Female Orgasm(s): One, Two, Several

Abstract

There is general agreement that it is possible to have an orgasm thru the direct simulation of the external clitoris. In contrast, the possibility of achieving climax during penetration has been controversial.
Six scientists with different experimental evidence debate the existence of the vaginally activated orgasm (VAO).
To give reader of The Journal of Sexual Medicine sufficient data to form her/his own opinion on an important topic of female sexuality.
Expert #1, the Controversy's section Editor, together with Expert #2, reviewed data from the literature demonstrating the anatomical possibility for the VAO. Expert #3 presents validating women's reports of pleasurable sexual responses and adaptive significance of the VAO. Echographic dynamic evidence induced Expert # 4 to describe one single orgasm, obtained from stimulation of either the external or internal clitoris, during penetration. Expert #5 reviewed his elegant experiments showing the uniquely different sensory responses to clitoral, vaginal, and cervical stimulation. Finally, the last Expert presented findings on the psychological scenario behind VAO.
The assumption that women may experience only the clitoral, external orgasm is not based on the best available scientific evidence.

Full text

Controversies in Sexual Medicine
Female Orgasm(s): One, Two, Severaljsm_2694 956..965
Emmanuele A. Jannini, MD,* Alberto Rubio-Casillas, Biologist,†Beverly Whipple, PhD, RN, FAAN,‡
Odile Buisson, MD,§Barry R. Komisaruk, PhD,¶and Stuart Brody, PhD**
*Course of Endocrinology and Medical Sexology, Department of Experimental Medicine, University of L’Aquila, Italy;
†Biology Laboratory, Escuela Preparatoria Regional de Autlán, Universidad de Guadalajara, México; ‡Professor Emerita,
Rutgers University, The State University of New Jersey, Newark, NJ, USA; §Centre d’échographie, Saint Germain en
Laye, France; ¶Department of Psychology, Rutgers University, The State University of New Jersey, Newark, NJ, USA;
**School of Social Sciences, University of the West of Scotland, UK
DOI: 10.1111/j.1743-6109.2012.02694.x
ABSTRACT
Introduction. There is general agreement that it is possible to have an orgasm thru the direct simulation of the
external clitoris. In contrast, the possibility of achieving climax during penetration has been controversial.
Methods. Six scientists with different experimental evidence debate the existence of the vaginally activated orgasm
(VAO).
Main Outcome Measure. To give reader of The Journal of Sexual Medicine sufficient data to form her/his own opinion
on an important topic of female sexuality.
Results. Expert #1, the Controversy’s section Editor, together with Expert #2, reviewed data from the literature
demonstrating the anatomical possibility for the VAO. Expert #3 presents validating women’s reports of pleasurable
sexual responses and adaptive significance of the VAO. Echographic dynamic evidence induced Expert#4todescribe
one single orgasm, obtained from stimulation of either the external or internal clitoris, during penetration. Expert
#5 reviewed his elegant experiments showing the uniquely different sensory responses to clitoral, vaginal, and
cervical stimulation. Finally, the last Expert presented findings on the psychological scenario behind VAO.
Conclusion. The assumption that women may experience only the clitoral, external orgasm is not based on the best
available scientific evidence. Jannini EA, Rubio-Casillas A, Whipple B, Buisson O, Komisaruk BR, and Brody
S. Female orgasm(s): one, two, several. J Sex Med 2012;9:956–965.
Key Words. Clitoris; Female Ejaculation; G-spot; Orgasm; Vagina
Despite a debate lasting more than 100 years,
the existence of different orgasms (mental,
from nipple/breast stimulation, clitoral, vaginal,
cervical, anal, etc.) in the human female is still
contentious. It seems that the sole noncontroversial
issue is that the (external) clitoris is the main organ
devoted to female orgasm. Hence, the real matter
of debate is if it is the unique one. Are there ana-
tomical bases for two different orgasms? In other
words, is the vagina itself able to trigger an orgasm?
On the basis of its supposedly low presence of
sensory receptors, the vagina was considered as
poorly responsive by Kinsey [1] and Masters and
Johnson [2] as contrasted with the clitoris. During
the sexual revolution, this idea was popularized,
for political reasons [3] and without scientifically
sound methods.
In order to help the reader in this controversial
topic, we will use the following terms: clitoral
orgasm (CO), as that obtained exclusively from
direct stimulation of the external clitoris, and
vaginally activated orgasm (VAO), as the climax
obtained during vaginal penetration, without
direct stimulation of the external clitoris [4,5].
© 2012 International Society for Sexual Medicine
956 J Sex Med 2012;9:956–965

Controversies in Sexual Medicine
Other authors in this Controversy section will use
the simpler term vaginal orgasm (VO).
Since 1950, there have been few studies on this
topic ([6] and references therein). Alzate and
Londoño [7] supported the existence in most
women of a zone (or zones) on either of the vaginal
walls, but especially on the anterior vaginal wall
(AVW), where tactile stimulation can lead to
orgasm. Furthermore, when an antiserum against
a general neuronal marker was used on normal
human vaginal mucosa, regional differences have
been found. The more distal areas of the vaginal
wall had more nerve fibers compared to the more
proximal parts. Moreover, biopsies from the AVW
generally were more densely innervated than the
posterior wall [8]. These findings gave anatomical
support in the identification of the AVW as the
region triggering the VAO. While other authors,
using questionable materials and methods, did not
find loco-regional differences in vaginal innerva-
tion [9], a more recent microdissection and immu-
nohistochemical study of the human vagina found
that the distal AVW is significantly thicker than
the proximal AVW and that this region is the most
densely innervated area [10].
