications of dissatisfying sexual interactions are not often suffered alone; they can cause distress in both partners. "If one person in a relationship is goal-oriented and the other is pleasure-oriented, and neither is aware of their own orientation, they don't communicate that with their partner," she explains. "A lot of relationship problems can develop. In my workshops with couples, I help them be aware of how they view sexual interactions and then communicate this with their partner."

Types of Orgasm

Clitoral Orgasm

The most common, they result from directly stimulating the clitoris and surrounding tissue. What many people don't realize is that the majority of the clitoris is actually hidden inside the woman's body. Recently, Australian urologist Helen O'Connell, M.M.E.D., studied cadavers and 3-D photography and found that the clitoris is attached to an inner mound of erectile tissue the size of your first thumb joint. That tissue has two legs or crura that extend another 11 centimeters. In addition, two clitoral bulbs—also composed of erectile tissue—run down the area just outside the vagina.

O'Connell's findings, published in the Journal of Urology, show that this erectile tissue, plus the surrounding muscle tissue, all contribute to orgasmic muscle spasms. With so much tissue involved in a clitoral orgasm, it's no wonder they're the easiest to have.

Pelvic Floor or Vaginal Orgasms

These occur through stimulating the G-spot, or putting pressure on the cervix (the opening into the uterus) and/or the anterior vaginal wall. Located halfway between the pubic bone and the cervix, the sensitive G-spot—named after its discoverer, German physician Ernest Grafenberg—is a mass of spongy tissue that swells when stimulated. Because it's difficult to locate, experts have developed a few guiding techniques:

  • Lying on her back, the woman tilts her pelvis upward so that her vulva presses flat against her partner's pelvic bone. According to the Bermans, this allows the penis to make contact with the G-spot, simultaneously stimulating the clitoris. Putting pillows beneath her buttocks makes angling her pelvis easier.
  • Whipple suggests placing two fingers inside the vagina and moving them in a beckoning motion. The fingertips should stroke the frontal vaginal wall, just where the G-spot is located.

The Blended Orgasm

This can be attained through a combination of the first two.

Her Benefits

  • Pain relief: Orgasms help alleviate menstrual cramps. In addition, studies have shown that a woman's pain threshold increases substantially during orgasm.
  • Enhanced mood: According to University of Virginia researchers, orgasms boost levels of the female sex hormone estrogen, which in turn betters your mood and helps ease premenstrual symptoms. They also release endorphins, the body's natural painkillers and depression fighters.
  • Increased intimacy: Oxytocin, a hormone that promotes feelings of intimacy, jumps to five times its normal level during climax.
  • Easier rest: Oxytocin also induces drowsiness. For women, sleepiness comes about 20 to 30 minutes after orgasm. Men, on the other hand, usually drift off after only two to five minutes.
  • Less stress: Stress in women is highly correlated with arousal difficulties, lack of libido and anorgasmia, the inability to reach orgasm, according to one 1999 study in the Journal of the American Medical Association. Just 20 minutes of intercourse, however, releases the lust-enhancing hormone dopamine, triggering a relaxation response that lasts up to two hours.

Physiologically speaking, male and female orgasms are surprisingly similar. The related problems men and women experience, however, are distinctly different.

"There are men who can't orgasm, but I think it's less than I percent of men," says Jed Kaminetsky, M.D., a professor of urology at New York University and director of the school's male sexual dysfunction clinic. "That's a much less common problem than premature ejaculation."

A study published in the Journal of the American Medical Association found that premature ejaculation is even more common than erectile dysfunction, especially among younger men. As with most sex-related problems, it affects both partners—some studies suggest that nearly 30 percent of couples report premature ejaculation as the most prevalent sexual problem in their relationship. One major obstacle to treating it is simply defining the problem to begin with.

"It depends on the relationship," Kaminetsky explains. "If a woman takes an hour to orgasm and the man can last 40 minutes, that's premature ejaculation for that couple." At the other extreme, one minute is too short an amount of time for most couples. "Not too many women are going to climax within a minute."

Kaminetsky also sees truth in Whipple's assessment of goal-oriented versus pleasure-oriented interactions. "Men are very goal oriented; they see a task and they want to successfully perform that task," he says. "Often that task is to make their partner have an orgasm. If the woman knows that, she feels like a laboratory animal—it's not a very sexy thing. That's why women fake orgasms, which is a sign of lack of communication in a relationship."

