A deep dive into devices for sexual health

Many women are dissatisfied with their sex lives, and reports suggest they feel discouraged as their doctors often fail to inquire about sexual health concerns.¹ Gynecologic providers should feel more comfortable proactively addressing the sexual well-being of their patients. Low libido, lack of arousal, diminished or absent orgasm, and painful sex are common complaints. Can sex toys or devices such as dildos, vibrators, or graduated dilators be part of the solution? Is this a data-free zone best left to the internet or the marketplace, or can health care providers help guide and support their patients who are seeking better sex?

More than half of women in the United States have used a vibrator, and more than three-quarters of women who have sex with women have used a vibrator.¹ A 2009 study found that approximately 52% of women incorporated vibrator assistance during sexual activity and up to 41% included a vibrator with partnered activity, but by 2022, approximately 80% of women reported using a vibrator.² A prospective study³ and correlational studies4 found that women using genital vibratory stimulation devices demonstrated substantial improvements in arousal, orgasm, sexual function, and satisfaction, and decreased sexually related distress. Dilators and, at times, vibrators are routinely included in the management of pelvic floor dysfunction and pelvic and vulvar pain.

What is out there?

Sexual devices or sex aids are broad categories referring to any 3-dimensional object designed to physically improve sexual stimulation, arousal, or activity to make sex easier or more enjoyable. A sex toy is a colloquial term for an object used to increase sexual pleasure. Vibrators and dildos (Figure) are the most used sex toys for both solo and partnered activity. There are various sizes, shapes, materials, speeds and intensities, battery or electrically powered. They can be designed for internal penetrative stimulation or external clitoral stimulation, or shaped with an appendage to provide a combination of both vaginal and clitoral stimulation. Some are handheld or worn on a finger or palm, hands-free and designed to fit between labia, or strapped onto the vulva with a harness or panty. Dildos are phallus-shaped devices; varieties include single-ended, double-sided, strap-on, or underwear style. Anal-specific devices such as butt plugs, vibrators, and beads require a string or wide flange to prevent upward migration. There is no data thus far on the use of silicone realistic sex dolls by women. In short, there are many styles and types for patients to try.

Who is the intended audience for a discussion of sex aids? Some patients may be curious and interested to try a device either solo or with a partner, but they may have questions or concerns and would like more information from their health care provider. Others may report general sexual distress, dissatisfaction, issues with arousal, orgasm, dyspareunia, or have a particular reason for desiring or needing additional stimulation.The first place to start the discussion is with a sexual history and attitude check. Education and counseling are crucial. Women with negative feelings about vibrators or sex devices use may not be good candidates. Some women may prefer more neutral terms such as marital aid or sexual health device. Medical professionals who recommend vibrators or other sex aids must be prepared to address views on entitlement issues, concerns about intimacy and the effect on a partner, and health and safety issues. Recommendations for vibrator use can have psychological, emotional, and interpersonal ramifications. Referrals can be made to a sex therapist or counselor if indicated.

Common questions raised by patients are discussed below.

Is it acceptable or normal to use a sex toy?

Vibrator use is common among diverse groups of women and is associated with positive sexual functioning, desire, arousal, lubrication, orgasm, and improvements in pain.⁴ A survey of individuals aged 18 to 60 years old in the US found that most men and women had many positive and few negative beliefs about women’s vibrator use, and women with positive beliefs reported higher scores on the Female Sexual Functioning Index (FSFI) related to arousal, orgasm, satisfaction, and pain.⁵ Measurement of sexual functioning using the FSFI and other screening tools assume cisgender heteronormative sexual functioning; however, the health care provider’s approach and care should be inclusive of transgender and nonbinary individuals. Furthermore, culture, background, and religiosity may engender conflicting feelings about the use of sexual aids, which can be best addressed with a referral for sexual counseling as needed.

How will my partner feel if I use a sex toy?

