1.28.2015

Coitus as revealed by ultrasound in one volunteer couple - a Journal Article I Read



Well, I found better access to journal articles - thanks to my friend Stephanie, my cousin McKenzie, and my husband's sneaky internet ways. It's exciting because I do like to read more than the abstracts, and if you don't have good student-type access, they cost about $40 a pop, which is bullshit. Anyway, I chose a short one for my next installment in the Journal Article's I Read series. It's called "Coitus as revealed by ultrasound in one volunteer couple." 

This article is interesting, I think, for this blog because it's one that is commonly used to support the argument about the deep inner parts of the clit being the real "G-spot." Well, maybe that's not the exact way to put it. There is an argument in the lady-gasm and sexology world right now that goes something like this: There is no difference between clitoral and vaginal orgasms. They are all clitoral. It's just that sometimes the clitoral glans is stimulated in order to cause the orgasm (what some might traditionally call a clitoral orgasm) and sometimes the clitoral legs/Crus Clitoris and/or the bulb of vestibule (aka clitoral bulbs) are stimulated to cause the orgasm (what some might traditionally call a vaginal orgasm). 

I find the argument a bit troubling for 1 simple reason. There is no actual physiologic evidence for an orgasm caused by stimulation inside the vagina (i.e. "vaginal" orgasm). The only orgasms recorded were due to some direct or indirect stimulation of the clitoral glans. No one has ever proven that an orgasm can be elicited from stimulation inside the vagina, so giving a cause for this orgasm that might not even exist (whether it be through stimulation of the clitoral legs, the "g-spot" or any other thing in the vagina), seems a little problematic.


Anyway, the main cause for this even-vaginal-orgasms-are-clitoral argument are studies showing that during penetration, part of this inner clitoral structure gets close to the area of the vagina that has traditionally been thought to house the "g-spot." You see, when a woman gets aroused, she gets at least as much blood pooling in her genitals as men, only for ladies, it mostly fills in these inner clitoral structures. They are largely erectile tissue that become engorged during arousal.

So that's the background. Here's the study.

Coitus as revealed by ultrasound in one volunteer couple. 
J Sex Med. 2010 Aug;7(8):2750-4. Buisson O1, Foldes P, Jannini E, Mimoun S.
 

This is a study meant simply to see what happens to the vagina and surrounding tissue and organs when a woman is aroused and having intercourse. It is quite simple actually. The couple (the study points out they are both medical doctors for some reason), is verified as having no medical issues, no sexual dysfunction, and the woman "was regularly capable of achieving a vaginally activated orgasm from penetration without concomitant stimulation of the external clitoris." She lay in a gynecological position (on a table with her legs in stirrups) in a doctors office. The man was standing, and he penetrated her.

An ultrasound was taken as she became aroused (the clitoral legs and bulbs became more engorged). From the ultrasound, the authors concluded:
The penis exerts pressure on the anterior vaginal wall resulting in pressure (and movement) of penis on the entire CUV* complex against the pubic symphisis. The clitoris was stretched by the penis. The roots of the clitoris were ascending and completely widened by the penis. During intercourse the anterior wall of the vagina was crushed against the root of the clitoris. The Kobelt plexis was well visualized and seemed to be repeatedly crushed by the penis like a pumping effect.
So, this study basically showed how the penis moves our lady junk around during intercourse, which is pretty interesting. It doesn't actually say anything about "vaginal" orgasm, though. Neither she nor the man in this study orgasmed. I do so very, very much wish they had though. If this women could actually have "vaginally activated orgasm from penetration without concomitant stimulation of the external clitoris," then by god, catching that on ultrasound would have truly been a big step forward in the study of female orgasm. Maybe next time, I guess.


*CUV - clito-urethrovaginal complex

1.24.2015

Random Male Hite Report #11



It's time for more Random Hite Report. In 1976, Shere Hite dropped The Hite Report where she compiled detailed survey answers from over 3,000 women about sex, masturbation, orgasms, and relationships. It's insane to me how revolutionary this book still is. Read it, seriously. We haven't changed that much. Then in 1981, she dropped The Hite Report on Male Sexuality where over 7,000 men give detailed answers about sex, relationships, and women. It too is revolutionary, and the honesty and detail in this book is so important and moving, I think everyone should read this too.



 So, I give you a taste every now and then to entice you to get these books (seriously, they are both like 1 cent online)  what I do is flip to one random page and copy the contents of that page, no more-no less, directly onto this blog. Enjoy.

The Hite Report on Male Sexuality
Knopf, 1981 pg 431

This is from the chapter Toward a New Idea of Intercourse. In the section "Stereotypes about intercourse." These are answers to the survey question : "Do you have your best orgasms during fellatio, masturbation, intercourse or some other activity? Which activity do you find overall the most enjoyable?"

"My best orgasms have been from masturbation with intercourse a close second. This is due to the refined techniques I need for which most women do not have the patience, skill, or interest."
    "In masturbation the pleasure is more intense, as I am concentrating a good deal more on my own pleasure, that little ol' button-pusher, me. My best orgasms have always been privately conceived."
    "The joys of masturbating a cock allow you many alternatives, you can develop a technique that allows you to give yourself all sorts of good feelings. In fucking you ejaculate because the head of the cock is stimulated by moving back and forth in a vagina. There is no change in pressure, no bending, and movement is slower than the hand or head-you don't have the variety. But when you masturbate you can grab the cock in many different ways, with many different pressures, you can slide your hand over the head for one sensation, or you can use the skin that forms a movable sheath over the head for another. It gives me the opportunity to enjoy many sensations missed in fucking. Masturbating gives me my greatest orgasms."
    "Mi best orgasms are masturbation with simultaneous rectal stimulation by penis or dildo."
    "The stimulation during masturbation is more concise; also I can fantasize during masturbation. the vagina actually is not much stimulation for me. Then too I don't have to worry about satisfying her. I can be selfish. If I try to cross over to the masturbation habits in lovemaking, I'm going to be a bad lovemaker because I'll just be trying to get my rocks off. I love the initial penetration into the vagina, but it's just not enough friction. Probably because I'm so used to masturbating."*
    "I have two distinctly different types of orgasm. One is produced bu penis-vagina intercourse, the other by masturbation. My first and favorite type of orgasm is produced by masturbating with anal penetration which results in a very different build-up and climax. The entire process is less frenzied, less penis-centered. The sensations are less localized, more diffuse, I feel sensations in my nipples, my inner thighs, the soles of my feet more intensely, and throughout the buildup, rather than only transiently as in the 'usual' thrusting orgasm buildup, where they are quickly overwhelmed by penis sensation. the climax too feels more global, less acute, and it's sensation is one of sweet, wonderful melting, suffusing out from the genitals."
    "I would like to differentiate between the kind of orgasm I feel when I'm masturbating versus the kind of orgasm I have when I'm having vaginal intercourse. When I'm masturbating I usually have a very strong orgasm. Also, I can have several mini-orgasms (orgasms with contractions but without ejaculation) before I finally want to have the ejaculatory orgasm. I've rarely had those kinds of min-orgasms in vaginal intercourse. I can't control it that closely. Also, if I'm masturbating I can feel all the accessory organs - the prostate, the urethra bulb, all those contracting. In the penis itself I can feel the muscles contracting. When...
*This statement somewhat parallels women's fears that possibly they couldn't orgasm during intercourse because the had masturbated too much or too well. See chapter 3 of The Hite Report on female sexuality to see why just the opposite is true.

