The literature reviewed will be organized by sexual functioning (specifically using the sexual response cycle as a framework), sexual satisfaction, cannabis, and finally cannabis’ influence on sexual functioning and satisfaction.
Sexual functioning and satisfaction
Masters and Johnson (1966) established the sexual response cycle that includes four phases: excitement, plateau, orgasm, and resolution. Each phase is identified by physiological responses of the body during sex; however, each phase may not be distinguishable from the next and may differ extensively each time and by each individual. Kaplan’s (1979) Triphasic Concept of sexual response included desire as the first stage of the sexual response cycle and Basson (2001) considered sexual satisfaction to be an important component of the sexual response cycle.
Newer research has expanded the sexual response cycle and adds to the original work of Masters and Johnson and Kaplan. Rather than being linear, the sexual response cycle is circular with overlapping phases that follow a variable order and incorporates mental and emotional components, not just physiological responses (Basson, 2005; Cherkasskaya and Rosario 2018).
Sexual desire, also known as libido, is characterized as a sexual drive or interest in sex that lasts throughout the sexual encounter until orgasm or satisfaction is reached (Kaplan 1979). Cherkasskaya and Rosario (2018) found that sexual desire is on a spectrum that varies between absent or diminished to high desire. Without desire, one may not experience the excitement phase or any following stages of the sexual response cycle because one’s mental state has greater implications than one’s physical desire and arousal (Basson 2008) Toates (2009) created the incentive motivation model that considers the “intertwined progression of desire and arousal” that reinforces the idea that desire and arousal are reciprocally reinforcing.
Excitement is characterized by an increase in sexual tension from an unaroused state and occurs as a result of physical and/or psychological sexual stimulation (Masters et al. 1995). Physiological responses that occur during the excitement phase for both sexes include myotonia (increased neuromuscular tension that occurs throughout the entire body, not just the genital region) and vasocongestion (the swelling of bodily tissues in the genital region due to increased blood flow). Vasocongestion can lead to lubrication in women and an erection in men; however, vaginal lubrication alone is not an accurate measurement of arousal. Women may have genital responses such as lubrication or vasocongestion while not experiencing desire (Chivers and Bailey 2005).
During the plateau phase, sexual arousal is increased while sexual tension levels off prior to reaching the threshold levels required to trigger an orgasm (Masters et al. 1979). During orgasm, there is a release of accumulated sexual tension, and the body induces involuntary rhythmic contractions within the genital region. However, an orgasm is a total body response and is not strictly localized to the pelvic region (Masters et al. 1979).
After orgasm, the body enters the resolution phase and returns to its unaroused state. Yet, if a woman maintains sexual arousal, she is physiologically capable of being multi-orgasmic, meaning having more than one orgasm before returning to her pre-aroused state. Men are typically unable to be multi-orgasmic because of the inevitable phase of the refractory period (i.e., the recovery period required for men to orgasm again after orgasm and ejaculation, which typically gets longer with age).
Sexual satisfaction can be defined as an individual’s subjective evaluation of the positive and negative aspects of one’s sexual relationships (Lawrance and Byers 1995) and may be influenced by many factors such as relationship quality, physical health, and overall well-being (Pascoal et al. 2018). Multiple and consistent orgasms and frequent sex were found to be correlated with higher sexual satisfaction (Kontula 2009; Kontula and Miettinen 2016).
While more than 90% of men report usually experiencing orgasm during sex, less than 50% of women regularly experience orgasm during intercourse and only 6% reported always experiencing an orgasm during sex (Kontula 2009; Koontula and Miettinen 2016). Mintz (2018) in her book Becoming Cliterate coined the term “orgasm inequality” to describe the phenomenon of men having routine and consistent orgasms, while women do not. Orgasm consistency is significantly related to sexual satisfaction in women. Women who experience orgasm infrequently or not at all report, on average, lower levels of sexual satisfaction (Kontula, 2009; Kontula and Miettinen 2016). This implies that orgasms during sex are expected for men, but a bonus if accomplished for women (Kontula 2009).
Sex and cannabis
Cannabis has been identified to have sexually stimulating effects and can intensify sexual experiences (Cohen 1982). The cannabinoid profile in cannabis influences sexual functioning and satisfaction as too much tetrahydrocannabinol (THC) may cause more inhibiting effects (Palamar et al. 2018). Due to its muscle relaxant properties (Small 2017), cannabis use may be inhibitory to men’s sexual functioning, yet, does not impair and may be beneficial for women’s sexual functioning (Sun and Eisenberg 2017). Cannabis may indirectly enhance sexual functioning by decreasing anxiety and increasing relaxation and sensory focus (Klein et al. 2012). It also has been found to be independently associated with increased sexual frequency with daily and weekly users having significantly higher sexual frequency compared to never-users (Sun and Eisenberg 2017).
