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Clitorally Stimulated Orgasms Are Associated With Better Control of
Sexual Desire, and Not Associated With Depression or Anxiety,
Compared With Vaginally Stimulated Orgasms
Nicole Prause, PhD,
1
Lambert Kuang, BS,
1
Peter Lee, BS,
1
and Geoffrey Miller, PhD
2
ABSTRACT
Introduction: Most women report that clitoral stimulation is an integral aspect of their orgasm experience. Thus,
recent claims that vaginal stimulation and vaginally generated orgasms are superior to clitoral stimulation and
clitorally generated orgasms pathologize most women and maintain a clitoral vs vaginal dichotomy that might not
accurately reflect the complexity of women’s sexual experience.
Aim: To have women report on their experienced source of orgasm, including combinations of vaginal and
clitoral stimulation, the solo or partnered context of the stimulation, and the intensity of the orgasms from
different sources and to predict indicators of mental health and sexual health using the orgasm source.
Methods: Eighty-eight women 18 to 53 years old answered detailed questions about their usual and recent
orgasm experiences, sexual history, depression, and anxiety. Then, they viewed a series of neutral and sexual films.
They were instructed to increase or decrease their sexual arousal or respond “as usual”to the sexual films. They
reported their sexual arousal after each film.
Main Outcome Measures: Outcomes assessed included mental health (depression and anxiety) and sexual
health (orgasm quality, ability to regulate sexual response to sex films). Reported sexual arousal was analyzed for
the regulation task.
Results: Most women (64%) reported that clitoral and vaginal stimulation contributed to their usual method of
reaching orgasm. Women who reported that clitoral stimulation was primarily responsible for their orgasm re-
ported a higher desire to self-stimulate and demonstrated greater control over their self-reported sexual arousal.
The primary stimulation site for orgasm was unrelated to measurements of depression or anxiety despite suffi-
cient statistical power.
Conclusion: Most women reported that clitoral and vaginal stimulation is important in orgasm. Women
experience orgasms in many varied patterns, a complexity that is often ignored by current methods of assessing
orgasm source. The reported source of orgasm was unrelated to orgasm intensity, overall sex-life satisfaction,
sexual distress, depression, or anxiety. Women who reported primarily stimulating their clitoris to reach orgasm
reported higher trait sexual drive and higher sexual arousal to visual sexual stimulation and were better able to
increase their sexual arousal to visual sexual stimulation when instructed than women who reported orgasms
primarily from vaginal sources.
J Sex Med 2016;-:1e10. Copyright 2016, International Society for Sexual Medicine. Published by Elsevier Inc.
All rights reserved.
Key Words: Orgasm; Clitoris; Self-Regulation; Anorgasmia; Depression; Anxiety
INTRODUCTION
Debate exists as to whether female orgasms can be generated
separately by the vagina and by the clitoris and what advantages
might exist to one type or the other.
1e3
These include diffi-
culties making clear physiologic distinctions between clitoral
and vaginal orgasm,
4e6
identification of better sexual health in
those reporting clitorally induced orgasm,
7
and failures to
replicate reported advantages of vaginal orgasms.
8
Specifically,
it was hypothesized that “psychological immaturity (psycho-
sexual immaturity, with its concomitant greater use of
Received October 31, 2014. Accepted August 23, 2016.
1
Department of Psychiatry, University of CaliforniaeLos Angeles, Los
Angeles, CA, USA;
2
Department of Psychology, University of New Mexico, Albuquerque, NM,
USA
Copyright ª2016, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jsxm.2016.08.014
J Sex Med 2016;-:1e10 1
immature defense mechanisms) couldleadtoinhibitionof
frequency and appreciation (including vaginal orgasm) of
penile-vaginal intercourse (PVI) in favor of other or no sexual
behaviors, with noxious consequences for mental health
and intimate relationships.”
9(p339)
“Real vaginal orgasms”
were distinguished from “masturbatory clitoral orgasms,”
including stimulation of the clitoris during coitus, and related
to “avarietyofpsychiatricdisorders”supported by “early
psychoanalytic theories.”Such reports have proved iatrogenic,
because women who desire clitoral stimulation to reach orgasm
during partnered interactions report feeling such stimulation
with a partner is “embarrassing”and “uncomfortable”to
request.
10
The present study tested the psychometric properties
of women’s self-reported orgasm and orgasm source. Then, the
relations between self-reported orgasm source and different
health indicators were tested. The hypothesis tested was that
women who stimulate their clitoris to reach orgasm during
coitus will exhibit poorer mental health than women who reach
orgasm through vaginal stimulation alone.