1.18.2015

SSL Vimeo sale, Dayton Premiere!, and Blogger is an Asshole



Hello! I thought I'd give you all a couple updates.

1 Science, Sex and the Ladies, as you may already know, is available on Vimeo on Demand (which you can get also access through Apple TV, Amazon Fire, and Roku). Well, by golly, now you can apply the promo code: OrgasmScience until January 26th to get streaming for $1.99 and download for $7.99. If you'd been interested in checking it out, now's the time. Oh - and if you do check it out, we'd love for you to leave a comment

2 A lovely woman from Dayton, Ohio contacted me recently, and she's going to be hosting a small screening or 2...or 3 with friends and maybe fellow church members. You know I love a small screening, and although it's not too far from me, I believe the first of her small screenings will be the Dayton Premiere of SSL! That's worthy of a shout-out, so here it is. Have fun you Dayton ladies!

If you are interested in hosting a small screening (you only need a couple friends and a TV) just contact me at trisha at ancmovies dottt com. SSL wants to come to your town! (Sorry, I have a ridiculous pull towards using the word "cum" instead of come in bad puns)


3 I was writing THIS reply, the first of my posts in the debate I'm doing with Edward Clint at Skeptic Ink, and I accidentally hit control+Z. In normal stuff that usually just takes you back one step. In blogger, it erases your whole fucking post and saves it immediately upon that keystroke. Let me just point out real quick that my reply is not short. It's long as hell, and I thought real hard about killing myself by walking in front of a bus holding my computer. I thought since my computer contains Blogger, it might hurt Blogger too and make Blogger regret what it did to me. I know Blogger is cold and dead inside, though, and I decided against it. After, my screams and hate subsided, I realized I hadn't lost that much - just a lot of formatting and some small rewrites of a few parts. I had most of it saved somewhere else. I'm not so stupid I guess. Blogger has fucked me enough that I don't fully trust it, and take measures to delay or defeat it's dick moves. I just wanted to share that in hopes of shaming or hurting blogger's feelings.

1.16.2015

The Female Orgasm Debate With Edward Clint at Skeptic Ink - My Response #1

   


I have to say, I’m excited to be having this debate, and I want to thank Edward Clint for agreeing to do this. Ed co-produces Skeptic Blogs and writes on a variety of topics there. He is currently a graduate student at UCLA studying Evolutionary Psychology. He has proven to be quite considerate to me and thoughtful about this topic. As Ed said, this is a new debate. It is not building from our original back and forth.

I have written extensively on my stance about female orgasm and  made a movie on the topic. So, since my view is already out there, Ed and I agreed that he would begin our discussion with a response to my stance (taken from my movie and my blog – particularly THIS POST explaining  why I say that vaginal stimulation has not been shown to cause orgasm). Please check out Ed’s post HERE. We are specifically taking opposite sides of the following statements. I’m on the pro side, of course.


for the record, I wouldn't define this as orgasm

The Statements to be Debated
1. Masters & Johnson's  (1966) book Human Sexual Response provides the best scientific description of the definition and nature of orgasm.
2. Orgasm is caused by direct or indirect stimulation of the clitoral glans/vulvar area in women.

I’m going to go about this by first outlining my support for these statements. I will keep in mind the objections Ed has outlined, and do my best to touch on those. After that, I will respond specifically and in more detail to each of his objections in the appendices. Hopefully, this can allow those who want to read just the gist to drop off before it gets more detailed.  

Support for Statement 1
Masters & Johnson's  (1966) book Human Sexual Response provides the best scientific description of the definition and nature of orgasm.

Masters and Johnson’s (M&J’s) description of the physical markers of orgasm are what I believe the scientific definition of the word orgasm should be based upon. Very basically, the main physical marker is a rhythmic release of the pelvic muscle tension and blood congestion that has developed during sexual arousal. It’s measurable, well known, possible in both men and women and in people all across the world, and relies on the well known and heavily agreed upon physical markers of sexual arousal in order to come about. No other commonly used definition of orgasm is that verifiable, that universal, or that directly linked to the physical elements of sexual arousal.

This definition of orgasm makes sense even given the immense variation in psycho-social elements that affect people’s ability to attain orgasm and the meaning and subjective pleasure they find in it. This physiological event exists as a human event that can and does occur in direct relation to human sexual arousal. Plus, although the psycho-social elements are absolutely integral in understanding things like who has orgasms, why people don’t have them, and what significance orgasm has to a population, the event still exists on its own and stands as a good definition of orgasm. Let me elaborate on why this physiologic definition of orgasm seems most sensible to me.

1 The orgasmic muscle contractions described by M&J are not under dispute as a marker for sexual climax. Although the word orgasm and its meaning are contentious, this marker for sexual climax is not, and it is already part of any sensible and knowledgeable definition out there for orgasm (Meston et al p174).  It is known to exist in both men and women and is a thing that the majority of women and almost all men experience (even if they have wildly different ways of getting to it and diverse feelings about it).  So, there is agreement that this exists and about how it behaves and is measured. It is already respected and widespread definition of orgasmI am merely proposing it be the definition. There is a universal element to this definition particularly because it is a physiologic one.

Ed objects to aspects of the 1966 M&J study in an attempt to discredit their findings about orgasm. The objections are sometimes blatantly wrong and other times simply not a good argument for disregarding or discrediting it. I have specific responses to his full list of objections and also a  response to Ed’s citation that claims to directly dispute M&J’s finding (it absolutely does not ) in appendix A below. M&J is a 50 year old study, and things have changed. Their work has been expanded on. More work has gone into things like hormonal activity during arousal and orgasm, and modern ways to record the physical markers of arousal and orgasm have been developed (M&J used to actually get down there and measure parts by hand to check for vasocongestion. Photoplethysmographs are now often used to do that), but these markers M&J identified are still understood as important markers. Their work in Human Sexual Response is by far the largest and most comprehensive physiological study of arousal and orgasm that exists. It is fundamental and has not been rejected or seriously debased over the last 50 years (Meston et al p180).

