Illustration by Katrin Friedmann
The science of sexual satisfaction
A happy sex life is an important part of a fulfilling life.
What a happy sex life means is subjective, as our sexual desires, expectations and needs differ from one another and change as we grow and age. Some people want to have sex daily, while other people are content never having sex throughout their lifetime.
The subjectivity of sexual satisfaction is an important consideration in research and diagnosis of sexual dysfunction. On the World Health Organization (WHO) quality of life survey, the four questions that ask about participant's sex lives are all subjective (1). Relatedly, although about 4 out of 10 women report some sort of sexual dysfunction, a little more than 1 out of 10 report that their sexual dysfunction is negatively impacting their lives (2–5), suggesting that a satisfying sex life doesn't mean a "perfect" sex life.
Despite this subjectivity, there are biological, psychological, physical, relational and socio-environmental factors that can positively or negatively affect our sex life. Some of these factors are modifiable, while others, like aging, are not (2–4). Regardless of how much control we exert over these factors, understanding that our sexual function isn't always 100% under our conscious-influence may reduce stigma and encourage people to discuss their sexual health concerns with their healthcare providers.
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Sexual anatomy and sexual pleasure
Our understanding of the female reproductive system as it relates to sexual enjoyment is incomplete. There is generally agreement that stimulation of the clitoris and nerve endings within the female reproductive system can lead to pleasure and orgasm, but scientists debate the existence and location of the Gräfenberg spot, better known as the "G-spot" (6–8).
There are few explanations for the G-spot. Researchers have suggested that the G-spot is a cluster of nerve endings connected to the pudendal nerve or is a highly sensitive area that triggers sensation within the vagina, for the clitoris and within the urethra (6,7). Alternatively, because the clitoris can move during arousal and sex, some scientists suggest that the G-spot is actually part of the clitoris or the clitoris is able to be stimulated during penetrative sex due to its movement (6). Given that nerve and muscular sensitivities may and probably do differ among most women, the G-spot may not be located in the same place or exist in every woman (6, 7).
Similarly, given the differences in physical sensitivities to touch and stimulation, a person may be sexually stimulated by interaction with parts of their body other than their genitals.
Categories of sexual function
Researchers and health care professional usually divide sexual complaints into four main categories:
Desire, which refers to interest in sex
Arousal, which refers to the physical changes, such as lubrication, and emotional changes people experience when thinking or participating in sex
Orgasm/satisfaction
Physical pain (2, 4–6)
Depending on the research, the categories may become more specific. For example, researchers examining physical pain associated with sex are usually interested in the specific location and onset of pain (6), as knowing more specific information can lead to better treatment or better understanding of the underlying cause.
Given how common sexual dysfunction is reported (about 4 in 10 women), a diagnosis of having sexual dysfunction disorder requires that the dysfunction seriously impacts a person's quality of life (2).
Biological factors
Age influences a strong effect on our sexual life (2–5, 7–9). As people age, they begin to report more sexual dysfunction, particularly as they experience perimenopause, or the transition, and menopause (2–5, 7–9). This increase in sexual dysfunction is most likely related to not just changing hormones but also worsening health (2–5, 7–9).
Age doesn't necessarily worsen all aspects of sexual function. For example, in study of over 2,600 Iranian women, women ages 50–60 were almost five times more likely to experience arousal dysfunction as compared to women ages 20–29 (5). However, in this same study, women ages 50–60 were only about half as likely to report a pain dysfunction as compared to women ages 20–29 (5). These results may be affected by socio-cultural differences among age groups, but they may also represent positive changes to the body that occur with age.
The menstrual cycle may also affect a person's sex life. In a study of 43 heterosexual women, researchers found that as the hormone progesterone increased in saliva samples, participants reported that their sexual desire for their partners decreased (10). This result makes some biological sense, because progesterone levels increase after ovulation and during a time it is highly unlikely for sex to lead to a pregnancy, so a person's body may not be as attuned towards having sex as during other parts of their cycle.
