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https://doi.org/10.1007/s13178-021-00618-2
The Influence ofTypes ofStimulation andAttitudes toClitoral
Self‑stimulation onFemale Sexual andOrgasm Satisfaction:
aCross‑sectional Study
MaditaHoy1 · KatharinavanStein1· BernhardStrauss1· KatjaBrenk‑Franz1
Accepted: 5 July 2021
© The Author(s) 2021
Abstract
Introduction Societal assumptions and individual myths that define vaginal penetration as normal sexuality can affect the
sexual pleasure of varied sexual activities. Although women orgasm much more easily through direct clitoral stimulation
than through vaginal intercourse, many couples desire the latter. The purpose of this study is to investigate how orgasms
from different types of stimulation with a partner affect sexual satisfaction and orgasm satisfaction in cisgender women. Also,
the attitude of women to stimulate their clitoris themselves to reach orgasm during sex with their partner will be included.
Methods Two independent surveys (N = 388 and N = 555) were conducted online in 2016 and 2020.
Results Regression analyses showed that orgasm consistency through sexual intercourse had a stronger influence on orgasm
satisfaction and sexual satisfaction than orgasm consistency through oral sex, stimulation by the partner’s hand, or self-
stimulation. Positive thoughts and feelings about self-stimulation of the clitoris during sex with the partner showed only
little effect, but in some cases, they were even negatively related to the reported satisfaction.
Conclusions The results indicate that the common misconception about sexuality, that it is normal for women to experi-
ence orgasms during penile-vaginal intercourse, influences the subjective evaluation of one’s own sexuality. Orgasms from
clitoral stimulation seem to have a second-class quality for some women, although there is no evidence that these orgasms
feel like less pleasureable.
Policy Implication Rigid assumptions about what normal sexuality should look like should be publicly addressed and dis-
cussed in sex education classes.
Keywords Female orgasm· Clitoral stimulation· Intercourse· Self-stimulation· Oral sex
Introduction
The female orgasm is a complex experience with emo-
tional, mental, and physical components (Bentler & Peeler,
1979). The variability of orgasmic experience ranges
widely, following that the description of a typical pat-
tern of female orgasm may oversimplify the phenomenon
(Mah & Binik, 2001). In addition to different sensations,
subjective evaluations and the significance of one’s own
orgasm can also vary significantly. Therefore, personal,
interpersonal, and sociocultural factors can be relevant
(Séguin & Blais, 2019). Often, the orgasm is seen as a
goal of sexual activity (Lavie-Ajayi & Joffe, 2009). Mes-
sages about the importance of orgasm can cause distress
and pressure to perform (Graham, 2010). Accordingly, the
subjective needs and feeling of sexual satisfaction should
be the focus rather than social norms about sexuality. For
this reason, this work focuses on sexual satisfaction and
orgasm satisfaction in dependence from orgasm consisten-
cies from different types of stimulation as well as attitudes
toward clitoral self-stimulation during partnered sexual
encounters.
The female orgasm can be important for the sexual sat-
isfaction of women (Leonhardt etal., 2018). For example,
sexually satisfied women in long-term relationships reported
a higher orgasm consistency (78%) than sexually unsatis-
fied women (41%), with the length of relationship having
* Madita Hoy
madita.hoy@med.uni-jena.de
1 Institute ofPsychosocial Medicine, Psychotherapy
andPsycho-Oncology, Jena University Hospital, Jena,
Germany
/ Published online: 21 July 2021
Sexuality Research and Social Policy (2022) 19:1205–1216
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1 3
an increasing effect on orgasm consistency (Frederick etal.,
2017). For most women, satisfaction with sex life is more
related to sexual intercourse than to masturbation or petting
(Philippsohn & Hartmann, 2009). Nevertheless, in average,
women reported vaginal penetration as less satisfying than
men, unless clitoral stimulation is included (Blair etal.,
2017). However, while for some women orgasm is a key fac-
tor for sexual satisfaction, for others, emotional aspects, such
as emotional closeness to a partner or feeling safe, may be
more relevant (McClelland, 2014). Although there is a sub-
stantial overlap between the constructs, sexual satisfaction is
more than satisfaction with intercourse or satisfaction with
orgasms. It includes personal experiences and sensations,
partner’s behaviors, and sexual activity in general (Stulhofer
etal., 2010). Therefore, sexual satisfaction can also be high
without experiencing orgasms (Philippsohn & Hartmann,
2009) or even without sexual activity (Matthias etal., 1997).
Whether women experience orgasms depends mainly
on the type of sexual activity (Andrejek & Fetner, 2019).
Direct stimulation of the clitoris improves the regularity of
experienced orgasms, called orgasm consistency and orgasm
quality (Herbenick etal., 2018). During sexual intercourse
without direct clitoral stimulation, only about one-third
of all females experience an orgasm (Prause etal., 2016).
In contrast, during masturbation, 59% of women usually
experienced an orgasm (Dunn etal., 2005). Approximately
14% of female participants have never had an orgasm or
are unsure if they had one (Dunn etal., 2005; Prause etal.,
2016). Moreover, there is a negative trend for young women
(under the age of 35) to experience orgasms during inter-
course. Large representative surveys from Finland showed
that in 1999, 53% of the women reported regularly achieving
orgasm during penile vaginal intercourse (PVI). In 2007,
this number decreased to 42% and in 2015 to 38% (Kontula
& Miettinen, 2016). Whether direct clitoral stimulation was
used during PVI was not differentiated.