In light of this recent evidence, the old and
wrong assumption that the vagina is poorly inner-
vated can no longer be sustained. This organ, and
especially the distal AVW, possesses enough nerves
to participate in the sexual response, as well the
whole biochemical machinery known to mediate
excitation and arousal in the male copulatory
organ [11–13]. However, human vagina does not
react alone during sexual arousal or orgasm. Our
fragmented view of the human anatomy and physi-
ology has impeded a comprehensive understand-
ing of the complex female sexual response.
Genital responses during sexual behavior in
females include vaginal and clitoral vasoconges-
tion, lubrication, and vaginal, anal sphincter, and
pelvic floor contractions [14]. Without consider-
ation of these anatomophysiological responses, the
supremacy of the CO has been claimed. Moreover,
it has been asserted that only the CO could exist.
Knowledge of the female sexual response probably
passes thru the renunciation to this reductionism.
We have other evidence justifying the existence
of the VAO. Doppler ultrasonography has been
used to study both anatomy and the vascular
response of clitoral arteries to vaginal stimulation.
A direct correlation between the presence of VAO
and the thickness of AVW was found [4]. Pressure
stimulations (20–160 mm Hg) along the lower
third of the vagina increased blood velocity and
flow into clitoris. In this study, no external clitoral
stimulation was applied [15]. Interestingly, it
should be noted that the lower vagina is also inner-
vated by the pudendal nerve, while the innervation
of the upper vagina is derived from the uterovagi-
nal plexus and pelvic splanchnic nerves [10]. This
is confirmed in the animal model, where the
stimulation of the sensory branch of the pudendal
nerve evokes changes in vaginal blood flow
through the activation of spinal autonomic effer-
ent pathways [16].
Another argument in favor of the VAO is pro-
vided by direct evidence in humans. Odile Buisson,
a gynecologist from Paris, expert in vaginal echo-
graphy, reviews her findings on the vaginal dis-
tension obtained by the penetration/finger
stimulation which induces the contraction of the
pelvic muscles (bulbocavernosus and ischiocaver-
nosus muscles) [17]. In this “vaginocavernosus
reflex” [18], the magnitude of contraction
increases with the volume of vaginal inflation, thus
suggesting that these events could increase the
contact between the vagina and the congestive cli-
toris [19]. Basically, her position is that the VAO
could be caused by contact of the internal clitoris
and the AVW. The proximity of the contact could
be enhanced by reflex perineal contractions and
vasomotor events, which occur in the case of erotic
stimulation.
These findings indicate a clear reciprocal rela-
tionship between the clitoris and the vagina. In
fact, in 1998, a close relationship between the cli-
toris, urethra, and vaginal wall was demonstrated
in the cadaver [20,21]. This has been functionally
confirmed in vivo. During vaginal penetration, in
fact, the root of the clitoris is stretched by the
penis and compressed against the AVW and the
pubic symphysis [17]. The clitoris and vagina
could be seen as an anatomical and functional unit
being activated by vaginal penetration during
intercourse. For this reason, and with the aim to
involve the urethra and the surrounding exocrine
glands, Jannini et al. named the area triggering the
VAO as clito-urethro-vaginal (CUV) complex
[22], a name probably more correctly able to
describe the G-spot, presented here by Beverly
Whipple, Professor Emerita at the Rutgers Uni-
versity, New Jersey.
If all female orgasms are clitoral in essence,
obtained through stimulation of the external or
J Sex Med 2012;9:956–965 957

Controversies in Sexual Medicine
internal clitoris, why are so many women able to
distinguish CO from VAO [23]? Are these referred
differences just psychological in nature? We may
argue that a particular woman may consider the
orgasm arising from the digital, external mastur-
bation less intense with respect to the (psychologi-
cally) stronger orgasm obtained during the unit of
the lovers’ bodies. The orgasm is, fact, a percep-
tion under psychorelational control.
Recent empirical evidence provided by two
other distinguished scientists discussing other con-
troversial aspects of the VAO here suggest differ-
ences instead of a unique functional unit. Stuart
Brody, Professor of Psychology at the University
of the West of Scotland, UK, maintains that
orgasm triggered by stimulation of the vagina and
cervix differs physiologically from climax induced
by clitoral stimulation. He firstly reported a dra-
matic difference (400%) in prolactin release (a
marker of psychoneuroendocrine involvement)
when comparing penile–vaginal intercourse (PVI)
to masturbation [24].
Barry R. Komisaruk, Professor at the Depart-
ment of Psychology, Rutgers, The State Univer-
sity of New Jersey and Adjunct Professor at the
Department of Radiology of the New Jersey
Medical School, found anatomical differences,
including innervation of the vagina and cervix
[25]. Interestingly, he found that women with a
completely severed spinal cord can have both
VAO and cervical orgasms, verifiable by func-
tional magnetic resonance imaging (fMRI), even
in the absence of any clitoral connection to the
brain [25,26]. This seems a convincing argument
in favor of more than one unique orgasmic
pathway. However, it could be argued that the
differences centrally demonstrated between the
two orgasms may reflect different perceptions:
VAO may stimulate other afferents in addition to
those connected to the clitoris.