Psychological, physical and pharmaceutical factors
There are many known psychological, physical and pharmaceutical factors that affect sexual function. These include:
Injury to the nervous system (ex. spine)
Injury to the reproductive system
Depression
Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs)
Surgery on reproductive organs, such as a hysterectomy
Diabetes
Urinary incontinence
Endometriosis
Cardiovascular disease
Hypertension
Obesity and large waist circumference
Hormonal birth control
Physical activity (2, 4, 6, 9, 11–16, 20–22)
Some factors that negatively affect sexual function are not modifiable, but some can be addressed with behavioral changes or the help of a health care provider. For example, some antidepressants affect sexual function less than others, and getting treatment for depression can improve sexual dysfunction despite SSRI use (17, 18). Similarly, certain treatments for endometriosis has been shown to decrease sexual dysfunction caused by the conditions, while others are less effective (19).
Higher amounts of physical activity been shown to positively affect sexual function (5, 12, 13). In a study of diabetic women, each Metabolic Equivalent of Task (MET) significantly decreased the risk of female sexual dysfunction by 9% (13). Similarly, in the same study of Iranian women mentioned previously, people who reported exercising several times per week were twice as likely to report female sexual dysfunction than those that reported daily exercise (5). Those who reported rarely/never exercising were three times more likely to report female sexual dysfunction (5).
Hormonal birth control
Researchers debate whether hormonal birth control is associated with decreased sexual interest, but this doesn't seem to be true for most people (20–22).
In a review on the relationship between sexual dysfunction and hormonal birth control, about 15% of combined oral contraceptive users reported negative sexual effects from their birth control, and this effect was primarily related to pills with lower doses of estrogen. Most people reported no change in sexual function, positive or negative (20).
For some people, the protection from pregnancy provided by hormonal birth control may improve their sexual experience by presenting them more peace of mind.
In a randomized control trial, women prescribed either a combined oral contraceptive or hormonal vaginal ring reported improved sexual functioning in multiple categories as compared to women not on hormonal birth control after three and six months of use (21). Women on either contraceptive reported statistically less anxiousness while also reporting statistically more initiative, orgasms and orgasm intensity as compared to women not using hormonal birth control (21).
Some studies have found opposite results, though the results are less clear. In a study of over 1,000 women, researchers found that hormonal birth control users were statistically more likely to report negative sexual functions, including fewer orgasms and decreased arousal; however, the authors did not report the size of the differences between these categories when adjusted for important secondary factors, like age or whether the participant had a steady sexual partner, making it difficult to assess the extent of the change in light of other factors (22).
External factors
External factors, such as personal history or partner factors, can also influence a person's sex life. These influences can be direct or mediated by factors such as depression or general health.
A history of abuse has been shown to be negatively associated with sexual function, though not for all women (4, 12, 23, 24). In one study, women who were sexual abused as children were more likely to report negative responses when discussing their sexuality or during arousal (23). Conversely, sexual assault, regardless of the gender of the attacker, was not found to be related to sexual dysfunction in one study of women who have sex with women (WSW), despite the fact that WSW are 2 to 3 times more likely to have been assaulted as compared to heterosexual women (24).
A person's partner has a strong influence on their sexual experience
In the same study of Iranian women, more than 7 out of 10 women with sexual dysfunction reported that the cause of their dysfunction was related to interpersonal problems with their partner. More than 8 out of 10 reported that their dysfunction was caused by their partner's sexual capabilities (5). Similarly, a study of Italian heterosexual women with sexual dysfunction found that the interest of a woman's partner might more strongly affect her sexuality than any of her partner's sexual dysfunction (25).
Women who have sex with women (WSW) sometimes experience different sexual effects than those who have sex with men. One study of over 1,500 WSW found many factors associated with sexual dysfunction, such as age, diabetes and menopausal status, were not related to sexual dysfunction (24). Although it's possible that WSW somehow experience different physiological responses to these factors, the authors suggest that WSW participate in different forms of sex as compared to women who have sex with men, and these sexual activities are less affected by the side effects of diabetes or menopause (25). This idea underscores the subjectivity of sexual dysfunction research, and emphasizes that sexual dysfunction does not necessarily mean sexual dissatisfaction.
If you're unhappy with your sexual function, consider reaching out to your healthcare provider. Sexual dysfunction is common, and it's normal for a person to experience changes to their sexual function through their life.
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