When women report orgasm difficulties, they usually
mean that they cannot reach orgasm during intercourse
(Lavie-Ajayi & Joffe, 2009). There have been myths about
the difference between clitoral and vaginal orgasm for a
long time. For example, it is a common misconception that
it is normal for women to orgasm during sexual intercourse
without clitoral stimulation (Ejder Apay etal., 2013).
Discussions distinguishing between vaginal and clitoral
orgasms are also common in media, such as women’s maga-
zines (Lavie-Ajayi & Joffe, 2009). There are deeply inter-
nalized assumptions that penile-vaginal intercourse is the
normal, natural way to have sex and therefore women should
experience orgasms in this way (Jackson, 1984). Female
orgasms can be created by different types of stimulation,
but the distinction between vaginal and clitoral orgasms is
outdated: The clitoris consists not only of the visible clito-
ris glans, but also of the clitoris bulbs next to the vaginal
walls. Erectile tissue stretches into the vaginal opening and
overlaps with other areas of heightened sexual responsive-
ness such as the G-spot (Blechner, 2017; O’connell etal.,
2008). There is no clarity if the G-spot is an anatomically
distinct area (Blechner, 2017). While approximately half
of all women report to have a G-spot, there are no hints for
genetical factors for the self-reporting of the presence of
this area (Burri etal., 2009).
So, during vaginal penetration, underlying parts of
the clitoris are stimulated. Most women report that they
use clitoral and vaginal stimulation to experience orgasm
(Prause etal., 2016). The subjective perception of an orgasm
can differ depending on whether an orgasm is reached by
vaginal or clitoral stimulation. Most women distinguish
between types of stimulation rather than based on qualita-
tive sensations (Lehmann etal., 2004). Whether orgasms
from vaginal penetration or clitoral stimulation feel better
may vary between women. In a large twin study analyz-
ing influences of self-reported aspects of the G-spot, it was
found that even when women reported having a G-spot and
experienced orgasms from vaginal penetration, many women
preferred orgasms from clitoral stimulation based on quality
of sensations (Burri etal., 2009). Other studies showed no
reported differences in the quality of orgasms from vagi-
nal and clitoral stimulation (Lehmann etal., 2004; Prause
etal., 2016). However, orgasms through vaginal penetra-
tion are stronger correlated with partnered sexual satisfac-
tion (Lehmann etal., 2004). In contrast, orgasm consistency
through clitoral stimulation is related to more sexual desire
and higher sexual arousal (Prause etal., 2016). Unrelated to
the type of stimulation, women who orgasm more frequently
reported a higher awareness of their bodily sensations, more
erotic fantasies during intercourse, more variation in their
sexual behavior (de Sutter etal., 2014), and higher emotional
intimacy (Mah & Binik, 2005). Many women who have dif-
ficulties experiencing an orgasm report psychological strain
and low satisfaction with their sexual relationship (Rowland
& Kolba, 2016). A low orgasm frequency is related to cog-
nitive distraction, e.g., automatic thoughts (Tavares etal.,
2017), suppression of erotic thoughts, pressure to perform
(Cuntim & Nobre, 2011), and sexual myths (Philippsohn
etal., 2003).
The presence of sexual myths and sexual pressure to per-
form indicates a strong expectation to experience orgasms
during sexual intercourse. Mainstream pornographic vid-
eos support this, showing female orgasm most commonly
through penetration without additional clitoral stimulation
(Séguin etal., 2018). Romantic novels promote a picture of
women, who orgasm fast and high frequently, which can feed
unrealistic expectations about one’s own sexuality (Cabrera
& Ménard, 2013). Traditional sex roles, like female pas-
sivity and male agency, are also promoted in these novels
(Cabrera & Ménard, 2013). Factors like these can cause
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1 3
heteronormative scripts, which place sexual intercourse in
the center of sexuality. These can hinder women’s orgasm,
because women are more likely to orgasm if the sexual
behavior is diversified (Willis etal., 2018). Women in same-
sex relationships reported a higher orgasm frequency and
satisfaction from partnered clitoral stimulation than women
in mixed-sex relationships (Blair etal., 2017).
Current Study
The fact that the orgasmic consistency of women is strongly
dependent on the type of stimulation was shown in several
studies. This study is more focused on the subjective per-
ception of orgasms and aims to investigate how sexual sat-
isfaction is related to orgasms created by different types of
stimulation. Sexual and orgasm satisfaction should be more
important than the mere frequency of orgasms or sexual
intercourse. Which factors are decisive for women in this
respect were rarely investigated. Also, this study aims to
find out how personal responsibility for one`s own orgasm
affects satisfaction. Therefore, self-stimulation during sexual
encounters will also be investigated. While masturbation in
women can enhance a sense of sexual empowerment, mean-
ing to feel strong, sexy, independent, and satisfied (Bowman,
2014), there is no evidence yet of how self-stimulation dur-
ing sex with a partner affects sexual satisfaction. A better
understanding of factors that influence satisfaction can be
helpful in sexual counseling to develop strategies with cli-
ents that promote a pleasurable sexuality.
The subjective importance women connect with the
experience of orgasms seems to be influenced by many
factors. The current study will investigate whether
orgasms by several types of stimulation in partnered sexu-
ality (PVI, PVI and direct clitoral stimulation, stimulation
by the partner’s hand, oral sex, and self-stimulation of the
clitoris during sex with a partner) are particularly relevant
for sexual satisfaction and orgasm satisfaction. In addition,
cognitive and affective aspects of clitoral self-stimulation
should be emphasized. Furthermore, a distinction should
be made between orgasm satisfaction and the broader con-
struct of sexual satisfaction. By focusing on the experi-
ence of orgasm through vaginal and clitoral stimulation,
this study is related to the sensations of cisgender women
with heterosexual experiences including PVI. In addition,
the study will be run in a second, independent sample to
validate the results.