2 There, of course, are other experiences some would put forward as being orgasms; ejaculation, tantric/spiritual/mental experiences,  or a type of inner/vaginal/uterine/g-spot/anal climax that specifically does not involve the recordable muscular activity described by M&J. That’s not a complete list, but it’s some of the usual suspects, and I think it's problematic to call or insinuate that any of these things are orgasm.

Ejaculation is a sexual response but is a different physiologic event than orgasm. This is true for both men and women...and although men almost always experience it, since it is linked to orgasm in males, it may not be common among women. The rest of the above options have no set of physical markers that could let a scientist know that these events are occurring. The respondent must be taken at their word that there is a climactic sexual experience happening. The only exception to this would be some studies showing mental activity during a time when the respondent claims to orgasm. This is a recordable response, but as of yet there is no clear understanding of whether the brain activity seen is a reliable marker to indicate any particular kind of climactic sexual experience, much less the muscle contractions identified by M&J’s work. There is also no understanding of what that brain activity correlates to physically, or if it correlates to anything physical at all.  Brain activity may be an interesting avenue of research to pursue, but to be convincing as a marker for orgasm, that mental activity should  also correlated with a culmination of or climax to physical sexual arousal.  

3 Which brings me to my major reason for calling the muscle activity described by M&J orgasm (and biggest qualm with calling these other things orgasm).  The M&J described orgasm has a physiologic quality that is quite specifically the physical climax of changes in the body that happen during human sexual arousal, and those other things in the list are not. To be clear here, I’m not arguing that those other things have no value, are not pleasurable, or don’t feel climactic. I’m not even arguing that orgasm is the most pleasurable thing a person can experience regarding sex. I’m arguing that these other things are something different and not events that rely on and relieve the muscle tension and blood congestion in the pelvic region induced by sexual arousal. I believe that makes this event more than just one of many possible experiences that people find pleasurable or climactic during sex. It makes this event an orgasm.

Before I move on, let’s get back to sexual arousal because I think it is often hard to separate the ideas of arousal and orgasm, and I’ve found over and over through the years that discussing the two as separate seems to cause major confusion about what I am arguing. So...Yes, sexual arousal can be “turned on” in humans in an infinite number of ways. It’s got everything to do with psycho-social and circumstantial variables. The thing is though, however one gets it started, sustains it, or increases it (and that process really is as unique as people are), when it happens, the body reacts largely the same in all humans. The basic markers of sexual arousal that M&J noted  (such as penile erection, vaginal lubrication, testes being pulled up against the body, and repositioning of the uterus/elongation of the vagina - all due to pelvic vasocongestion and muscle tension), have certainly been expanded upon over the last 50 years, but they are basically the same things researchers still today use to denote arousal. Increased heart rate, raised blood pressure, increased pain theshold and pupil dilation are also used but are indicators of regular ol’ non-sexual arousal as well. So, how one gets aroused, how he/she feels about it, and expectations surrounding arousal are incredibly complicated and variable, but how the body responds to that arousal seems to be quite universal.  

The orgasm is absolutely dependent on that physical arousal because there needs to be sexual muscle tension and blood congestion present for there to be an event (the orgasm) that releases that tension. It’s clear that orgasms don’t happen without arousal and arousal doesn’t happen without activities that are steeped heavily in psycho-social elements, so a complete study of orgasms among humans is naturally tied to the psycho-social. However, the definition of orgasm, doesn’t need to be.

Why it's important to make this distinction
I really do understand that the feelings around a word like orgasm are complicated. I really do know that although I have no intention of telling women that there is only one way to enjoy sex (for instance - experiencing the orgasm defined by Masters and Johnson), that none the less, my simply saying that there should be a standardized definition of the word orgasm, is enough to make some people feel slighted, misunderstood, or inadequate. I don’t love that, but I think that advocating for clarity in the discussion of female sexual response is worth the trouble it digs up.

There is confusion about the word orgasm. Researchers, doctors, therapists, sexual advisers, and random people who want to speak about orgasm from a place of even limited authority could continue to use that word loosely, to make statements about orgasm without being specific about what is meant, but I think it only leads to spinning our wheels on the topic. Saying that situation A causes an orgasm in one study and that situation B causes an orgasm in another study, is most helpful when the word orgasm means the same thing in both. Right now, it does not - way too often. It seems to me like people involved in this discussion are talking around each other and there needs to be clarity of language…to help women understand their situation and to help researchers build from each other's work more easily.

As I described above, I think orgasm should be used to describe the M&J definition of orgasm. I also think ejaculation should be used to describe ejaculation, and a climactic experience should be used to describe a climactic experience sans orgasm. Other more specific words could come to light to categorize these other mental or physical climactic experiences as researchers hopefully gain clear understanding of what these are and how to identify them. Also, I think scientists should be cognizant of the mixed use of the word "orgasm."   If talking about reported cases of orgasm, there should be an understanding that a claim of “orgasm” could mean a wildly large amount of different events, and data should be assessed with that in mind. I believe that clarity of language is absolutely necessary for the discussion about female orgasm to move forward (instead of in confusing circles like it seems to be doing now).

Statement 1 Conclusion
I do also get where Ed is coming from when he says that orgasm is “a mental event, an experience.” He’s right, it is both of those things, but so is every other thing we humans do. It’s not useful as a definition. It's also not a reason to disregard the M&J characterization as insufficient. The physical characterization of orgasm proposed is an undisputed reaction that can happen to both men and women all across the world at the climax of a person’s physical sexual arousal. The contractions can be weak or strong, have a somewhat variable rhythm, last for a somewhat variable amount of time, but the basic description set forth by M&J is a sensible definition for orgasm. The fact that there is infinite variation in how people get from no arousal to orgasm, or in how people subjectively experience this event does not mean that we don’t or can’t have a good definition of orgasm. Similarly the infinite subjective experience of a heart attack, and the many discussions existing about what causes them and what prevents them, does not negate that it is a blockage of oxygen-rich blood to the heart muscle. Both a heart attack and orgasm exist as a thing that can be defined, and all the psycho-social things around us can inhibit them, help them, affect the framework in which they are practiced, and bring different meanings to them. However, it is difficult to really discuss those psycho-social aspects in any meaningful way unless there is a clear definition of what it is they are affecting, and that clear definition is exactly what I propose.

Support for Statement 2
Orgasm is caused by direct or indirect stimulation of the clitoral glans/vulvar area in women.