Historically, and among different cultures, cannabis has been suspected to have an aphrodisiac effect increasing desire and sexual arousal among individuals (Chopra and Jandu 1976; Dawley et al. 1979; Halikas et al. 1982; Mayor’s Committee, 1944). Recent studies support this early research with reports of increased receptivity to and interest in sexual activity after using cannabis with women reporting higher rates of increased desire from cannabis use as compared to men (Androvicova et al. 2017; Lynn et al. 2019). Research has also found that cannabis users intentionally used cannabis for increased sexual desire as well as to decrease pain associated with sex (Green et al. 2003; Lynn et al. 2019).
Cannabis may also have implications during the excitement phase of the sexual response cycle which is characterized by the attainment of an erection in men and vaginal lubrication in women (Masters and Johnson 1966). Using cannabis has been reported to cause the inability to achieve and maintain an erection among men (Chopra and Jandu 1976; Masters et al. 1979) with a higher likelihood of developing erectile dysfunction among habitual users (Aversa et al. 2008). Foreplay could be considered an important part of the excitement stage and Palamar et al. (2018) found that cannabis use can increase the chances and duration of foreplay. Cannabis is also a vasodilator and because there are cannabinoid receptors in the genital region (Small 2017), cannabis may cause vasocongestion (i.e., lubrication) within female users. However, there is contradictory evidence on the influence of cannabis on female lubrication (Masters et al. 1979; Palamar et al. 2018).
During the plateau stage, which occurs after excitement but before orgasm, the vasocongestion response is at its peak in both men and women and the man’s penis is at its full-potential erection (Masters and Johnson 1966). Men are more likely to report increased duration of intercourse when using cannabis compared to women (Palamar et al. 2018; Weller and Halikas 1984). However, time may be perceived to last longer when using cannabis due to the altered time effect of cannabis use (Chopra and Jandu 1976; Kaplan, 1974; Palamar et al. 2018) or this may be due to increased time spent during foreplay when couples may engage in sexual exploration and try new behaviors while using cannabis (Palamar et al. 2018).
Orgasm is the release of sexual tension and cannabis use may contribute to more prolonged and pleasurable orgasms (Androvicova et al. 2017; Halikas et al. 1982). However, men’s daily cannabis use has been associated with inability to reach orgasm and reaching orgasm too quickly or too slowly (Smith et al. 2010). Those who are able to orgasm when using cannabis have also reported an increase in the quality and intensity of the orgasm, which was found to be especially apparent for men (Weller and Halikas 1984; Halikas et al. 1982; Palamar et al. 2018).
Cannabis use before sex has been reported to enhance sexual enjoyment and pleasure for individuals, including oral sex (Dawley et al.1979; Halikas et al. 1982; Traub 1977). Sensuality involves the senses (taste, touch, smell, sound, and sight) and, for the purpose of this study, is incorporated as an aspect of sexual satisfaction. Cannabis has continuously been reported to enhance taste and touch but seems to have less of an effect on hearing, smell, and sight (Koff 1974; Masters et al. 1979; Halikas et al. 1982; Weller and Halikas 1984). Increased sensation and sensuality have been found to be related to cannabis use which may be related to length and intensity of intercourse (Palamar et al. 2018). Cannabis use before sex has been associated with more tender, slower, and compassionate sexual acts while also feeling more relaxed with their partner (Palamar et al. 2018).
There is a need for updated research as cannabis use is becoming more prevalent due to legalization (Substance Abuse and Mental Health Services Administration 2018). The majority of existing literature is outdated and some of it is contradictory, such as the physiological effects of cannabis on sexual functioning and satisfaction.
The following exploratory research questions were proposed based on findings from previous literature as well as variables that have not been reported in previous literature: (a) Are there differences between men and women who use cannabis and their perceptions of sexual desire, orgasm intensity, and sexual satisfaction? (b) Does cannabis affect men’s ability to achieve and maintain an erection? (c) Does cannabis use affect women’s orgasm frequency? (d) How does cannabis use affect pleasure while masturbating? (e) What effect does gender, age, duration of cannabis use, intentionality, frequency of cannabis use, and cannabis form have on predicting sexual functioning and satisfaction?