In summary, the following questions can be derived:
To what extent are orgasmic satisfaction and sexual satis-
faction influenced by orgasmic consistency across different
types of stimulation (PVI, PVI and direct clitoral stimula-
tion, stimulation by the partner’s hand, oral sex and self-
stimulation of the clitoris during sex with a partner)?
To what extent are orgasmic satisfaction and sexual satis-
faction influenced by affective and cognitive attitudes toward
self-stimulation of the clitoris during sex with a partner?
Methods
We performed two cross-sectional online surveys in Ger-
many via SoSciSurvey.com (Leiner, 2014). The platform
offers high data privacy standards, providing optimal pro-
tection of the privacy of our proband. Data for sample 1 were
collected from Aug 2016 to Oct 2016. Four hundred twelve
cisgender women completed the survey. Some women were
excluded from analyses because they had never had sex with
a partner. Also, datasets were scanned for meaningless data,
those created very fast, straight, or weird. For this purpose,
SoSciSurvey provides the relative speed index (RSI), and we
excluded datasets with a RSI with a value of 2.0 and above
(Leiner, 2019). Since all questions had to be answered, there
was no missing data. The final sample included 388 cisgen-
der women. Data of sample two were collected from Aug
2020 to Sept 2020. The second survey was completed by 574
women. The same exclusion criteria as in the first survey
were applied. Five hundred fifty-five cisgender women were
included in the analyses.
The links to the anonymous studies were shared online.
They were spread via internet forums, student mailing
lists, and by snowballing methods. No financial incentive
was provided. Criteria for inclusion in the studies were
being at least 18years old and identifying oneself as a
cisgender woman. Exclusion criteria were insufficient Ger-
man language skills and the lack of informed consent. The
studies received ethical approval from the Ethics Com-
mittee of the University Hospital Jena, and we agree with
the terms of good clinical practice and the declaration of
Helsinki.
Measurements
Sociodemographic variables were collected, including age,
sex, education, sexual orientation, and relationship. Partici-
pants were also asked about the frequency of sexual activi-
ties, like masturbation, and partnered sexual activities.
NSSS
The New Sexual Satisfaction Scale (NSSS) (Stulhofer etal.,
2010) is an internationally established questionnaire for
assessing sexual satisfaction. The short version, which was
used in this study, comprises 12 items. The NSSS covers
different dimensions of sexual satisfaction. These include
individual aspects such as factors of sexual function and
partner-related aspects like partner creativity. The internal
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1 3
consistency for the German version is excellent (α = 0.96)
(Hoy etal., 2019). Internal consistency in the study samples
was α = 0.92 in sample 1 and α = 0.96 in sample 2. All items
were recorded on a five-point Likert scale ranging from
1 (not satisfied at all) to 5 (very satisfied). Higher scores
reflected higher satisfaction with one’s sex life.
FOS
The Female Orgasm Scale (FOS) (McIntyre-Smith &
Fisher, 2011b) assesses the consistency of orgasm depend-
ing on different types of stimulation (PVI, PVI and direct
clitoral stimulation, stimulation by the partner’s hand, oral
sex, and self-stimulation of the clitoris during sex with a
partner), as well as satisfaction with frequency and qual-
ity of orgasms. Five items assess how often an orgasm is
reached during specific sexual activities (e.g. “How often
do you have an orgasm from vaginal penetration only (no
direct clitoral stimulation) during intercourse with a partner?
Please indicate what percentage of the time on a 0–100%
scale”). A rating is applied in 10% steps, so the results are
between 0 and 10. There is one additional option per item
that allows participants to indicate that no such activity was
experienced. The authors suggest, depending on the focus
of the research question, to count this category either as
missing or as zero (no orgasms by this type of stimulation).
For the presented analyses, the second option was chosen
because the openness towards different types of stimulation
was also of interest, and this is also expressed at the behav-
ioral level. Two additional items were included to meas-
ure satisfaction with frequency and quality of orgasms on a
7-point scale ranging from very satisfied to very unsatisfied.
The original FOS was generated across three studies using
different samples and choosing items with the best psycho-
metric properties, resulting in good reliability and validity.
Internal consistency was good in all three studies for the
total scale (α = 0.84–0.86) and both subscales “Orgasm from
Clitoral Stimulation” (α = 0.81–0.82) and “Satisfaction with
Orgasm” (α = 0.72–0.90) (McIntyre-Smith & Fisher, 2011b).
“Orgasms from Vaginal Penetration” was only assessed by a
single item. Since the aim of the study is to focus on specific
types of stimulation, single items were also used to assess
orgasm consistency through different types of clitoral stimu-
lation. Internal consistency for “Satisfaction with Orgasm”
in the study samples were α = 0.88 in sample 1 and α = 0.89
in sample 2.
CSSS
The Clitoral Self-Stimulation Scale (CSSS) assesses
behavior, attitudes, and affects concerning clitoral self-
stimulation during sexual intercourse with a partner. The
scale includes six items (McIntyre-Smith & Fisher, 2011a).
The psychometric properties were mostly good: Internal
consistency of the total scale was good (α = 0.82–0.86), but
there were mixed results for the subscales (α = 0.59–0.86).
