More direct contact with the clitoris is possible from contact of pubis to pubis after the man has ejaculated and penile size is reduced, if the man maintains contact. The bodies are more closely approximated and the woman can move her pelvis on his at a rate that is most conducive to her orgasm. Breast stimulation, kissing, and clitoral stimulation during intercourse are other commons means of experiencing orgasm. Women are potentially multiorgasmic, capable of experiencing a number of orgasms close together during one sex response cycle and of resuming sexual activity without any refractory period.
Resolution Following the sudden release of sexual tension brought about by orgasm, women experience a feeling of relaxation and well-being. The gradual lessening of pelvic engorgement contrasts with the quicker loss of penile firmness in men. Nongenital changes that took place during arousal are reversed, and the body can return to a resting state after some 5 to 10 minutes. With further stimulation, the response can resume before or after this resting state is reached. As depicted in Figure 11.1, the cycle of response can be experienced a number of times during any given sexual encounter. Women who enjoy arousal without orgasm and without any sense that orgasm is very close but frustratingly absent report a similar sense of well-being and relaxation.
Numerous factors can affect sexual response (13,19,32–34). These factors include mood; age; relationship duration and quality; personal psychological factors stemming from relationships in childhood with parental figures; previous losses, traumas, and ways of coping with emotions; illness; and use of medication, alcohol, and illicit drugs.
Mental Health Studies find that mental health has the strongest links to women’s sexual function (4,17,35,36). Lack of mental well-being, even if it does not meet the criteria of a clinical diagnosis of mental disorder, is strongly linked to women’s symptoms of low desire (37). One study of women, where a diagnosis of clinical depression was excluded, showed a strong association between decreased sexual interest and self-reporting of negative emotional and psychological feelings, including low self-esteem, feelings of insecurity, and lost femininity (18). Impaired sexual desire is noted in most studies of women with depression, even before the administration of antidepressants with sexually negative side effects (35). Paradoxically, depressed women may masturbate more frequently than women who are not depressed, despite an increased prevalence of dyspareunia and difficulties with arousal and orgasm in partnered sex (38). Self-stimulation may cause calmness, relaxation, and improved sleep and in women is often not a consequence of sexual urge or desire.
Aging The degree to which aging itself, the marked changes in ovarian function associated with menopause, and the marked reduction of adrenal production of prohormones (importantly dehydroepiandrosterone [DHEA]) that can become estrogen and testosterone may affect women’s sexual response was addressed in large population studies. Some studies showned little increase in sexual problems with age, whereas in others almost 40% of the sample reported reductions in responsiveness and an increased desire for nongenital sexual expression (13,39,40). In one study, the prevalence of reduced desire increased significantly as a function of both menopause status and age, from 22% in the premenopausal group to 32% in the postmenopausal group (41). Low levels of desire were strongly associated with other sexual problems, including difficulties with arousal and orgasm. One large cohort of women studied over 10 years from perito postmenopause showed a decline in desire and responsiveness as a function of both age and menopause (42). The independent effect of menopause was indirect. The number of menopausal symptoms experienced inﬂuenced well-being, which in turn affected sexual responsiveness and sexual desire and interest.