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The Self‐Assessment of genital anatomy, sexual function and genital sensation (SAGASF‐M) questionnaire in a Belgian Dutch‐speaking male population: A validating study

November 2022
Andrology 11(4)

DOI:10.1111/andr.13348

Authors:

Wietse Claeys

Ghent University

Guy Bronselaer

Ghent University

Lumen Nicolaas

Universitair Ziekenhuis Ghent

Piet Hoebeke

Ghent University

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Introduction: Penile and genital surgery for congenital or acquired conditions is daily practice in reconstructive urology. These procedures, which carry the risk of disrupting nerves and blood vessels, may impair the genital sensation, and affect the capacity for sexual pleasure. Self-reported tools are needed to systematically assess the male genitalia before and after reconstructive surgeries in terms of genital sensation and sexual experience. Aim: This study validated the Dutch translation of the self-assessment of genital anatomy and sexual functioning (SAGASF-M) questionnaire and investigated the perceptions of healthy men regarding their genital anatomy and sensory function. Methods: Eight-hundred and eight sexually active men with a median age of 39 years (18-79 years) and no history of genital procedures other than circumcision filled out an online version of the questionnaire. Twenty-four participants were randomly recruited to confirm the responses of the SAGASF-M questionnaire by a clinical evaluation. Main outcome measures: The SAGASF-M questionnaire comprises of multiple-choice questions and clarifying illustrations asking men to rate their genital appearance, overall sexual sensitivity, and pain perception as well as the intensity and the effort to reach orgasm. Prespecified regions of the glans, penile shaft, scrotum, perineum, and anus are evaluated through this questionnaire. Results: Only slight variability in anatomical ratings was observed. Overall discrimination between different genital areas in terms of genital sensation was significant. The bottom of the glans or frenular area was rated the highest contributor to "Sexual pleasure", followed by the other regions of the glans and shaft. The same distribution was found for "Orgasm intensity" and "Orgasm effort". The anal region was generally rated the lowest. "Discomfort/Pain" was rated lower than any of the other sensory function indicators and the top of the glans and anal region were rated most likely to perceive this unpleasant sensation. Participants reported significantly more sexual pleasure and intense orgasms when stimulated by a sexual partner compared to self-stimulation. Homosexual and bisexual men reported a higher contribution of the perineal and anal regions in sexual pleasure and orgasm. No significant difference between circumcised and uncircumcised individuals regarding overall genital sensation could be found. Conclusion: The Dutch translation of the SAGASF-M questionnaire is a valuable and reliable tool for self-assessment of genital anatomy and sensation, providing a site-specific attribution of a patient's perceived sexual function. Further prospective research with this questionnaire could aid in the patient-centered improvement of genital surgery. This article is protected by copyright. All rights reserved.

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The Self-Assessment of Genital Anatomy, Sexual Function and Genital Sensation (SAGASF-M)

Questionnaire in a Belgian Dutch-speaking male population: A validating study.

Wietse Claeys, MD*°, Guy Bronselaer, MA*°, Nicolaas Lumen, MD, PhD*, Piet Hoebeke, MD, PhD*, Anne-

Françoise Spinoit, MD, PhD*

*Department of Urology, University Hospital Ghent and Ghent University, Ghent, Belgium

°Joint first authorship.

ABSTRACT

Introduction

Penile and genital surgery for congenital or acquired conditions is daily practice in reconstructive urology.

These procedures, which carry the risk of disrupting nerves and blood vessels, may impair the genital

sensation, and affect the capacity for sexual pleasure. Self-reported tools are needed to systematically assess

the male genitalia before and after reconstructive surgeries in terms of genital sensation and sexual

experience.

Aim

This study validated the Dutch translation of the self-assessment of genital anatomy and sexual functioning

(SAGASF-M) questionnaire and investigated the perceptions of healthy men regarding their genital

anatomy and sensory function.

Methods

Eight-hundred and eight sexually active men with a median age of 39 years (18-79 years) and no history of

genital procedures other than circumcision filled out an online version of the questionnaire. Twenty-four

participants were randomly recruited to confirm the responses of the SAGASF-M questionnaire by a

clinical evaluation.

Main outcome measures

The SAGASF-M questionnaire comprises of multiple-choice questions and clarifying illustrations asking

men to rate their genital appearance, overall sexual sensitivity, and pain perception as well as the intensity

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and the effort to reach orgasm. Prespecified regions of the glans, penile shaft, scrotum, perineum, and anus

are evaluated through this questionnaire.

Results

Only slight variability in anatomical ratings was observed. Overall discrimination between different genital

areas in terms of genital sensation was significant. The bottom of the glans or frenular area was rated the

highest contributor to “Sexual pleasure”, followed by the other regions of the glans and shaft. The same

distribution was found for “Orgasm intensity” and “Orgasm effort”. The anal region was generally rated the

lowest. “Discomfort/Pain” was rated lower than any of the other sensory function indicators and the top of

the glans and anal region were rated most likely to perceive this unpleasant sensation. Participants reported

significantly more sexual pleasure and intense orgasms when stimulated by a sexual partner compared to

self-stimulation. Homosexual and bisexual men reported a higher contribution of the perineal and anal

regions in sexual pleasure and orgasm. No significant difference between circumcised and uncircumcised

individuals regarding overall genital sensation could be found.

Conclusion

The Dutch translation of the SAGASF-M questionnaire is a valuable and reliable tool for self-assessment of

genital anatomy and sensation, providing a site-specific attribution of a patient‟s perceived sexual function.

Further prospective research with this questionnaire could aid in the patient-centered improvement of

genital surgery.

INTRODUCTION

Penile and genital surgery for congenital or acquired conditions, including hypospadias, buried penis,

urethral stenosis, and curvature is part of the daily practice for the reconstructive and pediatric urologist.

Surgical procedures for personal reasons such as circumcision at the request of the patient or the parents,

are also very common. Apart from surgical complications and objective measurements, patient-reported

outcome after penile surgery often emphasizes on voiding function, erectile function, and ejaculation.

Within these topics, validated Reported Outcome Measure (USS-PROM), International Index for Erectile

Function (IIEF) and Sexual Health Inventory for Men (SHIM) are readily available (1–4). Like other

surgeries, genital surgery carries the risk of disruption of nerves and blood vessels. This may impair the

genital sensation and therefore affect the ability to experience sexual pleasure (5). Anatomic and

physiologic studies have shed light on the innervation of the human penis (6–9). Yet, little is known about

the sensory regions being innervated by these genital branches. Various sensory function tests such as

Semmes-Weinstein monofilaments, the bio-thesiometer and somatosensory evoked potential (SSEV) tests

have been used to evaluate sensitivity thresholds of the male genital area (10–12). All of them measure the

objective decrease or increase in sensitivity of certain genital areas after surgery, but it has been argued that

objective evaluation does not always match that of the patient in an erotic setting (13–15). Therefore, the

evaluation for self-reported genital sensation and its relation to sexual function between patients with and

without a history of genital surgery is highly needed but no normative large body of data exists to date.

Tools are needed to systematically assess the male genitalia, as reported by the patient, before and after

reconstructive surgeries in terms of genital sensation and sexual experience in an actual erotic situation. To

address this shortcoming, the „Self-Assessment of Genital anatomy and Sexual function in Male‟ (SAGASF-

M) questionnaire was developed by Schober et al. in 2009 (16). The present study aimed to validate the

translated version of the SAGASF-M questionnaire in Belgian, Dutch speaking men. We investigated

whether a large sample of men without genital surgeries can discriminate between different areas of the

genital region in terms of sexual function. In addition, we compared the responses from this questionnaire

with respones to comparable questions asked by an examining urologist. We also performed a physical

examination to let patients rate their sensory function of this region as confirmation.