In conclusion, although there is anatomophysi-
ological overlapping among clitoris, urethra, and
vagina (the CUV complex), there is now enough
neuroanatomical, physiological, and biochemical
evidence to support the existence of the VAO, an
orgasm, at least partially (and functionally), differ-
ent from CO. In a healthy sexual setting, probably
because of individual anatomical differences [11],
CO is a constant, while VAO is a variable. Women
who are not able to climax through vaginal pen-
etration alone should be educated to reject the
feeling of being inadequate or underachieving.
Ipse dixit is a term labeling a statement,
asserted but not proven, to be accepted on faith
in the speaker. After Kinsey [1], Masters and
Johnson [2], and Hite [27], this was the case of
the clitorocentric dogma of female orgasm. The
growing fruits of research will definitively change
this paradigm.
Emmanuele A. Jannini, MD and
Alberto Rubio-Casillas, Biologist
My research focus in the area of sexual health has
been to validate the subjective reports of women
concerning their pleasurable sexual experiences
and responses. Based on our research findings, I
have reported that women are pleasure oriented
not goal oriented, and that their sexual responses
are circular, not linear (for review, see reference
[28]). We have also published a continuum of
orgasmic responses [29].
It was by listening to women that John Perry
and I rediscovered a sensitive area that is felt
through the AVW, that swells when it is stimu-
lated, and in some women leads to orgasm and/or
female ejaculation. We named this area the
Grafenberg spot or G-spot after Ernst Grafen-
berg, MD who in 1950 wrote about this area that
surrounds the urethra and an expulsion of fluid
from the urethra that is different from urine [30].
This sensitive area is usually located about halfway
between the back of the pubic bone and the cervix,
along the course of the urethra. It swells when it is
stimulated, although it is difficult to palpate in an
unstimulated state. This is the area that Jannini
now calls the CUV complex [22]. Women have
reported a “bearing down” sensation like a Valsalva
maneuver when they experience orgasm from
stimulation of the area of the G-spot [29].
The phenomenon of female ejaculation refers
to an expulsion of fluid from the urethra that is
different from urine [5]. In some women, G-spot
stimulation, orgasm, and female ejaculation are
related, while in other women, they are not
related. Some women have reported experiencing
ejaculation with orgasm from clitoral stimulation
and some have reported experiencing ejaculation
without orgasm. This phenomenon is reported
by most women who experience it as extremely
pleasurable.
We then investigated the adaptive significance
of this sensitive area. Was it there for more than
pleasure? Based on Komisaruk’s extensive studies
with vaginal mechanical stimulation in rats pro-
958 J Sex Med 2012;9:956–965

Controversies in Sexual Medicine
ducing pain blockage, I hypothesized that the
adaptive significance of stimulation of the area of
the G-spot would be to attenuate the pain of child-
birth. We found that pain detection thresholds
increased significantly by a mean of 47% over
resting control when pressure was self-applied to
the area of the Grafenberg spot. When stimulation
was self-applied to this area in a pleasurable
manner, the pain thresholds were significantly
greater (by 84%) than that in the resting control
condition. The pain detection thresholds
increased by a mean of 107% when the women
reported orgasm. There were no increases in
tactile (or touch) thresholds. This demonstrates
that the effect was analgesic not an anesthetic
effect and not a distracting effect [31]. Our further
studies demonstrated that this analgesic effect also
occurs naturally during labor [32].
Another type of orgasmic response that we
measured in my human physiology laboratory was
orgasm from imagery alone. That is, no one,
including the woman herself, touched her body,
but she experienced orgasm. The physiological
correlates of orgasm, that is, significant increases
in blood pressure, heart rate, pupil diameter, and
pain thresholds over resting control conditions,
were the same during orgasm from genital self-
stimulation and orgasm from self-induced imagery
alone in the same subjects [33].
We continued our research program by validat-
ing the subjective reports of women with complete
spinal cord injury (SCI), that they do indeed expe-
rience orgasm. These women have been told,
based on the literature, that they could not expe-
rience orgasm, or if they did, it was “phantom
orgasm.” We have documented that women with
complete SCI do indeed experience orgasm from
self-stimulation of the AVW, the cervix, and a
hypersensitive area of their body [34].
We have demonstrated that orgasm is experi-
enced in the brain, and the same brain regions are
activated when orgasm is reported, regardless of
the type of physical self-stimulation or mental
imagery (for review, see [35]).
I want to conclude by saying that orgasm in
women is in the brain, it is felt in many body
regions, and it can be stimulated from many body
regions as well as from imagery alone. Orgasm is
not a just a reflex, it is a total body experience. We
need to continue to be open to documenting the
various pleasurable sensual and sexual experiences
reported by women. It is important to be aware of
the variety of sexual responses that women report
and that have been documented in the laboratory.
It is also important not to put women into a model
of only one or two ways to experience sensual and
sexual pleasure, satisfaction, and orgasm. Women
need to be encouraged to feel good about the
variety of ways they experience sexual pleasure,
without setting up specific goals (such as finding
the G-spot, experiencing female ejaculation, or
experiencing a VAO). Healthy sexuality begins
with acceptance of the self, in addition to an
emphasis of the process, rather than the goals, of
sexual interactions.
Beverly Whipple, PhD
After Masters and Johnson [2], some scientists
believe that all orgasms in women are physiologi-
cally identical, regardless of the source of stimula-
tion. However, women anecdotally describe two
types of orgasm. The CO obtained by the direct
external stimulation is described as “warm” or
“electrical,” and the vaginal one, obtained by a
vaginal penetration, is depicted as “throbbing,”
“deep,” and generally stronger [36].