The importance of clitoral stimulation for female orgasm has
long been discussed.
11
When women are asked how they reach
orgasm, they overwhelmingly report stimulating their clitoris.
12
Clitoral stimulation results in more consistent orgasms during
solo masturbation, but the clitoral stimulation and orgasm
consistency decrease when a male partner is introduced.
13,14
The
investigators speculated that this was due to female reticence to
request clitoral stimulation. Women who continue to stimulate
their clitoris when with a partner are more likely to be orgasmic
with their partner.
15
When masturbating for a laboratory study,
all 26 women reported using clitoral stimulation as their primary
means of reaching orgasm.
16
Intersex surgeries in children that
involve the clitoris also increase their difficulty reaching orgasm
as an adult.
17
Vaginal and clitoral orgasms have not been differentiated
physiologically. However, when the vaginal opening is extended
by a phallus, the surrounding tissues are stretched and respond
reflexively.
18
In other words, it appears impossible for the penis
to enter the vagina without also moving structures of the
clitoris. Of course, other structures such as the periurethral
glans also are likely stimulated during vaginal penetration. The
reverse, that is, whether any clitoral stimulation necessarily
contributes to some vaginal stimulation, has not been investi-
gated to our knowledge. Because intravaginal reflexive con-
tractions increase during sexual arousal,
19
one could speculate
that clitoral stimulation similarly promotes vaginal motility.
Scientists disagree on the criteria for identifying female
orgasm,
20
making it difficult to imagine any consensually
acceptable physiologic test to differentiate the source of orgasm
at this time.
The relation of the clitoris to the vaginal opening also differs
among women and within individual women depending on their
current state, which could affect women’s ability to report on this
experience in a consistent way. Women whose clitoris is closer to
the vaginal opening are much more likely (moderate to large
effect sizes) to report consistent (67% of occasions) orgasms
from intercourse.
21
Also, anorgasmic women typically have a
smaller glans clitoris.
22
Clitoral body volume also grows largest
during the peri-ovulatory phase
23
of the cycle, probably reflecting
higher estradiol levels. These individual anatomic differences
could be important if, for example, some women experience
orgasm during penetration from clitoral stimulation, whereas
others experience orgasm during penetration from vaginal
stimulation.
Women tend to agree that clitoral stimulation facilitates
orgasm experience. In a large sample (N ¼749) of women, 94%
indicated clitoral stimulation could result in orgasm and 70%
reported that deep vaginal stimulation could result in orgasm.
24
This is consistent with women’s reports that stimulation of the
clitoris is the easiest method for generating an orgasm.
25
In fact,
vaginal intercourse ranks after manual clitoral stimulation or oral
sex for its ability to contribute to an orgasm from a partner.
26
These reports are supported by structural evidence, in which
the clitoral glans appears to be an analogous structure to the glans
penis as characterized by the density of difference types of
receptors (eg, mechanoreceptors).
27
In summary, most women
report that clitoral stimulation is important to generate an
orgasm.
Although there are objective tests for the presence of orgasm,
there are no objective tests of orgasm source. However, women
clearly are willing to answer questions about the source of their
orgasm. Orgasm “source”is complex and might refer to different
aspects of the sexual experience: the area of stimulation that
triggers orgasm, the area that feels most sensitized during sexual
arousal, the area in which orgasmic sensations are first felt, the
area that feels like the epicenter of motor responses to orgasm, or
something else. Also, although vaginal and clitoral differences are
most commonly discussed, many areas of the body could be
sensitized to provoke orgasm.
6
(Table 1) Women are typically
asked to report what proportion of orgasms they have had after
stimulation of different genital areas.
28
Even without clear
physiologic correlates, these self-report data could reflect
important subjective experiences of orgasm.
The present study had two goals. The first goal was to test
some of the psychometric properties of questions that women are
commonly asked to characterize their orgasm source. This
included identifying the most common areas (if any) thought to
contribute “most”and “next most”to orgasm, how strongly the
most recent orgasm source corresponded with the most usual
orgasm source, and women’s confidence that they have had
orgasms. The second goal was to test whether women who report
experiencing orgasm primarily by clitoral stimulation, compared
with women who report experiencing orgasm primarily by
vaginal stimulation, exhibit superior mental health (anxiety,
depression), sexual health (sexual satisfaction, distress about sex,
ability to control sexual feelings), and/or subjective orgasm
quality.