METHODS

To be eligible for inclusion, participants must be cisgender male, above 18 years of age and have been

sexually active in the past 12 months. Transgender men, gender non-conforming persons, individuals with a

history of surgery to the genitalia other than circumcision, or individuals who were sexually inactive in the

past year, were excluded. Over the course of eight consecutive months, respondents were randomly

recruited through flyers that were distributed in public places in the Dutch speaking region of Belgium. In

addition, the local press and social media were used to include participants. The leaflet explained that the

Ghent University Hospital was conducting a survey on genital sensitivity and sexual function in a cisgender

male population. Each individual was invited to complete the online version of this questionnaire and was

asked to provide informed consent for use of the provided information in scientific research. Participants‟

privacy and confidentiality were ensured by use of a secured and anonymous database. Quality control was

performed by use of repetitive questions. Entries with clear inconsistencies in these control questions were

excluded. All participants were asked to leave their contact information if they wished to continue

participating in the second part of the study. Of these, a test sample was randomly invited to participate in a

urological examination performed by an experienced reconstructive urologist (A.F.S.). Ethics approval was

obtained from the university‟s ethics committee (EC2009-629).

The original version of the SAGASF-M questionnaire (16) was translated into Dutch by two independent

researchers. Consensus between the two translations was obtained with discussion in case of

inconsistencies. The final version of the Dutch questionnaire was back translated by a native English

speaker. Comparison between the two versions of this questionnaire did not lead to substantial loss of

information (previous work). In the first part of the questionnaire, participants were asked to describe their

genital anatomy by selecting one of several options on questions like penile deviation, penile size, form of

scrotum and position of the urethral meatus. In the second part, participants were asked to rate genital

sensitivity on five-point Likert scales for sexual pleasure, discomfort or pain, effort for achieving orgasm

and orgasm intensity for several areas indicated on illustrations. Each of these areas were to be rated for

sexual self-stimulation or stimulation by a sexual partner. As an example, sexual touch or stimulation of the

lower (ventral) side of the shaft (area F) by self or partner produced sexual pleasure rated as 1, None; 2,

Mild; 3, Moderate; 4, Strong or 5, Very strong. Furthermore, feelings of numbness or a tingling in these

indicated areas as well as their intensity were assessed. In total 11 assessed anatomical locations were

included in this questionnaire (Figure 1).

For the assessment of genital sensation by a urologist (A.F.S.), participants were randomly recruited and

invited to the Urology department of the Ghent University Hospital for a clinical evaluation. Those

participants were placed in supine position with the legs spread out after having undressed the lower body.

The urologist rated genital anatomy in the same manner as the men had done before in the SAGASF-M

questionnaire. A cotton swab was used to designate the different areas of the genital region while the

participants were looking at the ceiling. For each of the different areas, participants were asked to rate

sexual pleasure, discomfort/pain, orgasmic intensity, and effort for achieving orgasm on five-point Likert

scales in a sexual context. The interval between the participants filling in the online questionnaire and

having the clinical evaluation was two weeks.

Descriptive statistics were used to report on the epidemiological features as well as genital anatomy of

included individuals. The different assessed anatomical locations of the genital area were compared using a

Bonferroni corrected repeated measures ANOVA tests with a significance level of

< 0.05. As the effort for

achieving orgasm was only indicated on those genital areas that contributed to orgasm, numbers for this

parameter were much lower. Therefore, we used separate Wilcoxon signed rank tests with a significance

level that was lowered 11 times (as 11 anatomical locations tested) resulting in

< 0.0045. All ANOVA tests

were followed by all possible pairwise group comparisons using paired students t-tests. ANOVA tests were

also applied for the comparison between circumcised and uncircumcised individuals. Paired Wilcoxon

signed rank tests were used to compare differences in stimulation between sexual self-activity and sexual

activity with a partner. Kruskal-Wallis tests were applied to evaluate differences in distribution of genital

sensation ratings for each of the evaluated genital locations between homosexual, heterosexual, and bisexual

men. Paired Wilcoxon signed rank tests were also used to compare differences in the four assessed

functional domains between the SAGASF-M questionnaires and the urological evaluation

Analysis was

carried out using the statistical software package SPSS statistics Version 27 (SPSS Inc, Chicago, IL, USA).

RESULTS

Over the course of 8 months, a total of 808 valid entries were completed in the online version of the

SAGASF-M questionnaire. All included participants were adults and had no history of genital surgery other

than circumcision. All men were sexually active (by self or through their partner) in the last 12 months

(Table 1). The median age of participants in the survey was 39 years (18-79 years). Correction for

oversampling was performed by age and sexual preference based on 2021 demographical data from the

National Office of Statistics (17). We could not correct for racial background as these numbers were not

readily retrievable. Men who participated in the clinical evaluation had a median age of 36 years (27-65

years).

Most participants rated their penis as straight (50.5%) or slightly curved (24.8%) and average in size, both in

flaccid (62.6%) and erect (67.9%) states. Scrotal anatomy was largely considered normal (80.1%) with

average sized testicles (88.8-90.0%). The mean length and girth of the penis in erection was measured at

15.6 ± 2.46 cm and 11.3 ± 3.26 cm respectively (Table 2). There was 100% agreement with urologist‟s

responses regarding anatomical variations. Perceived penile size however, corresponded in only 83% of

cases. No systematic differences in rating were observed.

Uncircumcised individuals could discriminate significantly well (

< 0.05) between the 11 designated areas

regarding genital sensation. The bottom of the glans was rated the highest contributor to “Sexual pleasure”,

followed by the other regions of the glans and shaft as described in Table 3. The anus was rated the lowest.

However, not all Bonferroni corrected pairwise comparisons were significant for areas other than the glans

region. This ranking was similar for “Orgasm intensity” and “Orgasm effort” but fewer pairwise

comparisons were significantly different. “Discomfort/Pain” was generally rated lower than any of the other

sensory function indicators. The top of the glans was rated highest, followed by the area around the anus.

There was no significant difference between circumcised (n of Circ = 152) and non-circumcised (n of N-

Circ = 550) individuals for the overall comparison between areas B to K for “Sexual pleasure” (F(1, 1) = 2.32,

= 0.128), “Orgasm intensity” (F(1, 1) = 0.06,

= 0.802), “Orgasm effort” (n of Circ = 42, n of N-Circ = 141 )

(F(1, 1) = 1.92,

= 0.167) and “Discomfort/Pain” (F(1, 1) = 0.04,

= 0.840).

