[ Editorials | Departments and Series | Index ]

Women's Sexual Pleasure and Satisfaction
A New View of Female Sexual Function

Beverly Whipple, PhD, RN

The last half of this decade has seen a surge of interest in female sexuality, not only in the medical community, but also in the research enclave, the general public, and government agencies. Data are just beginning to be accumulated on women's sexual satisfaction. This article focuses on why sexual pleasure and satisfaction are important criteria for women.

In the past, data on the effects of medical problems and pharmaceutical agents were based on the results of studies conducted on men, and then extrapolated to women. From 1977 to 1993, the US Food and Drug Administration (FDA) banned drug testing on women of childbearing age because of the need to control for the menstrual cycle and the potential risk to the fetus if a woman became pregnant during a trial. Consequently, nearly half of all drug studies conducted during these years excluded women. Few drugs were tested to determine whether their effects would be altered by oral contraceptives (OCs) and other drugs commonly taken by women. Also, drugs seldom were analyzed to ascertain whether they affected women and men differently.

Today, US drug trials are required to include women, and the same approach must be extended to the study of sexuality and sexual dysfunction; indeed, any diffences in a drug's sexual effects on men and women are especially important due to the dissimilarity of the hormonal milieu and the difference in neuropeptides at the cellular level.

There has been a paucity of laboratory research on female sexuality since Masters and Johnson published their groundbreaking findings in 1966.¹ To date, the number and depth of studies in men far exceeds those in women. From 1990 to 1999, 4,936 studies were published on male sexual dysfunction compared with 1,993 studies on female sexual dysfunction.²

In 1966, Masters and Johnson classified their findings into a linear sexual response cycle of excitement, plateau, orgasm, and resolution.¹ Men and women were described as having similar physiologic characteristics. More recent research has demonstrated that women do not always fit into this model, and that in fact they demonstrate a variety of sexual responses.

THE AUTHOR'S research

Some examples of the author's physiologic research on the different patterns of sexual response in women include Perry and Whipple's³ “rediscovery” and naming of the Grafenberg (or G) spot, a sensitive area felt through the anterior wall of the vagina, as well as the verification of the phenomenon of female ejaculation.^3,4 Specifically, women reported that orgasm from stimulation of the Grafenberg spot feels “deeper,” and there is indeed a physiologic difference in sensory pathways and muscle response during orgasm originating from Grafenberg spot stimulation compared with orgasm from clitoral stimulation, as described by Masters and Johnson.^5,6

Whipple and Komisaruk^7-9 documented the natural analgesic effect of stimulating the area of the Grafenberg spot, which is activated during both sexual stimulation and labor and childbirth. Whipple and colleagues¹⁰ have also documented the first laboratory study of orgasm in women from imagery alone, without the any physical stimulation, and orgasm in women with complete spinal cord injury.¹¹ These findings demonstrate that sexual response in women may be more varied than in men, and does not always follow a linear pattern. Whipple and Komisaruk are currently conducting studies in women using positron emission tomographic (PET) scans and functional magnetic resonance imaging (fMRI) to determine where in the brain orgasm from vaginal-cervical stimulation takes place and where pain is blocked.¹² Other researchers are looking at arousal using vaginal photoplethysmography and Doppler imaging.

Additional Reports

Numerous other writers and researchers have described how men and women view sexuality differently. Chalker¹³ contended that the male model of single orgasm has become the “gold standard” for women as well, and that the concept of female ejaculation lacks widespread acceptance despite abundant historical references, studies, and anecdotal evidence, leading to the perception of women's sexuality as“mysterious, perplexing, or unknowable.”¹³

Bancroft¹⁴ has noted that female sexuality is still conceptualized in male terms, even though women's responses differ in a variety of important ways. Tiefler¹⁵ has assailed the mechanical view of women's sexuality that is based on research into male erectile dysfunction. Fisher,¹⁶ an anthropologist, has attributed the mismeasurement of women's sexuality to the male focus on such criteria as the frequency of masturbation and the number of partners, rather than the emotional context in which women define their sexuality.¹⁶

Sexual function vERSUs dysfunction in women

The major research emphasis today is not on sexual function in women, but rather on sexual dysfunction. Although the pharmaceutical companies have an understandable interest in funding research on medications to treat dysfunction, it behooves physicians to understand healthy sexual function in women before classifying a behavior as dysfunctional. A new group has been established to examine sexual function in women, which was first called the Female Sexual Function Forum (FSFF), and is now called the International Society for the Study of Women's Sexual Health (ISSWSH). New data in this area are being presented at annual meetings to researchers, sexuality clinicians, and physicians, and the studies are being disseminated in sexuality journals.