I think my support of statement 1 stands on pretty firm ground, but I willingly admit this second statement is slightly mushier. However, it doesn’t have to do with the arguments about Female Genital Mutilation (FGM), cervical stimulation in women with spinal injuries, culture considerations or dildos as Ed suggests. It does have something to do with his point about M&J’s findings regarding orgasms during intercourse though. I actually think some of M&J's findings are the best arguments against this second statement. So, let me tell you why I think there’s mushiness in this argument, and then I’ll tell you why, even with the mushiness, it’s still the most sensible one. 

The reasons for this mushiness in Statement 2

1 My assertion is not based on undeniable proof. It’s based on an overwhelming amount of evidence that stimulation of the clitoral glans/vulva area can induce orgasm and an overwhelming lack of evidence that any-other-thing-stimulated can induce orgasm. That’s why I make that assertion. It’s about the evidence as is. However, although there has been about 50 years since M&J first came out, and so far there still isn’t much to go on for the “any-other-thing-stimulated can induce orgasm” statement, it's possible there could be in the future.

It is all very close together down there. It doesn’t seem impossible for the clitoral glans area, without being directly touched, to be stimulated just enough to orgasm from movement in areas close by such as; 
the in-out movement of a phallus in the vagina, 
or strong vibration on a close-by area, 
or specific muscular movement that might shift things slightly in the vulvar area. 

I think it’s incredibly important in science and in sexual advice to parse out as clear and detailed an understanding about what is and is not known to induce orgasm as we possibly can be. That means really trying to figure out the specifics of what touches what. I will continue to argue that this is meaningful and incredibly important, but I get that it can get a little nuanced for some people’s taste.

3 Like Ed mentioned about good ol’ Master’s and Johnson’s 1966 book Human Sexual Response, they did record orgasms in women during vaginal penetration with no additional stimulation. I would add that they also found 3 women (all of whom could additionally orgasm through clitoral glans area stimulation and through intercourse) who achieved orgasm through breast stimulation without additional clitoral manipulation.

Yet Statement 2 is still the best bet 
Those 3 points all kinda go together so let me just explain a little. The M&J accounts of both the intercourse and the breast induced orgasms were observed and recorded in the lab. They documented both subjective accounts of the orgasms and objective recording of the orgasmic pelvic muscular activity. There are no other studies that document an objective recording of orgasmic pelvic muscular activity for orgasms stimulated from anything but the clitoral/vulva area – not stimulation of the breasts (besides M&J), not anuses, not G-spots, V-spots, C-spots nor other spots, not from the inner clitoral legs being pushed on or "crushed" through the vaginal wall, not the vaginal wall itself, and not even any other intercourse induced orgasms like the M&J documented ones above (I’ll get back to these in a minute). 

Those studies just don’t exist. There’s plenty of claims in surveys and even in labs studies that these other types of stimulation do cause women to orgasm, but the physical evidence just has not been taken; or the physical evidence taken was things like heart rate, blood pressure, pupil dilation, or pain tolerance – all things that are certainly markers of arousal (both general arousal and sexual arousal) but not necessarily of orgasm; or it’s a brain scan that might suggest an orgasm, but there is no recording of the pelvic muscle activity to go along with it, and no certainty that the brain activity seen means anything about a physiologic response in the body – much less orgasmic muscular activity. These other studies and surveys that suggest female orgasm caused by something other than clitoral/vulva area stimulation exists, simply don’t give any actual evidence that this is the case.

Okay, so there is a striking lack of evidence for non clitoral/vulva area induced orgasms, except for M&J’s work. It might seem problematic to my statement, but it’s less than you’d think. M&J asserted that the orgasms through intercourse, the ones with no other clitoral/vulva area stimulation, were actually stimulated through the clitoral glans indirectly. They asserted that the clit was rubbed through a Rube-Goldberg-like situation in which the labia pulled on the clitoral hood which rubbed against the clitoral glans – so it was quite indirect. 

They give no explanation about the mechanism for which the breast orgasms happened, but they say that the timing of the physiologic markers during arousal and orgasm in both the intercourse and breast orgasm were quite similar. Both were also the weakest type of orgasms that the women had. All the physiologic markers and muscular activity for orgasm were recorded, but they were just objectively recorded as weaker and subjectively reported by the women as weaker. In fact, for the entire study, M&J report that in terms of both the objective intensity of muscle spasms recorded and the subjective reporting of the woman, the masturbatory orgasms were ranked highest, followed by partner manipulation and the lowest intensity reported and recorded was achieved through intercourse (and breast stimulation) (Masters 1966 p133). So, given that the low intensity of the orgasm correlated with more indirectness of the stimulation, it might be just as likely, if not more likely, evidence for the importance of clitoral glans area stimulation for female orgasm, rather than being evidence for inner vaginal induced orgasms. As for the breast stimulation, this is up for debate and hopefully more study. I once put forth a thought on my blog that maybe, during the breast stimulation, some muscle tensing in the vulvar area, once the women had become highly aroused, moved everything around down there just enough to get a touch of clit stimulation and set off the orgasm. Who knows? It’s merely a guess that goes along with the pattern of really indirect stimulation giving less intense orgasms.

Ed's Objections
As I said before, Ed's point about intercourse related orgasms in the M&J study was valid, but his other objections relating to cervical stimulation in women with spinal injury, orgasm in women with FMG, or lesbians buying dildos, aren't useful. They're interesting, but they simply don't contradict Statement 2. The truth is there simply are not studies (the one's Ed cites included) that document a situation where stimulation on anything other than the clitoral/vulva area causing the M&J identified muscle contractions of orgasm. You can read my more detailed response to each of his objections below in Appendix B. However, I do want to speak quickly on Ed's assertion about women with FMG. He cites a study from 1989 that surveys women in an area with an incredibly high incidence of a particularly ugly type of FMG in which the labia is sewn together leaving a flat surface with only a tiny whole left from which the women must pee, menstruate and eventually have intercourse (there is often a knife used on the wedding night). It has been long assumed that the clitoral glans was always cut off with this type of FMG (known as type III), but recently surgeons who do reconstructive surgery for women with FMG have discovered that this is not often the case. Intact clitoral glans are found behind the tissue. One study showed this finding in 40% of the women with type III FMG. So, at least some of the women in the study Ed cites may not be without a clitoris as he assumes they are. If these women are having orgasms (and it’s just a type of survey with no physical validation for their responses) they very well might be having them because they have clit-hiding scar tissue to rub up against their husbands’ pelvises.