When evaluating only the glans areas (B, top of glans; C, bottom of glans; D, sides of glans), we found

significantly lower scores in circumcised individuals for “Sexual pleasure” (F(1, 1) = 14.9,

< 0.001) and

“Orgasm intensity” (F(1, 1) = 5.29,

= 0.022), but not for “Orgasm effort” (n of Circ = 117, n of N-Circ =

451) (F(1, 1) = 1,19,

= 0.275) or “Discomfort/Pain” (F(1, 1) = 2.78, p = 0.096). None of the other

subdivisions of anatomic areas (e.g. shaft areas, scrotal areas, perineal areas) showed a significant difference

between circumcised and uncircumcised individuals. Further comparisons were made between

uncircumcised individuals and participants circumcised before or after sexarche (n of Circ shortly after

birth or in childhood = 96, n of Circ in adolescence or adulthood = 56) (table 6 and figure 2). Here, “Sexual

pleasure” and “Orgasm intensity” were rated significantly lower in individuals circumcised shortly after

birth or during childhood compared to uncircumcised individuals (F(1, 1) = 17.6,

< 0.001 and F(1, 1) =

7.41,

< 0.007 respectively) but no significant difference was found between individuals circumcised at

adolescence or adulthood and uncircumcised individuals (F(1, 1) = 1.40,

< 0.237 and F(1, 1) = 0.14,

0.714 respectively). “Sexual pleasure” and “Orgasm intensity” were not significantly different between

individuals circumcised shortly after birth or during childhood and individuals circumcised in puberty or

adulthood (F(1, 1) = 3.11,

< 0.080 and F(1, 1) = 2.49,

< 0.116 respectively). “Orgasm effort” and

“Pain/Discomfort” was not significantly different between uncircumcised individuals and those circumcised

shortly after birth or during childhood (F(1, 1) = 0.33,

< 0.564 and F(1, 1) = 6.43,

< 0.011 respectively)

nor between uncircumcised individuals and individuals circumcised during adolescence or adulthood (F(1,

1) = 1.32,

< 0.252 and F(1, 1) = 0.17,

< 0.680 respectively). “Pain/Discomfort” was rated significantly

higher in participants that were circumcised in puberty or adulthood compared to participants circumcised

shortly after birth or during childhood (F(1, 1) = 6.95,

< 0.009). Again, none of the other subdivisions of

anatomic areas showed a significant difference for age at circumcision.

We used the data from the unweighted sample to examine whether participant characteristics affected the

answers given to the questionnaires. Overall, participants reported significantly more sexual pleasure (n of

having sexual partner = 686; Z = 10.8;

< 0.001) and more intense orgasms (n = 686, Z = 4.52;

< 0.001)

when stimulated by a sexual partner compared to self-stimulation. These findings were consistent in

homosexual and heterosexual participants, but not in men having sexual contacts with both men and

women (Table 4). Looking at the proportions of genital sensation ratings for each anatomic site between

homosexual, heterosexual, and bisexual individuals, only the perineal and anal region showed significant

differences. In the perineal region, homosexual individuals reported more sexual pleasure and more intense

orgasms compared to heterosexual individuals (

= 0.001;

= 0.016, resp.), while bisexual individuals did

not seem to defer significantly between either group. In the anal region, both homosexual and bisexual

individuals reported more sexual pleasure (

< 0.001;

= 0.014, resp.) and more intense orgasm (

< 0.001;

=0.020, resp.) compared to heterosexual individuals. Between homosexual and bisexual men, no significant

differences were found in ratings of the anal region.

Comparison of genital sensitivity during clinical evaluation with SAGASF-M scores is summarized in Table

5. Overall, functional ratings between the questionnaire and clinical evaluation corresponded well, showing

the highest sensation ratings for “Sexual pleasure” and “Orgasm intensity”; and lowest ratings for “Orgasm

effort” at the glans areas B to D. Except for the “Orgasm intensity” at the back of the scrotum (as area I; n =

24; Z = -2.17;

= 0.030) and perineum (as area J; n = 24; Z = -2.24;

= 0.025), no significant differences in

genital sensation could be detected.

DISCUSSION

This study evaluated the use of the Dutch translation of the SAGASF-M questionnaire in a sample of 808

unoperated Dutch speaking, Belgian, cis-gender men, adding to the findings of previous publications on this

questionnaire (16,18). More than 60% of participants reported their penile (62.6% flaccid, 69.1% erect) and

scrotal (80.8%) size to be normal and urologist‟s ratings matched well with those of participants (≥83%).

These self-rated sizes seem to fit well in men‟s general views on penile size (19). However, the exact

numbers on penile size in our dataset revealed a slightly larger mean compared to the Caucasian mean of

14.3cm in erect state (20). As these numbers were self-reported, participants may have measured differently

and overestimated their penile size. Given that most congenital urological conditions are treated in early

childhood, only few individuals with minimal „anomalies‟ could be found in this surgically untreated

population sample. Sexual preference was originally reported higher for homosexual and bisexual

individuals compared to the Belgian mean (13.3% versus 4.2%) (17). A possible reason for this discrepancy

may be that homosexual and bisexual men are more open to discussing sexual health issues than

heterosexual individuals within the context of anonymity (21). This proportional difference is not present

in the focus group of participants that were willing to undergo a clinical assessment, which could imply that

the lifting of anonymity may cancel out any homosexual predominance.

Genital sensation scores on sexual pleasure and orgasmic intensity indicated that the bottom of the glans or

frenular area were rated highest, followed by all other glans areas. However, not all Bonferroni corrected

comparisons between genital areas were significant, meaning that the possibility to discriminate between

genital areas regarding sexual stimulation decreases when genital regions other than the glans and shaft

areas were assessed. These sensory distributions contrast with the results of the original study of Schober et

al. where both the ventral glans and ventral shaft were rated equal and significantly above levels of all other

areas (16). We could not indicate a specific reason for this difference in findings other than the difference in

sample size (n = 81 in the original paper versus n = 808 in this study), which might have affected sensory

distributions over these various tested genital regions. Anatomical and physiological papers suggested that

the highest nerve density in the penis is to be found in the prepuce and dorsal glans, arising from the dorsal

penile nerves which are the biggest sensory structures of the penis providing cortical input (8,22). The

perineal nerves on the other hand, form a fine network on the ventral penile shaft and frenular area (23,24).

These two nervous structures join together at the junction between the cavernosal bodies and the spongious

body. However, the ratio in which each of these sensory nerves have a sexual stimulation function remains

unclear. Looking more into the types of nerves that account for erogenous sensation, genital end bulbs (also

genital corpuscles) located in the glans and not in the prepuce have been put forward as being the largest

contributor to sexual pleasure compared to other receptors (free nerve endings, Meissner corpuscles,

Krause‟s end bulbs, panician corpuscles, Rufini corpusles) (9). These are coiled nerve endings of myelinated

axons involved in the sensation of light touch and are found to be most prominent at the penile frenulum

and coronal ridge. A recent paper studies this site-specific histology further and postulates a gradient

hypothesis, meaning that the distal ventral aspect of the penis has the highest general (and genital

corpuscular) nerve density and that concentrations of nerve endings diminish towards the dorsal and

proximal aspect. (25) These findings might indeed strengthen our results that the frenular and glandular

areas are rated highest contributors to sexual pleasure and orgasm intensity in our sample. As the prepuce is

moved back and forth in uncircumcised men, this in turn could stimulate the frenulum, corona and ventral

side of the penile shaft where it emerges from. Therefore, as a recent review on the histological basis of

genital sensation states, it would be arguable that not the prepuce itself but rather the presence or absence

of it has an impact on penile sexual sensation (26).

Despite discomfort and pain being generally rated as low, the glans areas together with the anal region were

rated as the most painful. As these regions were rated most sensitive across the board, it does not seem

surprising. In a previous report on genital sensation in women with sexual disfunction, the authors stressed

the link between discomfort in the genital area and being at risk for female sexual disfunction (27).

Therefore, a similar association could well exist in men. Alternatively, pain and pleasure have been

described as stimuli that are closely intertwined as they can both contribute to a hormonal reward

experience within a sexual context (28, 29). People seeking pleasure in pain show a rise in cortisol and

endorphin levels, which argues for the pleasure inducing impact of bodily induced stress that is also seen

after sport activities.

As one would expect, the overall genital sensation ratings did not differ significantly between circumcised

and uncircumcised individuals. However, when focusing on anatomical subgroups, circumcised individuals

rated sexual pleasure and orgasm intensity significantly lower in the glans region. When further examining

these individuals based on the age at which circumcision was performed, we found that this lower rating in

sexual pleasure and orgasm intensity was only significant in individuals circumcised before puberty.

