Sexual correlates of gagging and dental anxiety

Abstract

Both oro-related behavioural and sexual dysfunctions are non-life-threatening conditions which can have an impact on individual well-being. Possible common features include intra-body penetration, giving control to another person, and experiencing encounters that can sometimes be subjectively experienced as aggressive and/or abusive. The present study examined possible sexual correlates of dental anxiety and gagging.
A total of 448 individuals, who applied for sex therapy at the Sexual Medicine Center, Sheba Medical Center, Tel-Hashomer, Israel, completed the following sexual and dental functioning questionnaires: International Index of Erectile Function (men only), Female Sexual Function Index and difficulties with sexual penetration (women only), dental anxiety, gagging reflex and dentist preference (entire population).
Higher gagging reflex was associated with problems in sexual penetration and history of sexual abuse in women (especially one that included vaginal penetration). It was also associated with dental anxiety and higher preference for dentist of the same gender for both genders.
The study shows that gagging reflex can bear sexual connotations, especially in women.

Full text

Community Dental Health (2012) 29, 243–247 © BASCD 2012
Received 9 March 2011; Accepted 17 September 2011 doi:10.1922/CDH_2808Uziel05
Sexual correlates of gagging and dental anxiety
N. Uziel1, G. Bronner2, E. Elran2 and I. Eli1
1The Maurice and Gabriela Goldschleger, School of Dental Medicine, Tel-Aviv University, Tel-Aviv, Israel; 2Sexual Medicine Center, De-
partment of Urology, Sheba Medical Center, Tel-Hashomer, Israel
Objective: Both oro-related behavioural and sexual dysfunctions are non-life-threatening conditions which can have an impact on individual
well-being. Possible common features include intra-body penetration, giving control to another person, and experiencing encounters that
can sometimes be subjectively experienced as aggressive and/or abusive. The present study examined possible sexual correlates of dental
anxiety and gagging. Basic research design: A total of 448 individuals, who applied for sex therapy at the Sexual Medicine Center,
Sheba Medical Center, Tel-Hashomer, Israel, completed the following sexual and dental functioning questionnaires: International Index of
Erectile Function (men only), Female Sexual Function Index and difculties with sexual penetration (women only), dental anxiety, gag-
ging reex and dentist preference (entire population). Results: Higher gagging reex was associated with problems in sexual penetration
and history of sexual abuse in women (especially one that included vaginal penetration). It was also associated with dental anxiety and
higher preference for dentist of the same gender for both genders. Conclusions: The study shows that gagging reex can bear sexual
connotations, especially in women.
Key words: gagging, dental anxiety, sexual dysfunctions, psychological, sexual offenses, sexual abuse
Introduction
The oral cavity and its associated functions share many
psycho-social similarities with sexuality and sexual
functioning. The oral cavity is the rst zone of pleasure
and satisfaction to the newborn, not only as a supplier
of nutrition, but also as an erogenous zone that provides
sexual pleasure. Even in individuals who have successfully
passed to the genital stage of development, some sexual
activity remains xed with the oral cavity (Freud, 1999).
The face and mouth play an important role also in
sexual attraction, essential for the survival of the species.
The mouth is a source of gratication and reinforcement
of sexual behaviours, a pleasure that encourages the rep-
etition of sexual acts. Moreover, oral sex has become a
normative part of sexual activities contributing to sexual
arousal and orgasm in both genders (Shindel et al., 2008).
A possible connection between dental fear and sexual
trauma has been suggested. The studies refer mainly to
sexual abuse and neglect. A prevalence of high dental
anxiety was found in women reporting past experiences of
sexual assault (Humphris and King, 2011). When women
who had high and low dental fears were compared with
respect to trauma history, high levels of dental fear were
associated with a higher prevalence of several forms of
child maltreatment and adult sexual and physical assault
(Walker et al., 1996). Among sexually abused women,
most subjects reported experiencing problems related to
dental treatment (Willumsen, 2001). Women with dental
fear who reported a history of child sexual abuse, scored
higher on the Dental Beliefs Scale than women with
dental fear with no history of sexual abuse in childhood
(Willumsen, 2004). Subjects with self-reported histories
of childhood sexual abuse report that some aspects of
Correspondence to: Dr Nir Uziel, School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel. Email: niruzi@post.tau.ac.il
dental treatment (certain body positions, need for a sense
of control, fear of judgement) can be particularly difcult
(Stalker et al., 2005). Many patients with dental anxiety
report co-morbid psychosocial dysfunction due to effects
of sexual abuse, general anxiety, gagging, fainting or
panic attacks (Moore et al., 2004).