Also, the German version of the CSSS showed inconsist-
encies within the subscales. Therefore, we refer to sin-
gle items. Three positive poled items of the scale were
included in the analyses. Two items of the subscale “Atti-
tudes Towards Clitoral Self-Stimulation” (e.g., “Stimulat-
ing myself (i.e., massaging my genitals/clitoris) to help me
have an orgasm during intercourse with a partner would be:
important” or “good”). One item of the subscale “Affective
Reactions to Clitoral Self-Stimulation” (e.g., “Stimulating
myself (i.e., massaging my genitals/ clitoris) to help me
have an orgasm during intercourse with a partner would
be: exciting”) was included. Other items were not included
because of ceiling effects in the data or redundance with
the FOS.
Statistical Analysis
All analyses were conducted using IBM SPSS (version 23.0)
for Windows. The samples were analyzed for differences
in sociodemographic variables using T-tests for independ-
ent samples. Multiple linear regressions were assessed to
predict orgasm satisfaction and sexual satisfaction. The
assumptions for regression were tested, using the variance
inflation factors (VIFs), Durbin-Watson statistic, histograms,
and residual-vs-fitted diagrams. The results confirmed that
the variables were suitable for regression analysis.
All regression models were tested in both samples. The
same predictors were included in each model. This involved
orgasmic consistency by different types of stimulation (PVI,
PVI and direct clitoral stimulation, stimulation by the part-
ner’s hand, oral sex and self-stimulation of the clitoris dur-
ing sex with a partner). In addition, positive attitudes and
affections toward clitoral self-stimulation during partnered
sexuality were included as predictors in the model, indicat-
ing whether it was perceived as good, important, and excit-
ing. Age and relationship status were included as control
variables. The models were calculated in two independent
samples. Moreover, we used a hierarchical approach to
investigate which predictors might be responsible for shared
variance. In a first step, regressions were calculated with the
control variables, and in a second step, the attitudes toward
clitoral self-stimulation were added. Additionally, a cross-
validation of the model from sample one was performed
on the second sample. Therefore, the regression coefficients
from sample 1 were used to predict orgasm satisfaction and
sexual satisfaction in sample 2. The explanation of the vari-
ance of the predicted values in relation to the true values was
verified by regression analysis. For all analyses, the alpha
error threshold was set to 5%.
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Results
Participant Characteristics
The first sample consisted of 388 women ranging in age
between 18 and 58 (M = 27.48, SD = 8.02). Approxi-
mately half of the participants indicated to be currently
in a relationship. The level of education was high with
93% (N = 361) having achieved A-levels or specialized
A-levels, which corresponds to a school education of at
least 12years.
The second sample consisted of 555 women ranging in
age between 18 and 60 (M = 25.46, SD = 6.12). A total of
71.7% (N = 398) were in a relationship. A total of 91.7%
(N = 509) of the participants had a high level of education.
The orgasmic consistency for vaginal penetration was
2.6 in study 1 and 2.5 in study 2, meaning that women
experienced orgasm on average approximately 25% of the
time. The number of orgasms caused by clitoral stimu-
lation was more than twice as likely. A total of 40.2%
(N = 156) in sample 1 and 40.0% (N = 222) in sample 2
never achieved orgasm through penetration without direct
clitoral stimulation. For clitoral stimulation in sample 1
8.2% (N = 32) and in sample 2 4% (N = 22) of the women
reported to never reach orgasm. Further sample descrip-
tions can be found in Table1.
The samples differ with respect to some sociodemo-
graphic factors. The first sample was older (t(941) = 4.40,
p < 0.01) and the second sample had more women in partner-
ships (t(941) = − 5.97, p < 0.01). There were no significant
differences in sexual orientation (t(941) = 0.43, p = 0.67).
Predictors ofSatisfaction withOrgasms
A multiple regression was run to predict satisfaction with
orgasm from orgasm consistency via different stimula-
tion types and attitude and emotion toward clitoral self-
stimulation during partnered sexuality. The multiple
linear regression model (Table2) explains 30.2% of the
variance of the variable orgasm satisfaction in sample 1
and 35.4% in sample 2. Orgasmic consistency by PVI,
PVI and direct clitoral stimulation, and stimulation by
the partner’s hand indicated orgasm satisfaction in both
samples. Self-stimulation of the clitoris during sex with
a partner was only a significant predictor in sample 1.
Orgasmic consistency due to oral sex was not a signifi-
cant predictor. A negative predictor was to consider clito-
ral stimulation during sex as important. There was no
significant effect of perceiving self-stimulation as good
or exciting.
Additionally, we tested hierarchical effects. Therefore,
one regression was run with age and relationship status as
predictors for orgasm satisfaction, showing low explained
variance in sample one (F(2) = 3.50, p = 0.31, R2 = 0.02)
and sample 2 (F(2) = 9.01, p = < 0.01, R2 = 0.03). In a
second step considering self-stimulation of the clitoris as
good, important and exiting were added. The explained
variance remained low in sample 1 (F(5) = 3.99, p < 0.01.;
R2 = 0.05) and sample 2 (F(5) = 4.99, p < 0.01.; R2 = 0.04).
Predictors ofSexual Satisfaction
The multiple linear regression model to predict sexual
satisfaction was able to resolve 21.6% of the variance in
sample 1 and 16.5% of the variance in sample 2 (Table3).