Secondarily, we found that pain and discomfort were rated higher in individuals circumcised during or after

puberty compared to those circumcised in childhood. Vast bodies of literature on the impact of

circumcision on sexual function have been reported (26, 30-32). Most of these conclude that removal of the

prepuce has no impact on overall sexual function. Therefore, we took caution in interpreting these results

and the authors did not claim that these statistical results may have any clinical relevance. The minority of

adult individuals who are circumcised after sexarche usually have circumcision performed for specific

underlying conditions such as (para)phimosis, lichen sclerosis, trauma, balanitis, or penile cancer. These

underlying conditions themselves may have significant impact on sexual functioning, confounding the role

of the removed prepuce (33-35). This is a finding that has also been put forward in a study by Bassio et al.

(36) They compared light touch, pain and temperature sensations between circumcised and uncircumcised

men using monofilaments and thermal probes. They concluded on the one hand that circumcision does not

seem to impair sensation on the rest of the penis, while on the other hand finding that the prepuce is

sexually not the most important zone of the male genital region. Given that the density of the general light-

touch pressure receptors (Meissner corpuscles) is higher in the prepuce than the glans, it is not unexpected

that this zone has a lower pressure threshold. This however does not necessarily mean that sexual

stimulation follows this distribution. In our sample, around a third of circumcised individuals had

undergone this procedure during or after puberty and are reporting more pain sensation during sexual

activity. This could be an indication that the circumcision was performed for an underlying condition.

However, we did not inquire into the reason for circumcision in this study.

Participants who indicated having sexual intercourse with a partner reported significantly more sexual

pleasure and intense orgasms when stimulated by their partner compared to self-stimulation. This showed

that partnered intercourse yields a more intense genital stimulation and possibly a more qualitative sexual

experience than self-stimulation. A recent paper indeed showed these same findings in a sample of over five

hundred men and women using an online survey assessing their perceived sexual pleasure in various sexual

activities (37). Multiple factors, including closeness to each other, building trust, feeling desired and giving

pleasure to a sexual partner have been put forward to play a role in women‟s partnered sexual contact (38).

Another study showed that men tend to defer to masturbation as a compensatory measure when partnered

intercourse is not possible or not as often desired by the partner, suggesting that partnered intercourse is the

preferred form of sexual contact (39). In this same study, it is stated nonetheless that masturbation and

partnered sex should not be seen solely as substitutes. They do complement each other in both men and

women in healthy relationships.

Both homosexual and bisexual individuals reported significantly more sexual pleasure and orgasm intensity

in the perineal and anal regions. This could indicate that these groups of individuals are more likely to use

these anatomical regions compared to heterosexual individuals. Generally, homosexual men tend to engage

more in anal stimulation compared to heterosexual men during sexual activity. However, recent studies

indicated that numbers of heterosexual men discovering the anal region as pleasurable might be increasing.

(40, 41). A qualitative study on 30 young heterosexual men showed that participants could speak openly on

the idea of anal stimulation during sexual activity. They did not see anal stimulation as a form of homo-

erotic sexual activity but rather a form of sexual exploration. Nearly half of the individuals had actually

experienced anal stimulation and the majority of them would explore it further (42). The other study

showed that around 20% of heterosexual men would engage in anal sexual stimulation and that men aged

35 and above were more likely to do so (43). In our study, however, we did not ask individuals specifically

what sexual role (receptive or not) they fulfill during penetrative sexual intercourse, which might impact

the degree to which the anal and perineal regions contribute to the sexual act.

Several limitations must be addressed in our study. Firstly, we evaluated self-reported genital sensation in a

Dutch speaking Belgian male sample consisting mainly of Caucasian, heterosexual highly educated

individuals of younger age. Although we corrected our data for age and sexual preference, several other

factors, including socio-cultural background, religion, medical history, amount of sexual experience,

relationship quality and mental health status might affect the perceived genital sensation during sexual

intercourse or self-stimulation. Secondly, the cross-sectional design in this study prohibited possible

interferences about causality. Thirdly, participants were limited to providing only multiple-choice answers

to predefined regions selected by the researchers. Open questions and response options like „no sexual

experience in this genital area‟, or the possibility to add other sexually stimulable areas of the body could

have aided in the interpretation of results. Fourthly, questions regarding the sexual function as such were

not asked. We did not know whether underlying problems in sexual functioning might have affected

participants‟ answers to genital sensation in a sexual context. It is yet to be confirmed what effect a change

in genital sensation might have on overall sexual functioning. Lastly, more quantitative and objective

measures of genital sensation such as bio-thesiometry, Semmes-Weinstein monofilament testing, and others

may be considered when interpreting the results of the SAGASF-M questionnaire as they could build a link

between perceived and measurable genital sensation. This combined assessment could then be used to

evaluate the impact on sexual functioning of various surgical interventions to the genital area.

Until now, we do not have a better tool to discriminate the genital region regarding sexual pleasure and

contribution to orgasm other than asking specific questions on each target region. In this context, an

individual‟s own judgement on sensation provides pivotal information regarding sexual function. The

original study was designed to evaluate the use of this questionnaire in a healthy population. The

questionnaire itself tries to capture differences in perceived sensation for very specific areas of the genital

region. As sexual pleasure and orgasm are very personal sensory experiences with a multifactorial character,

it is nearly impossible to be captured by a single evaluation tool. The authors believed that this

questionnaire is not a good discriminator between different groups of individuals, but rather a tool to

evaluate the effect of certain conditions or interventions within the same individual on a longitudinal level.

To further analyze the construct and discriminant validity of this questionnaire, a large sample of men with

different grades of underlying conditions or different types of genital surgery considering the grade of

expected neuronal and vascular damage will be required.

CONCLUSION

This study extended the findings of previous reports on assessing an individual‟s anatomy and genital

sensation. The SAGASF-M questionnaire could be a valuable tool for this purpose, providing a location

specific mapping of a patient‟s perceived sexual function. Further prospective research with this

questionnaire could aid in the design and evaluation of genital surgery.

AUTHOR CONTRIBUTION STATEMENT

W.C.: Initial manuscript, data acquisition, data analysis and interpretation

G.B.: Conceiving of presented idea, initial manuscript, data acquisition

N.L.: Critical evaluation and review of manuscript

P.B.: Conceiving of presented idea, critical evaluation and review of manuscript

A.F.S.: Conceiving of presented idea, data acquisition, critical evaluation and review of manuscript

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FIGURES

Figure 1: Genital areas indicated by dotted lines (A-K).

(Foreskin)

B (Top of glans)

C (Bottom of glans)

D (Sides of glans)

E (Top of shaft)

F (Bottom of shaft)

G (Sides of shaft)

H (Front of scrotum)

I (Back of the scrotum)

J (Perineum)

K (Anus)

Figure 2.1: Violin and boxplot of sexual pleasure ratings for different anatomical locations in uncircumcised individuals, individuals

circumcised before sexarche (shortly after birth or during childhood) and individuals after sexarche (during adolescence or adulthood).

Top of glans (L1) – Anus (L10). Yellow lines: 25% and 75% quartile, black lines: median.

Figure 2.2: Violin and boxplot of orgasm intensity ratings for different anatomical locations in uncircumcised individuals, individuals

circumcised before sexarche (shortly after birth or during childhood) and individuals after sexarche (during adolescence or adulthood).

Top of glans (L1) – Anus (L10). Yellow lines: 25% and 75% quartile, black lines: median.

TABLES

Table 1: Demographic characteristics of study group. *Weighting performed by sequential weighting method based on age and sexual

preference.

