Female Sexual Dissatisfaction II: Sexual Dissatisfaction FAQ

Got an intimate question about your body and its pleasure zones? Glamour gathered seven of the country's top female experts for a closed-door Q & A every woman should read.

By Noelle Howey and Gayle Forman

For lots of women, having great sex is a complicated matter: You know it ("Why don't I feel like it tonight? Why haven't I felt like it for the last month? Am I going to have an orgasm, or what?"). Men know it ("Why doesn't she feel like it tonight? Why hasn't she felt like it for the past month? Is she going to have an orgasm, or what?"). Even the pharmaceutical behemoth Pfizer knows it--the company just abandoned an eight-year-long quest to perfect its blockbuster drug Viagra for women (you can just imagine a bunch of white coats standing around test subjects, rubbing their chins and muttering, "Why doesn't she feel like it tonight? Why hasn't she felt like it for a month? Is she going to have an orgasm, or what?").

So who do you turn to for answers to these questions you ask in the dark? Who's got a handle on how all the parts function and what makes sex reliably good? For most women it's their ob-gyn. That's right, your plain old, Pap-performing, Pill-prescribing ob-gyn. You've probably never said boo to her about your sex life, but you should, because she's in a position to know you and your sexual history, as well as the facts and the drugs out there that can help. That said, not all doctors think alike on the topic of women's sexuality. So to give you the range of expert advice out there, Glamour assembled a dream team of groundbreaking female physicians, therapists and researchers who know about sex. Read their opinions-then keep the conversation going with you ob-gyn.

What's the most common complaint you hear from women?

JENNIFER BERMAN, M.D.: Across the board, having a low libido is the number-one problem.

HILDA HUTCHERSON, M.D.: Women often say they used to have desire, and now it's gone.

EILEEN PALACE, PH.D.: And that's understandable-because every part of a woman's life can affect her sex drive: fatigue, stress, anger or lack of trust in her relationship, power issues, and emotional intimacy. A woman's not ready for sex at night because she's doing the grocery list. Thinking about work. Angry with her partner for not paying attention to her all day.

LAURA BERMAN, PH.D.: But sometimes there really may be a physiological cause. For example, is she on antidepressants or birth control pills, both of which can kill sex drive? That's a huge problem with younger women. So is anxiety. Through my practice, I've found that women who are under chronic stress can have lower levels of testosterone, which can cause a drop in their libido.

DR. HUTCHERSON: I don't know-I think it's very rare for a woman under 40 to have a hormonal imbalance. Certainly physical problems can come up-sometimes I think patients hope there is something wrong physically, because then maybe there's a pill they can take for it! Reaching for a pill or a cream is often easier than figuring out how to deal with difficult emotional issues in your relationship or you life.

So how do you get your desire back if it sputters out?

LEONORE TIEFER, PH.D.: I say to couples, focus on just having pleasure with the other person. Let's say I'm working with a couple and the first assignment I give them is to trade massages. Often they have a better time giving each other back rubs than when they had intercourse. Why? There was no pressure, and because they didn't know what they were doing or what felt good to their partner, they had to communicate with each other.

DR. HUTCHERSON: Women have heard this all before, but it's good advice: Learn how to tune out the world for a while. Take the phone off the hook. Take that bubble bath together.

DR. JENNIFER BERMAN: And get some rest. Stress can cause women to have more interest in sleep than in sex and can inhibit their ability to become aroused and have an orgasm. And for a woman to feel sexual, she needs to nurture and pamper herself.

PALACE: Experimentation is also important. I tell women to touch themselves to get to know their whole body, so they can communicate their needs more effectively to their partners. They can use an ice cube, a feather, a pillowcase, even a toothbrush, just to elicit different senses.