Medical professionals need to consider a patient’s concerns about the effect of sex toy use on the partner. The partner’s feelings of involvement or competence or ability to give their partner pleasure and their self-esteem may be related to the way their partner experiences orgasm. For example, 1 study found that young men had higher ratings of masculinity and accomplishment if they imagined their partner having an orgasm from intercourse, as compared to an orgasm from manual or oral stimulation.⁶

A vibrator may be used solo, as an option for self-pleasure, or with a partner. Most women achieve orgasm more quickly using a vibrator alone, but this does not replace the sexual experience and desire for intimacy with another human being. The physical and emotional connection, skin-to-skin contact, human touch, caressing, kissing, massaging, and intimate verbal and nonverbal communication are not obviated by addition of a sexual aid. The vibrator can be used during partnered sex; for example, vibratory clitoral stimulation during sex with penetration (with phallus, fingers, or dildo)or without penetration and can also be used to explore each other’s erogenous zones. Couples should coach each other about what they find mutually stimulating. However, if the patient is very interested in a sex device and the patient’s partner is not open to using sex aids, you can suggest they enjoy solo use or consider talking with a sex counselor or therapist to further explore options.

Will I become vibrator dependent?

Until the 1990s, the sexuality literature was replete with assumptions that a woman’s inability to orgasm with intercourse was a sexual dysfunction and that clitoral stimulation or vibrator use did not produce a mature orgasm. Concerns from women were reinforced by medical opinion suggesting women could become vibrator dependent for orgasm or that vibrator use may habituate women to ways of responding to sexual stimulation (eg, experiencing orgasm more easily with a vibrator and less so with a partner).⁴ However studies have not shown women to become dependent on vibratory stimulation to achieve orgasm after experiencing orgasm with a vibrator.⁷

Can I be harmed while using a sex toy?

Sex toys and devices are not FDA approved or regulated and are often sold with labels such as “body safe” or “for novelty use only” in order to avoid FDA regulation as a medical device.⁸ There are no US Consumer Product Safety Commission (CPSC) reports on sexual device safety.There is a searchable public database (SaferProducts.gov) managed by the CPSC where consumers’ experiences and manufacturers’ responses can be viewed. An exception is a battery-powered clitoral suction device approved in 2000 (Eros-Clitoral Therapy Device) that is intended to improve arousal and orgasm by increasing blood flow and engorgement.

Evidence of the device’s effectiveness is limited, and there is no evidence to suggest that it is better than over-the-counter sex toys, such as vibrators, which are widely available. Some devices, such as a set of stackable rings placed over the base of the penis to treat collision dyspareunia (deep pelvic pain when the penis collides with the cervix or vaginal apex), are designed with FDA approved “body safe” polymer blends. An expandable vaginal dilator is marketed as an “FDA-cleared device.”

There are possible risks of chemical exposure or harm with sex device usage, though the risks are thought to be low.^1,8,9 The devices come in contact with permeable tissues, and studies have found that varying levels of microplastics and phthalates can be transferred from the devices.⁸ Phthalates are pervasive in soft jelly-like plastics and are known endocrine disruptors, which are banned in children’s toys because they are linked with cancer and neurological issues. Some vendors and shops now ban products containing phthalates. The Danish Environmental Protection Agency recommends that the easiest way to protect oneself is to place a condom over the device. A device made of medical-grade silicone, hard plastic, glass, or stainless steel may be less toxic than soft plastic.⁹

According to a 2009 study, almost 7000 individuals, mostly those in their 30s, were seen in emergency departments because of a sexual aid mishap, usually to retrieve a vibrator or dildo from the rectum and, much less frequently, from the vagina.⁹ External vibrators used correctly will not get lost in a body cavity but have been associated with vibratory strain injury. In the 2009 study, 18% of women who used a vibrator had numbness, pain, or other adverse effects, generally transitory. Care should be taken to avoid continuous monotonous vibration so as not to lead to numbness and to avoid prolonged direct clitoral stimulation. However, nerve desensitization or injury are unlikely,⁹ but more research is needed.