UNWEIGHTE

WEIGHTED*

UNWEIGHTED

Total (n=808)

Total (n=803)

Clinical

evaluation (n=24)

Median age in years (range)

39 (18-79)

36 (18-79)

36 (27-65)

Sexual preference %)

Men

13.1

4.3

4.2

Women

81.1

90.0

95.8

Both men and women or other

5.8

0.0

Gender of current sexual partner (%)

Male

12.9

4.5

4.2

Female

72.6

80.3

91.7

Both

2.6

0.0

No sexual partner

11.9

12.6

4.2

Education (%)

No education or primary school level

0.8

0.3

25.0

Lower secondary

5.3

0.7

4.2

Higher secondary

24.4

16.7

Higher education short type

19.7

19.8

8.3

Higher education long type or

University

49.8

49.1

45.8

Has a child (%)

43.2

46.2

39.1

Median number of children (range)

2 (1-7)

1 (1-7)

1 (1-4)

Racial background (%)

Caucasian

99.0

98.9

91.7

African

0.6

0.7

0.0

Asian

0.0

Arabic

0.2

0.3

4.2

Other (not further specified)

0.2

0.1

4.2

Circumcised (%)

21.7

20.8

At birth

1.7

1.9

4.2

As a child (1-11 yo)

11.1

11.5

12.5

As an adolescent (12-18 yo)

2.0

1.4

0.0

As an adult (>18 yo)

6.9

4.2

Table 2.1: Different answers of SAGASF-M questionnaire regarding penile anatomy. Weighted cases based on age and sexual

preference.

Penile anatomy

(n=803)

Hypospadias (%)

Opening at tip of glans or above

97.9

Opening at underside of glans

1.1

Opening where glans meets shaft

0.4

Opening at underside of shaft

0.3

Opening in scrotum

0.3

Epispadias (%)

Normal opening at tip of glans or

below

99.8

Opening at the upper side of the glans

0.1

Opening up until midshaft

0.1

Up/down deviation during erection (%)

Up against body

0.4

Severe upward

5.4

Moderate upward

2.6

Slight upward

26.7

Straight

50.5

Slight downward

12.2

Moderate downward

2.1

Severe downward

0.1

Sideways deviation during erection (%)

Severe curve to left

0.6

Slight curve to left

18.4

Straight

73.6

Slight curve to right

6.9

Severe curve to right

0.6

Having erections (%)

99.9

Erections hard enough for penetration

95.9

Erections long enough for penetration

96.1

Penile size in cm (SD)

Mean flaccid penile length

9.4 (2.46)

Mean flaccid penile circumference

8.8 (2.95)

Mean erect penile length (n=670)

15.5 (2.48)

Mean erect penile circumference (n=613)

11.3 (3.26)

Self-perception of penile size, flaccid (%)

Very small

1.1

Small

31.1

Average

62.6

Large

5.1

Very large

0.1

Self-perception of penile size, erect (%)

Very small

0.4

Small

11.3

Average

69.1

Large

18,9

Very large

0.4

Table 2.2: Different answers of SAGASF-M questionnaire regarding scrotal/testicular anatomy. Weighted cases based on age and sexual

preference.

Scrotal anatomy

(n=803)

Scrotal size (%)

Absent

0.3

Flat scrotum

0.5

Small sac without

rugation

4.0

Full sac, non rugated

13.0

Full sac, rugated

80.8

Bifid scrotum

1.4

Testicular size Left (%)

Very small

0.3

Small

5.3

Average

88.6

Larger than average

5.8

Testicular size right (%)

Very small

0.8

Small

4.2

Average

89,6

Larger than average

5.4

Table 3: Repeated measures ANOVA on discrimination between genital areas for non-circumcised participants (n=550, lowering of

numbers due to case weighting). *1=none, 5=intense; °1=very strong, 5=very little; §Significant Bonferroni corrected pair comparisons.

# Tested using separate Wilcoxon tests with a p-value < 0.0045 to be statistically significant (0.05/11 different locations). This was

performed to maintain the maximum possible number of participants for the comparison. Weighted cases based on age and sexual

preference.

Domain and area

Mean (SD)

Areas sig.

Different §

Areas not sig.

different

Sexual pleasure*

C Bottom of glans

3.9 (0.93)

A, B, D, E, F, G, H, I, J, K

B Top of glans

3.7 (0.91)

A, C, D, E, F, G, H, I, J, K

D Sides of glans

3.6 (0.90)

A, B, C, E, F, G, H, I, J, K

F Bottom of shaft

3.3 (0.95)

A, B, C, D, E, H, I, K

G, J

G Sides of shaft

3.2 (0.96)

A, B, C, D, H, I, K

E, F, J

E Top of shaft

3.2 (0.97)

B, C, D, F, H, K

A, G, I, J

J Perineum

3.2 (1.22)

B, C, D, H, K

A, E, F, G, I

H Front of

scrotum

3.0 (1.04)

B, C, D, E, F, G, J, K

A, I

A Foreskin

3.0 (1.09)

B, C, D, F, G, K

E, H, I, J

I Back of scrotum

3.0 (1.10)

B, C, D, F, G, K

A, E, H, J

K Around anus

2.7 (1.39)

A, B, C, D, E, F, G, H, I, J

Orgasm intensity*

C Bottom of glans

3.6 (1.18)

A, B, D, E, F, G, H, I, J, K

D Sides of glans

3.3 (1.17)

A, C, E, F, G, H, I, J, K

B Top of glans

3.3 (1.21)

A, C, E, F, G, H, I, J, K

F Bottom of shaft

3.0 (1.20)

A, B, C, D, H, I, J, K

E, G

G Sides of shaft

2.9 (1.20)

A, B, C, D, H, I, J, K

E, F

E Top of shaft

2.9 (1.22)

A, B, C, D, H, I, J, K

F, G

A Foreskin

2.5 (1.38)

B, C, D, E, F, G, H, I, K

J Perineum

2.3 (1.41)

A, B, C, D, E, F, G, K

H, I

H Front of

scrotum

2.2 (1.29)

A, B, C, D, E, F, G

I, J, K

I Back of scrotum

2.2 (1.31)

A, B, C, D, E, F, G

H, J, K

K Around anus

2.0 (1.39)

A, B, C, D, E, F, G, J

H, I

Orgasm effort°#

C Bottom of glans

3.2 (0.80) n= 565

A, B, D, E, F, G, H, I, J, K

B Top of glans

3.1 (0.79) n= 545

A, C, E, F, G, H, I, J

D, K

D Sides of glans

3.1 (0.77) n= 544

A, C, E, F, G, H, I, J

B, K

F Bottom of shaft

3.0 (0.83) n= 512

B, C, D, E, H, I

A, G, J, K

A Foreskin

3.0 (0.84) n= 387

B, C, D, H, I

E, F, G, J, K

J Perineum

3.0 (0.91) n= 330

B, C, D, H, I

A, E, F, G, K

K Around anus

3.0 (1.02) n= 256

B, C, H, I

A, D, E, F, G, J

G Sides of shaft

2.9 (0.81) n= 511

B, C, D, E, H, I

A, F, J, K

E Top of shaft

2.9 (0.84) n= 499

B, C, D, F, G, H

A, G, I, J, K

I Back of scrotum

2.8 (0.88) n= 332

A, B, C, D, F, G, J, K

E, H

H Front of

scrotum

2.8 (0.90) n= 336

A, B, C, D, E, F, G, J, K

Discomfort/pain*

B Top of glans

1.3 (0.62)

A, E, F, G, H, I, J

C, D, K

K Around anus

1.3 (0.81)

A, E, F, G, H, I, J

B, C, D

D Sides of glans

1.2 (0.59)

A, E, F, G, J

B, C, H, I, K

C Bottom of glans

1.2 (0.61)

A, E, F, G, H, I, J

B, D, K

F Bottom of shaft

1.1 (0.32)

B, C, D, H, I, K

A, E, G, J

G Sides of shaft

1.1 (0.34)

B, C, D, H, I, K

A, E, F, J

A Foreskin

1.1 (0.39)

B, C, D, K

E, F, G, H, I, J

I Back of scrotum

1.1 (0.47)

B, C, E, F, G, K

A, D, H, J

J Perineum

1.1 (0.48)

B, C, D, K

A, E, F, G, H, I,

H Front of

scrotum

1.1 (0.49)

B, E, F, G, K

A, C, D, I, J

E Top of shaft

1.0 (0.29)

B, C, D, H, I, K

A, F, G, J

Table 4: Overall difference in penile sensitivity when stimulated by partner or self in the last 12 months compared for gender of sexual

partner using Wilcoxon signed rank tests. *1=none, 5=intense; °1=very strong, 5=very little.