J Sex Med 2016;-:1e10
2Prause et al
One part of the protocol tested women’s ability to change
their own feelings of sexual arousal. In emotion research
broadly, the ability to flexibly increase and decrease an emotion
is a positive skill that supports a person effectively managing her
affect
29,30
and is related to emotional intelligence.
31
Such
flexibility also is related to better executive functions.
32
Relat-
edly, the ability to increase and decrease sexual arousal is
associated with lower trait sexual drive,
33
suggesting that those
with lower sex drive are better able to control their responses to
visual sexual stimulation. Taken together, the ability to regulate
one’s own feelings of sexual arousal could be considered a
desirable skill. Thus, a common emotion regulation task using
sex films was included in the present study to assess whether
orgasm source was related to better self-control of sexual
arousal.
AIMS
The study had two aims. The firstaimwastobetterchar-
acterize women’s reports of their primary and secondary
sources of their orgasms. The second aim was to test whether
women who report mainly clitorally generated orgasms
differed in mental health, sexual functioning, or orgasm
occurrence from women who report mainly vaginally gener-
ated orgasms.
METHODS
Participants
Participants (N ¼88) were recruited through a confidential
web service from psychology classes at the University of New
Mexico in Albuquerque. They were required to have normal
Table 1. Demographic characteristics of participants
Ethnicity, n (%)*
Hispanic 40 (45.5)
White (not Hispanic) 34 (38.6)
Other 13 (14.8)
African American 1 (1.1)
Sexual orientation (self-identified), n (%)*
Heterosexual 73 (83.0)
Bisexual 13 (14.8)
Asexual 2 (2.3)
Homosexual 0 (0)
No sexual intercourse partners to date, n (%)*6 (6.8)
Relationship status, n (%)*
Monogamous 31 (35.2)
Non-monogamous 11 (12.5)
No relationship 46 (52.3)
Orgasm recency, n (%)*
Earlier today 6 (6.8)
Yesterday 12 (13.6)
Day before yesterday 8 (9.1)
3 d to 1 mo previously 30 (34.1)
>1 mo previously 14 (15.9)
Confidence experienced orgasm in lifetime, n (%)*
Very sure 49 (55.7)
Pretty sure 12 (13.6)
Not sure 13 (14.8)
Probably do not experience orgasms 9 (10.2)
Definitely do not experience orgasms 4 (4.5)
Experiences multiple orgasms, n (%)*25 (28.4)
Primary cause of most recent orgasm, n (%)*
,†
Vaginal penetration alone 29 (33)
Clitoral stimulation
‡
40 (45.5)
Do not have orgasms 15 (17.0)
Another method 3 (3.4)
Stimulation area that usually contributes most to
orgasm, n (%)*
Very tip (glans) of clitoris 29 (14.9)
Skin over or above clitoris 20 (10.3)
Side of the vagina toward my belly (might
include G-spot)
15 (7.7)
I don’t know 6 (3.1)
Nipples 5 (2.6)
Labia 2 (1.0)
Side of the vagina toward my back 1 (0.5)
Opening of my vagina 2 (1.0)
Somewhere else 2 (1.0)
I don’t experience orgasms 10 (5.2)
Age (y), mean (SD) 22 (7.3)
Sexual intercourse with partners (lifetime),
mean (SD)
7.3 (9.5)
Sexual intercourse 1 time only (lifetime),
mean (SD)
3.1 (6.9)
Sexual intercourse frequency, mean (SD)
§
2.9 (1.5)
Masturbation frequency,
mean (SD)
§
2.2 (1.2)
(continued)
Table 1. Continued
Frequency of viewing erotica (h/wk),
mean (SD)
1.7 (3.0)
Centers for Epidemiological StudieseDepression,
mean (SD)
k
15.6 (10.3)
Sexual Desire Inventory, mean (SD) 1.0 (1.8)
Desire for sex with partner
{
43.1 (13.6)
Desire for solitary sex
#
9.0 (6.0)
Female Sexual Function IndexeOrgasm,
mean (SD)**
3.1 (2.1)
*Values might not sum to total due to non-response.
†
Analyses included only those who reported their most recent orgasm as
caused primarily by clitoral or vaginal stimulation.
‡
Includes clitoral stimulation alone or in combination with vaginal
stimulation.
§
2¼“one to three times a month”;3¼“one time a week.”
k
A suggested cutoff of 16 for depression has been suggested.
