Gender attributions of orgasm non-occurrence in heterosexual relationships and their association with sexual and relationship outcomes

Abstract

The present study describes a mixed-methods approach to studying gendered attributions made in response to orgasm non-occurrence during sexual encounters with a partner. The study employed a concurrent nested mixed-methods design with primary data, which nested a quantitative analysis within a more extensive qualitative analysis (n = 390). Two qualitative questions regarding both the participant and their partner’s attributed reasons for being unable to orgasm were coded and analyzed thematically. These responses were then quantitized into dichotomous variables used as predictors of sexual satisfaction, relationship satisfaction, and orgasm frequency in a multiple regression analysis. Results of the study indicated that medical/health and technique/setting attributions were the most frequent reasons participants and their partners did not orgasm. Furthermore, relational attributions were negatively associated with sexual and relationship satisfaction in women. Finally, not knowing to what cause orgasm non-occurrence should be attributed was also negatively associated with sexual and relationship satisfaction in women and orgasm frequency in both men and women. Implications for clinicians and further research are discussed.

LAY SUMMARY

A mixed-methods approach to understanding the reasons why men and women indicated not being able to orgasm during sexual encounters with their partner. A qualitative analysis examined the common themes among responses. Quantitative analysis used the qualitative themes as predictors of sexual and relational outcomes.

Keywords:

• Orgasm non-occurence
• attribution
• mixed-methods
• couples therapy
• orgasmic disorder

Introduction

Experiencing orgasms is pivotal in maintaining sexual satisfaction in longer-term heterosexual relationships (Frederick et al., 2017). Though we understand its importance, decades of research suggest that orgasm is a complex biopsychosocial experience (Mah & Binik, 2001; Mahar et al., 2020). The physical mechanics are just as influential as the thoughts and emotions related to orgasm (Mah & Binik, 2001; Mahar et al., 2020). These complexities are heightened when considering the long-standing research suggesting an “orgasm gap” (Wade et al., 2005) between heterosexual partners. On average, men experience orgasm at least 30% more often during heterosexual partnered sex compared to women (Andrejek & Fetner, 2019; Frederick et al., 2017; Jones et al., 2018; Laumann et al., 1994; Leonhardt et al., 2018; Mahar et al., 2020; Piemonte et al., 2019; Struckman-Johnson et al., 2017). Such statistics are vastly different when compared to orgasm research with same-sex couples suggesting that gender is a significant component of orgasm gaps within the context of mixed-sex relationships (Blair et al., 2018; Frederick et al., 2017; Garcia et al., 2008). However, though few studies examine orgasm frequencies alongside sexual satisfaction, limited data suggest a lack of gender differences exist among reported sexual satisfaction regardless of orgasm occurrence (Blair et al., 2018). In other words, participants were equally satisfied whether they experienced frequent or infrequent orgasms during partnered sex. In this light, it is difficult to ascertain how gender, sexual satisfaction, and orgasm occurrence interact to explain the orgasm gender gap. Still, it appears to be clear that these factors are important.

A final layer includes the differences that potentially emerge when comparing partnered sex in committed heterosexual relationships as opposed to casual sexual encounters (Andrejek & Fetner, 2019; Blair et al., 20187; Cheng & Smyth, 2015; Frederick et al., 2017; Kontula & Miettinen, 2016; Shirazi et al., 2018; Wongsomboon et al., 2020). Namely, the notion that those in long-term heterosexual relationships report higher levels of sexual satisfaction and increased frequencies of orgasm occurrence compared to their single or less attached peers (Frederick et al., 2017; Shirazi et al., 2018). Yet, adding or subtracting relationship status does not entirely explain the heterosexual orgasm gender gap. To this point, men and women may perceive orgasms differently. Furthermore, emerging literature suggests that orgasms and sexual satisfaction are highly subjective (Arcos-Romero & Sierra, 2020; 2019; 2018; Buczak-Stec et al., 2019; Handy et al., 2018; Mah & Binik, 2005; Sierra et al., 2020), influenced by attributions (Garcia et al., 2008; Hevesi et al., 2020; Morry et al., 2019; Rowland et al., 2019), and require continued exploration. This study seeks to expand the minimal literature on the subjective experiences of orgasm through an attribution theoretical lens.

Literature review

Orgasm and orgasm non-occurrence

A linguistic study of terms and descriptions of orgasm in 27 languages across the globe identified the concept of orgasm as including a “physiological response, a psychological state, and an ideal goal” (Chiang & Chiang, 2016, p. 132). Though not the only goal of sexual interactions, 67% of the languages analyzed prioritized orgasm as an ideal destination. Chiang and Chiang suggest that the cognitive, emotional, and physiological facets of orgasm are each as fundamental as they are universal to the experience of orgasm. Relatedly, a review on orgasm research by Mah and Binik (2001) surmised that a biopsychosocial definition of orgasm moves away from an all-or-nothing operation to involve three dimensions: sensory (physical sensations), evaluative (non-physical cognitive appraisal), and affective (non-physical emotional experience). This suggests that the cognitive and emotional elements of orgasm, or the non-occurrence of orgasm, are essentially as influential as the physical elements. Relatedly, orgasm non-occurrence in partnered sexual interactions can be problematic regardless of gender and sexual orientation, given the attributions and emotional reactions attached to such experiences (Catalan, 1993; Chadwick & Anders, 2017; Conaglen & Conaglen, 2008; Gordon, 2006; McClelland, 2014). It is, therefore, important to further explore the affective and evaluative experience surrounding the occurrence and non-occurrence of orgasm.