Overall

Homosexual

Heterosexual

Bisexual or other

Median

(IQR)

Sig.

Median

(IQR)

Sig.

Median

(IQR)

Sig.

Median

(IQR)

Sig.

Sexual pleasure*

n=686

< 0.001

n=103

= 0.002

n=571

< 0.001

n=21

= 0.527

Partner

4 (4-5)

Self

4 (4-4)

4 (4-5)

4 (4-4)

4 (4-4.5)

Orgasm intensity*

n=686

< 0.001

n=103

= 0.006

n=571

< 0.001

n=21

= 0.180

Partner

4 (4-5)

Self

4 (4-4)

4 (4-5)

4 (3-4)

4 (4-4)

Orgasm effort°

n=686

= 0.652

n=103

= 0.245

n=571

= 0.991

n=21

= 1.000

Partner

3 (3-4)

Self

3 (3-4)

Discomfort/pain*

n=664

< 0.001

n=103

= 0.001

n=554

= 0.002

n=21

= 0.317

Partner

1 (1-1)

Self

1 (1-1)

Table 5: Wilcoxon matched pair signed rank test for comparisons of genital sensation ratings between SAGASF -M questionnaire and

during urological examination by medians (interquartile range) (n=24). For comparison of foreskin sensation (n=19). *1=none,

5=intense; °1=very strong, 5=very little.

Sexual pleasure*

Orgasm intensity*

Orgasm effort°

Discomfort/pain*

SAGASF-M

Urol

exam

SAGASF-M

Urol exam

SAGASF-M

Urol

exam

SAGASF-M

Urol

exam

A Foreskin (n=19)

4 (3-5)

4 (4-5)

4 (3-5)

1 (1-1)

B Top of glans

4 (4-5)

4 (3-5)

4.5 (4-5)

4.5 (3.25-5)

4.5 (3-5)

5 (3-5)

1 (1-1)

C Bottom of glans

4.5 (4-5)

4 (4-5)

4.5 (4-5)

4 (3.25-5)

4 (4-5)

5 (3.25-5)

1 (1-1)

D Sides of glans

5 (4-5)

4 (4-5)

1 (1-1)

E Top of shaft

4 (3-4)

4 (3-5)

4 (2.25-4.75)

4 (3-4.75)

4 (3-5)

1 (1-1)

F Bottom of shaft

4 (4-5)

4 (3.25-4)

4 (3.25-5)

4 (3-4.75)

4 (3.25-5)

4 (3-4)

1 (1-1)

G Sides of shaft

4 (3-4)

4 (3-4.75)

4 (3-4)

3 (3.25-4)

1 (1-1)

H Front of scrotum

4 (2.25-4)

3 (2.25-4)

3 (3-4)

3 (2.25-4)

3 (3-4)

1 (1-1)

I Back of scrotum

3 (2-4)

3 (2-3.75)

2 (1-3)

3 (2.25-3.75)

3 (2-3.75)

1 (1-1)

J Perineum

2.5 (2-4)

2 (1-4)

2 (1.25-3)

1.5 (1-3)

2 (1.25-3.75)

2 (1-3)

1 (1-1)

K Anus

1 (1-3)

1 (1-2)

1 (1-1.75)

1 (1-2)

1 (1-1)

Table 6: Genital sensation ratings for different anatomical locations in uncircumcised individuals, individuals circumcised before

sexarche (shortly after birth or during childhood) and individuals after sexarche (during adolescence or adulthood). Median

(interquartile range). Numbers in bold are significantly different.

Sexual Pleasure (SP), Orgasm Intensity (OI), Orgasm Effort (OE), Discomfort/Pain (DP). *1=none, 5=intense; °1=very strong, 5=very

little.

Anatomical

location

Uncircumcised (n=626)

Circumcised before sexarche (n=108)

Circumcised after sexarche (n=67)

SP*

OI*

OE°

DP*

SP*

OI*

OE°

DP*

SP*

OI*

OE°

DP*

Foreskin

3 (2-4)

3 (1-4)

1 (1-1)

Top of glans

4 (3-4)

1 (1-1)

3 (2-4)

3 (1-4)

1 (1-1)

4 (3-4)

1 (1-1)

Bottom of glans

4 (3-5)

4 (3-4)

1 (1-1)

4 (3-4)

1 (1-1)

4 (3-4)

1 (1-1)

Sides of glans

4 (3-4)

1 (1-1)

3 (3-4)

3 (2-4)

1 (1-1)

4 (3-4)

3 (3-4)

1 (1-1)

Top of shaft

3 (2.43-4)

3 (2-4)

1 (1-1)

3 (3-4)

3 (2-4)

1 (1-1)

3 (2.07-4)

3 (2-4)

1 (1-1)

Bottom of shaft

3 (3-4)

3 (2-4)

1 (1-1)

3 (3-4)

1 (1-1)

3 (2.61-4)

3 (2-4)

1 (1-1)

Sides of shaft

3 (3-4)

3 (2-4)

1 (1-1)

3 (3-4)

3 (2-4)

1 (1-1)

3 (3-4)

3 (2-4)

1 (1-1)

Front of scrotum

3 (2-4)

2 (1-3)

1 (1-1)

3 (2-4)

2 (1-3)

1 (1-1)

3 (2-4)

2 (1-3)

1 (1-1)

Back of scrotum

3 (2-4)

2 (1-3

2 (1-3)

1 (1-1)

3 (2-4)

2 (1-3)

1 (1-1)

3 (2-4)

3 (1-4)

1 (1-1)

Perineum

3 (2-4)

2 (1-4)

1 (1-1)

3 (2-4)

1 (1-4)

1 (1-1)

4 (2-4)

2 (1-4)

1 (1-1)

Anus

3 (1-4)

1 (1-3)

1 (1-1)

2 (1-4)

1 (1-3)

1 (1-1)

3 (1-4)

1.31 (1-4)

1 (1-1)

ResearchGate has not been able to resolve any citations for this publication.

Immunohistological study of the density and distribution of human penile neural tissue: gradient hypothesis

Article

Full-text available

May 2022

Immunohistological patterns of density and distribution of neural tissue in the human penis, including the prepuce, are not fully characterized, and effects of circumcision (partial or total removal of the penile prepuce) on penile sexual sensation are controversial. This study analyzed extra- and intracavernosal innervation patterns on the main penile axes using formalin-fixed, paraffin-embedded human adult and fetal penile tissues, single- and double-staining immunohistochemistry and a variety of neural and non-neural markers, with a special emphasis on the prepuce and potential sexual effects of circumcision. Immunohistochemical profiles of neural structures were determined and the most detailed immunohistological characterizations to date of preputial nerve supply are provided. The penile prepuce has a highly organized, dense, afferent innervation pattern that is manifest early in fetal development. Autonomically, it receives noradrenergic sympathetic and nitrergic parasympathetic innervation. Cholinergic nerves are also present. We observed cutaneous and subcutaneous neural density distribution biases across our specimens towards the ventral prepuce, including a region corresponding in the adult anatomical position (penis erect) to the distal third of the ventral penile aspect. We also describe a concept of innervation gradients across the longitudinal and transverse penile axes. Results are discussed in relation to the specialized literature. An argument is made that neuroanatomic substrates underlying unusual permanent penile sensory disturbances post-circumcision are related to heightened neural levels in the distal third of the ventral penile aspect, which could potentially be compromised by deep incisions during circumcision.