Prior to the 1999 meeting of the FSFF, a consensus panel of 19 interdisciplinary experts in female sexual dysfunction (including the author) from five countries was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease. The panel evaluated and revised the existing definitions and classifications of female sexual dysfunction from the International Classification of Diseases-¹⁰ and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Definitions were evaluated from both psychogenic and organic perspectives to provide clinical endpoints and outcomes for research and therapy.

The 1999 Consensus Classification System is as follows:¹⁷

1. Sexual desire disorder
   1. A.Hypoactive sexual desire disorder
   2. Sexual aversion disorder
2. Sexual Arousal disorder
3. Orgasmic disorder
4. Sexual pain disorders
   1. Dyspareunia
   2. Vaginismus
   3. Other sexual pain disorders

Sexual desire disorders includes hypoactive sexual desire disorder (HSDD), defined as the persistent or recurrent deficiency (or absence) of sexual fantasies and/or desire for, or receptivity to, sexual activity, which causes personal distress. Another condition in this category is sexual aversion disorder (SAD), defined as the persistent or recurrent phobic aversion to, and avoidance of, sexual contact, which causes personal distress.

Female sexual arousal disorder (FSAD) is the persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress. It may be expressed as a lack of subjective excitement, genital lubrication/swelling, or other somatic response.

Orgasmic disorder is the persistent or recurrent difficulty of, delay in, or absence of, attaining orgasm following sufficient sexual stimulation and arousal, which causes personal distress.

Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse, which causes personal distress. Vaginismus is recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration, which causes personal distress. Noncoital sexual pain disorder is recurrent or persistent genital pain induced by noncoital sexual stimulation, which causes personal distress.

Although“personal distress” was added as a criterion and the category of noncoital sexual pain disorder was added,¹⁷ there is still much that needs to be addressed. In fact, in the March-April 2001 issue of the Journal of Sex and Marital Therapy, there were 37 published commentaries by 48 authors from five continents responding to the consensus panel recommendations.
Sugrue and Whipple ¹⁸ and a few other authors pointed out that one of the main problems with the classification of female sexual dysfunction is that it is based on the triphasic functional pattern of desire, arousal, and orgasm—the same pattern described by Masters and Johnson¹ and later modified by Kaplan.¹⁹

Although this model has widespread acceptance, it is still based on the male linear model of sexual function, which may not describe the sexual experience of women. Women can experience sexual arousal, orgasm, and satisfaction without sexual desire, and they can experience desire, arousal, and satisfaction without orgasm. If a woman is sexually satisfied without experiencing every phase of the sexual response cycle, should she be considered as having a sexual dysfunction?¹⁸ In addition, this model does not take into account the documented variety of ways that women respond sexually. Finally, some important, newly identified conditions in women were omitted, including hyperactive sexual desire/
sexual compulsion, and persistent sexual arousal syndrome.

A new model

In 1997, in a chapter concerning the management of female sexual dissatisfaction, Whipple and Brash-McGreer²⁰ expanded Reed's Erotic Stimulus Pathway to demonstrate that if the sexual experience was pleasant and produced satisfaction, then it could lead to the seduction phase (Reed's term) of the next sexual experience. That is, a circular rather than a linear response pattern was proposed for women (Figure).

FIGURE. Whipple and McGreer’s expansion of Reed’s Erotic Stimulus Pathway Model

The reflection phase leads to the seduction phase of the next sexual experience, when the experience results in pleasure and satifaction for the woman.

Most health care providers who work with women and their sexual concerns support the contention that women's sexual experience is more complex than having an orgasm or the presence/absence of vaginal lubrication. Women's sexual experiences encompass self-esteem, body image, relationship factors, pleasure, satisfaction, and many other variables.¹⁸ Women do not conform to a linear model that describes only one type of sexual response, and health care providers need to recognize the variety of ways in which women experience sexual pleasure when listening to patients' sexual concerns.
An alternative approach to the normative sexual experiences of women was proposed in a paper published by Sugrue and Whipple.¹⁸ It considers normal female sexual function based on what women report to researchers, clinicians, and peers, which is free of physical or psychological impediments. This model includes:

• Capacity to experience sexual pleasure and satisfaction independent of the occurrence of orgasm
• Desire for, or receptivity to, sexual pleasure and satisfaction
• Physical capability to respond to stimulation (vasocongestion) without discomfort
• Capability to experience orgasm under suitable circumstances.

If these descriptors, or ones similar to them, were viewed as characteristic of normative female sexual function, then the persistent absence or modification of any of these descriptors would constitute sexual dysfunction. For example, persistent lack of sexual satisfaction for reasons other than absence of desire, arousal, or orgasm could be considered inhibited sexual satisfaction. Likewise, a woman who reports a lack of subjective pleasure, despite the presence of vasocongestion, could be diagnosed as experiencing anhedonic sex.¹⁸

This type of classification system, which is based on a psychobiosocial understanding of the female sexual experience, can provide the specificity that clinicians and researchers require without“medicalizing” a woman's sexuality. Such a system does not imply a linear progression of the sexual response, thus reflecting a woman's unique experience of sexuality. For women, pleasure and satisfaction are characteristics of normal sexual function. After hearing this model presented, many men have also reported thay they are more circular than linear in their sexual response.

