Improve Your Clit IQ: and help your patients too!
We’ve all heard the jokes about the oh-so-mysterious clitoris. Here’s one:
“Women send Clitpics too…
…but men just can’t seem to find them”
Trust me, there are a million more out there, and they follow the same troupe - that the clitoris is elusive, hard to find, an unsolved mystery - and leave it at that. But what might be more helpful can be to improve education about anatomy and sexual function in all adults. So here are some tidbits I have picked up…
Ah, the clitoris. With 8,000 nerve endings, it is the only organ in the body whose sole purpose is pleasure. During the sexual arousal phase, for those who have a vulva, this happens:
Clitoral Tumescence: a vasodilation and increased blood flow leading to vasocongestion at around 3 minutes, with a peak at 9 minutes. The clitoris engorges by 50-300% and the labia 2-3x its resting size
Vaginal lubrication: Transudative lubricant production peaks during arousal
Vaginal elongation and uterine tenting
How can I help my patients who have pain with sex?
If caused by increased friction after the vaginal lubrication has peaked, recommending a longer-lasting lubricant with quality ingredients may be helpful
If there is pain with deep thrusting, advice about increasing the time for foreplay/stimulation, therefore increasing vaginal elongation prior to penetration, may help
Offer different position options to try for less depth (ex: penetration from behind in side-lying)
Discuss the option of using an Ohnut for restricting deep depth and possibly improve comfort
How do hormones affect things?
The clitoris is estrogen and testosterone dependent and both levels decrease with menopause, taking oral birth control, and early postpartum. In one study by Battaglia et al, women who took oral birth control had:
decreased estradiol, testosterone, free androgen, free estrogen, clitoral volume, orgasm frequency, number of episodes of intercourse/week
and
increased pain with sex, SHBG (sex hormone binding globulin, which decreases free androgen and estrogen utilization)
Having a hormonal assessment or vulvar work-up by a sexual medicine specialist may be greatly beneficial for improving imbalances
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Other things to consider:
Neurologic Control: Orgasm requires coordination of the sympathetic T12-L2 and parasympathetic S2-4 spinal areas and the somatic nervous system via the pudendal nerve S2-S4. Does the patient have any mobility restrictions at T12-L2?
Pelvic floor muscle contractions correlate with the intensity and duration of the orgasm - are they lacking in force generation of the pelvic floor muscles?
Are there orthopedic factors influencing sexual function, such as hip, low back, or SIJ pain?
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For pelvic health providers, when doing a subjective assessment, it can be difficult to narrow down what the biggest driver is for their complaints. Consider using the FSFI - Female Sex Function Index for your cisgender women patients, which is a 19-item, validated questionnaire assessing 6 domains:
>Desire
>Arousal
>Lubrication
>Orgasm
>Global and relationship satisfaction
>Pain
Using their answers you can improve the efficiency and specificity of your subjective assessment.
Build the O-team:
Pelvic health PT
Medical provider who is specialized in sexual health - check out the directory at ISSWSH (International Society for the Study of Women’s Sexual Medicine) for your local area
Mental health: certified AASCECT (American Association of Educators, Counselors, and Therapists) members
Pain management - if you are lucky enough to have providers specialize in pelvic health in your area
Resources to check out
Sex Without Pain: A Self-Treatment Guide to the Sex Life You Deserve by Heather Jeffcoat, DPT
Becoming Clitorate - Why Orgasm Equality Matters - And How To Get It by Laurie Mintz
Come As You Are: Revised and Updated: The Surprising New Science That Will TrNsform Your Sex Life By Emily Nagoski
She Comes First: The Thinking Man’s Guide to Pleasuring a Woman by Ian Kerner
ISSWSH directory: https://app.v1.statusplus.net/membership/provider/index?society=isswsh
AASECT directory: https://www.aasect.org/referral-directory
Ohnut: https://ohnut.co/
Reference:
Based, in part, on information learned by me from The Female Orgasm: Understanding Function to Better Treat Dysfunction by Health Jeffcoat, DPT; Pelvicon 2022.
Rosen R, Brown C, Heiman J, Leiblum S, Meston CM, Shabsigh R, Ferguson D, D’Agostino R., Jr The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. Journal of Sex & Marital Therapy. 2000;26:191–208.
Battaglia C, Morotti E, Persico N, Battaglia B, Busacchi P, Casadio P, Paradisi R, Venturoli S. Clitoral vascularization and sexual behavior in young patients treated with drospirenone-ethinyl estradiol or contraceptive vaginal ring: a prospective, randomized, pilot study. Journal of Sexual Medicine. 2014;11(2):471-480.
Disclaimer: These self-care suggestions are for general use only and are not intended to be used as medical advice, diagnosis, or treatment. Refer to your medical provider for all questions and concerns regarding your individual care.
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