Single and Partnered Individuals’ Sexual Satisfaction as a Function of Sexual Desire and Activities: Results Using a Sexual Satisfaction Scale Demonstrating Measurement Invariance Across Partnership Status

Article

Full-text available

Jan 2022
ARCH SEX BEHAV

Although some evidence exists to suggest that single (i.e., unpartnered) individuals are less sexually satisfied on average than are partnered individuals, it is unclear whether the variables correlating with each group’s sexual satisfaction are similar or different. This research sought to examine how desire for and actual engagement in solitary and partnered sexual activities are associated with both groups’ sexual satisfaction. We first conducted a preliminary study (n = 572) to test and refine existing measures of sexual satisfaction for applicability across relationship status. In two follow-up studies (N = 1,238), measurement invariance (across relationship status and gender) of the resulting 4-item sexual satisfaction scale was established. Further, results across the studies showed that for singles dyadic sexual desire was negatively related to sexual satisfaction, whereas no significant link was found with solitary desire. For individuals in romantic relationships, having higher sexual desire involving a partner and lower solitary desire were both associated with greater sexual satisfaction. When analyzing participants’ responses on the desired and actual frequency of engaging in specific sexual acts, we found that for both single and partnered individuals, frequent engagement in partnered acts was associated with greater sexual satisfaction. Wanting frequent engagement in partnered acts was associated with lower sexual satisfaction for both groups, but only if the current frequency of engaging in these acts was low. These findings suggest that at least during the COVID-19 pandemic, meeting desires for partnered sex plays an important role in maintaining a sexually satisfying life, regardless of one’s relationship status.

Oral, Vaginal and Anal Sexual Practices among Heterosexual Males and Females Attending a Sexual Health Clinic: A Cross-Sectional Survey in Melbourne, Australia

Article

Full-text available

Dec 2021
Int J Environ Res Publ Health

Sex practices among heterosexuals are not well studied. We aimed to explore sexual practices among heterosexuals attending a sexual health clinic. This cross-sectional survey was conducted at Melbourne Sexual Health Centre between March and April 2019. Data were collected on kissing, oral sex (fellatio or cunnilingus), vaginal sex, anal sex and rimming in the previous 3 months. Univariable and multivariable logistic regression analyses were performed to examine the associations between engaging in anal sex and other sex practices. There were 709 participants (333 men; 376 women) who were eligible and completed the survey (response rate was 24.6%). In the past 3 months, most participants had had vaginal sex (n = 677; 95.5%), with a mean of 3.0 (standard deviation (SD): 3.9) vaginal sex partners, and half reported engaging in condomless vaginal sex in the past 3 months (n = 358; 50.1%). A total of 135 (19.0%) participants had had anal sex, with a mean of 1.3 (SD: 1.0) anal sex partners, with 63.5% (n = 94) engaging in any condomless anal sex in the past 3 months. Most participants (n = 637, 89.8%) had received oral sex in the past 3 months; this proportion did not differ by age group or gender. Women (n = 351, 93.4%) were more likely to perform oral sex than men (n = 275; 82.6% men) (p < 0.001) and to have received rimming (26.6% women vs. 12.6% men; p < 0.001). Men were more likely to have performed rimming (25.5% men vs. 9.3% women; p < 0.001). After adjusting for age, number of partners and sexual practice, anal sex was associated with being ≥35 years (adjusted odds ratio (aOR): 2.3; 95% CI: 1.2–4.2), receiving rimming (aOR: 3.8; 95% CI: 2.4–6.0) and performing rimming (aOR: 2.8; 95% CI: 1.8–4.6). Rimming and anal sex are practiced by one-fifth or more of heterosexuals. Older heterosexuals were more likely to engage in anal sex and to perform rimming. Future research should consider the benefits of testing extragenital sites where appropriate.

How Sensitive Is the Neophallus? Postphalloplasty Experienced and Objective Sensitivity in Transmasculine Persons

Article

Full-text available

Oct 2021

Introduction Tactile and erogenous sensitivity of the neophallus after phalloplasty is assumed to affect the sexual well-being of transmasculine persons and, ultimately, their quality of life. The experienced and objective sensation of the neophallus and their association are largely unknown. Aim This study evaluated experienced tactile and erotic sensation of the neophallus in transmasculine persons and investigated how this was related to objective tactile sensitivity. Methods Between August 2017 and January 2020, 59 transmasculine persons who underwent phalloplasty were recruited to participate in a prospective follow-up study. Tactile sensitivity of the neophallus and donor-site was measured (Semmes-Weinstein Monofilament test) and compared, and participants were asked to fill out a questionnaire about experienced sensation of the neophallus and sexual wellbeing. Main outcome measures Experienced and objective sensation of the neophallus were measured by using a questionnaire and Semmes-Weinstein Monofilament scores. Results Neophallic tactile sensitivity was significantly reduced compared to the donor-site (n = 44), with the proximal part being more sensitive than the distal part (median follow-up of 1.8 years, range 1.0–7.2)). Sensitivity of the neophallus was not significantly associated with the surgical flap used, yet increased significantly with follow-up time. The questionnaire was completed by 26 participants of which 24 (92.3%) experienced (some degree of) tactile sensitivity in their neophallus. Erogenous sensation was experienced by 23 (88.5%). Experienced and objectified tactile sensitivity were not significantly correlated (Spearmans's rho = 0.23, P = .26). Answers to open-ended questions showed that results often do not match expectations. Conclusion Tactile sensation of the neophallus was reduced in most transmasculine persons and improved slowly over time. A significant association between subjective and objective measures could not be detected. Although experienced sensitivity varied between individuals, the vast majority reported to have tactile and erotic sensitivity in the neophallus.Transmasculine persons should be informed that sensitivity of the neophallus will likely be reduced. Elfering L, van de Grift TC, Al-Tamimi M, et al. How Sensitive Is the Neophallus? Postphalloplasty Experienced and Objective Sensitivity in Transmasculine Persons. Sex Med 2021;XX:XX–XXX.

The Contrasting Evidence Concerning the Effect of Male Circumcision on Sexual Function, Sensation, and Pleasure: A Systematic Review

Article

Full-text available

Dec 2020

Introduction Active debate concerns whether male circumcision (MC) affects sexual function, penile sensation, or sexual pleasure. Aim To perform a systematic review examining the effect of MC on these parameters. Methods PRISMA-compliant searches of PubMed, EMBASE, the Cochrane Library, and Google Scholar were performed, with “circumcision” used together with appropriate search terms. Articles meeting the inclusion criteria were rated for quality by the Scottish Intercollegiate Guidelines Network system. Main Outcome Measure Evidence rated by quality. Results Searches identified 46 publications containing original data, as well as 4 systematic reviews (2 with meta-analyses), plus 29 critiques of various studies and 15 author replies, which together comprised a total of 94 publications. There was overall consistency in conclusions arising from high- and moderate-quality survey data in randomized clinical trials, systematic reviews and meta-analyses, physiological studies, large longitudinal studies, and cohort studies in diverse populations. Those studies found MC has no or minimal adverse effect on sexual function, sensation, or pleasure, with some finding improvements. A consensus from physiological and histological studies was that the glans and underside of the shaft, not the foreskin, are involved in neurological pathways mediating erogenous sensation. In contrast to the higher quality evidence, data supporting adverse effects of MC on function, sensation, or pleasure were found to be of low quality, as explained in critiques of those studies. Conclusion The consensus of the highest quality literature is that MC has minimal or no adverse effect, and in some studies, it has benefits on sexual functions, sensation, satisfaction, and pleasure for males circumcised neonatally or in adulthood.