Several variables could make a significant contribution to
the explanation of variance. Orgasmic consistency by PVI
without additional clitoral stimulation was found to predict
sexual satisfaction in both samples. In sample 1, orgasm
consistency due to stimulation by the partner’s hand and to
consider clitoral self-stimulation as exciting was also sig-
nificant predictors. In sample 2, orgasm consistency due to
PVI and direct clitoral stimulation and oral stimulation was
significant predictors, whereas considering self-stimulation
of the clitoris as important was a negative predictor.
Table 1 Characteristics of the study samples
Sample 1 Sample 2
N (%) N (%)
Age
< 19 18 (4.6) 37 (6.7)
20–29 269 (69.3) 423 (76.2)
30–39 69 (17.8) 76 (13.7)
40–49 18 (4.6) 13 (2.3)
50–60 14 (3.6) 6 (1.1)
Relationship
Yes 206 (53.1) 398 (71.7)
No 182 (46.9) 157 (28.3)
Heterosexual 302 (77.8) 460 (82.9)
Bisexual 78 (20.1) 75 (13.5)
Homosexual 8 (2.1) 9 (1.6)
Other – 11 (2.0)
Frequency of sexual activity (last year)
At least weakly 211 (54.4) 334 (60.2)
1–2 × per month 94 (24.2) 143 (25.8)
< Once per month 54 (13.9) 53 (9.6)
No sexual intercourse 29 (7.5) 25 (4.5)
Frequency of masturbation (last year)
At least weakly 160 (41.2) 292 (52.6)
1–2 × per month 108 (27.8) 163 (29.4)
< Once per month 80 (20.6) 72 (13.0)
Not at all 40 (10.3) 28 (5.1)
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1 3
Also, for sexual satisfaction, hierarchical regres-
sions were run, founding a small explained variance for
age and relationship status for sample 1 (F(2) = 2.19,
p = 0.11, R2 = 0.01) and sample 2 (F(2) = 11.23, p < 0.01,
R2 = 0.04). Adding the items about clitoral self-stimulation
rarely added explained variance in sample 1 (F(5) = 6.05,
p < 0.01.; R2 = 0.07) and sample 2 (F(5) = 6.70, p < 0.01,
R2 = 0.06).
For a cross-validation of the regression model, the
regression coefficients from the first sample were used
to predict orgasm satisfaction and sexual satisfaction in
the second sample. The predicted orgasm satisfaction was
able to explain 29.5% of the variance of orgasm satis-
faction in sample 2 (F(1, 553) = 231.49, p < 0.001). The
predicted sexual satisfaction was able to explain 13.7% of
the variance of the sexual satisfaction in sample 2 (F(1,
553) = 87.68, p < 0.001).
Discussion
The aim of this study was to investigate whether orgas-
mic consistency through different types of stimulation
(PVI, PVI and direct clitoral stimulation, stimulation by
the partner’s hand, oral sex and self-stimulation of the
clitoris during sex with a partner) influences orgasm sat-
isfaction and sexual satisfaction. The role of affective and
cognitive attitudes toward self-stimulation of the clitoris
during sex with a partner was also included.
Vaginal Penetration
Orgasmic consistency through PVI without additional direct
clitoral stimulation was the only factor that was a positive
predictor of orgasm satisfaction as well as sexual satisfaction
in both samples. This point is surprising, since many women
even describe orgasm as more pleasurable when stimulated
directly by the clitoris (Burri etal., 2009). Moreover, female
orgasms are least likely to be caused by this type of stimula-
tion. Although there is no biological difference between a
vaginal and a clitoral orgasm, many women seem to desire
orgasms through purely vaginal penetration. Likewise, these
orgasms are especially strongly related to partnership sat-
isfaction (Lehmann etal., 2004). Furthermore, orgasm is
sometimes seen as a success criterion for good sex, which
is why it is desired in order to help the partner feel compe-
tent (Salisbury & Fisher, 2014). Sometimes, orgasms are
faked to satisfy the partner as well as to finish the intercourse
(Thomas etal., 2016). Although many women report achiev-
ing sexual satisfaction even without climax, there is some-
times a normative pressure to experience orgasms in order
to feel normal and feminine (Nicolson & Burr, 2003). This
Table 2 Multiple linear regression for predictors of orgasm satisfaction regarding stimulation type and attitudes towards clitoral self-stimulation
LL lower limit, UL upper limit, CSSS Clitoral Self-Stimulation Scale
* p < .05, **p < .01, ***p < .001
Sample 1 Sample 2
b SE 95% CI βp b SE 95% CI βp
LL UL LL UL
PVI 0.30 0.06 0.19 0.41 0.25*** < .001 0.14 0.04 0.05 0.22 0.12** 0.002
PVI and clitoral 0.18 0.06 0.07 0.29 0.18** 0.002 0.34 0.04 0.25 0.42 0.33*** < .001
Hand stimulation 0.18 0.06 0.06 0.30 0.18** 0.002 0.21 0.04 0.12 0.30 0.22*** < .001
Self-stimulation 0.12 0.05 0.02 0.22 0.13* 0.017 −0.01 0.04 −0.08 0.05 − 0.02 0.654
Oral stimulation 0.07 0.05 −0.04 0.18 0.07 0.219 0.07 0.04 0.00 0.15 0.08 0.057
CSSS: good −0.25 0.15 −0.53 0.04 −0.10 0.090 0.23 0.13 −0.02 0.49 0.10 0.068
CSSS: Important −0.29 0.14 −0.56 −0.02 −0.12* 0.033 −0.25 0.11 −0.47 − 0.04 −0.12* 0.023
CSSS: exciting 0.22 0.13 −0.03 0.46 0.10 0.090 −0.01 0.08 −0.17 0.16 0.00 0.920
Age −0.01 0.02 −0.05 0.03 −0.01 0.742 −0.01 0.02 −0.05 0.03 −0.03 0.469
Relationship 0.63 0.34 −0.03 1.30 0.08 0.062 0.64 0.28 0.10 1.18 0.08* 0.022
R20.302 0.354
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1 3
means the desire for an orgasm during vaginal penetration
could arise from internal or external pressure (Chadwick
etal., 2019). The image that women experience orgasms dur-
ing sexual intercourse is spread in different media, whether
it is magazines, novels, or pornographic videos (Cabrera
& Ménard, 2013; Lavie-Ajayi & Joffe, 2009; Séguin etal.,
2018). Therefore, it is not surprising that many people think
that it is normal for women to reach orgasms during vaginal
penetration (Ejder Apay etal., 2013). It seems to be evident
that these heteronormative scripts about how sex should
be are important in this matter. The problem is: If PVI is
assumed to be the norm for sexuality, it can distract from
other sexual needs (Willis etal., 2018). Also, valuations are
found in the language we use, so that clitoral stimulation
is often seen as foreplay. The term foreplay gives clitoral
stimulation a minor role and implies that there is something
else that is actually more important (Mahar etal., 2020).