66
{
Range ¼8to70.
#
Range ¼3 to 26.
**Equivalent to a weighted score of 1.24, where 2.98 or lower was average in
a sample with orgasmic dysfunction.
67
J Sex Med 2016;-:1e10
Clitorally Versus Vaginally Stimulated Orgasms 3
(or corrected-to-normal) vision and hearing appropriate for
viewing films. Most participants identified as heterosexual,
were sexually experienced, not currently in a relationship, and
reflected the ethnic composition of the Albuquerque area, with
mostly Hispanic and white (not Hispanic) participants
(Table 1). No one declined to participate after reading the
informed consent statement. All procedures were approved
by the institutional review board at the University of New
Mexico.
Regulation Task
Computerized training was provided on the regulation task
using non-sexual stimuli (films of people eating, instructed to
regulate hunger). Participants were instructed to view each film
the entire time (20 seconds) it was on the screen and to refrain
from stimulating themselves sexually. An instruction was given
for 2 seconds immediately before each sexual film (Figure 1).
Participants saw a circle, an upward arrow, or a downward
arrow, which indicated that they should simply watch, increase
their sexual arousal, or decrease their sexual arousal to the
sexual film, respectively. They were not restricted to the
cognitive or affective strategies they used to alter their
responses, because the interest was in examining usual abilities
to alter responses.
Films were shown on a 1,280 1,024 cathode ray tube
monitor with a 75-Hz refresh rate and 32-bit color depth at a
distance of 1 m using Presentation (Neurobehavioral Systems,
Berkeley, CA, USA). Participants were shown 30 different sexual
films. Regulation instruction was pseudo-randomized to ensure
that preferences for certain films would not interact with regulation
instruction. Furthermore, participants did not receive the same
instructions more than three times consecutively. After watching
every film, participants rated the level of how “sexually aroused”
they felt on a seven-point Likert scale from “not at all”to “very.”
Self-rated sexual arousal was the primary dependent variable.
Film Stimuli
Two types of films were used: neutral and sexual. The neutral
film was previously standardized
34
not to evoke any particular
emotional state. It depicts neon lines appearing against a solid black
background at a slow rate of speed in random directions. Sexual
films were selected to be sexually arousing to men and women. Two
films were used from a previous study for scientificcontinuity.
35e37
Twenty-eight additional sexual films were selected from the Adult
Video Network Award winners for Best Film and Best Scene
38
for a
total of 30 sexual film clips. All sexual films showed one man and
one woman having consensual, vaginal intercourse, included their
faces in the opening screen, and did not show kissing or oral sex.
Sexual films did not include infrequent behaviors, such as bondage
and anal intercourse.
39
All films were edited to 20 seconds in
length. Thisbrief presentation period was used to replicate previous
studies of self-regulation to emotional films that ranged from 15
40
to 39
41
seconds. The same neutral film appeared after every sexual
film, for a total of 60 film clips in the task.
Questionnaires
Questionnaires were included to assess mental health and
sexual functioning. Specific questionnaires were included to
assess the two most common Axis I problems, depression and
anxiety. Sexual health was assessed as the presence of sexual
problems and the level of sexual desire to characterize the sample.
Centers for Epidemiological StudyeDepression Scale
The Centers for Epidemiological StudyeDepression Scale
(CES-D)
42
is a 20-item questionnaire that assesses symptoms of
depression by asking participants to rate how often they had felt
or behaved certain ways (eg, “I was bothered by things that
usually don’t bother me.”). Response options ranged from “rarely
or none of the time (less than one a day)”to “most or all of the
time (5e7 days).”The CES-D is a very widely used measure-
ment of depression in adolescents
43
to older adults.
44
Figure 1. Protocol and four trial types in the sexual regulation task.
J Sex Med 2016;-:1e10
4Prause et al
Beck Anxiety Inventory
The Beck Anxiety Inventory (BAI)
45
is a 21-item questionnaire
that assesses anxiety symptoms. Women were asked to rate how
much they were bothered by each symptom (eg, “unable to relax,”
“fear of the worst happening”) in the past month from “not at all”
to “severely—it bothered me a lot.”The BAI correlates with many
other measurements of anxiety.
46
The BAI appears less contami-
nated with depression symptoms than other common measure-
ments of anxiety
47
in non-symptomatic, college samples.
48
It is
moderately reliable (r ¼0.67) over an 11-day delay period.
