If you have followed my blogs for the past few years, you know that I have focused on practice management, the business of a medical practice, and recently AI. This blog will depart from those topics and discuss a clinical topic, the orgasm gap, that I have written with a colleague, Dr. David Mobley, a urologist at Weill-Cornell Medicine.

Everyone, both men and women, deserves to experience an orgasm or the climax of sexual arousal. There are several disparities between men and women, including longevity between men and women, gender pay disparity, and orgasm disparity. The orgasm gap, or pleasure gap, is a social phenomenon referring to the general inequality between heterosexual men and women in terms of sexual satisfaction—more specifically, the unequal frequency in the achievement of orgasm during sexual encounters. Currently, across every demographic studied, women report the lowest frequency of reaching orgasm during sexual encounters with men. The size of the orgasm gap varies from 20 percent to 72 percent, to the disadvantage of women.

Many changes occur throughout the entire body with orgasm. During arousal, blood flow to the genitals increases, causing them to become engorged and more sensitive, and the vagina lengthens and becomes lubricated. Vital signs also elevate as heart rate, blood pressure, and temperature increase, peaking during orgasm. Some women also experience rhythmic muscle spasms in the uterus, vagina, and pelvic floor during orgasm, which may be enhanced by regularly performing Kegel exercises. Other muscles in the body may also contract; for example, some women curl their toes during climax.

The orgasm gap or pleasure gap is a term coined to describe the disparity in orgasms between couples. Also known as orgasm inequality, studies have used it to measure sexual satisfaction among different demographics. A good and healthy sex life cannot be measured purely by how many orgasms people have.

The orgasm gap does not just exist between heterosexual women and men. It has been found that lesbian and bisexual women have more orgasms than heterosexual women. Similarly, there is an orgasm gap between women when they are alone and with partners. A study found that 39 percent of women always orgasm when they masturbate, compared to 6 percent experiencing an orgasm during sexual intimacy with a partner.

We have come a long way since the sexual experiments of Masters and Johnson in 1966, which allowed these researchers to describe the human sexual response as a progression of excitement, plateau, orgasm, and resolution. Our current understanding of the sexual response is best described by a biopsychosocial model, which looks at how psychology, biology, sociocultural phenomena, and interpersonal relationships all interact with each other.

Causes of the orgasm gap disparity

Although multiple factors may contribute to the orgasm gap, sociocultural contributors have been overlooked. The fault for the orgasm gap does not lie with penises, vaginas, or any individual man or woman. The fault lies primarily in cultural expectations and traditions.

From ancient times, sex has been surrounded by myths and misinformation. Since the beginning of recorded history, sexual intimacy was relegated primarily to procreative activity for conceiving children. Other forms of sexual intercourse, such as oral sex, anal sex, and oral clitoral stimulation, were considered immoral. We have now moved beyond antiquated values, and most people openly embrace sex for procreation and pleasure. However, while we have learned to embrace sex for pleasure, we still strongly emphasize penis-vaginal penetration.

Another holdover from our puritanical past is the definition of the end of a sexual act. Traditionally, since sex was associated with procreation, the act was considered complete once the male deposited his semen into the vagina. Unfortunately, female orgasm was not deemed necessary because it did not contribute to procreation. Unfortunately, even today, some men consider the sexual act complete after ejaculation, regardless of whether their female partners have achieved an orgasm.

There has been abundant information on the role of the penis and very little on the anatomy and physiology of the clitoris. The penis serves multiple purposes—urination, procreation, and pleasure. However, in female bodies, all these purposes are distributed among different organs. The clitoris is the seat of ultimate female pleasure, making it key to female orgasms. Less than 10 percent of women can orgasm with vaginal penetration alone. Most women need clitoral stimulation to achieve an orgasm. As such, women should teach themselves (and their partners) about clitoral stimulation.

Closing the orgasm gap
Foreplay is important because it takes a woman longer to reach the level of arousal needed to orgasm compared to a man. Caressing, spooning, kissing, and touching erogenous areas are commonly thought of as foreplay, but there are other things partners can do before engaging in sexual intimacy. Women need to communicate with their partners throughout the day so that both think of each other in a positive light. For example, partners can send short love notes, loving emojis via text message, or attach sexual images or 3-second videos on cell phones in anticipation of the bedroom later.

In recent years, numerous clitoral-focused sex toys, especially clitoral vacuum-suction vibrators, have arisen to help women achieve orgasms. These toys focus on clitoral stimulation to help women achieve regular orgasms and bridge the orgasm gap. Closing the orgasm gap requires knowledge and enhanced communication.

The following are tips to help women experience orgasms:

• Expect and request more oral sex and clitoral stimulation.
• Increase the duration of the sexual experience (greater than 15 minutes).
• Focus on methods to improve the overall quality of the relationship.
• Discuss expectations in bed.
• Praise the sexual partner when they do something correctly.
• Tactfully give instructions to the partner—do’s and don’ts.
• Explore new sex positions.
• Slow down or change the type of stimulation.
• Incorporate different types of sexual stimulation (e.g., anal stimulation).
• Discuss sexual fantasies.
• Use sex toys.
• Express love during the sexual experience.

What about the G-spot?

There has been debate among the scientific community as to the existence of the G-spot. Histologically, there is nothing special about the anterior vaginal wall tissue about 4-5 cm inside from the opening of the urethra. However, stimulation of this area can stimulate the crus and fork of the clitoris and help to bring a woman to orgasm. In some women, stimulation of erogenous zones can facilitate escalation to orgasm.

In most men, after an orgasm, there is a refractory period of greater than ten minutes when a man is incapable of having another orgasm. On the other hand, women have the capability of having multiple orgasms as there is no refractory period. A woman can have an orgasm and then have another within seconds. Some women have one orgasm, then decline in arousal, and then again can be aroused and have another climax a few minutes later.

Currently, there are no medications, botanicals, or surgeries that have shown convincing evidence of efficacy for orgasmic disorders. Elaeagnus angustifolia is a plant-derived extract that has been touted for anorgasmia along with sildenafil (Viagra). They have been studied via a randomized trial but have not been shown to be effective. Although endogenous oxytocin has been known to increase during orgasm in both men and women, a randomized, cross-over trial comparing oxytocin to placebo was not effective for orgasm. Additionally, vasodilators such as 2 percent theophylline and 0.3 percent isosorbide dinitrate were compared to placebo in a four-week random controlled trial (RCT), and again neither was better than placebo. Additionally, none of the genital cosmetic procedures (G-spot injection, clitoral hood reduction, vaginal rejuvenation, etc.) have been scientifically proven to help improve the female sexual response or to facilitate orgasm.

For women who have orgasmic dysfunction, despite overcoming all the barriers discussed above, they should be referred to the appropriate professional depending on what is creating the largest barrier to their ability to orgasm. For example, if she has never achieved an orgasm, she may benefit from a sex therapist who can coach her through sex education and directed masturbation as well as cognitive-behavior sex therapy. A woman who is distracted by thoughts that inhibit sexual arousal and orgasm may benefit from seeing a therapist who specializes in mindfulness training. If the orgasmic dysfunction is a result of interpersonal nature, then couples therapy may be a good starting point.

Bottom line: It’s probably obvious that closing the orgasm gap isn’t going to be easy—not for individual women or our culture. Still, it’s worth the effort. Both men and women will be happier if sexual intimacy and orgasm are a shared event and equal for both.

Neil Baum is a urologist. David Mobley is an interventional radiologist.