Premature Ejaculation

Rarely a physiological problem, premature ejaculation can result from over-excitement, positioning or rate of intercourse. "The roots of it go back to the way men learn to orgasm, which is typically through masturbation," suggests Kaminetsky. "A lot of young boys masturbate quickly, because they don't want their mom to walk in on them. It becomes a trained behavior." To treat premature ejaculation, experts suggest changing positions, breathing deeply, thinking about something other than sex or simply stopping for a moment. Here, Kaminetsky offers two additional techniques for delaying orgasm:

  • Practice this before reaching "ejaculatory inevitability," the point when ejaculation cannot be stopped; most men recognize it as a sensation of deep warmth or pleasure: Squeeze the head of the penis for about four seconds or until the sensation subsides, then resume.
  • During intercourse, the man should press his pelvic bone against the woman's and rock rather than thrust his body. "It won't be as stimulating for him so he'll last longer, and it may be more stimulating for the woman."

His Benefits

  • Long life: Men who have two or more orgasms a week tend to live significantly longer than do those who have only one or none, according to research at Cardiff University in Wales.
  • Less cancer: Breast cancer is rare in men, but once developed, the mortality rate is high. Fortunately, a study published in the British Journal of Cancer found that men who have more than six orgasms a month are significantly less likely to develop breast cancer than are those who have less frequent sex.
  • Healthy hearts: A study of 2,500 men at the University of Bristol and Queens University of Belfast found that men who have at least three or more orgasms a week are 50 percent less likely to die from heart failure or coronary heart disease.
  • Good health: Having sex once or twice a week also fights off the flu and other viruses by strengthening the immune system, psychologists at the University of Pennsylvania recently found.
  • Youthful looks: A study of 3,500 aging people at the Royal Edinburgh Hospital in Scotland found that those who looked the youngest also had the most vigorous sex life. The effects were even greater if the subjects were emotionally satisfied as well.

Getting Close And Personal

Bee, 25, Copywriter

Masturbating is the easiest way for women to learn how to have an orgasm. Women who masturbate will be a lot more likely to have an orgasm during sex. I think it helps you learn the actual mechanics of what turns you on, where things need to happen.

Because the guy isn't going to know that; there's no reason he would. Every woman is different. Also, the bonding that goes on during sex seems most extreme with an orgasm. It's kind of like one or both people have gone completely over the edge; they're suspended in the other person's grasp, and they're completely surrendered to it. That intensifies any connection.

Gabriel, 25, Musician

There are guys who don't get a rise out of giving a woman an orgasm and would just prefer not to have someone else there. I've even heard some guys say they have better orgasms during masturbation than sex. The mere thought of it astounds me, but it makes sense if a guy has a fear of intimacy or, even more, a fear of performing. It probably takes away from his own orgasm if he's overly concerned with his sexual performance or whether or not she's having one. It's ironic, because an orgasm during sex is enhanced when it's with someone you truly care about.

Getting Close and Personal

Kamara, 27, Musician

I'm amazed when I talk to anyone who claims to have never had an orgasm, probably because I just can't imagine not having them or not being able to have them. At the same time, it doesn't surprise me: I was raised in a very conservative religious atmosphere that actually called masturbation "self abuse," and all sexuality—not to mention orgasms—was beautiful and good only if it happened in a marriage bed. It takes awhile to expel the load of guilt that piles up around your sexuality if you're raised in that kind of culture, and I'm sure some people never do. But there was no way I wasn't going to aim for the prize once I knew what it felt like. Maybe it depends on your sexual drive—for me the drive was strong enough that I could never feel guilty about an orgasm for long.

Steven, 28, Veterinarian

Some guys think sex has to include an orgasm. Orgasms are great, but there's so much more to sex. An orgasm is more of a physical experience; I guess there is an emotional aspect, but it's over in a second. I think anybody can give you an orgasm, but it's the person there after the orgasm that matters. But I think I'm the exception.

Does Orgasm Equal Sex?

Our ever-changing definition of sex may hinge more on the climax than on the act itself; Psychologist L.M. Bogart, Ph.D., gave Kent State students a list of scenarios in which "Jim" and "Susie" engaged in vaginal, anal or oral intercourse and either did or did not achieve orgasm. Vaginal intercourse was considered sex 97 percent of the time, followed by anal intercourse (93 percent) and oral sex (44 percent). Researchers were surprised to find that orgasm occurrence dictated whether or not the activity was considered sex. Although the woman was more likely to label vaginal intercourse sex if neither partner climaxed, when it came to oral sex, the recipient was more likely to consider it sex than the partner performing the act, especially if the recipient achieved orgasm—because the stimulator was unlikely to achieve orgasm. For anal sex, it was more likely to be called sex if Jim had the orgasm, but it was sex to Susie regardless of whether she achieved orgasm. In general, the lack of orgasm for women was less likely to affect her labeling the act sex. Although most sex therapists argue against using orgasm as an end-all definition of sex, Bogart's study indicates that orgasm is still an important gauge by which we measure sexual activity.