Six Evidence-Supported Pathways to Orgasmic Access
Research involving women with orgasm difficulty has identified six pathways associated with orgasmic access.
Cannabis-Assisted Pathway
Cannabis is a therapeutic tool that can influence sensory, cognitive, emotional, and physiological processes. In 1970, sociologist Erich Goode documented a woman who reported being able to orgasm only under the influence of cannabis (Goode, 1970). That same year, Barbara Lewis reported that four women had learned to orgasm while using cannabis and subsequently were able to orgasm without it (Lewis, 1970). More than 50 years later, a 2025 systematic review of 16 studies including 8,849 women found evidence supporting cannabis-associated improvements in orgasmic function (Mulvehill & Tishler, 2025).
Fantasy & Imagery Pathway
For more than 50 years, fantasy and imagery have been used in the treatment of orgasm and other sexual difficulties. Historical approaches included fantasy training, guided imagery, and orgasmic reconditioning, while more recent clinical studies found improvements in sexual function, including orgasm, as well as increased desire and pleasure and reduced sexual distress and worries (Marquis, 1970; Wish, 1975; Mohammadi et al., 2023; Campos et al., 2026).
Hypnotic Induction Pathway
For more than 60 years, hypnosis has been used in the treatment of female orgasm and sexual difficulties. (Richardson, 1963; Glick, 1972 ). In 1983, Andersen identified hypnosis as one of the major treatment models for primary orgasmic dysfunction (Andersen, 1983 ). More recently, hypnotically induced orgasm was accompanied by increased plasma prolactin and characteristic pelvic-floor contractions, providing physiological evidence of orgasmic response without genital stimulation (Pfaus et al., 2025).
LSD-Assisted Psychotherapy Pathway
Research dating to 1960 documented LSD-assisted psychotherapy for women with sexual and orgasmic difficulties (Ling & Buckman,1960). In 1964, Ling and Buckman reported a woman with complete “frigidity” who, after six LSD- and Ritalin-assisted psychotherapy sessions, experienced her first full orgasm during intercourse; they also reported improvement in 16 other selected cases (Ling & Buckman,1964). A 1962 first-person account by Constance Newland separately documented recovery from longstanding “frigidity” during LSD-assisted psychotherapy (Newland, 1962).
Pelvic Floor & Somatic-Motor Pathway
Research linking pelvic floor function with female sexual response and orgasm dates back more than 70 years. In 1952, Arnold Kegel reported improved orgasmic response following pelvic floor training (Kegel, 1952). Nearly six decades later, research examined pelvic floor muscle training specifically in women with secondary anorgasmia (Riccetto et al., 2010). Most recently, Pfaus and colleagues demonstrated that a systematic technique of pelvic floor movements could induce non-genitally stimulated orgasms accompanied by measurable increases in plasma prolactin, identifying the technique as a potential therapeutic intervention for women with orgasm difficulties (Pfaus et al., 2026).
Tantra & Breath-Based Altered States Pathway
Yoga-, tantra-, and breath-based practices have been studied as approaches to female sexual function and orgasm. In 2010, 12 weeks of yoga significantly improved all six domains of female sexual function, including orgasm (Dhikav et al., 2010). In 2022, Pfaus and Tsarski documented a woman whose yoga and tantric training began in the context of vaginismus and orgasm difficulty and who later developed sustained non-genitally stimulated orgasmic states accompanied by measurable increases in plasma prolactin (Pfaus & Tsarski, 2022). More recently, diaphragmatic breathing significantly improved sexual function in women with sexual dysfunction (Elgayar, 2026).
What Six Converging Pathways Reveal
The six evidence-supported pathways show that women may access orgasm through very different routes, both genitally and non-genitally, and appear to converge on a shared feature: an absorbed, altered, or otherwise orgasm-supportive state of consciousness.
This convergence echoes a broader line of sexual-response research. In 1994, Swartz proposed that absorbed states of consciousness may play a particularly important role in female arousal and orgasm (Swartz, 1994). A decade later, Meston and colleagues described female orgasm itself as “creating an altered state of consciousness” (Meston et al., 2004), and in 2016, Costa and colleagues found that this kind of attentional absorption was strongly related to greater sexual responsiveness in women (Costa et al., 2016).
This raises a further possibility: for women with orgasm difficulty, the shift into that absorbed, altered, or orgasm-supportive state may begin before orgasm, and help make orgasm accessible in the first place.
Yet for more than 50 years, treatment has largely centered on a small group of behavioral and psychological approaches, without making that state transition a therapeutic target.