34
Personal and Sexual History
This questionnaire included questions about a participant’s
background, sexual behaviors, and sexual feelings. Sexual history
questions (eg, number of lifetime sexual intercourse partners)
were from the National AIDS Behavior Survey.
49
Specifically relevant for the present study, participants answered
many questions about their orgasm history and preferences. These
included, “Which of these best describes what you were doing that
caused this last orgasm?”Options included a list of sexual behaviors
(eg, “with a partner during intercourse alone,”“with a partner
during intercourse while also stimulating myself with my hand,”
“another method not listed here,”etc), which were recoded to
“vaginal only”if the participant reported that she experienced
orgasm through intercourse alone (Table 1). All other methods that
included clitoral stimulation, including stimulating the clitoris
during penetration, were coded as including “clitoral”stimulation.
To examine the relevance of questions sometimes used to
characterize orgasm source,
28
women were asked, “When you
experience orgasm, please select the top two body areas that
contribute the most to your experiencing orgasm when they are
stimulated.”A labeled photograph of the vulva was provided to
ensure that women were familiar with the available options
(Figure 2). All response options are listed in Table 1. For ana-
lyses, the clitoral hood and clitoral glans were coded as a “clitoral”
source, and any area of the vagina was coded as a “vaginal”
source. All other responses were excluded from these analyses
because they were too infrequent for analysis (Table 1). The
vaginal “opening”was not coded as “vaginal”because of concerns
that the opening might cause more obnubilation and pareidolia
in contrast to the clitoris.
Women also were asked how sure they were that they expe-
rience orgasms. The language was, “Some people get very sexu-
ally aroused, but are not sure that they have ever had an orgasm.
How sure are you that you experience orgasms?”They could
respond “very sure,”“pretty sure,”“not sure,”“probably do not
experience orgasms,”and “definitely do not experience orgasms.”
This question assesses whether the women themselves have
confidence in describing their own orgasm experiences.
Female Sexual Distress ScaleeRevised
The Female Sexual Distress ScaleeRevised (FSDS-R)
50
con-
sisted of 13 items and was used to compare the level of sexual
distress between women with vaginally stimulated orgasms and
women with clitorally stimulated orgasms (eg, “How often did
you feel distressed about your sex life?”with responses from
“always”to “never”). The scale exhibited a high internal
consistency (a¼0.93) and test-retest reliability (r ¼0.80 for
frequency and 0.83 for intensity) over 4 weeks.
50
The scale was
used as a general measurement of satisfaction with sexual
functioning.
Sexual Desire Inventory
The Sexual Desire Inventory (SDI)
51
is a 14-item question-
naire that measures the strength and frequency of a person’s
sexual desire. It is composed of two subscales: solitary (eg, “How
strong is your desire to engage in sexual behavior by yourself?”)
and dyadic (eg, “When you first see an attractive person, how
strong is your sexual desire?”). They measure desire for mastur-
bation and partnered sexual activity, respectively. The scale has a
high internal consistency (a¼0.96) and test-retest reliability
(r ¼0.76) over a 1-month period. The SDI is included as an
indicator of the role of orgasm type in sexual motivation, where
different types of stimulation might be pursued based on, or as a
reflection of, the strength of the sex drive.
Procedure
The study was conducted in a private, windowless testing
room at the Mind Research Network (Albuquerque, NM, USA).
After completing the informed consent process, participants
completed the questionnaires described earlier. At completion of
the questionnaires, they completed the sexual arousal regulation
Figure 2. Labeled photograph shown to women to ensure a
common understanding of genital anatomy (in color in study).
J Sex Med 2016;-:1e10
Clitorally Versus Vaginally Stimulated Orgasms 5
task. They wore headphones to listen to the videos and to
increase their sense of privacy during the task. The participants
received the instructions describing the task visually on the
computer screen and audibly in the recording to ensure the
participants’understanding. When the participants finished
receiving the instructions, the experimenter verbally answered
any other questions and then left the room. The participant was
given a standard keyboard to record her level of sexual arousal
and pleasantness during the tasks. After completing the regula-
tion task, instructions appeared on the screen instructing the
participant to alert the researcher. The researcher debriefed the
participants, answered any questions they had, and awarded
compensation in the form of participation credit for their
coursework.
MAIN OUTCOME MEASURES
The data collected from the questionnaires and video tasks
were analyzed in relation to the participants’most recent orgasm
by clitoral or vaginal stimulation. Recall (see earlier) of the most
recent orgasm was used, because state effects on the sexual
arousal task were of interest. The relation between the most
recent and the “usual”orgasm source is reported. A null-
hypothesis testing approach was used (a¼0.05). The exact
Pvalue is reported except when Pvalues were less than .001.