While dental anxiety is a prevalent and commonly
studied oro-related behavioural dysfunction (a dysfunction
related to the oral cavity and its functions) (Berggren and
Carlsson, 1985; Eli, 1992; Eli et al., 1997), excessive
gagging reex is another common obstacle to dental care
(Bassi et al, 2004). The co-morbidity between excessive
gagging and dental anxiety (Moore et al., 2004) may
result from gagging serving as an indirect expression of
anxiety. Presenting a “somatic” symptom, such as gag-
ging, may serve as an indirect way to avoid the threat
involved with dental treatment (Eli, 1992).
Unfortunately, the literature lacks accepted tools to
assess gagging. A Gagging Severity Index has been
proposed (Rosted et al., 2006), which is a descriptive
measure that may be useful in clinical settings but is less
appropriate for research because it is based mainly on
clinical parameters. More recently, a Gagging Problem
Assessment tool (GPA) was presented (van Linden van
den Heuvell et al., 2008). However, the GPA has been
tested on 25 individuals only and its substantial length
makes its use in research problematic. Although the
authors suggest a shorter version of the GPA for further
research, no data have been published on it, as yet.
The prevalence of both sexual dysfunctions and oro-
related behavioural dysfunctions is substantial (Eli, 1992;
Laumann et al., 1999). Neither pose immediate health
dangers, but they do have major inuences on a person’s
quality of life (Laumann et al., 1999; Mehrstedt et al.,

244
2007; Rosen et al., 1999; Shifren et al., 2008). To date,
there is no comprehensive research regarding possible
associations between oro-related behavioural dysfunc-
tions and sexual dysfunctions. The purpose of this study
was to examine the possible sexual correlates of dental
anxiety and excessive gagging reex in men and women.
Materials and Methods
This cross sectional study was conducted at the Sexual
Medicine Center, Sheba Medical Center, Tel-Hashomer,
Israel and approved by the Committee for Approval of
Experiments in Human Subjects under the Helsinki Ac-
cord at the Sheba Medical Center. All subjects signed
an informed consent form. Some 693 applicants for sex
therapy during the years 2005 to 2007 were requested
to complete questionnaires referring to sexual and dental
functioning and then had a structured interview with a
professional sex therapist (GB) leading to decisions re-
garding sexual diagnosis and treatment. Sexual diagnoses
were nalized according to Basson et al. (2000) and
Hatzimouratidis and Hatzichristou (2007).
The Dental Anxiety Scale (DAS), developed by Corah
(1969) as a specic measure of dental anxiety, has been
used extensively in research conducted on anxious dental
patients (e.g. Berggren and Carlsson, 1985; Eli, 1992; Eli
et al., 1997). Subjects’ DAS scores were categorised as
high dental anxiety or no/moderate dental fear using a
cut-off point of 13 as recommended in previous studies
(Corah et al., 1978). Regarding excessive gagging reex
however, there is no widely accepted scale or signicant
body of research. The tool proposed in this study, Gagging
Assessment Scale (GAS), was developed by two of the
present authors (NU and IE). It was tested for content
validity by gathering a group of subject matter experts
(SMEs) together to review test items. The group were 6
dentists who worked at the Tel Aviv University School of
Dental Medicine’s Clinic of Oral Psychophysiology with
clinical and academic experience in working with patients
unable to undergo routine dental treatment, mostly due
to dental anxiety and/or excessive gag reex. Each SME
proposed questions for the questionnaire and following
discussion 6 initial questions were agreed and presented
to a panel of 20 patients under treatment in the clinic.
Their feedback informed agreeing the nal 4-question
version of the GAS questionnaire: How do you feel when:
1, you brush your back teeth? 2, you are waiting in the
dental waiting room and thinking of the upcoming dental
treatment? 3, you are sitting in the dental chair and the
dentist is checking your teeth with his mirror and other
instruments? 4, the dentist is treating your back teeth?
