Six months after the birth of her second child, Patricia, a woman with an active and fulfilling sex life, found herself unable to achieve orgasm. “My partner and I tried everything,” she says. “And it was so frustrating because I'd almost reach climax, time and time again, and then … nothing.”
After a few months, her frustration led her to visit a local clinic for sexual disorders. “They brought in a social worker who asked me a lot of questions about abuse. They seemed worried about possible psychological causes,” Patricia notes. After grilling her about her sexual habits, her marriage and other potential stressors, they suggested her inability to reach orgasm might be because of birth-related nerve damage. “They told me, ‘Hopefully, the nerves will regenerate, but we don't know,’” she says. “And I left thinking, ‘Wow, that was massively unhelpful.’”
They may say that all you need is love—but lust, love's partner in crime (or, as some may say, its evil twin), refuses to be denied. And like love, it begs to be fulfilled.
Patricia is far from alone in her frustration. The statistics vary, but most sources agree that less than one third of women consistently reach orgasm during sexual activity. If such an inability persists for more than six months and results in distress to the individual, the Diagnostic and Statistical Manual of Mental Disorders (DSM, for short) classifies the condition as a psychosexual disorder: anorgasmia. The problem may be lifelong—the diagnosis for those who have never experienced an orgasm—or it may be acquired, as in Patricia's case. And although a small percentage of men acquire anorgasmia later in life, usually as the result of chronic medical issues, anorgasmia is primarily a disorder of women.
Today scientists are hard at work to understand the causes of anorgasmia and inhibited sexual response. Laboratories across the globe are using a variety of imaging techniques to pinpoint what happens in the brain during orgasm, how ideation can interfere with sexual response, and how our hormones can help—or hinder—climax. Clinicians are now pulling together these different research threads in the hope of discovering new, more effective treatments.
Before scientists can figure out how to help people who cannot have orgasms, though, they need to better understand what happens in the brains and bodies of people who can. “We're only really beginning to understand the orgasm, especially from a neuroscience perspective,” says Barry R. Komisaruk, a neuroscientist at Rutgers University.
Orgasm and the Brain
The first comprehensive scientific studies of orgasm were led by William H. Masters and Virginia E. Johnson in the 1960s. By considering both physiological and psychological factors, the duo came up with the four-stage model of sexual response: excitement (or arousal), plateau (full arousal), orgasm and resolution. They arrived at their findings primarily through direct observation in the lab; many of their initial study participants were professional sex workers. But the pair did not have the tools to investigate the neurobiological factors that might be in play.
Neuroimaging techniques such as positron-emission tomography and functional MRI are giving neuroscientists a unique way to study the phenomenon. Komisaruk and his colleague Nan Wise, now an assistant research professor at Rutgers University and also a licensed sex therapist in New Jersey, have been using fMRI to study orgasm in a variety of populations.
I volunteered to be one of their guinea pigs. Komisaruk and Wise were looking to track the time course of the orgasm—identifying which areas of the brain are recruited during genital stimulation, during the orgasm itself and then postclimax. By doing so, they may be able to find potential candidates for what Komisaruk calls a “blockage,” or an area that may interfere with orgasm when not activated properly.
When it came time for me to do my part at their lab in Newark, N.J., I found myself a bit apprehensive. My romantic soundtrack would consist of the spine-jangling clunks, clanks and whirs of the fMRI's magnetic apparatus—about as far from Barry White as you can get. Clad in a paper-thin cotton hospital johnny, I was slotted into the machine's claustrophobia-inducing tubular metal housing, my head immobilized in a tight mesh mask to keep it as still as possible while the magnet virtually sliced my brain. I wasn't feeling particularly sexy. Would I be able to achieve climax in such a setting?
I could but try. Using my hand to stimulate my clitoris while the scanner belched and bellowed overhead, I found that pure determination (and fear of disappointing the researchers calmly waiting in the control room) did the trick. Within a few minutes, I pushed a button to let Komisaruk and Wise know that I had successfully donated my orgasm to science. The two then analyzed the data from my session, along with those from approximately a dozen other study participants, focusing on 80 discrete regions of the brain. They found a complex pattern of activation at the point of orgasm—suggesting many different ways to develop anorgasmia.
Parsing the interplay among all those regions is a daunting task. “We know the orgasm starts with activation in the sensory cortex,” Komisaruk says. “But do anorgasmic people have a normal sensory cortex response? Is the sensory information not being integrated by other parts of the brain? We don't know yet.”
Searching for Answers
In trying to identify the cause of anorgasmia, scientists are exploring different realms: the physiological, the psychological and the chemical. Cindy M. Meston, director of the Sexual Psychophysiology Lab at the University of Texas at Austin, points to a few well-known medical and physiological factors that inhibit orgasm, including the nerve damage that Patricia may have suffered. “There are vascular disorders, spinal cord injuries, neuropathy, drug effects from antidepressants and other medicines,” Meston says. But, she adds, once you rule those factors out, no scientific evidence supports the idea that anorgasmia arises from dysfunctions in body systems.
A likelier culprit is the brain's frontal lobe, which is responsible for executive function—allocation of the mind's attention and control as circumstances require. Komisaruk's fMRI studies show that at the point of orgasm, the frontal pole, part of the frontal lobe, fires in tandem with areas in the temporal lobe associated with the senses and with regions down deep, near the brain stem, that are associated with rewards.