Gendered orgasm and orgasm non-occurrence

Gender, the socially constructed role expectations and norms of men and women, has an important impact on sexual outcomes. A national longitudinal study in Finland consisting of five waves from 1971 to 2015 found that approximately 50% of women reliably experience orgasm during partnered heterosexual sexual encounters compared to over 90% of men, who reported orgasm occurrence during the majority of partnered heterosexual intercourse (Kontula & Miettinen, 2016). Intercourse was defined as penile-vaginal penetration and these figures included all types of relational status (single, dating, married, etc.). They were in response to participants being asked about their overall sexual experiences (“do you usually have orgasms during intercourse [lovemaking]?” p. 3) as well as recently partnered sex (“Did you have an orgasm during your most recent sexual intercourse [lovemaking]?” p. 3). Such results speak to the heavily researched “orgasm gap” (Wade et al., 2005). Specifically, men report experiencing orgasm an average of at least 30% more often than their female peers during heterosexual partnered sex (Andrejek & Fetner, 2019; Frederick et al., 2017; Jones et al., 2018; Laumann et al., 1994; Leonhardt et al., 2018; Mahar et al., 2020; Piemonte et al., 2019; Struckman-Johnson et al., 2017). This orgasm gap remains largely a problem in cisgender heterosexual relationships, where the difference in orgasm occurrence is larger than in gay, lesbian, or bisexual relationships (Frederick et al., 2018). However, studies focusing solely on the role of sexual behavior (vaginal vs. clitoral stimulation; sexual positions) in orgasm occurrence might overlook the cognitive processing (attributions/social scripts) driving said behavior. Consequently, it might not be enough to ask how/when orgasm occurred but why/what thoughts might arise during orgasm occurrence. Doing so reveals underlying beliefs driven by permission to and responsibility for orgasm occurrence.

Sex differences have been documented during the stimulation leading up to orgasm, but absent during orgasm occurrence, suggesting that the path to orgasm might differ by sex but the resulting neurological experience is similar for men and women (Carvalho et al., 2013; Georgiadis et al., 2009). In fact, in a large meta-analysis (N = 255) assessing the neurology of human sexuality from 1936 to 2017, authors noted that gender was a commonly researched variable but just as typically yielded few differences in the data outside of stimulus responses (Ziogas et al., 2020). Meaning men and women process sensory input differently, but both can equally experience orgasm occurrence. Results suggest a cognitive factor influencing orgasm occurrence between genders rather than a biological/anatomical/behavioral reason.

It is essentially vital to note that heterosexual orgasm occurrence is socially scripted to be the goal of sexual interaction, and men are responsible for orgasm occurrence (Jackson & Scott, 2002; Moran & Lee, 2011). At the same time, heterosexual female orgasm has been normalized and prioritized as symbolic of sexual liberation (Stelzl & Lafrance, 2020). Consequently, heterosexual men tend to overestimate the occurrence of female orgasm during intercourse (Gagnon & Simon, 2011; Shirazi et al., 2018). This is not surprising considering a national study of heterosexual women ages 18-94 found that 58.8% of women falsely claimed to have experienced an orgasm during intercourse, and one-third of those women continue to fake orgasms with their partner (Herbenick et al., 2019). Such results imply that much goes unsaid between partners when it comes to orgasm occurrence to the point where assumptions are made between both genders.

Attribution theory

Since its inception in the 1950s (Thompson & Snyder, 1986), attribution theory has been applied to a variety of social science topics and organizational psychology (Martinko & Mackey, 2019), and romantic partnerships (Fincham, 1991). Notably, attribution theory is a helpful framework in relational research because it is impossible to truly understand relationships without grasping their underlying cognitive processes (Thompson & Snyder, 1986). Causal beliefs, or attributions, are used to make meaning of our actions and other people’s behaviors and experiences. Attributions (meaning-making, inferences, and perceived causation), generated from our experiences, shape emotional and behavioral responses such as one’s sense of control (locus of control/self-efficacy) and perceived levels of satisfaction and distress (Bandura, 1989; Kelley, 1973; Kelley & Michela, 1980; Rowland et al., 2019). At its core, attribution theory refers to how people interpret why something happens based on causal assumptions within themself (internal, relatively stable, primarily voluntary, dispositional) and outside of themself (external, changing, largely uncontrollable, situational) (Rowland et al., 2019; Thompson & Snyder, 1986; Weiner, 2019).

Often, attributions exist on a spectrum of responsibility and blame that can be categorized as internal (existing within one’s self and therefore stable/pervasive) and external (existing outside of one’s self and consequently unstable/situational) factors (Fincham, 1991; Kelley & Michela, 1980; Thompson & Snyder, 1986). For instance, Morry et al. (2018) examined attribution’s impact on relationship satisfaction and commitment between intimate partners. They found that how attributions are interpreted can both enhance and distress relationships. Thus, attributions serve various functions within intimate relationships, such as mitigating conflict, protecting and controlling self and others, and improving relationship quality and satisfaction (Durtschi et al., 2011; Morry et al., 2018; Thompson & Snyder, 1986).

Gendered attributions

Individual sexual scripts (beliefs and preferences for sexual practices) often play into attributions, especially when interpreting and predicting partner preferences and beliefs (Garcia et al., 2008). For instance, regardless of sexual orientation, men and women might attribute sexual dysfunction to internal factors, such as beliefs about personal inadequacies, rather than external factors such as their partner’s influence on sexual experiences (Rowland et al., 2019). In this example, the person experiencing sexual dysfunction takes responsibility for the negative experience rather than blaming external factors on the outcome. As a result, beliefs impact our sense of control and stability in the world around us (Weiner, 2019). More importantly, perceived causation shapes our reaction to behaviors and events (Kelley & Michela, 1980), which influences our sense of self-efficacy (Rowland et al., 2019) and can even predict relationship quality (Morry et al., 2019).