RESULTS
Questionnaires exhibited high internal consistency using the
Guttman l6,
52
a conservative estimate,
53
for the BAI (0.92),
CES-D (0.92), SDI (0.94), and FSDS-R (0.92). Women re-
ported significantly higher sexual arousal after viewing the sexual
film (mean ¼3.6 of 7, SD ¼1.6) than the neutral film (mean ¼
1.8, SD ¼0.8, t
65
¼11.45, P<.001, d ¼1.4). This indicated
that the film task worked as intended; thus, the planned analyses
for the film test were conducted (see below).
Validity and Reliability of Self-Report Measurement
Three aspects of self-reported orgasm source were examined.
These included how often women indicated a primary and
secondary source that contributed to their orgasm, how sure
women were that they have orgasms, and reliability of the source
reports (most recent vs usual orgasm source). First, women who
reported that the primary area that usually caused their orgasms
was vaginal or clitoral were significantly more likely to report that
the secondary area of stimulation that contributed to their
orgasm was the other (vaginal or clitoral) area (c
21
¼7.58,
P¼.007 by Fisher test, J¼0.42; Table 2). Second, women’s
ratings of how sure they were that they had experienced orgasm
in their lifetimes differed significantly from a rating of “sure”
(women were classified as being “sure”if they responded that
they were “very sure”they experience orgasms or “definitely do
not experience orgasms”;t
86
¼6.58, P<.001; Table 1), indi-
cating that women are frequently not sure that they are correctly
interpreting their orgasm experience (Table 1). Third, the area of
stimulation that women said caused their most recent orgasm
also was significantly likely to be the same area of stimulation
that they reported contributed the most to their orgasms (c
21
¼
10.92, P¼.002 by Fisher test, J¼0.43; Table 3). However,
16 women (27%) indicated a difference between their most
recent and their usual orgasm source.
Differences in Functioning by Primary, Last Orgasm
Source Reported
Next, the relations of orgasm source with mental and sexual
health indicators were tested. First, general indicators of mental
health were examined. Neither depression (CES-D) nor anxiety
(BAI) scores were predicted by the women’s source of their most
recent orgasm. Second, indicators of sexual health were exam-
ined. Women whose most recent orgasm was reached mainly by
clitoral stimulation reported more sexual arousal to the sexual
films that they were told to just watch (t
52
¼2.11, P¼.04,
d¼0.59; clitoral mean ¼4.02, SD ¼1.5; vaginal mean ¼3.11
of 7, SD ¼1.6) than the women whose most recent orgasm was
reached mainly by vaginal stimulation. However, women
reporting primarily clitoral stimulation did report continued
sexual arousal that also was higher after the neutral film that
followed the sexual films (mean ¼2.75, SD ¼1.3) compared
with women who reported their latest orgasm was from vaginal
stimulation (mean ¼2.06, SD ¼1.0, t
53
¼2.19, P¼.03,
d¼0.59). For films that elicited an increased sexual response,
the clitoral group also reported higher sexual arousal levels
(t
52
¼2.09, P¼.04, d ¼0.59; clitoral mean ¼4.28,
SD ¼1.5; vaginal mean ¼3.33, SD ¼1.7). The ability to
Table 2. Women who report usually experiencing clitoral or vaginal
areas as a primary source are likely to identify the other area as a
secondary source of their orgasm
Secondary source
Primary source
Clitoral Vaginal Total*
Clitoral 15 13 28
Vaginal 15 1 16
Total 30 14 44
*Missing data are due to women who report non-clitoral or non-vaginal
sources of orgasm (eg, nipple).
Table 3. Consistency of orgasm source comparing “most recent”
with “usual”orgasm source
Most recent source
Usual source
Clitoral Vaginal Total*
Clitoral 32 3 35
Vaginal 13 11 24
Total 45 14 59
*Missing data are due to women who report non-clitoral or non-vaginal
sources of orgasm.
J Sex Med 2016;-:1e10
6Prause et al
decrease sexual response did not vary as a function of orgasm
source. Women who reported that clitoral stimulation contrib-
uted more to their orgasm also reported a higher desire for
solitary sexual activity than women who reported that vaginal
stimulation contributed more to their orgasm (clitoral mean ¼
11.25, SD ¼6.4 vs vaginal mean ¼6.35, SD ¼3.4,
t
57
¼3.75, P<.001, d ¼0.96).