O’Connell et al. found in autopsies that the cli-
toris, urethra, and distal vagina form a united
complex [20]. Our functional sonography method
then demonstrated that, during perineal contrac-
tion and finger stimulation of the lower AVW,
there is close relationship between the internal
clitoris and the AVW itself. This finding suggested
that the special sensitivity of the lower AVW could
be explained by pressure and movement of the
clitoris [19]. Sonography during the coitus showed
that the penis exerts a force on the AVW against
the pubic symphysis. In turn, the PVI stretches the
clitoris [17]. In fact, the double arch of the cavern-
ous bodies and bulbs of the clitoris [37] is func-
tionally modified by the PVI [38].
Recently, Song et al. have demonstrated on
seven fresh cadavers with microdissection and
immunohistochemical study that the pudendal
nerve distributes to distal vaginal wall, clitoris, and
labia minora and that the second 1/5 partition of the
distal anterior wall had significantly richer innerva-
tion than the surrounding areas [10]. Hence, the
AVW seems to be a structure so interrelated with
the clitoris that it is a matter of some debate
whether the two are truly separate structures [21].
The direct stimulation of the external clitoris
arouses predominantly the glans and the raphe.
On the contrary, the coital stimulation of the lower
J Sex Med 2012;9:956–965 959

Controversies in Sexual Medicine
AVW mainly activates the double arch of the cli-
toris [17]. Further sonographic studies are needed
to carefully evaluate which parts of the clitoris are
stimulated during masturbation of the external cli-
toris vs. masturbation of the AVW.
If two kinds of orgasms are reported by
women, two different afferent pathways should,
reasonably, exist. O’Connell et al. demonstrated
that the neurovascular supply to the clitoris is
derived from the pudendal and cavernous nerves
[39]. Recently, computer-assisted anatomic dis-
section and 3D reconstruction described neural
supply to the clitoris in five human female fetuses
[40]. It has demonstrated both somatic (dorsal
clitoris nerve) and autonomic pathways (the neu-
rovascular bundle which is the terminal portion
of the inferior hypogastric plexus). The dorsal
clitoris nerve is a somatic nerve which contains
sensory fibers in its distal part. The inferior
hypogastric plexus gives four main terminal effer-
ences: bladder, urethral sphincter, vagina, rectum.
They show that the inferior hypogastric branch
consists in thick branches from a neural bundle
that is associated with the vaginal pedicle, consti-
tuting a neurovascular bundle. The neurovascular
bundle contains adrenergic and cholinergic
innervations and rare sensory fibers [40]. Consid-
ering that innervations evolve with puberty and
adult life, could this interconnection in fetal
innervation constitute another afferent sensory
pathway?
For the first time, Komisaruk et al. demon-
strated that clitoral, vaginal, and cervix (and nipple)
stimulations activate sensory cortex in the medial
paracentral lobule, and that the sites are regionally
differentiated and, to some extent, separable and
distinct [41]. These findings tended to prove the
different sensations perceived during orgasm,
according to the experience of several women.
However, relatively poor vaginal innervations have
been described [9]. Moreover, echo scan during
coital activity demonstrated that it is problematic to
stimulate the vagina per se without stimulating its
lower part and, thus, the clitoris [17].
The distal and proximal AVWs are not uniform,
because of their different developmental origins
from the urogenital sinus and Mullerian ducts [39].
Hence, the two components of the clitoris (exter-
nal and internal) could activate two different parts
of the sensorial cortex (with some possible over-
laps) and may generate the different perceptions of
orgasm reported by several women. To be pro-
vocative, is the sensory cortex stimulated by the
VAO the central projection of the CUV com-
plex?[22] The ultimate and technically compli-
cated answer would be during fMRI and
sonographic examination of genitals, to conduct
accurate, different stimulations.
Odile Buisson, MD
In their landmark study, Kinsey et al. [1] popular-
ized the notion that in women, the vagina and
cervix are insensate. They stated, “. . . the walls of
the vagina are ordinarily insensitive...”(p.581),
and “All of the clinical and experimental data show
that the surface of the cervix is the most com-
pletely insensitive part of the female genital
anatomy” (p. 584). However, it is remarkable that
their own data, which they present in their table
174, diametrically contradicts their claim! The
table shows that among 878 women to whom they
applied pressure to the cervix, 84% responded, and
pressure applied to the anterior or the posterior
wall of the vagina of the same women elicited
responses in 89 and 93%, respectively!
Our recent findings provide evidence that the
clitoris, vagina, and cervix project to distinct and
separate regions of the sensory cortex [41]. We
mapped the projections of each of these genital
regions to the sensory cortex using fMRI. As
points of reference in the same individuals, we also
mapped the projections to this cortical region of a
finger, a toe, and a nipple. Stimulation or self-
stimulation of these reference points activated the
sensory cortex in precise agreement with the clas-
sical “homunculus” of Penfield and Rasmussen
[42] (Figure 1). Self-stimulation of the clitoris,
vagina, or cervix activated the medial cortical wall,
specifically the “paracentral lobule,” where the
penis is represented in the homunculus. The cli-
toral, vaginal, and cervical representations were
each uniquely different from each other, although
their fields overlapped partially, resembling a
cluster of grapes. It is likely that their differential
distribution is due to their differential sensory
innervation, which is predominantly pudendal
nerve (clitoris), pelvic nerve (vagina and cervix),
and hypogastric and vagus nerves (cervix and
uterus) [35]. In the same study, surprisingly, nipple
self-stimulation activated not only the expected
thoracic region of the homunculus, but also these
genital sensory fields. Because the vaginal and the
cervical self-stimulation activated sensory cortical
regions that are distinctly different from the
960 J Sex Med 2012;9:956–965

Controversies in Sexual Medicine
region activated by clitoral self-stimulation, this
refutes the possibility that awareness of vaginal or
cervical stimulation is simply a consequence of
indirect clitoral stimulation.