Statement 2 conclusion
So, there are things that could easily make me change my mind on the basic need for clitoral/vulva area stimulation in order to orgasm. One of those things would be one study, any study, that makes a physically verified causal connection between stimulation not involving that clitoral/vulva area and orgasmic muscle contraction. There's certainly studies connecting other types of stimulation to arousal or to feelings of pleasure, and those are interesting and useful inquiries into human sexuality. However, this is about the orgasm, and studies like what I'm asking for are hard to come by, and I challenge anyone to find one. Studies trying to make this causal connection can be done and should be done. It's quite mystifying that they don't exist. 

Like I mentioned above, there is actually some debatable evidence for a direct connection between breast stimulation and orgasm, but those studies were done 50 years ago and reported in the M&J study that Ed thinks is not quite up to par, so take that as you will. Other than the M&J study, the only thing to go on is the accounts of women who say they can orgasm from other kinds of stimulation. These accounts are great starting points for investigation into female sexuality, and should never be discounted. However, there should be an effort to physically verify these claims, and as of yet, this has not been done properly. 

There's plenty more to read in the Appendices. Appendix C was added for my responses to Ed's objections that weren't categorization with Appendix A or B. Enjoy. Thanks again to Ed Clint!

Appendix A
Masters and Johnson made major contributions to knowledge about sex. However, the idea that the scientific understanding of the clitoris, orgasm, and female sexual response crystallized 5 decades ago thanks to a non-refereed publication based on a few experiments with tiny, unrepresentative samples in artificial, ecologically non-valid circumstances is preposterous on the face of it. As a psychologist, I do believe I would be laughed out of the room if I proposed such a basis for some description of a pan-human bit of psychology. Here is a short list of the limitations and flaws of M&J 1966.
  • Tiny sample sizes that offer no statistical power to generalize
It may be too small for Ed’s tastes, but there is no other physiological investigation into the body’s responses to arousal and orgasm that is near this large; 382 women and 312 men and a minimum of 7,500 complete cycles of sexual response (Masters 1966 p.12-15). I’d love a bigger study with more modern amenities, but this is the best we have, and honestly, I think calling it tiny is a bit of a stretch.
  • Use of sex workers as participants, which can hardly be called representative of women in general
Not actually true - although, I don’t see this as a problem anyway. Sex workers were used as preliminary subjects, because they were available, as an investigation into how tests should be set up and run. M&J explicitly said that they did not use this population in their final analysis.  “The interrogative material and experimental results derived from the prostitution population have not been included in the material being presented.”  (Masters 1966 p.11) And frankly, even if they did use prostitutes, I don’t see why their physiological sexual response would be any different than any other woman or man. We all have the same parts down there (as long as no disease is present).
  • Sex in a laboratory setting probably is not representative of other settings
Agreed. Sex in a laboratory setting is different from sex in other places. This is an issue to consider in any sexual study, and M&J knew this. My biggest worry here would be that people find it hard to become aroused in this situation. The people in the M&J study obviously were able to overcome that since they did physically become aroused and physically orgasmsed. Of course this may skew the study towards people who are able to become aroused in these situations, but that is a common problem among any study of the body during arousal and orgasm....and even people who get aroused by laboratories have the same genitals as the rest of us.
  • No replications
Granted, a giant study where people are hooked up to physiologic monitors and asked to do sexual acts while the researchers measure and record has not, very unfortunately, been done since. However, like I said above, the work is fundamental and there have been many studies that replicate the measurement of arousal and orgasm in people without finding anything contradictory to what M&J found. There has even been findings that work within M&J's, but also expand on it. For instance THIS study found some more variation in the pelvic muscle responses than did M&J (1 male who could have multiple orgasms before his ejaculation). (3)
  • Participants were “WEIRD” in the Henrichian sense: of a Western, Educated, Industrialized, Rich, and Democratic society. Trisha believes the study of one culture, ours, proves things about the human species.
Well, if Human Sexual Response was a study focused on behavior or psychology rather than physiological  reactions to arousal and orgasm then I think this would be an incredibly valid criticism. However, ladies all over the world have the same parts, just like men all over the world do. Granted, the women in other parts of the world might need to think and do different things to become aroused (this is incredibly dependent on psycho-social element), but when they do become aroused, it can be detected in their bodies just the same way we detect it in WEIRD bodies. We can also detect when they are having orgasms, just the same way we detect it in WEIRDs.
Sometimes producing findings that directly contradict M&J, such as Robert King et al. 2011:Fundamentally, these data would seem to contradict the Masters and Johnson (1965) view that masturbatory orgasms are the same as those achieved through intercourse, especially in terms of pleasure and sensation.
This quote boldly stood out to me, back when I read this particular article, as fully inaccurate, so it’s unfortunate that it was picked to prove there is data contradicting M&J’s work. “These data” that the quote is discussing are ones that show (they thought somewhat surprisingly) that a good number of orgasms with a partner were subjectively rated lower than masturbatory orgasms by women in their study (another group of partner orgasms were rated higher, but they found that less surprising). Anyway, that’s not contradictory at all to M&J’s findings. Although M&J were clear through the study that the basic physiological elements such as spasmic release of muscle tension were universal to all orgasms, including masturbatory and those had during intercourse, they never held that they were the same in terms of pleasure or sensation.

In fact, the surprising finding from the study above is specifically supported. M&J reported in terms of both the objective intensity of muscle spasms recorded and the subjective reporting of the woman, that masturbatory orgasms were ranked highest, followed by partner manipulation. The lowest rated orgasms were those achieved during intercourse (Masters 1966 p133). M&J clearly claimed that the physical markers in orgasms during masturbation and intercourse were the same, but never claimed that any other element of these orgasms including intensity, length, meaning, or subjective pleasure were the same.


Appendix B
V. Infibulated women in the SudanWomen in a non-western culture without all that Freud baggage and social expectation still have VIO’s. Hanny Lightfoot-Klein (1989) described the culture as such that women must hide all sexual interest and response in order to appear chaste and modest. They must hide orgasms, or, if they can’t hide them, deny that the outburst was caused by the sex acts. Nonetheless, 90% of the 300 women interviewed said they had orgasms, some even saying “always”. We know, too, that none of these were “clitoral” orgasms, because none of these women have a clitoral glans or labia. They all have a “full pharaonic” type infibulation that involves removal of virtually all external genitalia. I am beyond astonished that women who have been so tragically mutilated can ever enjoy sex at all (many of them do not). Lightfoot-Klein is not the only report of this phenomenon, in the paper she also cited Money et al. (1955) and Verkauf (1975).
First off – love this article. I had not heard of it before this. I found it to be informative, sincere, and thought provoking, but not contradictory to my stance for variety of reasons. Firstly, it is actually quite possible some of these women had partial or intact clits under their scar tissue that could be engaged for orgasmic response.