From a relational perspective, ego and esteem are directly tied to sexual scripts and outcomes. For instance, within heterosexual partnered sexual, the occurrence of female orgasm bolsters a sense of masculinity and increases self-esteem in men (Chadwick & van Anders, 2017). Conversely, the non-occurrence of female orgasm can result in heterosexual women perceiving the outcome to bruised male egos (Salisbury & Fisher, 2014). Barnett et al. (2018) theorized that cultural messages (women are not expected to orgasm as often as men, women are caregivers or subservient to men) and levels of experience (inexperienced men may not be distressed over women’s orgasm occurrences) impacted their study. Furthermore, a review of orgasm equality by Mahar et al. (2020) points out that sexual behavior must be understood within the context of the society in which they exist. Sociocultural forces shape critical messages such as who deserves pleasure and education on achieving satisfaction. Ultimately, this suggests that genders differ in their opinions about orgasm occurrence, which may mean that heterosexual men and women perceive the non-occurrence of orgasm differently.

Attributions and orgasm

A recent systematic review found that understanding the psychological aspect of sexual function and dysfunction is equally essential to other factors such as physical components (Tavares et al., 2020). While orgasm occurrence is not synonymous with sexual functioning any more than it equates to sexual satisfaction (Kontula & Miettinen, 2016), attributions regarding orgasm occurrence remain significant. Along these same lines, Mah and Binik (2005) found that interpersonal (e.g. coital) orgasm pleasure among predominantly heterosexual individuals was most often attributed to psychosocial factors (e.g. emotional intimacy) rather than physical or anatomical determinants. Such findings are of particular importance when considering that attributions, subjective well-being, and relationship satisfaction are often influenced by sexual functioning and orgasm occurrence (Bhutto et al., 2021; Buczak-Stec et al., 2019; Durtschi et al., 2011; Frank & Maass, 1985; Frederick et al., 2017; Rowland et al., 2019; Rowland & Kolba, 2019; Stephenson & Meston, 2016). However, other findings suggest that notable aspects of identity, such as gender, highly influence attribution and orgasm occurrence research (Rowland et al., 2021; Bhutto et al., 2021). Additionally, recent results in an extensive study of women found reason to believe that contextual factors (conservative views of sexuality referred to as “sociosexuality”) mediated orgasm occurrence and sexual satisfaction in both the non-committed and committed sexual encounters (Wongsomboon et al., 2020).

Gender orgasm attributions

To date, several studies have investigated the cognitive and emotional process around orgasm occurrence (Tavares et al., 2020). This includes assessing the value placed on a partner’s orgasm, distress when orgasm does not occur, and beliefs surrounding the occurrence or non-occurrence of orgasm (Catalan, 1993; Chadwick & Anders, 2017; Conaglen & Conaglen, 2008; Gordon, 2006; McClelland, 2014). Previous literature suggests that interest in and reaction to partner orgasm and narratives surrounding the non-occurrence of orgasm differ based on gender (Barnett et al., 2018; Salisbury & Fisher, 2014). For instance, Barnett et al. (2018) found that men and women both consider their partner’s orgasm important, and neither gender experienced extreme distress or relief at orgasm occurrence. Yet, their results indicated that women tend to value men’s orgasms slightly more and are therefore moderately more persistent towards ensuring male partners’ orgasm.

Similarly, Rowland and Kolba (2018) found that, regardless of gender, participants negatively attributed (blamed) their orgasm difficulties to themselves. However, more so than men, women assumed responsibility for their partner’s distress (Rowland & Kolba, 2018). Salisbury and Fisher (2014) results indicated that both men and women experienced distress when the female partner did not orgasm, but for differing reasons. Hevesi et al. (2020) specifically measured distress in women with orgasm difficulties because the non-occurrence of an orgasm does not always result in distress. Their results indicated that the causes women attributed to orgasm difficulties impacted the presence and severity of self-reported distress. Additionally, individuals’ perceptions of their sexual functioning also impact attributions to orgasm, or lack thereof (Rowland et al., 2019).

These various studies highlight differences in how each gender experiences the non-occurrence of orgasm and support further research in exploring gendered attributions towards orgasm. Rowland and Kolba (2018) theorized that, in part, women’s orgasm difficulties do not inhibit overall sexual activity. In contrast men’s orgasm difficulties can impair both partners’ sexual engagement, depending on the type of sexual activity. Their study underscored the importance of addressing dysfunction relationally rather than individually. Wongsomboon et al. (2020) challenged future research to pay particular attention to contextual influences, such as beliefs about sex, to understand individual differences. Consequentially, future research should seek a better understanding by examining the causes to which individuals in committed heterosexual relationships attribute the non-occurrence of orgasm and how those causes impact relational and sexual outcomes.

Orgasm, sexual satisfaction, and relationship satisfaction

Both nationally representative cross-sectional studies and longitudinal cohort studies found sexual satisfaction significantly associated with overall subjective well-being in life and an important factor in successful aging (Cheng & Smyth, 2015; Buczak-Stec et al., 2019; Blanchflower & Oswald, 2004). Sexual satisfaction is one of many contributing factors in maintaining healthy and passionate heterosexual relationships over time (Frederick et al., 2017). Additionally, compared to those with two or more sexual partners, sexual satisfaction and happiness are highest among those with one committed partner (Cheng & Smyth, 2015). As such, sexual satisfaction is often rated higher in committed relationships than casual sexual encounters (Cheng & Smyth, 2015; Wongsomboon et al., 2020). This might, in part, align with research suggesting that the occurrence of heterosexual female orgasms is higher in steady sexual relationships (Kontula & Miettinen, 2016). Frederick et al. (2017) identified the occurrence of orgasm as positively correlated to increased sexual satisfaction in heterosexual couples. Meaning there is a link between the increased likelihood of female orgasm occurrence during committed sex and sexual satisfaction (Wongsomboon et al., 2020).