Our previous finding in women diagnosed with
“complete” SCI [43] is consistent with the above
conclusion that awareness of vaginal and cervical
stimulation is uniquely different from awareness of
clitoral stimulation. The women in that study had
no external bodily sensation or voluntary move-
ment below the level of the SCI, which was in all
cases at the midthoracic level (T-10 or above).
Thus, they had no clitoral sensibility. However,
they all reported that they experienced menstrual
discomfort. Furthermore, they could feel vaginal
or cervical stimulation applied by self or others.
This was a surprising finding, because at that tho-
racic level of SCI, all the genital sensory pathways
through the spinal cord would be interrupted. To
account for this observation, I hypothesized that
the vagus nerves (i.e., cranial nerves # 10) convey
the vaginal and cervical sensation directly to the
brain, bypassing the spinal cord [25]. We tested the
hypothesis by observing whether vaginal or cervi-
cal self-stimulation in these women activated the
solitary nucleus in the medulla oblongata of the
brain stem, which is the sensory projection nucleus
of the vagus nerves. We found that this nucleus
was indeed activated by the stimulus in each of the
five women whom we tested. Three of the women
experienced orgasms from the vaginal or cervical
self-stimulation. This is further evidence that
vaginal and cervical stimulations generate their
own unique sensory input to the brain that is sepa-
rate and distinct from clitoral sensory input, and
adequate to activate orgasm.
Figure 1 Sensory cortical responses (indicated by arrows) to finger stimulation and self-stimulation of clitoris, vagina, cervix,
and nipple in relation to Penfield and Rasmussen’s [42] classical sensory homunculus. The female genital sensory
responses are located in the same medial cortical region as that in the classical map, which was based on men. An intriguing
exception is that in our study, women’s nipple self-stimulation activated their genital sensory region. The large activations in
the lateral cortical regions were produced by the hand activity used for the self-stimulation.
J Sex Med 2012;9:956–965 961

Controversies in Sexual Medicine
As pointed out by Ladas et al. [29], the quality
of orgasms activated by clitoral stimulation (rela-
tively localized) is different from VAOs (deeper
and more whole-body involving). Thus, there is
substantial subjective and objective evidence that,
contrary to the notion promulgated by Kinsey
et al. [1], the vagina and cervix are insensate, the
clitoris, vagina, and cervix each have a unique and
significant sensory cognitive representation and
can contribute unique qualities to orgasm.
Barry R. Komisaruk, PhD
In contrast to CO, VO refers to a woman’s orgasm
triggered purely by penile–vaginal intercourse
(PVI) without concurrent clitoral masturbation by
self or partner. There are both neurophysiologic
and clinical (psychological, emotional, interper-
sonal, developmental) differences between these
two categories of women’s orgasm.
This is clear evidence that VO is not dependent
upon the clitoris. Because cervical and vaginal
stimulation activate different regions of the soma-
tosensory cortex [25,41,44], it is quite likely that
cervical orgasm is a distinct subtype of VO (thus
making for three, rather than two major categories
of female orgasm). However, at the clinical level,
the associations noted below involve a comparison
of orgasm from PVI per se vs. requiring extrinsic
clitoral stimulation for climax. Future research
might examine differences between distal vaginal
and cervical focused penile stimulation to elicit VO.
Of note, women who have greater VO consistency
have a slight tendency to prefer a longer penis [45],
and it is plausible that more efficient cervical stimu-
lation is part of the basis for that preference.
It has been claimed that VO has been experi-
enced only by a minority of women. There is good
evidence to the contrary. Large representative
samples from various countries show that the
majority of coitally experienced women had VO
(e.g., in two large nationally representative
samples of Czechs, only 22% of the general popu-
lation sample [45] and 17% of the middle-aged
sample [46] never had VO).
There appear to be both prenatal/perinatal and
educational/developmental/experiential effects on
likelihood of VO. An example of the former is the
observation that women with a more prominent
tubercle of the upper lip (which might be related
to some aspects of fetal forebrain development)
have a greater lifetime likelihood of VO (but not of
CO) than women with flatter or concave tubercle
areas [47]. An example of the educational aspect is
the finding in a large representative sample that
women who were educated in their youth that the
vagina is a source of female orgasm (as opposed to
either receiving no sex education, or being told
that the clitoris is the sole source of female
orgasm) have greater VO consistency [45].
Given that vaginal and cervical stimulation acti-
vate different regions of the brain from clitoral
stimulation (thereby disproving the assertion of
some that intercourse is simply an inefficient form
of clitoral stimulation), the clinical questions are:
(i) what impedes some women from responding
fully to penile stimulation of the vagina?, and (ii) in
what ways are such women psychologically differ-
ent from vaginally orgasmic women?