Let me explain a bit. In the study, the author interviews over 800 women and 300 men, and found that 90% of the women claimed to have orgasms with their husband anywhere from rarely to always. It doesn’t break down the percentages of the always or the sometimes or the rarelys, but it doesn’t matter too much. At the time this was written, the standard thought was that women with FGM could not possibly orgasm, and this article’s author, I think, really wanted to point out that this is simply not true. Since then, there have been plenty more studies suggesting that women with FGM can orgasm (4,5,12). This seemingly improbable ability is likely in no small part to what surgeons who do reconstructive surgery for FGM have begun observing.There is often some parts of the clitoral glans left after FMG. 

In fact, in the type of FGM that is practiced among the culture in this study, type III (also called infibulation), there was an unexpected reality that came to light when reconstructive surgery became more common (4,5,12). Nour et al found an intact clitoris in 48% of 40 infibulated/type III women undergoing corrective surgery. Type III FMG is pretty terrible.  At its worst, the clitoral glans inner labia are completely cut off, then the labia majora is sewn together leaving only a pinhole sized opening for, you know, urination, menstruation, childbirth, and intercourse (knifes are often used on the wedding night). As I discussed, it used to be assumed that the clitoris was always cut in this type III, but as surgeons have shown us more recently, this isn't always the case. In fact, after direct observation, this definition has been disputed enough that the World Health Organization changed the definition of Type III FMGs (the type from the ) from saying that the clitoris is always cut to defining it as one in which the skin is sewn together “with or without excision of the clitoris.” (14) Given that this article mentions that these surgeries, especially in the outlying areas, are done by untrained midwives, it doesn't seem that strange that there would be a variety in the types of cutting that is done. The statement from some women in the article that their scar tissue was erotically sensitive would also indeed point to some having a clitoris or part of a clitoris behind the scar tissue.

However, there’s not a lot of information to go on in this article besides a few specific anecdotes. It’s more like a thoughtful and informed story than a set of data being discussed. There is no distinction given about how all these women achieved the orgasm. Were they grinding against their husbands? One woman who said she orgasmed frequently said she “moved around a lot during intercourse.” Could she be grinding her hidden clitoris against her husband during intercourse? Or, was it a vaginally induced orgasm? We just don’t know. The “moving around a lot” woman was about as detailed as it got. It’s also questionable whether all or any of the events these women describe as “orgasm”  was even a physiological event. If I know anything about the word orgasm, I know that it is an incredibly culturally steeped word, so I have no idea what they mean when they say orgasm, and neither does the author.

My point here is that this study is not much different from any study asking women about orgasm. There simply isn’t any physical data to verify what they mean when they say it, and their method for getting an orgasm during intercourse (I’ll go ahead and assume there’s not a lot of oral or masturbating going on, but it’s not actually discussed) are not disclosed. Given that these FMG procedures do not universally leave women without an intact clitoral glans, these women could be getting these orgasms just about anyway any American woman could have gotten one.

(Just for fun, I’d like to openly wonder if these women and men in this culture, having probably not seen a lot of simulated sex on tv, movies, and porn, might be somewhat better off in terms of women reaching orgasm during intercourse than western folks. The fast, in-out-in-out style that is often depicted here, doesn’t tend towards a body position with the outer vulva in constant contact with the males body. Maybe, left to our own devices without pre-conceived ideas about what sex should look like, women and men tend to cling closer to each other and more gently move their pelvises in whatever ways feels good – making a grinding-the-clit style orgasm during intercourse more likely. Just a thought to ponder.)
VI. Women with spinal cord injuries experience orgasmsThe clitoris and vulva are innervated by the pudenda spinal nerve. However, in women who have no sensation in the pelvic region due to spinal cord injury, sexual response including orgasm have been documented in several papers. Komisaruk et al’s (2004) replication included fMRI brain imaging showing activation consistent with orgasm. They postulate this is possible due to the vagus nerve, a cranial, not spinal, nerve with projections in the pelvis. Several studies including that one also used as stimuli penetrative vaginal-cervical stimulation, not clitoral.See Sipski et al 1995a and b; Whipple et al 1996; and Komisaruk et al 2004.
I actually think the research into women with Spinal Cord Injury (SCI) and ability to orgasm is pretty cool stuff - and incredibly promising for many women with SCI. The studies Ed includes here show that although spinal injury has occurred at a location and to an extent that would seem to indicate a lack of ability to orgasm, orgasm does still occur for many women with SCI. Sipski et al tends toward this having something to do with reflex autonomic activity and Komisaruk , and Whipple tend towards this having something to do with the Vagus nerve having a direct path from the cervix to the brain. 

Also, the approaches in these 2 articles were different. Sipski’s work compared SCI and non SCI women, finding that when left to their own devices to stimulate themselves to orgasm, all of the non-SCI and about 50% of the SCI women verbally reported orgasm within 75 minutes (although many as quickly as under 10 minutes). All but 3 of the women chose the clitoris as part of their preferred stimulation (the other 3 reported their stimulation as vaginal area. None reported vaginal penetration). Physiologic data including blood pressure, heart rate, and respiration were recorded and reported. Pelvic muscle contractions were recorded, but not reported - and it doesn't say why.

In the Komisurak, Whipple study, 5 women were given cervical stimulation (and it’s a particular kind of cervical stimulation that involves a pessary, which is kinda like a hard cervical ring that had to be sutured to the cervix. Then there is a piece on the pessary that can be attached to the cervical stimulator device that is inserted into the vagina. It sort of puts suction-y pressure on the cervix that the woman controls herself. It’s not your average vaginal stimulation, ya know?) and 3 of them verbally reported orgasm which was accompanied by an increase in brain activity in places the researchers felt, given some past studies, were consistent with what would be expected during orgasm.  Pelvic muscular contraction, heart rate, respiration, and blood pressure were not measured and neither was pelvic muscular activity. They suggest the Vagus nerve bypasses the spine and makes this possible.