It is important to note that orgasms are not the only factor contributing to heterosexual sexual satisfaction, particularly in long-term relationships (Frederick et al., 2017). Yet, the high correlation between orgasm occurrence and sexual satisfaction is undeniable (Herbenick et al., 2019; Kontula & Miettinen, 2016). Such results suggest that committed relationships offer a better understanding of a partner’s likes and dislikes, leading to higher frequency of orgasm occurrence. In turn, greater intimacy leads to more orgasms, and an increase in the occurrence of orgasms is one factor that contributes to greater sexual satisfaction in heterosexual relationships (Herbenick et al., 2019). From a biological standpoint, the occurrence of orgasm is marked by a surge of arousal neurotransmitters that facilitates pair-bonding (Coria-Avila et al., 2016). In other words, orgasm occurrence makes partners feel closer to one another and increases the desire to stay paired.

Current study

The current study employs a mixed-method design to explore the highly variable experiences that contribute to sexual and relationship satisfaction by investigating the breadth of interpretations accompanying self and partner orgasm non-occurrence. This study is unique because it contextualizes subjective satisfaction and objective orgasm occurrence within an attribution theoretical framework. The following research questions guided the present study:

Research Question 1: To what factors do heterosexual cisgender men and women attribute orgasm non-occurrence during a sexual encounter, both personally and for their partner.

Research Question 2: How do the attributions of orgasm non-occurrence impact one’s orgasm frequency, sexual satisfaction, and relationship satisfaction.

Methods

Sample

The sample consisted of cisgender, heterosexual individuals (N = 390) that participated in an online survey. Participants were recruited through social media outlets, organization listservs, and research panels. An IRB-approved letter of information was presented before beginning the anonymous survey. Demographics of the sample consisted of 40% men (n = 156) and 60% women (n = 234) who indicated being in a committed, heterosexual relationship. A large majority of participants indicated being married (83.6%) or cohabiting (10.7%), with about 5% in dating relationships. The length of the participants’ current relationships ranged from 3 months to 61 years (M = 9.79 years, SD = 10.41). Participant ages ranged from 19 to 83, (M = 32.81, SD = 11.42; male M = 35.17, male SD = 11.91; female M = 31.27, female SD = 10.83). The majority of participants identified as Caucasian (88%), with participants also identifying as Hispanic/Latino (4.3%), Biracial/multiracial (3%), Black (2%), Asian (2%), and American Indian (less than 1%). The highest achieved education level of the participants included a high school diploma or lower (16%), associate’s degree/technical certificate (23%), bachelor’s degree (36%), master’s degree (19%), and doctorate degrees (6%).

Measures

Attribution of orgasm non-occurrence

Participants responded to two open-ended questions regarding the non-occurrence of orgasm. The questions assessed their interpretation of why an orgasm did not occur during a recent sexual interaction. The questions read, “If you have recently been unable to reach orgasm, what do you think are the reasons for being unable to do so?” and “If your partner/spouse has recently been unable to reach orgasm, in your best guess, what are their reasons for being unable to do so?”

Orgasm frequency

Participants responded to a single item estimating the frequency in which they reached orgasm at any point during their partnered sexual encounters. The survey item read, “In what percent of your sexual encounters do you reach orgasm?” Participants could choose one of five responses indicating increments of twenty percent (1(0-20%) to 5 (80-100%)). Men reported an average response of 4.80, indicating most men in the sample reached orgasm during 80-100% of partnered sexual encounters (SD = .63). Women reported an average response of 3.56, indicating most women in the sample reached orgasm during 60-80% of partnered sexual encounters (SD = 1.55).

Sexual satisfaction

The New Sexual Satisfaction Scale-Short (NSSS-S) was employed to measure sexual satisfaction. The NSSS-S is a 12-item questionnaire that divides sexual satisfaction into two dimensions: satisfaction with personal and partner contributions to sex. The measure uses a 5-point Likert-type scale to assess satisfaction across both dimensions in five areas: (1) sexual sensations, (2) sexual presence/awareness, (3) sexual exchange, (4) emotional connection/closeness, and (5) sexual activity (Štulhofer et al., 2011). Response options scaled from 1 (not at all satisfied) to 5 (extremely satisfied). Scores ranged from 13 to 60. Men reported an average score of 43.96 (SD = 8.40). Women reported an average score of 44.02 (SD = 10.19). Reports indicated an average score near the “very satisfied” indicator regardless of gender. As a bi-dimensional measure, the NSSS-S has shown strong psychometric support (including internal consistency, convergent validity, and test-retest reliability) (Mark et al., 2014). The measure also showed strong internal consistency for both dimensions in the present study (Personal dimension male α = .83, female a = .88; partner dimension male α = .85, female α = .89).

Relationship satisfaction

Relationship satisfaction was measured using a 16-item Couple Satisfaction Inventory (CSI) version. The measure used items with six- and seven-point Likert scales across multiple question types (e.g. statement responses and rating between dichotomous options) (Funk & Rogge, 2007). Scores on the CSI ranged from 2 to 81, with increased satisfaction reflected in higher scores. Men reported an average score of 63.65 (SD = 14.82). Women reported an average score of 64.40 (SD = 15.58). There was strong internal consistency on the CSI in the present study (male α = .97, female α = .97).

Analysis

The present analysis employed a concurrent nested mixed-methods design. Over the last several decades, mixed-method designs (combining both open-ended and closed-ended data collection procedures) have emerged to harness the strengths and overcome the limitations, of conducting only qualitative or only quantitative research (Creswell & Creswell, 2017). In other words, mixed designs allow researchers to contextualize data for to understand better the process and outcome of a phenomenon (Creswell & Creswell, 2017). In this study, mixed-method procedures were used first to identify the process of orgasm non-occurrence (ONO) attributions (e.g. what attributes were formed following ONO) and second to identify the associations of ONO attributions on sexual satisfaction, relationship satisfaction, and orgasm frequency.