So what has actually been shown to work, and for whom?
The Best-Established Treatment Addressed One Specific Orgasm Problem: Women Who Had Never Experienced Orgasm
In a landmark 1997 review, directed masturbation was the only treatment identified as “well-established,” and only for primary anorgasmia, women who had never experienced orgasm (Heiman & Meston, 1997), a group estimated at 10–15% of women (MedlinePlus, 2024).
For women with other forms of orgasm difficulty, including those who could orgasm during masturbation but not with a partner, or who had lost a previously available orgasmic response, no treatment met that same standard. These approaches were classified only as “probably efficacious,” with a “generally less optimistic prognosis than primary anorgasmia” (Heiman & Meston, 1997). Heiman and Meston named the problem directly:
“Interventions have not been adequately tailored toward individual needs.”
Nearly Three Decades Later
The scale of the problem only grew clearer. By 2022, the DSM-5-TR reported prevalence estimates for female orgasmic problems as high as 72% among premenopausal women, up from a 2013 high of 42% (American Psychiatric Association, 2013, 2022). It was also global: a 29-country study of more than 27,000 adults found orgasm difficulty common worldwide (Laumann et al., 2005). And it persisted across generations: five decades of Finnish surveys found that rising sexual education, gender equality, and masturbation rates had not made women more orgasmic (Kontula & Miettinen, 2016).
Yet treatment innovation had not kept pace:
“Treatment of FOD has seen little innovation since the 1980s.”
The Treatment Gap
Female orgasm difficulty affects a substantial proportion of women, occurs throughout the world, and has persisted across generations, yet treatment innovation has remained remarkably limited.
The Sexual Response Model Behind Decades of Treatment
For decades, treatment for female orgasm difficulty has been shaped by dominant models of sexual response. In 1966, Masters and Johnson described the human sexual response cycle as a progression through excitement, plateau, orgasm, and resolution (Masters & Johnson, 1966).
Their model was enormously influential in advancing the scientific understanding of sexual response. But it was designed primarily to describe what happens physiologically during sexual response, not to explain how a woman who cannot orgasm develops access to orgasm in the first place.
That distinction matters.
A model that describes the progression from sexual arousal toward orgasm does not necessarily explain why that progression stops, why orgasm becomes inaccessible, or how orgasmic access can be learned.
The six evidence-supported pathways point toward a different possibility: orgasm may depend not simply on increasing arousal, but on the ability to transition into and sustain an absorbed, altered, or otherwise orgasm-supportive neurophysiological state.
If the therapeutic target changes, the treatment model may need to change with it.
A Clinical Framework
The Neuroregulatory Model of Female Orgasm
The Neuroregulatory Model of Female Orgasm (in peer review), developed by Suzanne Mulvehill, PhD, proposes that orgasm is a state-dependent neurophysiological process governed by the nervous system’s capacity to access and sustain the conditions in which orgasm becomes possible.
Research demonstrates that orgasm is centrally mediated and can arise through multiple pathways, including genital stimulation, non-genital stimulation, imagery, internally generated processes, and altered-state pathways. Within this model, desire and arousal are not necessarily universal prerequisites for orgasm, but variable features of particular pathways.
Different pathways. A shared neuroregulatory process.
Whether orgasm begins through genital stimulation, fantasy and imagery, hypnosis, pelvic-floor movement, cannabis, or other altered-state practices, the pathways may converge on a common process in which attention shifts, cognitive interference decreases, sensory and internally generated experience become increasingly salient, and the nervous system enters and sustains an orgasm-supportive state. This describes a multi-pathway framework in which structurally different routes can access a shared state-dependent process.
The Hierarchy of Female Orgasm Response
Orgasmic Release
Orgasm emerges as the peak expression of the established neurophysiological state, involving coordinated neural, autonomic, sensory, and motor activity.
Sensory Amplification
Sensory, interoceptive, emotional, and internally generated signals intensify and integrate. This experience may or may not include localized genital sensation.
Absorption
Attention becomes deeply immersed in sensory, affective, imaginative, or internally generated experience, with reduced self-monitoring and cognitive interference.
State Transition
The nervous system begins shifting away from ordinary consciousness and toward increased attentional and sensory engagement.
Safety
A baseline regulatory condition in which threat monitoring is sufficiently reduced to permit movement into subsequent states. Safety is the gating condition that permits access to the states above it.
This is the neuroregulatory foundation of Orgasmic Learning.
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