BEVERLY WHIPPLE, PH.D.: I give participants in my workshops a list of 36 body parts and 16 types of touch, such as rubbing or stroking. Alone or with a partner, they mix and match the parts and the types of actions and rank their feelings on different combinations, say from one to ten. I help guide them by bringing in my own experience. For example, if my husband blows in my ear I want to barf. If he sucks on my big toe, it's like a plus 12. A lot of women don't really understand what arouses then, so this exercise helps them get to know themselves.

What's up with all the new drugs? Can any of them help women have better sex?

DR. HUTCERSON: First, women have to know that there isn't one pill that cures every thing. Patients will say, "you have to give me a drug that will make it all better". Doctors will still prescribe Viagra-the men's version-to women, but I can give you a huge dose, and if you hate your partner or your body, it won't do a thing. Yet in some cases, drugs like testosterone and Viagra can help.

LAURA BERMAN: If a woman feels good about herself and the person she's with but has had a medical problem, maybe from a hysterectomy or pelvic surgery, I've found that Viagra can work well.

PALACE: Here's the bottom line on Viagra prescribed for women. It may increase women's orgasmic frequency, lubrication and their excitement-that is, arousal. But it doesn't work well with desire. Arousal is the physiological change that takes place: lubrication, breast sensation. But desire comes before arousal; it's the wanting, dreaming, initiation, being receptive, how much you think about sex.

LAURA BERMAN: If a woman has low desire and low testosterone levels, sometimes I recommend testosterone replacement, maybe cream or a patch. Women can get it from ob-gyn. It's not yet approved but the FDA for use in women, but many doctors prescribe it off-label.

DR. HUTCHERSON: Yes, it's a miracle. I've had women cry in my office after I've given them testosterone cream and it's brought their orgasms back.

PALACE: I'm not at all impressed with testosterone. Researchers thought for years that testosterone was going to increase male sexual desire, but it has not been proven to be an effective treatment. Now doctors are prescribing creams, films and patches for women, and overall it's not having a dramatic effect.

TIEFER: I think it's premature to use testosterone, based on the available research. If women are benefiting from it, it could just be that they're more comfortable using a cream as a lubricant-the active ingredient isn't all that important. I think if a person is comfortable touching herself and using lubrication, that's a lot more empowering than having her feel like she's defective and needs medicine to be sexual.

LAURA BERMAN: We know this is not just about lubrication because women may use a patch, cream or other form of testosterone replacement, and they don't necessarily take it before sex or apply the cream only to their genitals.

TIEFER: I believe that with testosterone and Viagra, the only effect is the placebo effect.

PALACE: But the placebo effect is powerful, I once studied women who'd complained of a lack of desire and arousal problems. After monitoring them while they were watching an erotic film, I told them that they'd had an increase of blood flow to their vaginas. They hadn't. But after I told them about their "results," their blood flow matched women who had no problems with sexual desire or arousal, and they had better sexual response in follow-up tests.

Should we be this focused on more and better sex? Could all the talk about drugs, creams and the number of orgasms be putting too much pressure on women?

DR. HUTCHERSON: In many ways, there is too much pressure. Women today are much freer than previous generations to discuss their sexuality with their partners and their doctors. But we also have to be aware of what I call the "Samantha syndrome," because patients tell me all the time, "I thought I was having an orgasm, it's not like Samantha's on Sex and the City. I'm not having multiple orgasms, I'm not screaming, I'm not breaking down the bed. I must be missing something." Women in their twenties are the ones telling me this, and they really take it to heart. They come in raw to my office because they had been rubbed so much, trying to have the right kind of experience.

LAURA BERMAN: It's great that there are all these role models, like Samantha, who are asking for what they want. On the flip side she's having this fabulous sex every time; she doesn't have any sexual problems. I've seen women who think that's what their sex life is supposed to be like.

WHIPPLE: Most women are still pleasure-oriented-they are as fulfilled holding hands or cuddling as having sex. But some women have become more goal-oriented about sex, the way many men have always been. I see this especially among women in the business world. A woman sets an appointment for when she's supposed to have sex on her Palm Pilot. Her mind-set is: I've got to check sex off the list. But where's the pleasure in that?