Additionally, the female orgasm achieved solely through
penetration may be perceived as particularly important to
protect the partner’s feelings of masculinity and his ego
(Muehlenhard & Shippee, 2010). However, even education
rectifying these sexual myths does not necessarily help to
reduce these concerns (Bell & McClelland, 2018). Emotions
and norms about how sexuality should be experienced seem
to be much more deeply rooted and need to be worked on
more intensively to change.
PVI withDirect Clitoral Stimulation
If the clitoris is stimulated manually during intercourse,
the orgasmic consistency increases clearly. Orgasm con-
sistency through this type of stimulation was a predictor of
orgasm satisfaction, but only in sample 2 also a predictor for
the broader construct of sexual satisfaction. Nevertheless,
it seems that simultaneous stimulation of the vagina and
clitoris is particularly pleasurable for women. About 70%
of women report that they use clitoral stimulation during
penetration to make it more pleasurable (Hensel etal., 2021).
Also neurobiologically, it can be shown that orgasms that
result from stimulation of several regions also activate more
orgasm-relevant neurons. Women describe these orgasms as
more intense, more pleasurable, and more complex (Nemati
& Weitkamp, 2020). Nevertheless, orgasms through addi-
tional direct clitoral stimulation seem to be evaluated differ-
ently by some women. Phrasing of questions about women`s
orgasm produces markedly different orgasm reports: While
women experience orgasms during intercourse with direct
clitoral stimulation in 51–60% of cases, it is significantly
less if you ask unspecifically with the phrasing “intercourse”
(31–40%). Asking specifically for intercourse without addi-
tional direct clitoral stimulation further reduces orgasmic
consistency (21–30%) (Shirazi etal., 2018). Accordingly,
it seems to differ what women understand by orgasms dur-
ing intercourse. It is possible that some women consider
orgasms during intercourse with additional clitoral stimu-
lation to be inferior and therefore do not report them. In
addition, there is evidence that self-reported sexual satis-
faction among women, and likewise among sexual minority
men, relates to their partner’s sexual satisfaction rather than
to their own (McClelland, 2011). This phenomenon seems
to be also influenced by heterosexual scripts, as women in
same-sex relationships report enjoying orgasms through
clitoral stimulation more than women in mixed-sex rela-
tionships (Blair etal., 2017). Moreover, some women find
Table 3 Multiple linear regression for predictors of sexual satisfaction regarding stimulation type and attitudes towards clitoral self-stimulation
LL lower limit, UL upper limit, CSSS Clitoral Self-Stimulation Scale
* p < .05; **p < .01; ***p < .001
Sample 1 Sample 2
b SE 95% CI βp b SE 95% CI βp
LL UL LL UL
PVI 0.77 0.16 0.46 1.08 0.24*** < .001 0.41 0.13 0.17 0.67 0.14** 0.001
PVI and clitoral 0.22 0.16 −0.08 0.53 0.08 0.154 0.26 0.13 0.01 0.51 0.10* 0.039
Hand stimulation 0.52 0.17 0.19 0.85 0.19** 0.002 0.24 0.13 −0.01 0.49 0.10 0.064
Self-stimulation 0.03 0.14 −0.24 0.30 0.01 0.816 0.04 0.11 −0.17 0.25 0.02 0.719
Oral stimulation 0.09 0.15 −0.21 0.39 0.03 0.566 0.27 0.12 0.05 0.50 0.12* 0.017
CSSS: good 0.33 0.40 −0.46 1.13 0.05 0.411 0.66 0.38 −0.08 1.39 0.11 0.082
CSSS: important −0.50 0.38 −1.24 0.25 −0.08 0.190 −0.70 0.32 −1.34 −0.07 −0.13* 0.030
CSSS: exciting 1.01 0.35 0.32 1.71 0.18** 0.004 0.42 0.24 −0.06 0.90 0.08 0.087
Age −0.14 0.09 −0.25 − 0.03 −0.11* 0.017 −0.05 0.06 −0.18 0.05 −0.05 0.232
Relationship 0.89 0.95 −0.97 2.74 0.04 0.348 2.93 0.80 1.35 4.50 0.15*** < .001
R20.216 0.165
1211Sexuality Research and Social Policy (2022) 19:1205–1216
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1 3
it awkward to ask their partner about clitoral stimulation
(Salisbury & Fisher, 2014) or even consider that their part-
ner may be bored by clitoral stimulation (McCabe, 2005).