Characteristics of the orgasm that varied by their reported
source were compared. Orgasm source (clitoral vs vaginal) did
not predict self-reported orgasm intensity (clitoral mean ¼3.91,
SD ¼1.4; vaginal mean ¼3.18, SD ¼1.7; t
55
¼1.70,
P¼.1, d ¼0.48), overall sex-life satisfaction (clitoral mean ¼
3.56, SD ¼2.3; vaginal mean ¼2.96, SD ¼2.0; t
57
¼1.049,
P¼.3, d ¼0.28), or sexual distress scores (FSDS-R; vaginal
mean ¼11.05, SD ¼8.7 vs clitoral mean ¼10.85, SD ¼7.9,
t
53
¼0.085, P¼.933, d ¼0.02).
DISCUSSION
Some have suggested that orgasms generated by clitoral
stimulation are associated with inferior sexual, emotional, and
relationship functioning.
1
The results from the present study
suggest a more complex and nuanced picture of female orgasm
that goes beyond the clitoral vs vaginal dichotomy in two key
ways. First, these data clarify that the way in which orgasm
source has been assessed (“clitoral or vaginal?”) is misleading,
because most of our participants who reported a vaginal or
clitoral orgasm source as the primary site then reported the other
as the secondary site. Women experience orgasms in many varied
patterns, a complexity that is often missed by current methods of
assessing orgasm source. Second, women whose most recent
orgasm was caused primarily by clitoral stimulation indicated
better sexual functioning in several domains. Specifically, these
women reported higher levels of sexual arousal when watching
sexual films, were better able to increase their sexual arousal when
instructed, and reported a higher motivation to masturbate.
Higher sexual arousal reports to films have been consistently
linked to better sexual function.
54
They also did not differ in
their general mental health (depression or anxiety).
Self-reported orgasm source data might be useful in women sure
of their orgasm experience who have experience with clitoral and
vaginal orgasms. However, these data suggest that women feel
compelled to report a source for their orgasm when asked,
including women who are unsure that they even experience
orgasms. No physiologic data have yet demonstrated differences to
support self-reported differences in orgasm source. However, most
women still selected an area of stimulation to describe the source
of their orgasm. In this rather complex picture, it is understandable
that significant confusion could occur that would make attribution
of orgasms to a particular area of stimulation difficult.
Reframing the vaginal vs clitoral distinction might be useful in
future examinations of female sexual function. Most women in
this study reported that vaginal and clitoral stimulation
contributed to their orgasm(s). In fact, only one woman indi-
cated that her vagina was the primary and secondary area that
contributed to her orgasm. Put another way, asking women to
make a forced choice between clitoral and vaginal orgasm might
be similar to asking men to make a forced choice between a
“penile glans”or a “penile shaft”orgasm.
8
Many men report that
their shaft and glans are important in orgasm,
55
just as many
women in our study reported that the clitoris and the vagina are
important as primary or secondary sources of orgasm. Men also
were surveyed in this study (full results to be reported elsewhere).
Of those 99 men who reported having orgasms, the primary
stimulation site was reported as the “very tip of my penis”by 35,
“just under the tip of the penis”by 31, and the “shaft of the
penis”by 24 (others cited other sites of stimulation, such as
“testicles”). Also, the preference for the site of stimulation can
change with the partner and the sexual activity. Furthermore, the
preference might shift as perception changes with sexual arousal,
such as the shifts seen in pain thresholds
16
and sensitivity
56
with
increasing sexual arousal. Some have suggested shifting the
discussion to distinguish whether the external or internal clitoral
structures are involved, because evidence of uniquely “vaginal”
stimulation could not be identified by sonography.
18
Others
have suggested shifting to a description of “genital”orgasms,
possibly distinguished from clitoral, given the many structures
stimulated by intercourse.
6
The present data appear consistent
with these views.
Although self-report data of orgasm were analyzed in this
study, they appear of limited utility. In this study, a substantial
number of women were unsure of whether they were experi-
encing orgasm. Physiologic studies of orgasm in women rarely
verify the presence of orgasm through any objective means,
57
despite the availability of such physiologic methods as anal or
vaginal pressure monitors,
58
or through the use of direct obser-
vation as in studies of men.
59
Surprisingly, even very invasive
spinal surgery interventions to improve anorgasmia continue to
rely on self-reported orgasm events alone as an outcome.