Large devices can also tear vaginal or anal skin, resulting in pain and risk of infection. Using a lubricant may lower the risk of discomfort and improve satisfaction while using a sex toy; however, it is important to check compatibility of the sex toy with various types of lubricants per the manufacturer’s guidelines.

Can I get an infection from using a sex toy?

Sexually transmitted infections, including human papilloma virus, HIV, and, in women who have sex with women, bacterial vaginosis, can conceivably be transmitted through sex toy use. In general, sex toys should not be shared with nonmonogamous partners and should be disinfected between partners. Specifically, toys should be cleaned well with soap and water before and after use and before switching to use in another orifice, and devices can be disinfected according to manufacturer’s instructions. Soft, jelly-like devices are porous and more difficult to clean and, therefore, are most safely used with a condom. Toys that are nonvibrating, lack any battery-operated moving parts, and are made of high-grade silicone, stainless steel, or Pyrex can be boiled for 3 to 5 minutes to sanitize. Barriers such as condoms can be used to reduce risk.¹

Specific medical conditions

Genito-pelvic pain/penetration disorder

Dilators can have a key role in enhancing sexual experience for those with dyspareunia/vaginismus. Dilators are tapered, tube-shaped devices of graduated width and length made of plastic, silicone, or glass, and are available for purchase online. They are used with a water-based lubricant daily or a few times per week for up to 20 minutes per session. Women are advised to start with a small dilator that enters the vagina comfortably and to slowly increase the dilator size over time.¹⁰

Dilators can improve introital elasticity and narrow caliber stemming from lack of estrogen, radiation, age-related fibrosis of the hymen, or narrowing due to scarring or certain congenital conditions. The underlying cause of narrowing or atrophy must be addressed first or concurrently. Scarring secondary to vulvar dystrophy or surgery (obstetrical repairs, perineorrhaphy, gender-affirming procedures) can respond to progressive dilation and may not require further surgery. Topical local anesthetic can be applied prior to dilation if needed.

Dilators are commonly used as part of a program to treat pelvic pain and sexual pain syndromes related to pelvic floor muscle hypertonus and dysfunction. Therapeutic dilation includes exercises provided by a pelvic floor physical therapist to relax the pelvic floor muscles. Sexual activity can be introduced after progress has been made in treating muscle dysfunction.A sex therapist or a behavioral psychologist can be added to the care team to change maladaptive protective response, whereby the brain anticipates pain instead of pleasure, particularly in the setting of fear of pain with sex or concerns about intimacy with a partner.

One pilot survey study employed a vibratory device as part of a multimodal program for dyspareunia due to vulvodynia.¹¹ The vibratory device was placed on the vulva and nearby pelvic floor to target the myalgia and somatosensory components of vulvodynia. Acceptability, affordability, and convenience were positively reported in most cases, and over 70% of the 76 participants said sex was less painful and more enjoyable after treatment; however, controlled trials are lacking.¹¹

Vibrators such as a vibrating pelvic wand or flexible vibrating devices that can be molded to reach a tight muscle or trigger point may have variable speeds and intensities. Women should be cautioned that although vibrators can increase blood flow, arousal, and overall pleasure, some may find them irritating to the pelvic muscles or nerves.¹²

Pregnancy and postpartum

Sexual function is commonly altered by pregnancy, and dysfunction affects up to 80% of women in the postpartum period.¹³ Pregnant women should discuss ongoing sexual activity and use of vibrators during pregnancy with their clinicians. There may be contraindication for vaginal penetration, such as placentation abnormalities. Historically, it was thought that orgasm may increase obstetrical risk by inducing uterine contractions, but this hasn’t been well studied and no adverse outcomes have been reported. Some women may benefit from use of a sexual device during pregnancy because of the physical challenges that make sexual activity and masturbation more challenging.¹³ Supportive care and counseling should be offered first. Local vaginal estrogen may help women with dyspareunia or vaginal changes due to hypoestrogenic state of lactational amenorrhea, and pelvic floor physical therapy is indicated for postpartum pelvic floor dysfunction, including pelvic organ prolapse, pain, urinary incontinence, or fecal incontinence. In addition to pelvic floor muscle training, various rehabilitation devices such as curved wands for trigger points, dilators, or surface biofeedback units may be used by the pelvic floor physical therapist.¹⁴