Scores for each answer are: 1, I experience no nausea
whatsoever; 2, I feel slightly nauseous; 3, I am afraid I
will vomit; 4, I can’t do it because immediately I feel
nauseous and feel like vomiting; 5, I experience actual
spasms in my throat, sometimes even vomiting. As with
the DAS, the total score ranges from 4-20.
As the SMEs were unanimous in their conviction that a
close relation exists between dental anxiety and excessive
gagging reex, a construct validity evaluation was made
by calculating correlations between the GAS question-
naire and accepted parameters measuring dental anxiety
(DAS). Furthermore, the SMEs observed that patients
suffering from gagging tend to avoid dental treatment.
Therefore, in addition to DAS, an additional question was
presented to subjects: “How has your dental treatment
worked in recent years?” with possible answers being:
(a) I have routine dental care, (b) I go to the dentist only
occasionally when I need to; and (c) Not in treatment
at all. A low (nevertheless highly signicant) correlation
was found between GAS and DAS (r=0.282, p<0.0001)
as well as between GAS and the above mentioned ques-
tion (r=0.113, p<0.05). The correlation between the GAS
and DAS was also conrmed among a population of 402
random Israeli adults, in another study performed with
the assistance of the developers of the GAS scale (r=
0.604, p<0.001; Winocur et al. 2011).
A specic question regarding dentist preference was
presented to all subjects as follows: “What kind of dentist
do you prefer? Male, Female, Does not matter.”
Questionnaires also assessed sexual functioning. A
validated questionnaire, the Female Sexual Function Index
(FSFI, 6 domains, 19 items, women only) was used to
assess six domains of female sexual function (desire,
arousal, lubrication, orgasm, satisfaction and pain). The
six domains were summed to calculate a total FSFI
score (Rosen et al., 2000). Secondly, regarding sexual
penetration, a series of questions addressed the following
3 domains: difculties in penetration (PEN), pain during
penetration (Pain), and sexual abuse domain (SAD). In
PEN, difculties in vaginal penetration (VP) were as-
sessed by a 5-item yes/no scale, asking each woman to
report if she ever experienced problems in inserting a
tampon, participating in a gynaecological examination,
inserting self-nger, experiencing insertion of spouse’s
nger and/or participating in penile-vaginal intercourse.
Difculty with at least one of the PEN stimuli classied
subjects as PEN positive. For Pain, woman evaluated the
pain experienced during each 5 VP items on a 0-100mm
visual analogue scale (VAS). For SAD, each woman
reported if she had ever experienced an unpleasant/
abusive sexual encounter (yes/no scale) and if positive,
if the experience included VP.
For men the International Index of Erectile Function
(IIEF), a 15-item validated instrument was used to assess
5 domains of male sexuality: desire, erectile function,
intercourse satisfaction, orgasmic function and overall
satisfaction (Rosen et al., 1999).
Cronbach α was used to assess internal consistency.
Two-sample t-tests were used to compare between two
groups regarding continuous parameters. One-way
Analysis of Variance (ANOVA) was used when 3 groups
were compared. Distribution of categorical variables was
compared between groups by applying the Chi-square
test. Relationships between continuous measures were
evaluated by Pearson Correlation Coefcients. For mul-
tivariate analysis linear regression was used. SAS v9.1.3
was used for all statistical analyses with a signicance
level of p<0.05.
Results
Response rate was 64.6%. The nal study population
consisted of 236 women (mean age 31.5, sd 9.7y) and
212 men (mean age 36.0, sd 12.3y). The psychometric
properties of the scales in the present study (Cronbach

245
α) were as follows: DAS=0.89; GAS=0.67; FSFI (total
score)=0.94; IIEF (total score)=0.88. There were signi-
cant differences between women and men in the GAS and
DAS scores (4.88 sd 1.52 vs. 4.52 sd 1.16, p<0.01; and
9.66 sd 3.19 vs. 7.96 sd 3.02, p<0.0001, respectively),
with women indicating greater anxiety on both scales.
Classied by dental anxiety 69 were anxious (DAS
≥13) and 374, non-anxious. Anxious participants scored
signicantly higher on GAS than the non-anxious group
(5.60 sd 2.00; vs. 4.56 sd 1.16; respectively; p<0.0005).
There was a positive correlation between the DAS and
GAS scores (r=0.282, p<0.0001).