The first study does not support the idea that any kind of inner vaginal stimulation causes orgasm. All the stimulation to orgasm in it was in the form of some kind clitoral/vulvar stimulation (although 3 seemed to be closer to the vagina than the clitoris). The 2nd article doesn’t even discuss it. The Komisurak,Whipple study supports a very type of particular type of cervical stimulation having some amount of direct pathway to the brain. It also found increased brain activity at the time women stimulating their cervix this way claimed to orgasm. However, as of yet there is no clear understanding of whether that brain activity is a reliable marker to indicate any particular kind of climactic sexual experience, much less the muscle contractions identified by M&J’s work (which were not tested for). There is also no understanding of what that brain activity correlates to physically, or if it correlates to anything physical at all.  None of these studies discredit the 2 statements in question.
The dildo problem[The sex shop called] Sh™  have an extensive lesbian clientele who have no motivation to pander to male egos, expectations or even existence in sexual terms. Thus they provide an interesting test of what women actually want, away from ideological constraint, voting with their wallets. A typical, although by no means universal, lesbian desire, as represented by products bought, is for penetration. For example the Fun Factory Strap-on™ provides internal stimulation for both (female) partners. If it were true that penetration in sex is something done only to pander to male egos then the existence of such toys requires explanation.
How exactly does this defy my explanation? I certainly never said penetrative sex is something done only to pander to male ego. I never even said women don’t like vaginal penetration. In fact I took great pains in the last two responses I wrote to Ed to make that point clear. Of course vaginal stimulation and penetration can be and often are desired, arousing, and well liked sexual activities. My beef is about people saying or insinuating that stimulation on the inner parts of the vagina – alone - cause orgasm. Women buying dildos doesn’t also mean they are orgasming from vaginal stimulation. I think that is obvious.
VIII. On sensitivity and innervationIt is argued that the vagina has little or no sensitivity, and therefore it is unlikely to be instrumental in orgasm, particularly compared to the highly sensitive clitoris. It is a fact that the vagina is not especially sensitive compared to other body parts. However, there are three reasons I think this argument is inadequate...
He’s got a valid point. The simple fact that the vagina has a lower amount of nerves doesn't automatically lead to the vagina's inability to induce orgasm. I admit I have used the lack of vaginal innervation in this way even though it's not a good argument. I have seen the errors of my ways, and I don’t do it anymore (even though it is mentioned in the movie…Sorry - I talk about that HERE). However it is still true that there is no positive evidence that stimulation of the inner vagina causes orgasm.

Appendix C
I further submit that M&J is not considered the “gold standard” among psychologists, psychiatrists and other researchers. Seminal, perhaps. But the reigning and authoritative model? Not hardly. One of the problems M&J stipulated themselves: the relationship between physiologic, psychological, and sociological factors is qualitatively and quantitatively “totally variable” from one woman to the next (p. 127). M&J focus on the physiologic, calling it an admittedly limited jumping off point that has a degree of objectivity, even if it does not capture the nature of the phenomenon.
It might not be the reigning and authoritative model on how people feel about orgasm or how they describe them or any other thing psychologists study, but it’s pretty fundamental to the physiologic understanding of orgasm and arousal. That’s pretty hard to deny. There is simply not another large study that recorded and described what the body does during sufficient sexual stimulation. It’s clear that Masters and Johnson understood that there were subjective psycho-social aspects to arousal and orgasm – things like; the way a person subjectively feels about their orgasm, how a person prefers to control their orgasmic response, what kind of noises a person makes, what stimulus halts the progression of arousal, and what stimulus increases arousal. The options are unlimited. These are not unimportant to a person’s experience. However, they don’t change the basic physical path the body takes.
If you read further in that passage Ed takes from above,

“Where possible, material presented reflects consideration of three interacting areas of influence upon female orgasmic attainment previously recognized in attempts to understand and to interpret female sexual response: (1) physiologic (characteristic physical conditions and reactions during the peak of sex tension increments); (2)psychological (psychosexual orientation and receptivity to orgasmic attainment); (3) sociologic (cultural, environmental, and social factors influencing orgasmic incidence or ability. The quantitative and qualitative relationship of these factors appears totally variable between one woman’s orgasmic experiences, and orgasm as it occurs in other women. Only baseline physiological reactions and occasional individually characteristic modes of expression remain constant from orgasm to orgasm, reflecting the human female’s apparent tendency toward orientation of sexual expression to psychosocial demand.”

It seems that M&J were actually saying that even with the incredibly variable psycho-sociol elements that make women’s relationship to orgasm quite diverse, the physiological markers of orgasm were the only constant. So, yes, to have a deep, full, complex understanding of what an orgasm is in the human experience is quite complicated and beyond Human Sexual Response, but to have a clear, detailed, seemingly universal understanding of what an orgasm looks like physically, is not that complicated at all and within the scope of Human Sexual Response.
Kaplan (1977) wrote that M&J did not even mention sexual desire! How can a coherent account of human sexual response neglect to consider sexual desire? As if sexuality and sexual experience is about quantified muscle contractions and blood flow.
I honestly don’t know how to be more clear about this. Sexuality and human sexual experience does not need to be quantified or described in order to understand what an orgasm is. An orgasm is an orgasm. Obviously sexuality and sexual experience is not merely about muscle contractions and blood flow, but the physical definition of an orgasm is very much about that.
Research has expanded in other directions as well. MRI and sonography have provided better understanding of the biomechanics of sex than M&J ever had. They wrote that the sole purpose of the clitoris was to create or elevate sexual tension by stimulation of the glans. This is almost certainly not correct. Research is on-going, but more recent studies suggest the erectile tissue of the clitoral complex helps tent the vagina for intercourse. During intercourse, the penis tends to compress the clitoral body and jam the anterior vagina against the root of the clitoris, causing a pumping action on the Kobelt plexus (Buisson et al, 2010).
MRI and sonography have certainly expanded on the understandings of biomechanics of sex. M&J actually did acknowledge their limitations in understanding the clitoris.

“It should be emphasized that the exact roles of the crura (clitoral legs), suspensory ligaments, and various muscle bundles in clitoral retraction have not been determined with total conviction.” (Masters 1966 p51)

I think these and other technologies could be promising in allowing observation of the physical reactions during intercourse in women who say they have orgasms from nothing more than inner vaginal stimualtion. Unfortunately, to date, these observations have never been made. The Buisson et al 2010 paper Clint speaks of was useful and interesting in that it did in fact show that in one couple the erect penis compressed the clitoral legs during intercourse. Although the woman in this study claimed that she regularly has vaginally induced orgasms (VIO), she nor her partner orgasm in this study, so it really gives us nothing but a possible future investigative direction when it comes to the question of what VIOs are, what stimulation is needed to attain them, and how the body reacts. And on a side note, the study doesn’t give a reason why the couple stops before orgasm. Wouldn’t it have been a great aspect to this study?
Evolutionary psychologists have also investigated possible psychological mechanisms involved in sexual response—Men’s masculinity and attractiveness predict their female partners’ reported orgasm frequency and timing. [Link]
Maybe women with more attractive men orgasm more frequently during intercourse, and maybe they don’t. It doesn’t matter to the physical definition of orgasm.  Just to humor it though, if this is meant to have something to do with the idea of a VIO, then it is a terribly inconclusive study on the topic. The questionnaires the women answered did not differentiate between orgasms from vaginal intercourse only and those caused with ancillary clitoral stimulation. It’s also a questionnaire without physical verification of these women’s answers, so any claims of VIO are subject to doubt.