In a concurrent nested design, qualitative and quantitative data are collected simultaneously but analyzed sequentially for various reasons (Hanson et al., 2005). With this design, one analysis (qualitative or quantitative) is nested in the other (Creswell & Creswell, 2017). In the present study, qualitative results were first coded and analyzed in a thematic analysis. The nested quantitative analysis was employed as an exploratory approach to empirically validate the findings of the qualitative analysis. In the present study, we used the quantitized ONO attribution codes in a point-biserial correlational and multiple regression analysis to explore the association between ONO attributions and sexual/relational outcomes (Bazeley, 2004). Previous mixed-methods analyses have utilized similar approaches (e.g. Driscoll et al., 2007; Tashakkori et al., 1998).

The concurrent nested strategy offered several potential benefits. A mixed-methods approach provided a more robust exploration than the qualitative analysis alone could provide. Furthermore, a nested method allowed researchers to gather multiple data sources at one time and interpret the data in novel ways (Terrell, 2012).

Qualitative analysis

The present qualitative analysis involved identifying themes among responses to open-ended questions regarding participants’ attributions surrounding the non-occurrence of orgasm during sex. These responses were organized in a spreadsheet and for the analysis coding. A team of six coders followed procedures for thematic analysis (Braun & Clarke, 2006; Mays & Pope, 2020). The analysis process followed five phases: (1) Becoming familiar with the data, (2) Generating initial codes and subthemes, (3) Deductively coding of subthemes, (4) Reviewing potential subthemes, and (5) Organizing and defining themes (Braun & Clarke, 2006).

Phase one: becoming familiar with the data. During this phase, each member of the coding team received their own printed copy of the qualitative data. Each member reviewed the responses and made preliminary notes on potential codes.

Phase two: generating initial codes and subthemes. This process involved the inductive grouping of responses into substantive themes. The coding team was divided into groups of three and assigned one of two questions for which they were to develop codes inductively. The individual members categorized their responses and separated the cases by men and women. These groups met individually to discuss their codes and develop common themes. Any coding discrepancies were discussed with the principal investigator until an agreement was reached. Each group created a consistent list of subthemes that incorporated their codes (Mays & Pope, 2020). This list of subthemes was not mutually exclusive. Therefore, when multiple attributions were provided in participants’ responses, the response would be coded in all related subthemes.

Phase three: deductive coding of subthemes. At this point in the process, the two coding groups then received the inductively developed subthemes of the other group. Each coding team then used the subthemes to code the other group’s question deductively. For example, group one then used the subthemes of group two to code the second question. Any coding discrepancies were discussed with the principal investigator until an agreement was reached.

Phase four: Reviewing potential subthemes. After the inductive and deductive rounds of coding were completed. Both groups met to discuss any discrepancies between the inductive and deductive coding results. The group then discussed any discrepancies among the rounds of coding. At this point, several adjustments to the subthemes were made. Clarifying definitions for each subtheme were then discussed. Discrepancies among the two rounds of coding were then addressed to fit within the clarified subtheme definitions.

Phase five: organizing and defining themes. The group of coders then developed major themes among each of the subthemes. Themes were developed to conceptualize the organization of the sub-themes. Themes were organized and defined for each question separately. Detailed notes of theme organization were recorded through each coding phase to monitor bias in coding (Bazeley, 2004). The two authors then reviewed the themes and notes, which served as an outside check on how the themes and subthemes were organized.

Quantitative analysis

The quantitative analysis in this study was designed to explore whether ONO attributions made by men and women were associated with sexual attitudes or outcomes. This exploratory research was intended to help inform future studies on the attributions of the non-occurrence of orgasm. Responses in each major theme were dummy coded for their use in point-biserial correlation and multiple regression analyses. Only the codes for each individual’s orgasm non-occurrence attributions were used in the analysis; attributions about partners’ ONO were not used.

Point-biserial correlations assessed the strength of the relationship between dichotomous orgasm non-occurrence variables and continuous measurements of sexual satisfaction, relationship satisfaction, and orgasm frequency. Three separate regression analyses were conducted to examine the relationships to the outcome variables listed. The multiple regression was performed using SPSS Version 25. Each analysis was conducted separately for male and female participants using a split file feature.

Results

Qualitative analysis findings

Participants self-reported individual attributions for instances of ONO and assumed reasons for instances of a partner’s ONO. A total of 390 participants answered at least one of the two questions in the study, consisting of 156 men and 234 women. Four major attributional themes emerged from their responses: medical/health attributions, psychogenic attributions, relationship attributions, and technique/setting attributions.

Two additional subthemes were identified which did not specifically address ONO. First, many participants indicated being unsure as to why they or their partner were unable to orgasm (e.g. “Close but just won’t orgasm” and “haven’t figured it out yet” and “I wish I knew”). Another frequent response, coded as not-applicable (N/A), was tabulated for participants who identified that they had not experienced difficulty reaching orgasm. Though these additional subthemes did not indicate any attribution for the non-occurrence of orgasm, the responses were coded for use in the correlational analyses.

Medical and health-related attributions included both sexually and non-sexually related medical or health-related causes. The most frequently reported attribution in this category indicated feeling “exhausted” or “too tired to orgasm.” Other attributions included non-sexual medically related injury or illness (e.g. “blood pressure medication hurts his libido” and “severe dental issues…neck pain, headache”), or sexually related medical conditions (e.g. “erectile dysfunction”). Any indications of a low sex drive that was not attributed to another cause were listed within this theme. The use or misuse of alcohol or other substances was also added to this theme. Substance use was the most commonly self-reported attribution among men’s non-occurrence of orgasm.

