This is another one of those blogs where my close family members need to look away, if me talking frankly about sex is embarrassing for them. But I want them to remember that the silence around sexual dysfunction is massive and it is important that, as a health professional working with women and men with problems in this area, I need to cover this topic in my blog.
I have written previously about orgasm and sexual function in this blog here. Most importantly, it is imperative that if anyone out in the stratosphere is reading this and you have pain, uncertainty or questions about sexual function, then your local Pelvic Health Physiotherapist will be able to help you or refer you on to someone who can. Google for your nearest pelvic health physiotherapist.
Over the nearly 30 years I’ve been treating (mostly) women but some men for sexual dysfunction, one of the most destructive phrases or beliefs that keeps cropping up over and over is a common one which patients report from their Catholic (church or school) upbringing and probably from many other religions also and it is: “Masturbation is a sin”.
That simple phrase has caused much angst for many women and men and their sexuality. This phrase must have been said and reiterated to these patients when they were young, vulnerable and impressionable because for many, it has caused them to deny themselves a lifetime of autonomy over their bodies. It has encouraged them to repress sexual feelings they have had and to feel guilty if they don’t ignore those sensations and feelings and actually decide to acknowledge them and do something about them by doing self-stimulation.
What it also has done is create mystery around how women can actually achieve orgasm and made women afraid to actually explore their own bodies with the view to learning what feels pleasurable and what doesn’t. This is an important skill for women to learn as they need to be able to tell their partner what feels comfortable and what feels uncomfortable or just plain hurts. This is another life-area where there is very little proper instruction – a lot like having a baby. I mean is anyone else absolutely incredulous (if you truly think about it) how little instruction is given to mothers and fathers about the most important task they will ever be given – here take this baby home and look after it……. FAROUT.
So in the ranking of important information we should talk much more about – how to orgasm and what is involved in having pleasurable pain-free sex is right up there because sexual dysfunction is a common cause of marital disharmony. If women (or men) can’t have pain-free sex and are too afraid/ embarrassed/ ashamed (yes shame is a common emotion women feel if they can’t have sexual penetration with their partner) to openly talk about it, seek help or counselling for it – then it sometimes causes relationships to fail, which then causes untold grief to families and particularly children.
Professor Helen O’Connell
Back to women learning about their clitoris (‘their’ being the operative word – it is an important part of every woman’s anatomy and belongs to her). The clitoris exists purely for pleasure. But sadly the clitoris is a mystery to many women and most men – and I am including some doctors in that broad statement. The interesting thing about the clitoris is that it wasn’t until 1998 that a female Australian Urologist, the now Professor Helen O’Connell, actually did detailed dissections and discovered the previous-held views on the true anatomy of the clitoris were completely misleading. A big fail in Grey’s Anatomy for many years! I’m not sure if all health professionals have caught up with this fact and still believe the clitoris is merely that (magic) button just above the urethra. Here is a great article about the anatomy of the clitoris by Dr Mark Blechner.
Most of the components of the clitoris are buried under the skin and connective tissues of the vulva. It comprises an external glans and hood, and an internal body, root, crura, and bulbs; its overall size is 9-11 cm. (1) Therefore the clitoris is huge! Clitoral somatic innervation is via the dorsal nerve of the clitoris, a branch of the pudendal nerve, while other neuronal networks within the structure are complex. (1)
Image from an article by Mark Blechner (see full article linked above and at the reference below)
Understanding about the power of the clitoris is important because when we are teaching women about how to manage persistent pelvic pain, we talk about the body’s own ability to administer some pretty powerful drugs of its own. This relates to the “The Drug Cabinet in the Body” and Dave Butler explains this very well in the linked 5 minute video. General exercise (walking, running, gym, netball, rowing, swimming, in fact, anything) releases some of the ‘drugs’ (such as serotonin, oxytocin and dopamine) in our bodies that helps with persistent pain management. But another excellent way to access the ‘drug cabinet’ in the body is via the clitoris and particularly apt if one has female sexual dysfunction (FSD).