Are There Different Types of Female Orgasm? [Link]
This is based on analysis of a questionnaire that 1) did not include physical verification for the women’s claims about how the event they describes as “orgasm” was achieved or what the physical reality of that event was, and 2) did not make a distinction between intercourse with ancillary clitoral grinding vs. intercourse with no ancillary clitoral stimulation. These results are an interesting look into how women describe a thing that they call orgasm, but that is it. It is not certain that experiences these women are speaking of have anything to do with each other in a physical sense, and if the scientific community is going to accept that anything any woman says is an orgasm should be defined as an orgasm, I would think that to be  incredibly confusing and problematic for getting any kind of meaningful understanding about female sexual response.

Genetic influences on variation in female orgasmic function: a twin study [Link]
This study indicates, using a traditional twin study questionnaire, that the variability in the ability to orgasm for women may be somewhere between 34 and 45% due to genetics. This is due to the fact that genetically identical twins answered questions about their ability to orgasm through masturbation and through intercourse more alike than sets of non-identical twins. As the authors say, this might be due to genetic qualities of the genitals or hormones or it might have to do with things like depression and temperament, so it’s an interesting angle to investigate further. However,  I’m not sure what it’s supposed to convince me of in relation to psychology and/or social elements changing the meaning of orgasm.
M&J took pains, several times, to spell out the importance of non-physical factors and influences: the psychosocial. To wit,A detailed psychosocial study of the research population cannot be presented within the framework of this text. Yet neither this book nor this chapter can be considered complete without emphasizing an acute awareness of the vital, certainly the primary influence, exerted by psychosocial factors upon human sexuality, particularly that of orgasmic attainment of the female. . . .physiologic detail is of value only when considered in relation to [behavioral theory and sociologic concept].M&J are saying that the physical signs are correlative indicators of orgasm, not that they literally are orgasm themselves. If you believe M&J is the “gold standard” (I would not recommend it), you should accept their contention that physiology is not the definition of orgasm.
What M&J are saying there is that social and physiological aspects are incredibly important to human sexuality and to the attainment of female orgasm – meaning the female’s ability to get to the point of having those muscle spasms we call orgasm. I would agree. In Human Sexual Inadequacy, their book describing research into therapy for sexual dysfunction, they were clear that arousal and orgasm are basic functions of the human body, but that psycho-social factors can easily put a stop to the physiological progression of sexual response. They were, as am I, quite aware that orgasm is attained and experienced through a filter of infinitely diverse psycho-social variables, but beyond “orgasmic attainment” there is an objective physiological aspect that is the physiologic orgasm. If you want to call that merely the indicator of an orgasm, I’m okay with that. I would call the blockage of oxygen rich blood to a section of heart muscle a heart attack. However, I’m okay with you calling it an indicator of a heart attack, given all the psycho-social elements that go into the lead up it

Asserting that it is of critical importance to one’s sexual experience the fact of whether the key sensors are in the vaginal tissue, or a couple centimeters away in the clitoral body that can often be smashed against it during penetrative intercourse, strikes me as pedantic and a little silly.

For the record, I don’t and wouldn’t argue whether the key sensors are in the vaginal tissue, clitoral legs sitting close to and being smashed by a penetrated vagina, nor even in the prostate tissue. I would argue they are on none of those and as yet have only been proved to be in and around the clitoral glans. However, if we do find that something within the vagina which seems to trigger orgasm also, I think it is absolutely of scientific import to clearly understand what the mechanism and what the key sensors are. I also think it is of personal import for many people, because knowing what the mechanism is can help people describe and teach how to attain orgasm this way.

Cited
1. Buisson, O., Foldes, P., Jannini, E., & Mimoun, S. (2010). Coitus as revealed by ultrasound in one volunteer couple. The journal of sexual medicine, 7(8), 2750-2754.

2. Barry R. Komisaruk, Beverly Whipple, Audrita Crawford, Sherry Grimes, Wen-Ching Liu, Andrew Kalnin, Kristine Mosier, 2004. Brain activation during vaginocervical self-stimulation and orgasm in women with complete spinal cord injury: fMRI evidence of mediation by the Vagus nerves, Brain Research, Volume 1024, Issues 1–2, 22. Pages 77-88.

3. Carmichael MS. Relationships among cardiovascular, muscular, and oxytocin responses during human sexual activity. Arch Sex Behav. 1994 Feb;23(1):59-79.

4. Catania L. Pleasure and orgasm in women with Female Genital Mutilation/Cutting (FGM/C). J Sex Med. 2007 Nov;4(6):1666-78.

5. Fazari AB et al. Reconstructive surgery for female genital mutilation starts sexual functioning in Sudanese woman: a case report. J Sex Med. 2013 Nov;10(11):2861-5

6. Lightfoot-Klein, Hanny, 1989. The Sexual Experience and Marital Adjustment of Genitally Circumcised and Infibulated Females in the Sudan. The Journal of Sex Research. Vol. 26, No. 3, pp. 375-392.


7. Masters, W and Virginia Johnson. Human Sexual Response. Little, Brown and Co., Boston, 1966.

8.Masters, W and Virginia Johnson. Human Sexual Inadequacy. Little, Brown and Co., Boston, 1970.

9. Meston CM, Levin RJ, Sipski ML, Hull EM, Heiman JR (2004). Women's orgasm. Annual Review of Sex Research, 15, 173-257

10.M. Sipski, C. Alexander, R. Rosen, 1995a. Orgasm in women with spinal cord injuries: a laboratory-based assessment. Arch. Phys. Med. Rehabil., 76, pp. 1097–1102.

11.M.L. Sipski, C.J. Alexander, 1995b. Spinal cord injury and female sexuality. Annu. Rev. Sex Res., 6 (1995), pp. 224–244.

12. Nour et al. Defibulation to Treat Female Genital Cutting: Effect on Symptoms and Sexual Function. Obstet Gynecol 2006;108:55–60

13. B. Whipple, C.A. Gerdes, B.R. Komisaruk, 1996. Sexual response to self-stimulation in women with complete spinal cord injury J. Sex Res., 33, pp. 231–240.

14. World Health Organizations. Classifications of female genital mutilation.
 http://www.who.int/reproductivehealth/topics/fgm/overview/en/ Accessed January, 14 2014.