Psychogenic attributions included participants who indicated experiencing stress, anxiety, depression, and/or being distracted as common contributors. Participants who indicated feeling distracted or having their mind elsewhere were coded in this category (e.g. “Mind has a hard time turning off from other things’’) unless it was indicated that the distraction came from an external source (e.g. “kids banging on the door”). Other psychogenic attributions included stress or sexual anxiety (worrying about body image, religious guilt, and purposely delaying orgasm).

Relationship factors to which the ONO was attributed included focusing on a partner’s pleasure (e.g. “concerns over satisfying spouse” and “a night where it is all about her and her orgasm”), lack of desire (e.g. “not in the mood”), and experiencing relationship problems (e.g. “worried about partner straying”).

Technique and setting attributions focused on aspects of the sexual encounter that impeded or made it difficult to orgasm. These subthemes included attributions of timing issues (such as the sexual encounter ending after their partner orgasm), lack of foreplay or stimulation, interruption (e.g. “kids banging on the door”), having already orgasmed multiple times, or being impacted by the temperature of the setting or time of day. A breakdown of men’s and women’s frequencies for each subtheme is included below.

Quantitative analysis findings

Point-biserial correlations between attributional themes and the observed sexual and relational outcome measures were calculated separately for men and women. Additionally, three separate multiple regression analyses were conducted with all of the themes as predictors of the outcomes. Due to high collinearity statistics (Dormann et al., 2013), the “Not Applicable” subtheme was removed from the analysis. The overall attribution model was significantly related to sexual satisfaction in women (F (5,223) = 5.08, p < .001, R² = .10), relationship satisfaction in women (F (5,217) = 4.51, p < .001, R² = .09), and orgasm frequency in both men and women (male F (5,112) = 4.69, p < .001, R² = .17; female F (5,227) = 7.75, p < .001, R² = .15). The regression models of ONO attributions predicting sexual and relationship satisfaction were not significant. The multiple regression analyses yielded the same significant findings as the point-biserial correlations. All correlations and standardized beta coefficients are listed below in Tables 3 and 4.

Table 3. Summary of participant attributions for their own non-occurrence of orgasm.

Theme	Subtheme	Men	Women	Total
Medical/health attributions	Tired/lack of energy	27	27	54
	Medical injury or illness (not sexually related)	11	37	48
	Sexually related medical condition	11	7	18
	Substance use	3	1	4
	Total	52	72	124
Psychogenic attributions	Distracted/mind elsewhere	6	37	43
	Stress/anxiety (not sexually related)	12	31	43
	Sexual anxiety (body image, guilt, witholding)	3	7	10
	Total	21	75	96
Relationship attributions	Not in the mood/low desire	10	34	44
	Focused on partner’s pleasure only	21	16	21
	Relationship problems	2	9	11
	Total	17	59	76
Technique/setting attributions	Not enough time/partner orgasms and encounter ends	10	61	71
	Technique problems/ lack of foreplay or stimulation	2	52	54
	Interruption	9	8	17
	Already orgasmed multiple times/ frequent masturbation	9	5	14
	Temperature of setting/time of day	3	3	6
	Total	33	129	162
Other responses	Never had a problem/ not applicable	32	18	50
	Unknown	10	18	28

Table 4. Summary of participant attributions for the non-occurrence of orgasm of their partner.

Theme	Subtheme	Men	Women	Total
Medical/health attributions	Tired/lack of energy	20	30	50
	Medical injury or illness (not sexually related)	15	23	38
	Sexually related medical condition	7	15	22
	Substance use	1	10	11
	Total	43	78	121
Psychogenic attributions	Distracted/mind elsewhere	21	15	36
	Stress/anxiety (not sexually related)	27	13	40
	Sexual anxiety (body image, guilt, witholding)	6	4	10
	Total	54	32	86
Relationship attributions	Not in the mood/low desire	24	11	35
	Focused on partner’s pleasure only	6	3	9
	Relationship problems	0	1	1
	Total	30	15	45
Technique/setting attributions	Not enough time/partner orgasms and encounter ends	30	16	46
	Technique problems/ lack of foreplay or stimulation	21	8	29
	Interruption	4	11	15
	Already orgasmed multiple times/ frequent masturbation	1	11	12
	Temperature of setting/time of day	1	1	2
	Total	57	47	104
Other responses	Never had a problem/ not applicable	15	88	103
	Unknown	22	7	29

Discussion

Studying the attributional processes in response to a specific outcome can provide an essential roadmap for approaching assessment and treatment. In the present study, we explored cis-gendered, heterosexual men and womens’ attributions made in response to Orgasm Non-Occurrence (ONO) among predominantly cisgender, heterosexual, White participants. While the homogenous sample represents a limitation, previous literature has noted similar automatic thoughts associated with distressing sexual symptoms regardless of sexual orientation (Peixoto & Nobre, 2016). Specifically, participants were asked to reflect on why they did not experience orgasm and to hypothesize what reasons might have contributed to their partner’s ONO. This study proceeded with the recognition that orgasm is not the only goal for sexual activity and orgasm occurrence is not necessarily synonymous with sexual pleasure (Chadwick et al., 2019). Previous findings suggest those who experience partner ONO, regardless of gender and sexual orientation, felt varying levels of distress (Catalan, 1993; Chadwick & van Anders, 2017; Conaglen & Conaglen, 2008; Gordon, 2006; McClelland, 2014; Tavares et al., 2020). Furthermore, men and women tend to provide different reasons for the distress related to ONO (Peixoto & Nobre, 2016; Salisbury & Fisher, 2014). However, regardless of whether the ONO is distressing, examining the attributions people make about it can give insight into beliefs about where partners consider placing the responsibility of sexual outcomes within a relational framework.