JEANNE ALEXANDER, M.D.: There is tremendous pressure on women to be like men in bed, but we're not. For the most part, the average woman wants to feel close to the person she's with. Sometimes you're going to have the physical and emotional connection, like rockets are shooting off. And sometimes it's going to be quite peaceful but still enjoyable.

WHIPPLE: Because women are hearing so much more about sex these days, we're much more about sex these days, we're more informed about sexual pleasure and satisfaction. But that can have a downside. For example, more than two decades ago my research showed that the G-spot could be a center for orgasm for many women. But somehow some women started thinking they had to have a G-sport orgasm instead of one through clitoral stimulation. Absolutely not! I was just trying to validate women's range of experiences. My concern for the 30-year-olds of today is that they're going to think that they're missing something when they're not.

DR. HUTCHERSON: Women are experiencing a lot of confusion, pressure and performance anxiety, which can affect their orgasms. When I tell my patients that more than 70 percent of women don't have an orgasm through intercourse alone, they give me this sigh of relief. The thing is, you need to decide whether you really want to have sex more often-or whether you feel like you're supposed to want to have it more often. Twice a day is normal for some couples, and once a moth is just as normal for others. Your degree of frequency is only a problem if you think it is. And if it is, you should initiate sex more. Don't expect the man to do all the work.

So why don't some women have orgasms? And are women still faking it?

DR. JENNIFER BERMAN: Here's what an orgasm is: Your nerves get stimulated, which leads to increased blood flow and engorgement of your genitals. Your heart rate and blood pressure rise, and continued stimulation leads to an orgasmic release. Unless a woman has a hormonal imbalance or physical issue, we still don't know why some women can't have that response.

PALACE: All women have a capacity for an orgasmic response, and the sooner they can listen to their bodies, the better. But our culture tends to teach women that paying attention to their sexual needs is not OK.

LAURA BERMAN: The problem is compounded when men are with woman after woman after woman who pretends to have an orgasm with intercourse even when she doesn't, which gives him false expectations. And then he puts pressure on his partner to have this amazing experience and thinks something's wrong with her if it doesn't work out that way. Then she starts feeling inadequate. It's a cycle.

DR. JENNIFER BERMAN: That's partly why more than half of all women have faked and orgasm at some point.

DR. TIEFER: It happens for the same reason people fake anything: Oh yes, I watched the President's press conference. Yes, I read last week's New Yorker. Many women want to be seen as someone who's had this experience-so they may lie.

LAURA BERMAN: No, no, no. It's not necessarily to make themselves feel better but to please their partner, or perhaps to get sex over with sooner. For some men, their goal is to make you have an orgasm, and eventually you may feel so sorry for him-so much of his ego is wrapped up in this quest-that you may fake it to make him feel better. Even the most empowered woman will succumb at one point.

DR. HUTCHERSON: Yes; men, for some reason, seem to think something is wrong with them if they can't make a woman have an orgasm-as if they could put it in a little Tiffany blue box with a bow and hand it to her. But I think women are moving away from faking orgasms because we're finally learning that the man doesn't just magically make to orgasm happen, and women are saying, "I want to understand my body and figure out how to get myself to the point of climax. I deserve a great orgasm!"

How does body image affect women's sex lives?

LAURA BERMAN: It's huge. But often women don't connect their feelings about their bodies-like not wanting to be in a position where part of their body might look droopy-with what's going on in the bedroom. But it's so important for women to have a positive, realistic body image.

TIEFER: One problem is that women, especially when they're younger, confuse looking good with feeling good.

DR. HUTHCERSON: And if you're someone who gets your sexual self-esteem from the way you look when you're 20, you're gong to lose some of that when you get older-our bodies change!-and you'll have to find a new way to feel good in you skin. That's especially important if you have a baby, because I don't care how old you are-21, even-once you have a baby, your body will never be exactly the same again. Being comfortable with your body and touching your own body is so key to great sex.