Oral Sex
Orgasmic consistency through oral sex was a positive pre-
dictor of sexual satisfaction in only one sample and no pre-
dictor of orgasm satisfaction. The ambiguous results could
indicate that oral sex is perceived ambivalently by women.
This may be related to conflicts with the body image and the
genital self-image. While the woman is receiving oral sex,
the vulva is exposed to the partner’s view. This could be
uncomfortable for certain women, because there are cultural
norms indicating that the female genitals are unattractive
(Braun & Kitzinger, 2001). A positive attitude toward the
female genitals is related to experiencing orgasms during
cunnilingus and also to the ability to orgasm through this
type of stimulation (Herbenick, 2009). In addition, sexual
self-efficacy in achieving sexual pleasure also plays a role in
whether or not women ask for and receive oral sex (Satinsky
& Jozkowski, 2015).
It is probably easier for women in long-term relationships
to engage in oral sex. In long-term relationships, receiving
oral sex is associated with sexual satisfaction (Frederick
etal., 2017). Nevertheless, men enjoy oral sex more than
women (Galinsky & Sonenstein, 2011), and apparently not
only in the receiving role: In mixed-sex relationships, men
expressed the desire for more cunnilingus. However, women
did not like to receive more oral sex (Blair etal., 2017).
Stimulation bythePartner’s Hand
Orgasmic consistency by clitoral stimulation by the part-
ner’s hand was only a predictor for orgasm satisfaction in
sample 2 and for sexual satisfaction in sample 1. This type
of stimulation is most similar to female masturbation. The
majority of women have one or two preferred masturbation
techniques. The most common are up-and-down, as well
as circular movements to stimulate the clitoris (Herbenick
etal., 2018). More frequent masturbation is not necessarily
related to more orgasms during sexual intercourse. There is
a shift, that women masturbate at a younger age and more
often than 20years ago, but still have fewer orgasms dur-
ing sexual intercourse (Kontula & Miettinen, 2016). Maybe
some women have to relearn how to enjoy different types
of stimulation and experience orgasms through them. The
stimulation of the clitoris by hand may be something normal
and familiar and was therefore associated with increased
satisfaction. A study investigating differences in the pleasure
experienced during various sexual activities also found that
women find receiving stimulation by the hand of their part-
ner more pleasurable than men do (Pinkerton etal., 2003).
Clitoral Self‑Stimulation During Sex withaPartner
Orgasm consistency through self-stimulation of the clito-
ris during sex with a partner was only a positive predictor
of orgasm satisfaction in the first sample and no predic-
tor for sexual satisfaction. All over, hierarchical regression
approaches showed that there was little explained vari-
ance for attitudes towards clitoral self-stimulation with regard
to orgasm and sexual satisfaction. This is surprising, as it might
be assumed that women who are empowered to care for their
own orgasms and sexual needs would report more satisfaction
with sexuality. However, considering the self-stimulation of
the clitoris during sex with a partner as good had no influence
at all. The rating of self-stimulation as important even had a
negative influence on orgasm satisfaction and in one sample
also with sexual satisfaction. It could be assumed that women
who have general problems reaching orgasm are more likely to
perceive self-stimulation as important. However, it is equally
reasonable to assume that these women experience clitoral
orgasms; otherwise, this type of stimulation would probably
not be perceived as important. Therefore, there is no generally
valid explanation for a lower ability to orgasm that could cause
the dissatisfaction. Maybe a mediating effect through sexual
pressure to perform could be a cause of the negative relation-
ship between considering self-stimulation of the clitoris as
important and orgasm satisfaction. For example, the pressure
to reach orgasm can cause orgasm problems, and concerns
about orgasm difficulties can inhibit sexual functioning and
may trigger a vicious circle (Sanders etal., 2008). Moreover,
considering something as important is a cognitive factor and
therefore maybe also a cognitive distraction. Cognitive dis-
tractions are known as negative factors for sexual satisfaction
and sexual functioning (Adam etal., 2015; Cuntim & Nobre,
2011). Another explanation for the negative association could
be that some women need a very specific stimulation of the
clitoris to reach orgasm and therefore self-stimulation is con-
sidered as important. When the body becomes immobile dur-
ing stimulation, this is associated with fewer orgasms (Bischof-
Campbell etal., 2019). Some women also find it embarrassing
to stimulate their clitoris during sex and are worried that their
partner might feel incompetent as a consequence (Salisbury &
Fisher, 2014). In addition, self-stimulation is the sexual activity
that is most rarely practiced during sexual encounters, although
it increases during longer relationships (Smith etal., 2012).
On the other hand, considering the stimulation of the clitoris
as exciting was a positive predictor of sexual satisfaction in the
first sample. It was no predictor of orgasm satisfaction. In this
case, the emotional instead of the cognitive level is addressed.
A positive effect on clitoral self-stimulation therefore seems to
be more likely to be positive for sexual satisfaction.
The results indicate that a differentiated consideration of
the types of stimulation during sex with a partner is important,
with special emphasis on the motives and deeper assumptions
1212 Sexuality Research and Social Policy (2022) 19:1205–1216
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1 3
about sexuality, like internalized heteronormative scripts. If
considering the clitoral self-stimulation during sex with a part-
ner as important is no positive predictor for sexual satisfac-
tion or orgasm satisfaction, the question arises why this type
of stimulation is considered as important at all. If it happens
for one’s own pleasure, why does not it increase satisfaction?