Quite often women have pain with penetration – pain at the vulva or internally generated by their over-protective pelvic floor muscles, but have no pain around the region of the clitoris. This means that with a good lubricant, they are able to gently touch the clitoris for short periods of time and build up tolerance to the touch, release warm, fuzzy feelings and gain arousal to assist with dilator work or with penile penetration. This graded exposure to clitoral self-stimulation will also help with any feelings of guilt or shame that may be present. This can be used in conjunction with dilators (or trainers as they are sometimes called) and as progress is made, then with adding a gentle vibrator which can be purchased from here and here (from Pelvic Floor Exercise an online store for all things Pelvic Health)
For your interest, there has been a change in definition of Female Sexual Dysfunction (FSD) and the International Continence Society (ICS) went with the definitions from the DSM 5 (The Diagnostic and Statistical Manual of Mental Disorders fifth edition). The DSM 5 has combined disorders that overlap in presentation and reduced the number of disorders from six to three.
- Hypoactive sexual desire disorder (HSDD) and female sexual arousal disorders (FSAD) have been combined into one disorder, now called Female Sexual Interest/Arousal Disorder (FSIAD)
- The DSM-IV categories of vaginismus and dyspareunia have been combined to create Genito-Pelvic Pain/Penetration Disorder (GPPPD).
- Female Orgasmic Disorder remains its own diagnosis
- All diagnoses now require a minimum duration of approximately 6 months and are further specified by severity. (3)
There it is – Female Orgasmic Disorder all on a line by itself. Orgasmic dysfunction in women is the inability to achieve an orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm during any kind of sexual stimulation. They report (high) sexual arousal/excitement. (Prevalence 16–25% in 18–74‐year‐old women in US, Canada, Australia, Sweden but in 2 other studies from Nordic countries 80% of all sexually active women age 18–74, independent of age, report some degree of orgasmic dysfunction). (4)
One of the reasons there could be such high rates of female orgasmic disorder is women wracked with guilt. When girls and women are actively told by their church or their peers or their mothers/fathers that masturbation is a sin? It sounds so wrong. This statement makes it difficult for them to explore their bodies, to chat to someone about it – even their friends, because the knowledgable ones might be skiting about having three orgasms every night and that in itself is intimidating for someone who may barely know where their clitoris is.
Context matters with pain also.
Many women are able to wipe their perineum after they have urinated with no pain experienced at all around the vulva, but when they (or their partners) are attempting to touch this area to explore in a sexual way, it is then that they experience pain. This is an example of the brain believing there is a potential for danger associated with sexual intimacy. The evidence has been accumulated by the brain over the years and much cortisol and adrenaline has been released with every attempt at penetration or really any sexual intimacy. Even thinking about having sex can trigger off this sympathetic nervous system response (the fight- flight response). The brain perceives the threat even without any physical contact. And the response of the pelvic floor muscles is to become over-protective and women experience levator myalgia – the muscle tissues become sensitive and tender points are palpated in the muscles. History matters to the brain! Good and bad experiences leave their indelible impression in the brain. Memories are important and laying down new memories with positive experiences will be useful when moving forward with persistent sexual pain.
Finally after lots of explanations about the anatomy, persistent pain and the like, some resources to help you are important.
OMGYES (the link is here) is a website where you pay a one-off $49 for a lifetime subscription. It teaches about the art of orgasm. Warning: It is very graphic.
I have another blog which has many links within in it called: Persistent Pain Resources in One Area
I hope this frank blog will give you some strategies and the confidence to pursue some help from a pelvic health physiotherapist.
Below is a link to a TED talk on ‘The unknown greatness of the clitoris’ with Maria Røsok
(1) Pauls R 2015 Anatomy of the clitoris and the female sexual response Clinical Anatomy 376-384
(2) Blechner M 2017 The Clitoris: Anatomical and Psychological Issues, Studies in Gender and Sexuality, 190-200