Qualitative analysis

Previous literature has identified that men and women tend to focus on internal, rather than external, attributions when experiencing distressing sexual outcomes, blaming their orgasm difficulties on themselves (Rowland & Kolba, 2018). The present study goes beyond internal and external attributions to identify the specific attributional tendencies related to the ONO. The thematic analysis for the gendered attributions of men and women about the ONO yielded four primary themes, including: (1) Medical/health attributions, (2) Psychogenic attributions, (3) Relational attributions, and (4) Technique/Setting attributions. Of the four themes, attributions related to the technique/setting were most frequently used to explain participants’ own ONO. However, medical/health-related attributions were most frequently used to explain the ONO of the participants’ partners. Relationship factors were least frequently attributed to the ONO for both individuals and their partners.

The findings of the current research study present a new paradox compared to previous research on orgasm. Mah and Binik (2005) identified that orgasm pleasure among predominantly heterosexual individuals is often attributed to psychosocial factors rather than physical or anatomical determinants. However, the current finding suggests that when orgasm does not occur, the psychosocial factors (psychogenic and relational attributions) were attributed less frequently than physical or anatomical determinants (medical/health and technique/setting attributions).

One potential explanation for this paradox could be that people have a tendency to value the psychosocial aspects of sexual pleasure (cognitive-affective and relationship satisfaction), and are more likely to overlook these factors as causes for the ONO. Therefore, when disappointing or distressing sexual outcomes occur, heterosexual individuals may consider physical or anatomical determinants quicker.

Another explanation for this paradox may be that when people are confronted with the non-occurrence of orgasm, they are more likely to consider medical/health and technique/setting attributions because they might be regarded as being within one’s control to change. In contrast, psychogenic and relational attributions may feel less accessible. The inverse may also be true. Future research will need to examine the pathways through which these attribution processes impact relationship processes and outcomes.

Gender comparison

The subthemes with the most significant discrepancies between men and women were within the technique/setting theme. More frequently than men, women attributed ONO to not having enough time or having the encounter end after their partner orgasms. Women more frequently attributed technique problems to their ONO, including a lack of foreplay or stimulation, than men. Men also most frequently attributed these two causes to their partner’s non-occurrence of orgasm, indicating some potentially shared understanding as to the importance of technique, time, foreplay, and stimulation in the occurrence of orgasm.

Attributing ONO to time and technique could indicate many factors (e.g. the intent or attitude toward orgasming); however, these attributions may suggest that the technique and time required for women to orgasm may not always be prioritized. Previous research also suggests that women tend to value men’s orgasms slightly more and are, therefore, moderately more persistent toward ensuring their male partners’ orgasm (Barnett et al., 2018).

The second most significant discrepancy between men and women was how often they reported being distracted or their minds being elsewhere. Women also more frequently attributed non-sexual stress and anxiety as the reason for their ONO Men also commonly attributed non-sexual stress to the ONO of their partners. Not being in the mood was indicated by both women and men to be a frequent attribution for ONO in women.

Heterosexual men and women also differed in how frequently they indicated that male partners had never had a problem reaching orgasm. Previous findings have suggested that heterosexual men tend to overestimate how frequently their heterosexual female partners’ orgasm in both assisted (with concurrent clitoral stimulation) and unassisted (without concurrent clitoral stimulation) intercourse (Shirazi et al., 2018). The orgasm frequency gap also tends to be largest between heterosexual men and women, when compared with men and women in same-sex relationships (Frederick et al., 2017). However, the present study identified women more frequently indicated the ONO had never happened to their partners than men did. Future research should further examine the accuracy of estimating their partners’ orgasm occurrence and their ONO. Doing so may help identify whether cisgender socialization and heteronormativity may bias the perception of sexual difficulties.

Quantitative analysis

While previous literature had examined how attributions of orgasm difficulty impact the severity of self-reported distress (Hevesi et al., 2020), their impact on sexual and relational outcomes has not been studied. The exploratory quantitative analysis employed a novel approach to quantitizing and analyzing participants’ qualitative responses. Using the dichotomous coding of each theme as predictor variables, we explored the relationships of these attributional themes on sexual and relational outcomes among heterosexual couples.

Differences in heterosexual male and female attributions about the ONO were found in each of the outcome variables examined. Relational attributions were the only of the primary themes that were significantly related to sexual and relational outcomes. For women, relational attributions were negatively associated with sexual and relationship satisfaction. This finding might help clarify some of the qualitative paradoxes from earlier. While Medical and Technique/Setting attributions were more common, only relational attributions were significantly related to satisfaction outcomes in women. However, orgasm frequency was not significantly related to relational attributions, suggesting that satisfaction may have more to do with perceptions of the relationship than the associated sexual outcomes.

Confusion about the non-occurrence of orgasm

Beyond the themes discussed earlier, one frequently coded response indicated that participants did not always know to what cause they should attribute the ONO. Heterosexual men more commonly reported not knowing to what they should attribute to their partners’ ONO. This not knowing could be impacted by several factors (e.g. lack of communication or sexual knowledge). However, the distress that may result from the ONO may be exacerbated by the feeling that one’s partner does not know how to help. One previous study identified that heterosexual women commonly assumed more responsibility for their partner’s distress after the ONO (Rowland & Kolba, 2018). Additional research should examine the dyadic impact of confusion about ONO on distress and other sexual outcomes.

Not knowing what to attribute the ONO was also negatively associated with orgasm frequency for both genders and women’s sexual and relationship satisfaction. This finding may indicate that attributing a cause may potentially be a protective factor in experiencing negative sexual and relational outcomes. It may be that the attribution-making process provides an avenue to make meaning of the ONO, identifying social scripts guiding that meaning, and finding possible ways to change if desired.

