Essentials of Female Sexual Dysfunction from a Sex Therapy Perspective

Linda E. Ohl, MSW, CSW, ACH


Urol Nurs. 2007;27(1):57-63. 

In This Article

Normal Female Sexual Function

Developing a basic understanding of what is considered "normal" is important in helping to determine at what stage a patient may be experiencing difficulties within the sexual response cycle.

What does the sexual response cycle look like in the healthy female? Masters and Johnson developed a model for normal sexual function in the 1960s, in their landmark publication, Human Sexual Response (Masters & Johnson, 1966), and that model is still in use to this day. In their system, there are four phases that women experience during a complete sexual encounter: excitement, plateau, orgasm, and resolution. There have been some modifications to the cycle suggested by others. Helen Singer Kaplan, for in stance, introduced the concept of "desire" into the response cycle (Kaplan, 1995), and Basson emphasized the importance of desire (Basson, 2001), but even in these modified systems, the basic Masters and Johnson system remains widely used.

The initial phase of the normal sexual response cycle is the excitement phase. During this time, a woman experiences physical changes in her body, such as swelling of the nipples and of the breasts. During this stage, she will have an increased respiratory rate, elevation of blood pressure, and vasocongestion of the pelvic organs. The woman may experience a skin flush due to increased blood flow to the skin, and may even note a rash on the chest, breasts, and face. Other signs that signify the excitement phase are increased size of the clitoral shaft and labia separation as blood flow increases. The labia may also have notable physical changes. The labia majora become flatter, thinner, and raise upward and outward. The labia minora may increase in size and may protrude from the labia majora, as blood flow increases.

The second stage in Masters and Johnson's sexual model is the plateau phase. This is a continuation of the excitement phase, although more intense at its peak. During the excitement phase, events are happening very fast, but during plateau, these changes are continuing to increase, although at a slower rate, until maximum excitement is reached. The plateau concept describes the woman reaching her peak level of physical excitement prior to orgasm occurring. The vasocongestive response is at its highest. There is continued myotonia, increased heart rate and blood pressure, and the clitoris retracts under its hood. It is at this point in time that many women need extensive clitoral stimulation in order to continue into the orgasmic phase.

This phase lasts anywhere from a few seconds to several minutes and is many times reported as the most intense. Feelings of desire are described as a sense of warmth and tingling in sexual regions, and a desire for further arousal is common.

During the orgasm phase, a several-second time period of very significant myotonia occurs, followed by an abrupt release, and rhythmic contractions of the perineal, bulbocavernosus, and pubococcygeus muscles (Bohlen, Held, Sanderson, & Ahlgren, 1982). The uterus contracts, as well as the rectal sphincter muscle. Collectively, these muscle contractions lead to perceived rhythmic tightening of the perivaginal muscles. These localized specific contractions may become generalized to the rest of the body, leading to a relatively involuntary spasm of skeletal muscle throughout the body. The time of tonic contraction at the beginning of orgasm is commonly described as when the most intense pleasurable feeling is noted.

The last phase of the sexual response cycle is the resolution phase. During resolution, there is a return of all the physiologic changes described previously to their normal basal state. Heart rate, blood pressure, and respiration return to normal minutes after orgasm. Muscles that were in a state of contraction become very relaxed, and many women describe their bodies as "limp." Women may describe their relaxation as a time of complete calm. Feeling of closeness to the partner may be at the maximum during resolution.

There is variation in an individual's sexual response cycle. Some women do not feel fully satisfied if all phases of sexual response are not experienced, while others may typically bypass phases. For instance, a woman who is highly orgasmic may pass very quickly from excitement to orgasm, without a discernible plateau phase. Some women with medical problems that limit lubrication may be able to proceed to orgasm without notable physical changes of the excitement and plateau phases. Many women who suffer from anorgasmia never reach the orgasm phase, but may still be quite satisfied with the total sexual experience. Sexual satisfaction is a subjective term and is solely determined by each individual. For many, feelings of closeness, bonding, touching, and intimacy are enough.

Women may also focus on their partners' needs, at the expense of their own sexual experience. This is partly due to the higher relative importance placed on achieving orgasm by men. A woman may choose to quietly wait for the partner to reach orgasm and abandon her own sexual needs.


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