At the clinical level, there is evidence that rather
than being a simple variant, inability to have a VO
(given an adequate man) is consistently associated
with poorer psychological and perhaps physiologi-
cal health status (even if there is ability to have a
CO). This is broadly consistent with the finding
that of all sexual activities, it is specifically and
nearly exclusively PVI that is associated with
better physical and psychological health for both
sexes [48]. At a theoretical level, such associations
are consistent not only with some aspects of early
psychoanalytic theory (that were not adequately
empirically tested until recently) [49], but also with
evolutionary forces (perhaps providing an indica-
tor of psychological health for both partners, and
strengthening quality of pair bonding) [50].
Resting heart rate variability is longitudinally
predictive of lower mortality risk, and correlated
with several indicators of better psychological and
physical function. It is also associated specifically
with having a VO in the past month, but not with
any of a variety of clitorally focused sources of
climax [51].
In contrast to vaginally orgasmic women, vagi-
nally anorgasmic women (even if clitorally orgas-
mic) tend to have a gait that indicates impairment
of pelvic and vertebral rotation [52]. Chronic
pelvic region muscle blockage or flaccidity might
be a symptom and/or mechanism of blocked VO.
Psychological problems could become manifest in
two related psychosomatic disturbances: distorted
gait and impairment of VO. Additionally, the dis-
turbance of pelvic muscle tone might be among
the mechanisms undermining specifically VO.
A study of a large representative sample of
Swedes revealed that women who ever had a VO
962 J Sex Med 2012;9:956–965

Controversies in Sexual Medicine
had greater satisfaction with: their sex life, their
partners, their mental health, and their life in
general, compared to the vaginally anorgasmic
women (even if the latter were clitorally orgasmic)
[53]. A study of a large representative sample of
middle-aged Czechs revealed that VO consistency
was associated with greater satisfaction in the same
domains as in the Swedish study [46], and a study
of Chinese women found that frequency of PVI
and orgasm from PVI—but not from other
sources—was associated with sexual satisfaction
[54].
A large representative study of Czech women
found that a history of specifically VO was protec-
tive against female arousal disorder with distress
(but not without distress) [55].
Defense mechanisms are “automatic psycho-
logical processes that protect the individual against
anxiety and from the awareness of internal or
external dangers” [56]. Defenses can be under-
stood along a developmental scale ranging from
immature through neurotic to mature. The imma-
ture defense mechanisms are most clearly related
to various forms of psychopathology in adults, and
some are also found in normal young children.
Immature defenses include: somatization, disso-
ciation (fragmentation of normally integrated
psychological functions; e.g., consciousness,
perception, etc.), displacement (displacing an
emotion from one person or object onto a substi-
tute), autistic fantasy (excessive daydreaming as a
substitute for human relationships or effective
action), and isolation of affect (disconnection of
emotions associated with a specific experience
while maintaining cognitive aspects). Perhaps the
first adequate empirical test of the implication of
Freud’s hypothesis regarding female psychosexual
maturity involving a shift from the clitoris to the
vagina was presented in the Journal of Sexual Medi-
cine in 2008 [49]. In that study, as well as replica-
tion and extension (additionally finding poorer
VO consistency to be associated with less tactile
sensitivity and more alcohol consumption before
sex) studies in other countries [57,58], we consis-
tently found that VO was associated with less use
of immature psychological defense mechanisms.
We also found that masturbation (including clito-
ral masturbation by self or partner during PVI)
was associated with more use of immature defense
mechanisms. The vaginally anorgasmic women’s
mean immature defenses score was comparable to
that of groups of women with depression, social
anxiety disorder, panic disorder, and obsessive–
compulsive disorder.
Intimate relationship quality (especially in the
longer term) depends on capacity for attachment.
In contrast to a healthy secure attachment style,
there are the insecure attachment styles of anxious
attachment (preoccupation with abandonment
fears) and avoidant attachment (avoidance of being
too emotionally involved). Insecure attachment
styles are associated with sexual and relationship
difficulties, and with poorer mental health. We
recently reported that anxious attachment was
associated with poorer VO consistency, but with
higher frequency of vibrator and anal sex climax
[59]. In addition, avoidant attachment was associ-
ated with higher frequency of vibrator climax (and
with a nonsignificant trend toward poorer VO
consistency).
The most likely explanation for these cross-
culturally coherent findings is that immature
defense mechanisms and insecure attachment are
processes that can psychologically impair specifi-
cally VO. However, one must also consider the
possibility that specifically VO facilitates emotional
growth and intimacy. If the latter is the case even in
part, then failure to be supportive of specifically VO
constitutes iatrogenic damage. As noted over a half
century ago by Kegel, for some women, repeated
climax from direct clitoral stimulation might
undermine the development of some psychological
pathways leading to VO [60]. Women’s health and
sexual function (led by scientific evidence) deserve
to be put ahead of the prejudices cherished by many
people working in the field of sexology.
Stuart Brody, PhD
Corresponding Author: Emmanuele A. Jannini, MD,
Course of Endocrinology and Sexology, Department of
Experimental Medicine, University of L’Aquila,
L’Aquila 67100, Italy. Tel: +39-0862433530; Fax: +39-
0862433523; E-mail: emmanuele.jannini@univaq.it
References
1 Kinsey AC, Pomeroy WB, Martin CE, Gebhard PH. Sexual
behaviour in the human female. Philadelphia: WB Sanders Co;
1953.
2 Masters WH, Johnson VE. Human sexual response. Boston:
Little, Brown; 1966.