Those linkages may account for a barrier to orgasm that Masters and Johnson called “spectatoring”—staying outside of a sexual encounter to monitor and judge it instead of fully experiencing it. The frontal lobe governs all that monitoring and judgment. “You may not get to the high level of arousal needed for orgasm if you are paying attention to what you look like, or how you measure up to past partners, or what's happening in your relationship instead of what you're actually feeling and experiencing during sex,” Meston says. “That kind of stuff is just not conducive to increasing arousal—and so it's going to get in the way of your orgasm.”
The primacy of the mind in sexual response helps to explain a seemingly counterintuitive finding in clinical practice: treating anorgasmia is easiest in individuals for whom it has been a lifelong condition. The reason is that attitude is easier to alter than physiology. “It's often a shame thing,” says Wise, who has treated many patients as a sex therapist, “and once you give someone permission to explore their body, to masturbate and learn what feels good, they figure it out. After all, you have to learn how to play your own instrument before you can play in a band.”
Directed masturbation, introduced back in the 1970s by Julia Heiman, now director of the Kinsey Institute, and Joseph LoPiccolo, a sex researcher at the University of Missouri, has proved to be remarkably effective in the treatment of lifelong anorgasmia. The technique is much as it sounds—patients work with therapists on masturbatory activities during one-on-one sessions. “A ton of research shows that women who have never had an orgasm can learn how just by learning more about their sexual anatomy and how to explore their own bodies,” Meston says, with directed masturbation succeeding for about 90 percent of participants. As early as 1978, for instance, a study led by researchers Alan J. Riley and Elizabeth J. Riley of the University of London found that 18 of 20 women were able to reach orgasm after following a directed masturbation program. Other studies have since shown similar success. Indeed, the greatest obstacle to an antidote for anorgasmia may be squeamishness about masturbating in the presence of a stranger.
Acquired anorgasmia could require a different kind of toolkit. Sometimes partner conflicts are to blame; they can often be resolved with communication and psychotherapy. But what if talking does not provide the cure?
One day people may be able to fine-tune their own brain for a remedy. Komisaruk is optimistic that neurobiofeedback techniques will help in complex cases. In such a setup, a person hooked up to an electroencephalogram or an fMRI would see real-time displays of brain activity and learn to self-regulate and correct the problem. “Let's say we see that the genital sensory cortex response is normal but other areas down the line are not being activated,” Komisaruk says. “We may be able to coach those with anorgasmia to voluntarily activate [those areas] and move themselves toward orgasm.”
Biofeedback has proved effective in the treatment of conditions such as blood pressure regulation and anxiety and has even helped stroke patients regain function in paralyzed muscles. But given how much is still unknown about the timing and sequence of neural connections during orgasm, this kind of system remains an exciting possibility for another day.
In the meantime, relief may come from intervention in our brain chemistry. Researchers studying animals and human patients have identified an array of neurochemicals that help to promote orgasm. Testosterone, a sex steroid, works its magic in the brain and the genitals, and although its role in female sexuality remains controversial, it is linked to feelings of both desire and arousal. Oxytocin, often called the “cuddle chemical,” is released by the paraventricular nucleus—a small cluster of cells in the brain's hypothalamus—at the onset of climax. It then floods oxytocin receptors on cells in the nucleus accumbens, a reward center in the brain, and releases a glut of dopamine, a feel-good neurotransmitter, which delivers the pleasant rush that accompanies orgasm. To counter dopamine's effects (and keep us from having too much of a good thing, which could interfere with the brain's natural learning mechanisms or lead to addictive behaviors), the neurotransmitter serotonin and the protein prolactin act as brakes, resulting in feelings of satisfaction and relaxation after orgasm—although too much of either interferes with sexual response and may prevent orgasm from occurring.
Researchers of anorgasmia are now trying to fine-tune this natural pharmacopeia. One new female desire drug, Lybridos, under development by Dutch research firm Emotional Brain, consists of serotonin-inhibiting buspirone coated in testosterone. Preliminary results from a four-week trial conducted in 2012 with 56 women who have hypoactive sexual desire disorder, or low libido, indicate that Lybridos may increase desire and orgasms more than a placebo or testosterone with a serotonin promoter, and further trials are ongoing. In August 2015 the Food and Drug Administration approved Addyi, a drug that targets neurotransmitters, for generalized hypoactive sexual desire disorder in premenopausal women. By most accounts, though, the reception to this drug has been lukewarm at best.
Waguih W. IsHak, a psychiatrist specializing in sexual medicine at Cedars-Sinai Medical Center in Los Angeles, has successfully treated anorgasmia with oxytocin and Dostinex, an antiprolactin agent, in individual case studies. But IsHak expresses caution. Anorgasmia is more complicated than an imbalance in one or two chemicals—and tinkering with these natural systems may result in fixes that may be only temporary or that bring unwanted side effects. “These are innovative interventions,” IsHak says. “But they should be used only as a last resort after you've ruled out everything else.”
Patricia, who found her own visit to the clinic “massively unhelpful,” regained her ability to reach orgasm after about three years. Her nerve damage, the likely cause, healed over time. In the future, better understanding of the brain may help improve diagnosis and treatment for individuals like Patricia—showing which pathways are damaged and perhaps how to redirect them. Wise is cautious but hopeful: “In more complex cases of anorgasmia, we're probably looking at a combination of psychological, social and biological factors. If we can figure out how they interact as we better map out what is happening in the brain during orgasm—perhaps identifying critical structures or processes in the timeline that push people from arousal over into orgasm—there's the possibility we can do a lot more.”
And that's an outcome many women are waiting for.