60
Studies claiming to analyze the locus of orgasm in women
might not be tapping into real physiologic distinctions among
orgasm types. In this study, self-reported orgasm source data
were collected to attempt to replicate, extend, or challenge
existing publications. Future studies should begin to verify the
presence of other orgasm markers (eg, physiologic, behavioral)
to ensure convergence between self-report and physiologic
measurement of orgasm.
This study has limitations. The sample was a convenience
sample of relatively young students who might differ from the
general population of women. Also, Hispanic and non-Hispanic
women were well-represented by chance, and they might have
different experiences of orgasm that are unknown. Perhaps the
most difficult limitation to address is that many of the differences
in self-reported orgasm source can be attributable to the presence
of a partner. For example, vaginal stimulation is more likely to
occur in a partnered context, in which a male partner would
J Sex Med 2016;-:1e10
Clitorally Versus Vaginally Stimulated Orgasms 7
promote vaginal penetration where he receives direct physical
pleasure. Ideally, analyses should be conducted in four cells:
partner present with vaginal source, partner absent with vaginal
source, partner present with clitoral source, and partner absent
with clitoral source. Very few women reported that they expe-
rienced a vaginal orgasm source without having an intercourse
partner (eg, using an inserted toy during solo masturbation).
This suggests it might be difficult to identify women who
masturbate using penetration alone, limiting even experimental
options for testing the importance of the presence of the partner.
The approach itself represents a challenge, because a self-report
approach was used to demonstrate the limitations of a self-
report approach. For example, these reports still cannot be
linked to specific physiologic events that might distinguish them.
Also, the study was conducted in a laboratory setting. Although
research attempting to link laboratory responses to real-world
sexual behaviors is increasing,
61e63
it is unclear how closely
self-reports resemble behaviors and experiences at home. Further,
institutional review boards have prevented the study of orgasms
in the United States. Specifically, a protocol submitted to the
Institutional Review Board of the University of New Mexico in
Albuquerque was rejected after months of review when we
refused to remove just the orgasm component of the study,
although no safety, confidentiality, science, or similar concerns
were identified as a problem.
CONCLUSION
Many women report feeling sexually inadequate, because they
cannot experience orgasms by penile penetration alone (eg, “all real
women do,”“I am sure [clitoral stimulation during intercourse]
doesn’t look nice”).
64
This dissatisfaction is so significant that
methods purported to surgically enhance vaginal sensitivity are
peddled.
65e67
This second failure to replicate previous reports of
the superiority of women who experience vaginal orgasms
8
and
contrary data patterns suggest that data suggesting the problems
with clitoral stimulation to reach orgasm are not replicable. Some
women already have shifted away from prioritizing orgasm as a
neurophysiologic response to clitoral or vaginal stimulation
essential to sexual satisfaction, such as this focus group participant:
“Idon’t think that the act of sex is to have an orgasm. It’snotthe
goal. The goal of sex is to be intimate with your partner and show
them you care and that you love them.”
10(p621)
The goal of sexual
interactions is likely to shift with the social context, individual
preferences, and the state of the individual. These data suggest
that, when orgasm is a part of the sexual interaction, the superi-
ority of one stimulation area or another is likely to change with the
context and the desired outcome. Women who experience orgasm
regularly during masturbation with good knowledge of their
clitoris often cannot experience orgasm when they want to with a
partner.
12
Such partnered anorgasmia can worsen if a woman’s
preferred method of stimulation is pathologized (for review, see
Levin
5
). The study of orgasm will remain in its infancy stage until
scientists successfully overcome scientificandmoralchallengesto
strong empirical methods.
Corresponding Author: Nicole Prause, PhD, Department of
Psychiatry, University of CaliforniaeLos Angeles, 730 West-
wood Boulevard, Los Angeles, CA 90024, USA; E-mail: nicole.
prause@gmail.com
Conflicts of Interest: The authors report no conflicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Nicole Prause; Lambert Kuang; Peter Lee; Geoffrey Miller
(b) Acquisition of Data
Nicole Prause
(c) Analysis and Interpretation of Data
Nicole Prause; Lambert Kuang; Peter Lee
Category 2
(a) Drafting the Article
Nicole Prause; Lambert Kuang; Peter Lee; Geoffrey Miller
(b) Revising It for Intellectual Content
Nicole Prause; Geoffrey Miller
Category 3
(a) Final Approval of the Completed Article
Nicole Prause; Lambert Kuang; Peter Lee; Geoffrey Miller
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