Most participants (86% of women and 88% of men)
showed no preference for the gender of their dentist.
Participants who preferred a dentist of their own gender
scored higher on GAS than those who showed no such
preference (p=0.05; Table 1). Signicant differences in
GAS were observed between PEN positive (114, 50.9%
of women) and PEN negative women (5.25 sd 1.85 vs.
4.57 sd 1.07, respectively, p<0.005). A correlation was
observed between GAS and the number of PEN positive
stimuli (r=0.237, p<0.001; Figure 1), i.e. the more dif-
culties in vaginal penetration among women, the higher
the tendency for gagging. No such differences with regard
to DAS could be detected. Pain levels ranged from 1.17
to 3.70 (for PEN negative stimuli). There were no cor-
relations between Pain and DAS or GAS.
Unpleasant/abusive sexual experience was reported by
93 women (SAD positive, 39.7%). SAD positive women
scored higher on GAS (5.28 sd 1.92) than women who
did not report such an experience (SAD negative, 4.61
sd 1.11; p<0.01). No such differences with regard to
DAS were detected. Unpleasant/abusive sexual experi-
ence which included vaginal penetration was reported
by 38 women. The GAS scores from this specic group
were higher than those of SAD positives without vaginal
penetration and of SAD negative women (5.79 sd 2.40
vs. 4.98 sd 1.40 and 4.61 sd 1.11, respectively, p<0.001).
Namely, the tendency of women to gag was found to
be lowest when no abuse has been experienced, higher
among women who had experienced some sexual abuse
and highest among women who experienced sexual abuse
which included vaginal penetration. No such differences
with regard to DAS were detected.
Table 2 presents the relationship between SAD group
and preference for a dentist of a particular gender. While
11% of the SAD positive women preferred a woman
dentist, the percentage among the SAD negative women
was only 2% (p<0.05).
Finally, a multivariate analysis of the data was cal-
culated (linear regression) with the dependant variable
being GAS and independent variables being: the six
domains of FSFI, PEN positive, SAD positive, and SAD
positive including vaginal penetration. The two variables
best predicting GAS were SAD which included vaginal
penetration (Parameter Estimate, PE=0.22, p<0.005) and
the PEN stimuli (PE=0.17, p<0.005)
Although detailed descriptions and analyses of the
sexual diagnoses (FSFI and IIEF scales) were beyond
the scope of the present paper and will be presented
elsewhere, the mean scores of these scales are presented
here for the readers’ general information: FSFI total
score=17.96 sd 7.76 (women only); IIEF total score=46.5
sd 15.83 (men only). No correlations were found between
sexual diagnoses, FSFI, IIEF scales, or either of the DAS
or GAS scores.
Figure 1. Mean GAS scores in women with regard to number
of PEN stimuli a
a PEN refers to inability to experience vaginal penetration
as described in the text
Table 2. Percentage dentist preference of women who
reported sexual abuse (SAD) compared to women who did
not report such experience
SAD group (%)
Negative
n=141
Positive
n=91
Male dentist preferred 8.5 7.7
Female dentist preferred 2.1 11.0
Does not matter 89.4 81.3
Table 1. Mean GAS scores according to gender and dentist preference
Male respondents Female respondents
GAS (n) sd GAS (n) sd
Male dentist preferred 5.40 (20) 2.24 5.00 (20) 0.16
Female dentist preferred 4.40 (5) 0.52 5.92 (12) 2.64
Does not matter 4.48 (183) 0.92 4.80 (192) 1.40

246
Discussion
The aim of this study was to examine possible sexual
correlates of gagging and dental anxiety. The GAS used
in the present study was developed according to the
principles of content and construct validity and shows an
acceptable internal consistency The positive association
between DAS and GAS indicates that excessive gagging
reex can be an indirect manifestation of dental anxiety
as previously proposed (Eli, 1992; Moore et al., 2004;
Ramsay et al, 1987). Additional studies are needed to
further explore the GAS (and possibly also the GPA)
questionnaires in various populations to prove its valid-
ity and reliability.
The results also agree with ndings that women show
higher dental anxiety levels than men (Eli, 1992; Milgrom
et al., 1988). Concomitantly, in the present study, women
had higher GAS scores than men. One explanation is
that women experience more oro-related behavioural
dysfunctions. However, another possibility may be that
men are more reluctant to report fear in questionnaires
(Pierce and Kirkpatrick, 1992), which may be one of the
reasons men report lower DAS and GAS scores.