Also, if it does not happen for one’s own pleasure, is it again
just about the man’s satisfaction or for a normative pressure
to reach orgasm? Chasing an orgasm may distract from
pleasure and cause pressure to perform. Maybe self-stimulation
is also used to appear sexy and confident. Also, in heterosexual
encounters, the male desire to observe a woman masturbating
could be a possible motive (Fahs & Frank, 2014).
Limitations andStrengths
A limiting factor is that both samples were acquired online,
consisting mainly of young, heterosexual, and well-educated
women. Also, because the survey was spread through e-mail
lists and internet forums to interested persons, it is likely
that the sample is biased towards individuals who are open
minded toward the topic of sexuality. Still, we found concerns
about clitoral self-stimulation and great variations in given
responses. Nevertheless, these results should be interpreted
with caution and cannot be applied to the general population.
Another limitation is the cross-sectional nature of the data.
Therefore, assertions about causality cannot be derived.
Although the FOS and the CSSS are still relatively unknown
instruments, they offer an unusual and unique view on female
sexuality. By asking detailed questions about orgasmic consist-
ency, orgasm satisfaction and attitudes toward self-stimulation
of the clitoris, we expect it to help to gain a deeper understand-
ing of this. Since this is an exploratory study, a replication in
a second, independent sample was performed to methodically
support the results. The fact that most of the results could be
found in both large samples should be emphasized as strength
of the study. The cross-validation of the regression model from
the first sample in the second sample showed an explained
variance in the medium to good range. There were shifts in the
significant predictors, but the differences were mostly small,
and the direction of the effects remained the same.
Future Directions andConclusions
The results indicate that some young women are still
strongly driven by the desire to experience orgasms through
vaginal penetration and that clitoral stimulation can cause
ambivalent feelings.
The exact roles of heteronormative scripts and sexual per-
formance pressure would be interesting to investigate in further
studies. It also remains an open question whether similar results
occur in older women or whether it could be expected that a
more pleasure-oriented sexuality would develop in later life.
Depending on the types of stimulation used, women’s
orgasms can be given different subjective meanings. There is no
simple connection that all orgasms lead to sexual satisfaction;
rather, there seem to be complex and sometimes ambivalent
relationships. The findings indicate that even behaviors that
might initially be associated with empowerment, such as self-
stimulation during sex with a partner, may be related to a vari-
ety of mechanisms. An empowered woman during sex may also
trigger discomfort in the man, making him appear dissatisfied
and thus minimizing the woman’s satisfaction. Investigating
such dyadic aspects would also be of high relevance. Overall,
the work reveals many indications of the extent to which heter-
onormative sexual scripts influence sexuality. This shows the
importance of challenging and discussing these assumptions.
Especially for young people who are just discovering their
sexuality, such rigid ideas about the process of sexuality could
be intimidating, making it difficult to explore personal needs.
Also, the samples in this study consisted mainly of young and
highly educated women; this group may be vulnerable to this.
It is also possible that well-educated young women are par-
ticularly engaged in self-optimization, which may encourage
sexual pressure to perform. Moreover, there is little education
about sexual functioning at school (Cormier & O’Sullivan,
2018), which could be a possible reason for this pressure. It
is especially important for adolescents to discover their own
bodies: Regular masturbation during this time facilitates experi-
encing orgasms during sexual intercourse (Carvalheira & Leal,
2013). Therefore, sex-positive education in school is important,
including pleasure, clitoris stimulation, and the natural differ-
ences between female and male sexuality (Koepsel, 2016).
Historically, the clitoris as an organ was long neglected and
tabooed (Charlier etal., 2020). Against this background, it is
not surprising that the clitoris still triggers ambivalent feelings
today. Without public statements against such assumptions, sex
education is largely left to the media, which convey the image
of sexually submissive women with a lack of sexual autonomy
(Sanchez etal., 2006). Benevolent sexism is also linked to
orgasm frequency, because women scoring high on implicit
sexism scales are less willing to speak about sexual needs
(Harris etal., 2016). Difficulties in talking about clitoral stimu-
lation in a couple are related to female anorgasmia (Herbenick,
2009). In this context, it is important to promote female sexual
self-efficacy. If women feel confident that they can enjoy sex,
they are more likely to talk to their partner about their sexual
desires (Satinsky & Jozkowski, 2015).
Sexuality which is pleasure-oriented instead of only
goal-oriented and orgasm-focused is especially intense
and valuable. For this, a mindful contact with oneself
and the partner is important (Nemati & Weitkamp, 2020).
Questioning one’s own sexual scripts can be an important
task in this context. Naming them in a non-judgmental
way and assessing whether or not they are helpful for
a satisfying sexuality could have a positive influence.
1213Sexuality Research and Social Policy (2022) 19:1205–1216
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1 3
Therefore, sexual education and counseling should help
people to identify sexual thoughts and activities, which
are the results of normative pressures and to encourage
people to connect more with their inner needs and feel-
ings about sexuality.
Funding Open Access funding enabled and organized by Projekt
DEAL.
Declarations
Ethics Approval The studies received ethical approval from the Ethics
Committee of theJenaUniversity Hospital, Germany (4837–06/16
and 1859–2020).
Informed Consent Informed consent was obtained from all individual
participants included in the studies.
Conflict of Interest The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
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