Difficulty Reaching Orgasm in Women (Female Orgasmic Disorder)

"I've never had one. Is something wrong with me?" This is the question asked most quietly in the consulting room. I want to start with a fact that relieves many women: not reaching orgasm from penetration alone is normal for a great many women. It does not mean you are deficient or "not woman enough" in any way.

Facts worth knowing first

• A US national survey (Herbenick and colleagues, 2018) found that only about 18% of women said penetration alone was enough for orgasm. Most needed clitoral stimulation as well, or preferred it.
• The clitoris is highly sensitive. A 2023 study counted more than 10,000 nerve fibres in the main nerve of the clitoris, more than the figure of 8,000 that has been repeated for years.
• There is something called the "orgasm gap": in heterosexual couples, women reach orgasm clearly less often than men. Part of this comes from sex that centres on penetration, not from women's bodies working badly.

When is it called female orgasmic disorder?

Under the DSM-5-TR criteria (2022), female orgasmic disorder (FOD) means:

• orgasm is very delayed, infrequent or absent, or its intensity is greatly reduced
• this happens on almost all occasions of sexual activity (about 75–100%)
• it has lasted at least 6 months
• it causes clear distress
• it is not better explained by violence in the relationship, another mental health condition, or the effects of a medicine or physical illness alone

The doctor will also distinguish whether it is lifelong (never having had an orgasm) or acquired (it used to happen and has changed), and whether it is generalised or situational, for example being able to reach orgasm alone but not with a partner. These point to quite different treatments.

Normal

• No orgasm from penetration alone
• Clitoral stimulation also needed
• No orgasm but enjoying sex and not distressed

Female orgasmic disorder

• Very delayed, infrequent or absent orgasm
• Almost every time (about 75-100%)
• Lasting at least 6 months
• Causing clear distress

vs

Herbenick et al. (2018): only about 18% reach orgasm from penetration alone.

Common causes

Physical and medication factors

• SSRI/SNRI antidepressants are a very common cause of acquired difficulty with orgasm. Read antidepressants and sex
• Hormonal changes, menopause, dryness or pain. Read vaginal dryness
• Diabetes, neurological conditions, pelvic surgery, heavy alcohol use

Psychological factors

• Repetitive thoughts during sex, such as worrying about your body, fearing you are taking too long, or watching yourself to see whether you are "nearly there" (spectatoring)
• Stress, depression, anxiety
• Beliefs that touching yourself is wrong, so you have never learned about your own body

Relationship factors

• Not feeling able to tell your partner what you like, or a partner who does not pay attention
• Short foreplay, a focus on penetration, and sex ending when the man finishes
• Conflict or lack of trust that makes it hard to let go

Evidence-based approaches

1. Directed self-exploration (directed masturbation) is well supported for women who have never reached orgasm. It is structured, step-by-step practice, starting with getting to know your body and moving on to discovering what kind of touch feels good. Once you know, you can share it with your partner. Read sex toys and masturbation, safely.
2. Vibrators or air-pulse devices make clitoral stimulation more consistent. They can be used alone or with a partner. They are not "competition" for your partner, just an aid.
3. Mindfulness helps bring your attention back to present sensations instead of looping thoughts. Read mindfulness and sex.
4. Sex therapy and couples therapy: practising communication and using sensate focus exercises to reduce pressure.
5. Reviewing medicines: if it started after an antidepressant, the doctor may consider adjusting the dose, changing the drug or adding another medicine. Never stop the medicine yourself.
6. Treating other conditions, such as dryness, pain or menopausal symptoms.

1. 1Learn your bodyDirected masturbation, practised step by step
2. 2Use aidsVibrating or air-pulse devices give steady stimulation
3. 3Practise mindfulnessBring attention back to what you feel now
4. 4Share with your partnerCommunicate and practise sensate focus
5. 5Review medicines and conditionsWith your doctor; never stop medicines yourself

No medicine is approved specifically for this condition.

Small things you can try straight away

• Allow more time for foreplay, and do not set orgasm as a goal.
• Tell your partner, in words or by guiding their hand, where and how firmly.
• Use a lubricant to reduce friction.
• Try positions that allow clitoral stimulation during penetration, or let yourself control the pace.

When to see a doctor

If this causes you distress or affects your relationship, if it started after a new medicine, surgery or with a long-term condition, or if there is also pain, it deserves an assessment. At Dr. Kris Clinic, I talk with you privately and without judgement, work through the causes layer by layer and make a plan that suits you. You can come alone or with your partner, and English-speaking consultations are available in person or online.