3 Jannini EA, Whipple B, Kingsberg SA, Buisson O, Foldès P,
Vardi Y. Who’s afraid of the G-spot? J Sex Med 2010;7:25–34.
4 Gravina GL, Brandetti F, Martini P, Carosa E, Di Stasi SM,
Morano S, Lenzi A, Jannini EA. Measurement of the thickness
of the urethrovaginal space in women with or without vaginal
orgasm. J Sex Med 2008;5:610–8.
J Sex Med 2012;9:956–965 963

Controversies in Sexual Medicine
5 Rubio-Casillas A, Jannini EA. New insights from one case of
female ejaculation. J Sex Med 2011;8:3500–4.
6 Alzate H. Vaginal eroticism: A replication study. Arch Sex
Behav 1985;14:529–37.
7 Alzate H, Londono ML. Vaginal erotic sensitivity. J Sex
Marital Ther 1984;10:49–56.
8 Hilliges M, Falconer C, Ekman-Ordeberg G, Johansson O.
Innervation of the human vaginal mucosa as revealed by PGP
9.5 immunohistochemistry. Acta Anat (Basel) 1995;153:119–
26.
9 Pauls R, Mutema G, Segal J, Silva WA, Kleeman S, Dryfhout
Ma V, Karram M. A prospective study examining the anatomic
distribution of nerve density in the human vagina. J Sex Med
2006;3:979–87.
10 Song YB, Hwang K, Kim DJ, Han SH. Innervation of vagina:
Microdissection and immunohistochemical study. J Sex
Marital Ther 2009;35:144–53.
11 D’Amati G, di Gioia CR, Bologna M, Giordano D, Giorgi M,
Dolci S, Jannini EA. Type 5 phosphodiesterase expression in
the human vagina. Urology 2002;60:191–5.
12 D’Amati G, di Gioia CR, Proietti Pannunzi L, Pistilli D,
Carosa E, Lenzi A, Jannini EA. Functional anatomy of the
human vagina. J Endocrinol Invest 2003;26:92–6.
13 Jannini EA, d’Amati G, Lenzi A. Histology and immunohis-
tochemical studies of female genital tissue. In: Goldstein I,
Meston C, Davis S, Traish A, eds. Women’s sexual function
and dysfunction: Study, diagnosis and treatment. London:
Taylor and Francis; 2006:125–33.
14 Giuliano F, Rampin O, Allard J. Neurophysiology and phar-
macology of female genital sexual response. J Sex Marital Ther
2002;28(suppl 1):101–21.
15 Lavoisier P, Aloui R, Schmidt MH, Watrelot A. Clitoral blood
flow increases following vaginal pressure stimulation. Arch Sex
Behav 1995;24:37–45.
16 Cai RS, Alexander MS, Marson L. Activation of somatosen-
sory afferents elicit changes in vaginal blood flow and the
urethrogenital reflex via autonomic efferents. J Urol 2008;180:
1167–72.
17 Buisson O, Foldes P, Jannini E, Mimoun S. Coitus as revealed
by ultrasound in one volunteer couple. J Sex Med 2010;7:
2750–4.
18 Shafik A. Vaginocavernosus reflex. Clinical significance and
role in sexual act. Gynecol Obstet Invest 1993;35:114–7.
19 Foldes P, Buisson O. The clitoral complex: A dynamic sono-
graphic study. J Sex Med 2009;6:1223–31.
20 O’Connell HE, Hutson JM, Anderson CR, Plenter RJ. Ana-
tomical relationship between urethra and clitoris. J Urol
1998;159:1892–7.
21 O’Connell HE, Eizenberg N, Rahman M, Cleeve J. The
anatomy of the distal vagina: Towards unity. J Sex Med
2008;5:1883–91.
22 Jannini EA, Gravina GL, Buisson O, Foldes P. A letter to the
editor on the article by Burri et al. J Sex Med 2010;7:2289–92.
author reply 2292–2284.
23 Burri AV, Cherkas L, Spector TD. Genetic and environmental
influences on self-reported G-spots in women: A twin study. J
Sex Med 2010;7:1842–52.
24 Brody S, Kruger TH. The post-orgasmic prolactin increase
following intercourse is greater than following masturbation
and suggests greater satiety. Biol Psychol 2006;71:312–5.
25 Komisaruk BR, Whipple B, Crawford A, Liu WC, Kalnin A,
Mosier K. Brain activation during vaginocervical self-
stimulation and orgasm in women with complete spinal cord
injury: fMRI evidence of mediation by the vagus nerves. Brain
Res 2004;1024:77–88.
26 Whipple B, Komisaruk BR. Brain (PET) responses to vaginal-
cervical self-stimulation in women with complete spinal cord
injury: Preliminary findings. J Sex Marital Ther 2002;28:79–86.
27 Hite S. The Hite report: A nationwide survey of female sexu-
ality. London: Bloomsbury; 1976.
28 Whipple B, Brash-McGreer K. Management of female sexual
dysfunction. In: Sipski ML, Alexander C, eds. Maintaining
sexuality with disability and chronic illness: A practitioners
guide. New York: Aspen Publishers; 1997:509–37.
29 Ladas AK, Whipple B, Perry J. The G-spot and other recent
discoveries about human sexuality. New York: Holt, Reinehart
& Wiston; 1982.
30 Grafenberg E. The role of the urethra in female orgasm. Int J
Sexol 1950;3:145–6.