Between Pleasure and Pain: A Pilot Study on the Biological Mechanisms Associated With BDSM Interactions in Dominants and Submissives

Article

Full-text available

Jan 2020
J SEX MED

Background BDSM is an abbreviation used to reference the concepts of bondage and discipline, dominance and submission, sadism and masochism, enacted by power exchanges between consensual partners. Although pain is an evolutionary protection mechanism to prevent individuals from further exposing themselves to damage, afflicting or receiving pain is a core element of BDSM play. Aim To shed light upon the rewarding biological mechanisms associated with BDSM interactions. Methods Dominant and submissive counterparts of 35 BDSM couples were recruited through Fetlife, a BDSM-themed internet forum, and by word-of-mouth within the Belgian BDSM community. In order to control for social evening interaction effects, non-BDSM interested controls (n=27) were recruited at the bar of a local sports club and by word-of-mouth. Main outcome measures We compared the evolution of the stress and reward hormone levels of cortisol, beta-endorphins and endocannabinoids (2AG and AEA) in a group of BDSM practitioners before and after an active BDSM interaction with the levels in control individuals. Results We showed that submissives showed increases in cortisol levels due to BDSM interactions. Endocannabinoid levels in submissives increased during the play compared to the control group, but no such increase was observed in dominants. However, when taking play type into account, dominants showed a significant increase in endocannabinoids associated with power play but not with pain play. Conclusion Even though this is one of the first studies of its kind, we can conclude that there is a clear indication for increased pleasure in submissives when looking at biological effects of a BDSM interaction, which was related to the increases in experienced stress.

Critical evaluation of arguments opposing male circumcision: A systematic review

Article

Full-text available

Sep 2019

Objective: To systematically evaluate evidence against male circumcision (MC). Methods: We searched PubMed, Google Scholar, EMBASE and Cochrane databases. Results: Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems. Conclusions: Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.

A Study of Differences in Penile Dorsal Nerve Somatosensory Evoked Potential Testing Among Healthy Controls and Patients With Primary and Secondary Premature Ejaculation

Article

Mar 2021

Background Penile dorsal nerve somatosensory evoked potential (DNSEP) is a scientific and objective technique that provides effective and objective data to establish the diagnosis of premature ejaculation (PE). Aim To explore differences in DNSEP between patients with primary premature ejaculation (PPE) and those with secondary premature ejaculation (SPE), in order to investigate the clinical value of DNSEP in the diagnosis of PE. Methods The participants were divided into a PPE group (34 cases), an SPE group (25 cases) and a healthy control group (18 cases). All participants underwent DNSEP testing, and the latencies and amplitudes of DNSEP were recorded. Outcomes Differences in the latencies and amplitudes of DNSEP were compared among the PPE, SPE, and healthy control groups. Results The latencies of DNSEP in the PPE and SPE groups were shorter than those in the healthy control group, and these differences were statistically significant (P < 0.01). However, there was no statistically significant difference between the PPE and SPE groups (P > 0.05). The amplitudes of DNSEP in the PPE group were significantly higher than those in the healthy control group (P < 0.01). However, the amplitudes of DNSEP in the SPE group were significantly lower than those in the healthy control group (P < 0.05). Clinical Implications PPE and SPE can be differentiated based on differences in the amplitudes of DNSEP, providing an objective basis for treatments and follow-up examinations. Strengths and Limitations We evaluated differences in the amplitudes of DNSEP between PPE and SPE patients, which were rare in the published literature. However, specific causes of these differences are still unclear. SEP only reflects afferent pathways in the ejaculatory reflex arc, and role of the brain as a higher center should not be ignored. Conclusion Both PPE and SPE patients are characterized by an increased excitability of the penile sensory nerves. Sun Z, Liao Z, Zheng Q, et al. A Study of Differences in Penile Dorsal Nerve Somatosensory Evoked Potential Testing Among Healthy Controls and Patients With Primary and Secondary Premature Ejaculation. J Sex Med Rev 2021;xx:xxx–xxx.

Sexual Practices and Satisfaction among Gay and Heterosexual Men in Romantic Relationships: A Comparison Using Coarsened Exact Matching in a U.S. National Sample

Article

Jan 2021

Gay men are underrepresented in research on sexual satisfaction. We examined sexual satisfaction and over 50 sexual practices in an online U.S. national survey of men in relationships. Coarsened exact matching created comparable samples of heterosexual (n = 3527) and gay (n = 452) men on six demographic factors, including relationship length. Results identified many similarities between the groups, including sexual frequency, orgasm frequency, duration of sex, and sexual satisfaction. The majority of heterosexual and gay men expressed physical or emotional affection during their last sexual encounter, reporting that they or their partner said “I love you” (66%; 57%) and engaged in deep kissing (69%; 75%) or gentle kissing (82%; 72%). Heterosexual men were less likely than gay men to usually-always receive (27%; 61%) or give (37%; 68%) oral sex when intimate in the past month; were less likely to view pornography with their partner (35%; 61%); but were more likely to give their partner massages in the past year to improve their sex lives (71%; 58%). Number of sexual communication behaviors was a strong predictor of sexual satisfaction, particularly for gay men (β =.36). These findings enhance our understanding of heterosexual and gay men’s sexual lives.

Sexual and functional long-term outcomes following advanced pelvic cancer and reconstruction using vertical rectus abdominis myocutaneous and gluteal myocutaneous flap

Article

Sep 2020
EJSO-EUR J SURG ONC

Introduction After extensive pelvic surgery for cancer two flap types are used at Skåne University Hospital (SUS), Sweden for perineal reconstruction: vertical rectus abdominis myocutaneous flap and gluteal flap with or without vaginal reconstruction. The objective was to study the long-term outcomes in patients treated for advanced pelvic cancer receiving a flap. Method Patients with pelvic cancer subjected to surgery including perineal reconstruction between January 2010 and August 2016 at SUS were included retrospectively. Participating patients were scheduled for an out-patient visit. Questionnaires addressing quality of life, (QLQ-C30 and EQ-5D) and sexual function (FSFI and IIEF) were filled in. Sensitivity test, using monofilaments on the gluteal/posterior thigh area, neovaginal measurements using silicon gauges and muscular functionality tests (timed stands test and stairs test) were performed. Results Thirty-six (24 women, 12 males) out of 71 invited patients conceded participation. Patients scored a median of 85/100 regarding global health using EQ-5D. All women reported sexual dysfunction and 75% (9/12) of men reported severe erectile dysfunction. Neovaginal measurements showed adequate reconstructions. Sensitivity test implied decreased sensitivity on the operated side compared to the unoperated side in patients with gluteal flap. Both physical tests demonstrated adequate muscular functionality in everyday life activities after reconstructions using gluteal flap. Conclusion This long-term follow up after extensive surgery treating pelvic cancer with perineal flap reconstruction implies high quality of life, good muscular functionality and adequate neovaginal measurements. However sexual function is impaired among both sexes and sensitivity in the surgical area of the gluteal flap is decreased.