PALACE: Unfortunately, too many women remain uncomfortable with masturbation.

DR. HUTCHERSON: That's true. Believe it or not, some of my patients-brilliant attorney, businesswomen, even doctors!-don't have a clue about how their clitoris works. I started asking my patients with sexual problems to look at themselves. Most would protest, "Oh, it's dirty, it's nasty down there." But you can't enjoy oral sex if you are worried about him being turned off by the taste. And if you don't know what turns you on, how can you expect someone else to know? Women often say, "He's supposed to know". Well, how?

What, besides getting comfortable with their bodies, can women do for their bodies, can women do for their health?

DR. JENNIFER BERMAN: We should all be aware of the fact that medications like birth control pills or antidepressants can lower libido. Also, fibroids, high blood pressure, endometriosis, yeast infections, just getting older are all potential problems.

DR. HUTCHERSON: I would say the number-one cause of sexual problems in young women are medications like birth control pills-they can cause vaginal dryness or a lowered sex drive. Women won't have a clue as to what's going on, why sex is suddenly painful. Their partners think they've become frigid, but all they need is a little water-based lubricant. And many women don't realize that antidepressants can hinder libido. Of course depression must be treated. It's a very serious condition. But women can have their cake and eat it too-SSRIs [a type of antidepressant] like Prozac can interfere with orgasm, but Wellbutrin, for example, can actually increase desire. There have also been studies that show Viagra helps women with depression who are taking SSRIs enjoy sex more. Any good doctor should be working with a woman to find the drug or combination of therapies that works best for her. There's no reason for anyone to throw their hands up and say, "Oh well, there's nothing we can do."

So what's the best piece of advice you give to your patients?

PALACE: I tell them not to have a candlelit dinner and wind down. You need to get revved up. Turn on an action-adventure flick. Have a pillow fight. Dance, exercise, laugh, take a walk. You want to give your body a jump-start, and increase your heart rate and blood flow. That's how you can get your body ready for sex.

DR. HUTCHERSON: Get a sex toy. Start with something that's not shaped like a penis, if that's inhibiting for you. Your partner can use it and feel like he's the one giving you pleasure, not the toy.

PALACE: Men like going from foreplay to orgasm to ordering a pizza. But it shouldn't be so regimented. I always say if you know you're having foreplay, you're doing it wrong. You should be in the moment. You can kiss, then feed strawberries to each other, then have intercourse, then give each other a massage and kiss. Sex does not have to end with his orgasm.

TIEFER: I tell women to never summarize a sexual encounter in a single word or sentence. People often say, "It was great." or, "It was lousy." That's not useful! It's better to try to get into what you expected, how did you conduct yourself, did you like what your partner did? How did it affect you? What will be different next time?

DR. HUTCHERSON: Women are starting to talk more with each other about sex. And we're learning that talking about sex can make our experiences different, and better, as soon as the next time.

Know These Doctors

JEANNE LEVENTHAL ALEXANDER, M.D., psychiatrist, founder and president of the Alexander Foundation for Women's Health (afwh.orf) in Berkeley, California

JENNIFER BERMAN, M.D., assistant professor of urology and director of the Female Sexual Medicine Center at UCLA

LAURA BERMAN, PH.D., sex therapist and founder of Chicago's Berman Center, which is devoted to women's sexual issues; and, yep, she's Jennifer's sister

HILDA HUTCHERSON, M.D., assistant professor of obstetrics and gynecology at Columbia University, author of What Your Mother Never Told You About S-E-X and Glamour contributor

EILEEN PALACE, PH.D., psychologist and associate professor of obstetrics and gynecology at Tulane University School of Medicine in New Orleans

LEONORE TIEFER, PH.D., sex therapist at New York University School of Medicine in New York City and author of Sex Is Not a Natural Act & Other Essays

BEVERLY WHIPPLE, PH.D., sex researcher and coauthor of The G Spot and Other Discoveries About Human Sexuality

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