Menopause

Sex devices can have various benefits for postmenopausal women. Enhanced pleasure and improvement in orgasmic functioning may be achieved with vibrators and dildos. Stimulation of the vulvar and vaginal areas helps to maintain blood flow and vaginal secretions. Sexual activity, with penetration with or without a partner, helps to maintain vaginal caliber and tone. Postmenopausal women often have fewer opportunities for partnered sex due to death or debilitation or absence of available partners. Self or mutual masturbation may include the use of dildos or vibrators and should be encouraged as appropriate.

After addressing libido and arousal with psychological or pharmacological interventions, difficulty with orgasm or female orgasmic disorder (FOD) and female hypoactive sexual desire disorder (HSDD) should also be addressed. With advancing age, women report weaker, shorter orgasms that are more difficult to achieve, though some studies find age has a negligible effect on orgasm.⁷ Vibrators may also play a role in treatment of FOD and HSDD in menopausal women by enhancing receptive desire and arousal. Relief of pain with penetration after use of vaginal dilators (generally combined with pharmacological therapy for genitourinary syndrome of menopause) can be highly effective.

Disability or other chronic illness

Orgasm during partnered or solo sex can be difficult for those with arthritis or neurological disorders such as spinal cord injury, multiple sclerosis, Parkinson disease, stroke, traumatic brain injury, cerebral palsy, or carpal tunnel syndrome.¹⁵ Advice and suggestions for vibratory devices may be appreciated. Sex aids with larger handles or buttons and straps, bolsters, or mounts are available for masturbation. For those with lower genital sensation, vibratory devices with variable intensity and speed can be recommended.

Cancer survivors

Patients with gynecological cancers have the highest prevalence (78%) of problems with sexual functioning; patients with colorectal cancer and breast cancer are less affected (65%).¹⁶ All domains are affected by cancer or cancer treatments: desire, arousal, orgasm, and pain. Changes in anatomy, neural sensation, hormonal alterations, and psychological sequalae due to a cancer diagnosis and treatment all must be addressed. The role of sex aids in management of sexual dysfunction in patients with cancer requires further study. Psychoeducation in group or individual sessions is the most common approach to improve sexual functioning in cancer survivors. Most studies show improvement in relationship adjustment, emotional distress, and communication but not necessarily in pain with penetration. Programs generally include discussion of moisturizers and dilators; however, there are no quality data on dilators and vibrators.^16,17

Pelvic radiation commonly leads to vaginal stenosis. Regular vaginal dilation during radiotherapy may prevent stenosis or improve quality of sexual functioning. Several observational studies found that frequent dilation is associated with lower rates of self-reported stenosis.¹⁸ One study noted that regular habit, slower placement of a smaller dilator, extra lubrication, and the addition of a vibrator helped women comply.¹⁸

Conclusion

Sexual health is a cornerstone of women’s emotional and physical health and well-being.Women consistently report that their providers do not inquire about sexual health, and they would like us to do so because they trust us. Most women and couples have tried a sex device for enjoyment or therapeutic reasons, and there is a small body of research supporting a role for vibrators and dilators in improving sexual functioning and gratification. Health care providers can become a helpful resource by staying informed on the topics their patients primarily search the internet for advice on. Excellent online resources are also available on websites of the American Association of Sexuality Educators, Counselors, and Therapists; the International Society for the Study of Women’s Sexual Health; and the American Cancer Society.

References

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