Though female masturbation has long been shrouded in taboo and, for some women, shame or embarrassment, solo masturbation is one of the most common sexual behaviors engaged in by women across the life span.1-4 A form of autoeroticism, masturbation is generally defined as stimulating one's body for the purposes of sexual pleasure, whether or not orgasm is experienced. During adolescence and again in advanced age, more women engage in masturbation compared with vaginal intercourse, which is the most common female sexual behavior during the reproductive years.2-4
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CHARACTERISTICS OF MASTURBATION
Masturbation is highly prevalent among women and may be used for any number of reasons, including those related to pleasure, orgasm, relaxation, or release of sexual tension, or to fall asleep.1,2,5 Similarly, women may begin using a vibrator (a common part of masturbation for many) for such reasons, in addition to those related to fun, curiosity, partner suggestion, and novelty.6 Women may masturbate whether they are single or in a relationship,5,7 and though some may masturbate while watching sexually explicit images (such as pornography), this is less common compared to the masturbatory experiences of men.8 More often, women may fantasize or focus on physical sensations they are experiencing while self-pleasuring.9
Although masturbation can be experienced by anyone, there is a higher prevalence among women with higher education, those with higher socioeconomic status, those who engage in more frequent vaginal sex, and those who report a more varied sexual repertoire.6 Having a more positive female genital self-image (eg, feeling more positive about one's own genitals) has also been linked to female masturbation and vibrator use (as well as having had a gynecologic exam in the previous year and having performed vulvar self-examination in the past month).10
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SAFETY AND CLINICAL RISKS
In most cases, solo female masturbation is a safe activity that is without serious clinical risks or consequences.11 In fact, some women may choose to engage in masturbation because it is considered a safe sexual activity that does not carry risk of pregnancy or infection.7
Women may masturbate or self-pleasure using any number of methods or objects. Although many women use their hands to masturbate, a recent nationally representative probability survey of US women ages 18 to 60 found that 46.3% of respondents had used a vibrator during masturbation (and more than half had used a vibrator for either solo or partnered sex).6 While the vast majority of women who had used a vibrator reported having never experienced side effects from its use, more than a quarter had experienced side effects such as genital numbness, irritation, or cuts or tears, most of which were mild and transient. The proportion of side effects that occurred during solo versus partnered stimulation is not known. Indeed, more research is needed to identify characteristics of vibrators themselves or vibrator use (such as duration of use or intensity of vibration) that may influence the risk of such side effects.
Because of the risk of side effects from vibrator use or other types of masturbation (or partnered sexual activity), gynecologists should ask their patients about their masturbation and partnered sexual activities in cases where genital redness, itching, or inflammation is noted. Some women may be particularly prone to masturbation-induced genital irritation or tears as a result of a hypoestrogenic state (eg, menopause or breastfeeding) or a condition such as genital lichen sclerosus, which can cause the genital skin to be vulnerable to cuts or tears following solo or partnered sexual activity. As such, women who pre-sent with genital irritation or tears may be best served by seeing a clinician who asks them questions about how the symptoms came about, whether they experience such symptoms commonly from masturbation or partnered sex, and what duration or intensity of masturbation or partnered sex led to such symptoms.
The proportion of genital side effects that arise from normal use of vibrators or other sexual enhancement products versus those that result from misuse is not known. However, some women may misuse vibrators during solo masturbation or partnered sex, such as by inserting a vibrator into the rectum (which in some cases has led to a vibrator that was irretrievable by the woman herself and required removal by a physician) or leaving a vibrator inside the vagina for a long duration, resulting in a rectovaginal fistula.12,13
In addition to vibrators, women may use a variety of other objects for masturbation, including nonvibrating dildos, household objects (eg, candles) or produce (eg, cucumbers or bananas) inserted vaginally or anally and, in rare instances, resulting in clinical complications.12,14,15 It has been reported that some female children and adolescents have presented with lower abdominal pain, and upon examination, it was found that they had inserted batteries into their vagina and left them inside for a period of days, resulting in deep vaginal wall ulcerations.16,17 It is not known whether the batteries were inserted as part of masturbation.
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MASTURBATION AND PRIMARY ANORGASMIA
Historically, it is claimed that the electric vibrator was originally used as part of clinical treatment for hysteria.20 Over the past several decades, masturbation (with or without a vibrator) has been recommended by counselors, therapists, and health care professionals for the treatment of primary anorgasmia.21,22 In several research studies, directed masturbation—often in conjunction with meeting with a sex therapist—has been found to be a helpful strategy for women as they learn to orgasm.22,23
Along with taking a complete medical history, gynecologists who counsel women about learning to orgasm may find it helpful to ask patients whether they have tried masturbating or self-pleasuring their body alone or using a vibrator, which can speed the time to orgasm. Gynecologists may also find it helpful to use diagrams or models to educate women about the female body; many women have not been educated about the existence, location, or full size of the clitoris (such as the internal crura) or the fact that without direct stimulation of the clitoris, many women find it difficult, if not impossible, to achieve orgasm during intercourse.