Unlike GAS, in the present study no direct associa-
tion was found between dental anxiety (measured by
DAS) and sexual abuse as measured by SAD. This is
in contrast to Humphris and King (2011), Walker et al.
(1996) and Willumsen, (2001) but in accordance with
Oosterink et al. (2009) who found that pathological dental
anxiety was not associated with sexual assault and other
reports of traumatic experiences outside the dental setting.
The differences in ndings may result from the differ-
ent questionnaires used, and differences in the studied
populations. In one of those studies, Willumsen (2004)
found different parameters, like touching the back of
the mouth, to be highly associated with dental fear and
sexual abuse. This further supports our assumption that
gagging (which has been found to correlate well with
dental anxiety) may serve as an indirect manifestation of
dental anxiety, especially among victims of sexual assault.
In this study, participants suffered from sexual dys-
functions and not necessarily from oro-related behavioural
dysfunctions. Therefore, the general level of their dental
anxiety was not particularly high: about 15% suffered
from high dental anxiety similar in prevalence to the
general population (ter Horst and de Wit, 1993; Milgrom
et al., 1988)
Gagging reex was associated with a higher prefer-
ence for a dentist of the same gender, problems in sexual
penetration in women, and a history of sexual abuse in
women, especially one that included vaginal penetration.
Furthermore, the two variables best predicting GAS
were problems in sexual penetration in women and experi-
ence of sexual abuse which included vaginal penetration.
Apparently, among this population it is not the mere fact
of suffering from a sexual dysfunction, but rather the
experience of problems with sexual penetration and/or
history of abuse (with vaginal penetration) which serve
as predisposing factors for excessive gagging.
Taken together these data suggest that the symptom
of excessive gagging during dental treatment may have
more complex meanings than merely being an indirect
somatic manifestation of dental anxiety. The fact that
gagging was not associated with pain during the sexual
penetration stimuli (in women) suggests that gagging
may represent a woman’s reluctant response to the idea
of intra-body penetration. Unfortunately, the present study
did not investigate men’s difculties in experiencing
sexual penetration. Future research in this direction may
teach us more about these issues.
In spite of the temptation to declare that gagging has
immediate connections to sexual functioning, such a state-
ment needs further investigation. Physiological gagging
reex is generally elicited by immediate noxious stimuli
applied to the oropharynx. Nevertheless, gagging is also
associated with cognitive aspects which may cause “neu-
tral” stimuli to be recognized as noxious, threatening or
unpleasant by the patient, evoking the associated response
(Eli, 1992). The present study showed that some of these
stimuli may have sexual connotations in their origins.
Sexual abuse survivors show more personal distress
concerning their sexuality and less sexual satisfaction
(Rellini and Meston, 2007). It is therefore not surprising
that among the women seeking sexual therapy in the
present study, about 40% reported experiencing some
sort of sexual abuse in their past. Among this specic
group, a higher percentage of women preferred a female
dentist than those who did not report such experience.
This was also true for women who experienced difculties
with gynecological examination and/or penile penetration
during intercourse. These ndings further emphasize the
possible sexual connotations of the dental situation.
Although the study did not show signicant asso-
ciations between any of the FSFI or IIEF scales and
GAS or DAS, it raises several questions which should
be examined in more detail in the future. Possibly, the
FSFI and IIEF tools, which were built to achieve spe-
cic diagnoses in the eld of sexual functioning, are
inadequate when dealing with patients who suffer from
dental anxiety or excessive gagging reex. The questions
regarding problems in penetration and sexual abuse in
women did yield positive associations with GAS possibly
due to the more direct approach involved.
Patients with sexual dysfunctions do not necessarily
suffer from high dental anxiety or gagging. Unfortunately,
when a patient arrives for treatment with high dental
anxiety and/or excessive gagging reex, it is almost
impossible to inquire about sexual functioning. Such an
attempt would be considered intrusive and inappropriate.
At this stage, further study is recommended to address
these intriguing issues and to reach conclusions regarding
the psycho-dynamics of the presented ndings.
Acknowledgment
The authors would like to thank Mrs. E. Shabtai for
statistical analysis .

247
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