Guidance for Women Seeking More Satisfying Sex

Treatment of sexual dysfunction in women is specific to the particular challenges a woman is experiencing, so we must truly understand her unique perspective. Also, a formal diagnosis isn’t always necessary to make helpful changes in a woman’s sexual functioning. Some options for treatment include:

• Psychotherapy. This includes individual and/or couple’s therapy based on interpersonal therapy (IPT) and cognitive behavioral therapy (CBT) techniques.
• Sex therapy.
• Pelvic floor physical therapy.This is typically used to treat sexual pain.
• Vibrator therapy. This is typically used for anorgasmia.
• Pharmacological treatments.

Psychotherapy for Sexual Dysfunction

If there's a lot of strain or conflict within a relationship, issues with a woman’s self-concept or body image following a major life transition, or a history of difficulty with communication in the relationship (“We never talk about sex anymore. We just pretend it’s not a problem"), we may consider interpersonal therapy (IPT), an evidence-based treatment for depression and other concerns.

Cognitive behavioral therapy (CBT) may be recommended when there is significant anxiety related to sexual functioning, such as performance anxiety (“What if I say the wrong thing and it turns him off?”) or negative partner-related expectations (“I know if I try to initiate sex, she will just turn me down" or “He doesn’t even seem attracted to me anymore, so he never initiates.”)

Sometimes, during sex, one or both partners can start monitoring or evaluating themselves and their performance, a behavior known as “spectatoring.” This shift in focus from current sensations to self-evaluation can negatively affect women’s experience, especially her subjective arousal or sense of being “turned on.”

Along with CBT, we may also recommend the addition of mindfulness, which allows us to focus our attention, without judgment, on the here and now: “What is happening in the present? What are these sensations? What am I feeling, what am I experiencing,” rather than “How am I performing? Am I doing this right? Are they enjoying themselves?”

Mindfulness can be practiced both in partnered sexual experiences and during self-exploration. Some research suggests sex therapy can help lower the non-concordance between subjective and physical arousal. Overall, mindfulness has been noted to improve sexual functioning, especially if mindfulness allows women to be in the moment with their sensations.

We can also combine techniques to investigate and intervene when identifying areas where excessive brakes may create roadblocks for sexual pleasure. Is the woman carrying a burdensome cognitive load for her family, such as remembering the minutia involved in day-to-day functioning, while also trying to manage her professional workload and childcare responsibilities? Could a redistribution between partners positively impact the couple's sexual activity? If her partner is highly motivated to improve their sex life, they may be willing to take on more tasks to help remove these brakes.

When Sex Therapy Is Recommended

When an assessment suggests a particular focus on the specifics of sexual functioning, sex therapy might be recommended. This therapy begins with a complete review of the individual’s (or couple’s) sexual history, from first experience to current functioning. The therapist seeks information about potential traumatic experiences, prior challenges to sexual functioning, and how external factors may affect sexual functioning.

An important goal of sex therapy involves identifying and creating a sex-positive context for women: low-stress, highly affectionate, and explicitly erotic, including some ways to trigger that responsive desire.

Within sex therapy, we also provide education to make positive changes. This may involve showing women the shape and location of a clitoris and discussing topics such as spontaneous and responsive desire, and physical and subjective arousal. Additionally, a discussion of the myths around female orgasm, as well as the research on the types of stimulation that most likely lead to climax, are important. Finally, encouraging women to explore their bodies to identify stimulating types of touch, or experiment with erotic materials, can be helpful.

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Masters and Johnson developed a particular technique called sensate focus therapy. Typically, this technique begins by assessing a couple’s current sexual functioning, and then, to lower the pressure on their relationship, telling them, “Okay, we're going to give you a hiatus from penetrative sex. So no intercourse as we begin your treatment.” We then ask them to experiment with different forms of touch, maybe bringing in different stimulating things, such as a feather or different toys, or a vibrator. Then, as this exploration occurs, they are encouraged to work on their communication, talking to each other while we experiment with some of these areas of touch, letting each other know what feels good.

The intercourse “ban” can be very helpful, creating relief for both partners. Maybe things have become so tense that whenever they move toward any physical intimacy, there can be some significant conflict or feelings of anxiety or concern. Pressing pause on intercourse, they can just begin re-exploring each other's bodies and figuring out, “What are the different things that are exciting for me?” Then, penetrative sex can be slowly reintroduced.

Interestingly, it's not all that uncommon to have couples return to session and say, “Ok, I know we weren't supposed to have sex this week. But we did, and it was good.” This shows how shifting the expectations or context can make a big difference.

Decreasing Pain During Intercourse

When women are experiencing genital pelvic pain, especially with any attempts at penetration, whether it’s a penis, a speculum, or even a small tampon, pelvic physical therapy (PT), paired with relaxation techniques, can be very helpful. Pelvic PT typically involves a controlled and gentle insertion of progressively larger dilators into the vagina while practicing relaxation imagery, deep breathing, and other calming strategies. This allows the mind and body to slowly adapt to stimulation in the vaginal area without spasms or pain.

Treating Primary and Secondary Anorgasmia

We may recommend vibrator therapy for women struggling to reach orgasm, either those who have never experienced this type of climax (primary anorgasmia) or who have previously had orgasms but for whom they are no longer occurring in a particular environment or relationship (secondary anorgasmia). By experimenting with a vibrator, either alone or with a partner, they can learn which sensations are most pleasurable and what type of stimulation time is best for them. They should try to incorporate the primary organ of female sexual pleasure, the clitoris, into their exploration.

Medications for Female Sexual Disorders

Despite public interest and a growing body of research, we do not have many pharmacological (medication) treatments for female sexual disorders.

• Oral hormone therapy (HT). Women in perimenopause and early menopause may begin hormone therapy to target significant symptoms associated with a biological decline in estrogen and progesterone. These include vasomotor symptoms such as night sweats, hot flashes, and vulvovaginal atrophy. HT may improve sexual functioning by increasing lubrication and decreasing pain during sex. Data has not found a consistent increase in libido with this treatment.
• Vaginal (topical) estrogen therapy. Some data suggest that topical estrogen cream can help improve lubrication and reduce pain without the systemic effects or risks that taking oral hormone therapy carries.
• Another option for sexual pain during intercourse is the selective estrogen receptor modulator Ospemifene (Osphena), an FDA-approved oral medication for women with vulvovaginal atrophy due to menopause.
• There are two FDA-approved medications for low sexual desire in premenopausal women: Flibanserin Addyi—a pill you take at night that can be sedating and interact significantly with alcohol, causing dizziness, nausea, fatigue, and fainting; and Bremelanotide (Vyleesi)—an injectable agent self-administered 45 minutes before sexual activity has been seen to cause significant nausea.
• Some data suggest that androgen therapy, including testosterone, may improve sexual dysfunction in women, but without robust long-term safety evidence, and no current FDA approval, its use is controversial.

Just a note: Using a high-quality lubricant is certainly recommended, even for people who aren't having sexual dysfunction and at all ages. This can really be a helpful way to make sex more pleasurable and less uncomfortable.

To find a therapist, visit the Psychology Today Therapy Directory.