Because it often takes more time to provide women with information about orgasm than clinicians have available, patients may benefit by reading a book about orgasm. Several books are available, among them Becoming Orgasmic: A Sexual and Personal Growth Program for Women, which details solo and partnered exercises for women who wish to learn to orgasm, and Because It Feels Good: A Woman's Guide to Sexual Pleasure and Satisfaction, which provides detailed information about the clitoris and vulva as well as solo and partnered exercises related to enhancing arousal and orgasm.24,25 Women may also be directed toward resources for identifying a professional sex therapist in their area; these resources include the websites of the American Association of Sex Educators, Counselors and Therapists (www.aasect.org) and the Society for Sex Therapy and Research (www.sstarnet.org).
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MASTURBATION, VIBRATOR USE, AND CLINICAL OPPORTUNITIES
Vibrator use has been associated with more positive sexual function as measured by the Female Sexual Function Index, which provides scores on subscales related to desire, arousal, orgasm, lubrication, satisfaction, and pain during sex, as well as a total score of sexual function.6,7 The direction of the relationship between vibrator use and sexual function is not known, although clinically, vibrators have long been recommended for the enhancement of orgasm, arousal (and consequently lubrication), and desire. More recently, vulvar vibration therapy has been examined as adjunct treatment for vulvar pain.26
Further, the use of nonvibrating vaginal dilators is often recommended for maintaining vaginal patency following radiation treatment for gynecologic cancers.27 However, the use of vaginal dilators is not necessarily to be considered "masturbation" (in fact, some patients may resist dilator treatment if they perceive that it is equivalent to masturbation, with which they may associate shame or embarrassment). Regarding dilator use, women may choose to partially insert a lubricated dilator into the vagina and leave it inside for an amount of time specified by their clinician, or they may choose to use it as part of masturbation or partnered sex play.
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MASTURBATION, VIBRATOR USE, AND PREGNANCY
Little is known about sexual behavior, including solo masturbation, during pregnancy. Many women continue to be sexually active throughout pregnancy. However, as a woman's body changes, certain partnered sexual positions may become physically uncomfortable. Or she may worry that her partner does not find her pregnant body attractive, which may result in a greater frequency of solo masturbation in order to meet her needs.
Research about the methods women use to self-pleasure themselves during pregnancy is needed. Some women have commented that they began using a vibrator while pregnant because they felt that their male partner no longer desired them. It is not known to what extent vibrator use is safe during pregnancy. More research is needed to understand how many pregnant women use vibrators in each trimester, how pregnant women use vibrators (eg, intravaginally, on the vulva, or anally), to what extent women receive counseling from their ObGyns about masturbation or vibrator use, and pregnancy outcomes of these women.
In addition to asking pregnant patients about their partnered sexual activity and risk for sexually transmitted infections, ObGyns would be wise to ask pregnant patients about their solo masturbation, including vibrator use (eg, type of vibrator used, duration of vibrator use, intensity of vibration, and location of stimulation).
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Although masturbation is common among women, many may have had little experience talking about it with friends or a sexual partner, let alone with their gynecologist. However, there are health-promoting reasons that gynecologists may want to ask patients about their solo masturbation practices (in addition to their partnered sex). Such conversations may help gynecologists identify vaginal or rectal foreign bodies among women who describe other symptoms (such as abdominal pain). They may also help gynecologists to better advise women on sexual practices during pregnancy or in the context of having certain genital conditions that predispose to vulvar atrophy, pain, or tearing.
Since many women have been made to feel shame or embarrassment about masturbation, these conversations may be difficult to begin, but they have the potential for clinical benefit. Questions about masturbation can be asked as part of a larger sexual history taking. It can be helpful to use words that reassure patients that masturbation is common and normative (eg, "Many women have questions about the safety of sex with their partner, as well as masturbation, throughout their pregnancy.") By asking about or discussing masturbation using clinical terms, and providing reassurance that it is common and part of a healthy sexual life, women may feel more comfortable asking their gynecologist questions that have important clinical implications.
The author reports research funding from Church & Dwight Co and Pure Romance, Inc.
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Debra Herbenick, PhD, MPH, is a Research Scientist and Associate Director, Center for Sexual Health Promotion, School of Health, Physical Education and Recreation, Indiana University, Bloomington, IN.