CONCLUSION

Other researchers also support the importance of satisfaction in defining female sexuality. For example, Tiefer²¹ has stated that sexual satisfaction is essential to a woman-centered classification system.²¹ Leiblum²² has further noted that women can experience sexual arousal and orgasm without feeling any genuine satisfaction, pleasure, or desire to repeat the encounter.²² Therefore, it is vital that physicians consider pleasure and satisfaction when evaluating sexual health in women.

REFERENCES

1. Masters W, Johnson V. Human Sexual Response. Boston: Little, Brown & Co; 1966.
2. Sugrue DP. The medicalization of female sexuality–a step forward or a Trojan horse? Presentation at the Michigan Section Meeting of the American Association of Sex Educators, Counselors, and Therapists, Ann Arbor, MI, 1999.
3. Perry JD, Whipple B. Pelvic muscle strength of female ejaculators: evidence in support of a new theory of orgasm. J Sex Res. 1981;17:22-39.
4. Addiego F, Belzer EG, Comolli J, et al. Female ejaculation: a case study. J Sex Res. 1981;17:13-21.
5. Ladas A, Whipple B, Perry JD. The G Spot and Other Recent Discoveries About Human Sexuality. New York City: Holt, Rinehart and Winston; 1982.
6. Whipple B, Komisaruk BR. The G spot, orgasm, and female ejaculation: are they related? In: Kothari P, ed. The Proceedings of the First International Conference on Orgasm. Bombay, India: VRP Publishers; 1991;227-237.
7. Whipple B, Komisaruk BR. Elevation of pain thresholds by vaginal stimulation in women. Pain. 1985; 21:357-367.
8. Whipple B, Komisaruk BR. Analgesia produced in women by genital self-stimulation. J Sex Res. 1988;24:130-140.
9. Whipple B, Josimovich JB, Komisaruk BR. Sensory thresholds during the antepartum, intrapartum, and postpartum periods. Intl J Nurs Stud. 1990;27(3):213-221.
10. Whipple B, Ogden G, Komisaruk BR. Physiological correlates of imagery induced orgasm in women. Arch Sex Behav. 1992;21(2):121-133.
11. Whipple B, Gerdes CA, Komisaruk BR. Sexual response to self-stimulation in women with complete spinal cord injury. J Sex Res. 1996;33(3):231-240.
12. Whipple B, Komisaruk BR. Brain (PET) responses to vaginal-cervical self-stimulation in women with complete spinal cord injury: preliminary findings. J Sex Marital Ther. 2002;28: 79-86.
13. Chalker R. The Clitoral Truth. New York City: Seven Stories Press; 2000;23.
14. Bancroft J. The sexual well being of women. Kinsey Today. 2000;4(2):1.
15. Tiefer L. The medicalization of women's sexuality. Am J Nurs. 2000; 100(12):11.
16. Fisher H. The First Sex. New York City: Random House: 1999.
17. Basson R, Berman J, Burnett A, et al. Report of the International Consensus Development Conference on Female Sexual Dysfunction: definitions and classification. J Urol. 2000; 163:888-893.
18. Sugrue DP, Whipple B. The consensus-based classification of female sexual dysfunction: barriers to universal acceptance. J Sex Marital Ther. 2001; 27(2):221-226.
19. Kaplan HS. The New Sex Therapy. New York City: Brunner/Mazel; 1974;17.
20. Whipple B, Brash-McGreer K. Management of female sexual dysfunction. In: Sipski ML, Alexander C, eds. Maintaining Sexuality with Disability and Chronic Illness: A Practitioners Guide. Baltimore: Aspen Publishers; 1997;509-534.
21. Tiefer L. The“consensus” conference on female sexual dysfunction: conflicts of interest and hidden agendas. J Sex Marital Ther. 2000;27(2):232.
22. Leiblum S. Critical overview of the new consensus-based definitions and classification of female sexual dysfunction. J Sex Marital Ther. 2001;27 (2):165.

Parts of this paper were published in Whipple B. Editorial: Women's sexuality in the 21st century. Med Aspects Hum Sex. 2001;1(4):7-8; and Whipple B. Women's sexual pleasure and satisfaction. Scand J Sexol. 2001;4(4):191-197.

Beverly Whipple, PhD, RN, FAAN, is professor emerita at Rutgers, The State University of New Jersey; vice president of the World Association for Sexology (2001-2005); president-elect of the Society for the Scientific Study of Sexuality; and past president of the American Association of Sex Educators, Counselors and Therapists