31 Whipple B, Komisaruk BR. Elevation of pain threshold by
vaginal stimulation in women. Pain 1985;21:357–67.
32 Whipple B, Josimovich JB, Komisaruk BR. Sensory thresholds
during the antepartum, intrapartum and postpartum periods.
Int J Nurs Stud 1990;27:213–21.
33 Whipple B, Ogden G, Komisaruk BR. Physiological correlates
of imagery-induced orgasm in women. Arch Sex Behav
1992;21:121–33.
34 Whipple B, Gerdes C, Komisaruk BR. Sexual response to
self-stimulation in women with complete spinal cord injury. J
Sex Res 1996;33:231–41.
35 Komisaruk BR, Beyers-Flores C, Whipple B. The science of
orgasm. Baltimore: Johns Hopkins University Press; 2006.
36 Levin RJ. The physiology and pathophysiology of the female
orgasm. In: Goldstein I, Meston CM, Davis SR, Traish AM,
eds. Women’s sexual function and dysfunction. London:
Taylor & Francis; 2006:228–35.
37 O’Connell HE, DeLancey JO. Clitoral anatomy in nullipa-
rous, healthy, premenopausal volunteers using unenhanced
magnetic resonance imaging. J Urol 2005;173:2060–3.
38 Buisson O, Foldes P, Paniel BJ. Sonography of the clitoris. J
Sex Med 2008;5:413–7.
39 O’Connell HE, Sanjeevan KV, Hutson JM. Anatomy of the
clitoris. J Urol 2005;174:1189–95.
40 Moszkowicz D, Alsaid B, Bessede T, Zaitouna M, Penna C,
Benoit G, Peschaud F. Neural supply to the clitoris: Immuno-
histochemical study with three-dimensional reconstruction of
cavernous nerve, spongious nerve, and dorsal clitoris nerve in
human fetus. J Sex Med 2011;8:1112–22.
41 Komisaruk BR, Wise N, Frangos E, Liu WC, Allen K, Brody
S. Women’s clitoris, vagina, and cervix mapped on the sensory
cortex: fMRI evidence. J Sex Med 2011;8:2822–30.
42 Penfield W, Rasmussen T. The cerebral cortex of man. New
York: The Macmillan Co; 1950.
43 Komisaruk BR, Gerdes CA, Whipple B. “Complete” spinal
cord injury does not block perceptual responses to genital
self-stimulation in women. Arch Neurol 1997;54:1513–20.
44 Komisaruk BR, Bianca R, Sansone G, Gomez LE, Cueva-
Rolon R, Beyer C, Whipple B. Brain-mediated responses to
vaginocervical stimulation in spinal cord-transected rats: Role
of the vagus nerves. Brain Res 1996;708:128–34.
45 Brody S, Weiss P. Vaginal orgasm is associated with vaginal
(not clitoral) sex education, focusing mental attention on
vaginal sensations, intercourse duration, and a preference for a
longer penis. J Sex Med 2010;7:2774–81.
46 Brody S, Weiss P. Simultaneous penile-vaginal intercourse
orgasm is associated with satisfaction (sexual, life, partnership,
and mental health). J Sex Med 2011;8:734–41.
47 Brody S, Costa RM. Vaginal orgasm is more prevalent among
women with a prominent tubercle of the upper lip. J Sex Med
2011;8:2793–9.
964 J Sex Med 2012;9:956–965

Controversies in Sexual Medicine
48 Brody S. The relative health benefits of different sexual activi-
ties. J Sex Med 2010;7:1336–61.
49 Brody S, Costa RM. Vaginal orgasm is associated with less use
of immature psychological defense mechanisms. J Sex Med
2008;5:1167–76.
50 Brody S, Costa RM, Hess U, Weiss P. Vaginal orgasm is
related to better mental health and is relevant to evolutionary
psychology: A response to Zietsch et al. J Sex Med 2011;
8:3523–5.
51 Costa RM, Brody S. Greater resting heart rate variability is
associated with orgasms through penile-vaginal intercourse,
but not with orgasms from other sources. J Sex Med 2012;9:
188–97.
52 Nicholas A, Brody S, de Sutter P, de Carufel F. A woman’s
history of vaginal orgasm is discernible from her walk. J Sex
Med 2008;5:2119–24.
53 Brody S. Vaginal orgasm is associated with better psychological
function. Sex Relat Ther 2007;22:173–91.
54 Tao P, Brody S. Sexual behavior predictors of satisfaction in a
Chinese sample. J Sex Med 2011;8:455–60.
55 Weiss P, Brody S. Female sexual arousal disorder with
and without a distress criterion: Prevalence and correlates
in a representative Czech sample. J Sex Med 2009;6:3385–
9.
56 American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. 4th edition. International
Version. Washington, DC: American Psychiatric Association;
1995.
57 Brody S, Houde S, Hess U. Greater tactile sensitivity and less
use of immature psychological defense mechanisms predict
women’s penile-vaginal intercourse orgasm. J Sex Med 2010;
7:3057–65.
58 Costa RM, Brody S. Immature defense mechanisms are
associated with lesser vaginal orgasm consistency and
greater alcohol consumption before sex. J Sex Med 2010;7:
775–86.
59 Costa RM, Brody S. Anxious and avoidant attachment, vibra-
tor use, anal sex, and impaired vaginal orgasm. J Sex Med
2011;8:2493–500.
60 Kegel AH. The Kinsey report. JAMA 1953;153:1303–4.
J Sex Med 2012;9:956–965 965