Clinical implications

This study examined the common attributions that men and women in heterosexual relationships make about ONO, and the impact of those attributions on sexual and relational outcomes. Sex and relational therapists should pay close attention to the attributions to which their clients attribute the ONO. Discussing attributions is not only a critical step towards explicitly discussing social scripts; it might also shed light on the perceived sources of distress. Recognizing that clients may not know to what they should attribute to ONO; clinicians should prioritize assessment and education related to their clients’ sexual problems. As discussed in the PLISSIT model (Annon, 1976), providing limited information directly affect the sexual and relational outcomes of the client.

Couple therapists should recognize the tendency for heterosexual partners to focus on medical/health and technique/setting attributions rather than psychosocial aspects of sex. While these attributions may be most common, it is essential to note that they were not significantly related to sexual or relational outcomes. Reframing individual-level sexual distress as the result of a relational process may provide helpful insight for distressing ONO among heterosexual couples.

Clinicians would do well to assess the attributions heterosexual clients make surrounding the ONO of either one or both partners. Some well-validated assessment measures (e.g. PROMIS sexual function and satisfaction measures version 2.0; Weinfurt et al., 2015) ask questions about the attributions surrounding the ONO. Utilizing measures like this might increase clinical speed and precision for assessing a client’s perceived explanations of distressing sexual experiences. Additionally, such measurements help identify a targeted intervention approach that acknowledges both partners’ views on who is responsible for their sexual outcomes.

Limitations

Semantics influence outcomes when studying sexual interactions and orgasm. Literature suggests that explicitly defining ‘sex’ as ‘intercourse’ and whether intercourse includes clitoral stimulation significantly impacts reported rates of sexual frequency and orgasm frequency with heterosexual participants (Shirazi et al., 2018; Wakil, 2021). However, in the interest of inclusivity, the term ‘sexual interaction’ was purposefully utilized in this study. This approach allowed each participant the opportunity to self-define sex. Yet, there is also no ability to know what participants considered to be included within their definition of “a sexual interaction.”

Because responses were generated through an online survey, there was no interviewer to encourage rich, thoughtful responses. Responses to the qualitative responses were generally short and occasionally incomplete. While the coders did their best to reach a consensus on whether a response was codable or not, short responses were occasionally left to the interpretation of the research team.

The present findings were also limited in that they present the results of a monolithic sample (mostly White Americans). Furthermore, the sample only included heterosexual participants and presumed to be cisgender. The study results should only be interpreted in the context of the demographics of the studied population.

Lastly, this analysis compares the descriptive frequencies of heterosexual male and female responses alone, yet there were also unequal numbers of men and women. Discrepancies between response numbers may not be attributable to gender differences but participation. The authors were careful not to indicate any significant differences between groups because inferential testing was not done in the qualitative analysis. Readers should be careful to recognize that no statistical conclusions can be drawn from the frequency differences displayed in Tables 1 and 2.

Table 1. Point-biserial correlations of attributions made with sexual and relational outcomes.

	Sexual satisfaction		Relationship satisfaction		Orgasm frequency
	Male rpb	Female rpb	Male rpb	Male rpb	Female rpb	Male rpb
Medical/health attributions	.14	.03	.17	-.00	.00	-.03
Psychogenic attributions	-.04	.09	-.12	.09	.01	.10
Relational attributions	-.07	-.14*	-.15	-.19**	-.09	-.02
Technique/setting attributions	.01	-.04	-.02	-.02	-.01	-.01
Unknown	-.07	-.25***	.15	-.20**	-.38***	-.36***
Non-applicable	-.03	.24***	-.05	.20**	.15	.23**

* p ≤ .05;

**p ≤ .01;

***p ≤ .001.

Table 2. Multiple regression analyses of attributions made with sexual and relational outcomes (standardized beta coefficients).

Predictor	Sexual satisfaction		Relationship satisfaction		Orgasm frequency
	M	F	M	F	M	F
R^2	.03	.10	.08	.09	.17	.15
Medical/health attributions	.14	-.04	.21	-.06	-.07	-.11
Psychogenic attributions	-.04	.02	-.11	.03	.02	.04
Relational attributions	-.07	-.18**	-.11	-.22***	-.14	-.06
Technique/setting attributions	.03	-.09	.05	-.08	-.09	-.08
Unknown	-.06	-.28***	−17	-.24***	-.42***	-.38***

* p ≤ .05;

**p ≤ .01;

***p ≤ .001.

Conclusion

The findings revealed several consistent themes heterosexual men and women attribute to ONO both for themselves and their partners. Men and women attributed ONO to health and technique attributions more frequently than psychogenic and relational attributions. Study results reveal the possible negative impact ONO confusion may have on sexual and relational outcomes for heterosexual couples. Additionally, the findings also provide nuanced insight into the paradoxical nature between attributions of orgasm pleasure and orgasm non-occurrence. This mixed-methods approach provides important considerations for both clinicians and researchers in more aptly assessing and treating orgasm difficulties when working with heterosexual clients.

Acknowledgment

The authors would like to sincerely thank the following individuals for their contributions to the coding and analysis of the data presented in this article: Dave Robinson, Hunter Nilson, Jennifer Walker, Douglas McPhee, Ashley Bell, Ashley Fischer, and Alex Remund.

Disclosure statement

No potential conflict of interest was reported by the authors.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Adam C. Jones

Adam Jones, is an assistant professor in the department of Human Development, Family Studies, & Counseling at Texas Woman’s University. Dr. Jones teaches in the MS and PhD programs in Marriage and Family Therapy. He researches sexual relationships in couples and clinical effectiveness of relational therapists. He has recently published articles on dyadic sexual communication in the Journal of Sex and Marital Therapy and the Journal of Marital and Family Therapy.

Holly E. Eddy

Holly Eddy, is a doctoral student in the Marriage and Family Therapy program at Texas Woman’s University. Her research interests include applying critical theory to sexual education and communication within families and deliberately practicing multicultural orientation with relational therapists. She is a Licensed Marriage and Family Therapist-Associate and an AAMFT Approved Supervisor Candidate.