HUMAN SEXUAL

RESPONSE
Human Sexual
f)

Response
WILLIAM H. MASTERS
n'
RESEARCH DIRECTOR

VIRGINIA E. JOHNSON
RESEARCH ASSOCIATE

THE REPRODUCTIVE BIOLOGY RESEARCH FOUNDATION

ST. LOUIS, MISSOURI

LITTLE, BROWN AND COMPANY

BOSTON
COPYRIGHT © 1966 BY WILLIAM H. MASTERS AND VIRGINIA E. JOHNSON

ALL RIGHTS RESERVED. NO PART OF THIS BOOK MAY BE REPRODUCED

IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

LIBRARY OF CONGRESS CATALOC CARD NO. 66-1837O

FIRST EDITION

Third Printing

Published in Great Britain

by J. 6 A. Churchill Ltd., London

PRINTED IN THS UNITED STATES OF AMERICA

 PREFACE

In view of the pervicacious gonadal urge in human beings, it is

not a little curious that science develops its sole timidity about the
pivotal point of the physiology of sex. Perhaps this avoidance . . .
not of the bizarre and the extreme, the abnormal and the diseased,
but of the normal usages and medial standards of mankind . . .
perhaps this shyness is begotten by the certainty that such study
cannot be freed from the warp of personal experience, the bias of
individual prejudice, and, above all, from the implication of pruri­
ence. And yet a certain measure of opprobrium would not be too
great a price to pay in order to rid ourselves of many phallic falla­
cies. Our vigorous protests against the sensual detail of porno­
graphic pseudoscience lose force unless we ourselves issue succinct
statistics and physiologic summaries of what we find to be average
and believe to be normal, and unless we offer in place of the prolix
mush of much sex literature the few pages necessary for a standard
of instruction covering sex education. Considering the incorrigible
marriage habit of the race, it is not unreasonable to demand of
preventive medicine a place for a little section of conjugal hygiene
that might do its part to invest with dignity certain processes of
love and begetting.”
Forty years ago Dickinson issued this challenge in the pages of
the Journal of the American Medical Association, and for forty
years medicine steadfastly has refused to accept the challenge.
Science’s “sole timidity” has not gone unnoticed either within or
without the profession. Golden has called attention to the results
of medicine’s refusal to accept its responsibility: “Dissemination
of sexual information by lay authorities has been enormously lucra­
tive. The lure of pornography serves to emphasize the tremendous
need for sexual details of the most basic type.”
If the current tentative approach to sex education is to achieve
the widespread popular support it deserves, there must be physio­
v
vi PREFACE

logic fact rather than phallic fallacy to teach. During the past five
years, Lief has highlighted repeatedly the consistent refusal of
medical schools in this country to instruct in human sexual physi­
ology, and, in doing so, he personally has been responsible for the
most sweeping change in medical curriculum developed in the last
two decades. Calderone has taken a pioneer step in sex education
at both lay and professional levels with the development of the Sex
Information and Education Council of the United States. Both
of these physicians have given positive support to the growing
demand that medicine accept its responsibility and educate its
own, young and old alike. As in all things, there must be a begin­
ning. There must be some way to teach the teachers.
Nor have the behavioral sciences failed to note and to reject
science’s sole timidity. Freud was well aware that his hypotheses
lacked fundamental physiologic support when he wrote “It should
be made quite clear that the uncertainty of our speculation has
been greatly increased by the necessity of borrowing from the Sci­
ence of Biology. Biology is truly a land of unlimited possibilities.
We may expect it to give us the most surprising information and
we cannot guess what answers it will return in a few dozen years
to the questions we have put to it. They may be a kind which will
blow away the whole of our artificial structure of hypothesis.”
If problems in the complex field of human sexual behavior are
to be attacked successfully, psychologic theory and sociologic con­
cept must at times find support in physiologic fact. Without ade­
quate support from basic sexual physiology, much of psychologic
theory will remain theory and much of sociologic concept will
remain concept.
There is every evidence from rapidly increasing individual and
community-oriented pleas for aid, directed to all counseling re­
sources, that our culturally induced sexual instability has gone far
beyond the limited abilities of the concerned professions to cope.
Nizer has written that the greatest single cause for family-unit de­
struction and divorce in this country is a fundamental sexual in­
adequacy within the marital unit. Kirkendall has stated that “if
traditional morality no longer serves as a curb, neither does fear
of consequence.” How can biologists, behaviorists, theologians, and
educators insist in good conscience upon the continued existence
 PREFACE vii

of a massive state of ignorance of human sexual response, to the

detriment of the well-being of millions of individuals? Why must
the basics of human sexual physiology create such high levels of
personal discomfort among the very men and women who are re­
sponsible for guiding our culture? There is no man or woman who
does not face in his or her lifetime the concerns of sexual tensions.
Can that one facet of our lives, affecting more people in more ways
than any other physiologic response other than those necessary to
our very existence, be allowed to continue without benefit of ob­
jective, scientific analysis?
Why then must science and scientist continue to be governed
by fear—fear of public opinion, fear of social consequence, fear of
religious intolerance, fear of political pressure, and, above all, fear
of bigotry and prejudice—as much within as without the profes­
sional world?
Van de Velde and Dickinson first dared to investigate and to
write of sexual physiology. Yet they were forced to wait until the
twilight of their professional careers before challenging public and
professional opinion. Obviously, they were shocked when, aside
from the expected opprobrium and implication of prurience, the
biologic and behavioral sciences emphatically shut the door of in­
vestigative objectivity. Possibly history will record as Kinsey’s
greatest contribution the fact that his incredible effort actually
enabled him to put his foot firmly in this door despite counter­
pressures that would have destroyed a lesser man.
This text represents the first step, a faltering step at best, but
at least a first step toward an open-door policy. The door of inves­
tigative objectivity must not be closed again.
W. H. M.
V. E. J.
St. Louis
 ACKNOWLEDGMENTS

lhe contributions and the contributors to this investigation and

to this book are almost endless. Without their personal, profes­
sional, and monetary support, the work never would have achieved
origin or substance.
There are those whose special skills we must acknowledge:
William S. Slater of the Department of Medical Physiology,
K. Cramer Lewis and Marilyn Harris of the Department of Medi­
cal Illustration, and Sallie Schumacher of the Department of
Psychology, all of Washington University, and Irene Gossage, our
secretary.
To these friends and to all who have contributed, our respect
and our gratitude.
W. H. M.
V. E. J.
 CONTENTS

PREFACE V

ACKNOWLEDGMENTS ix

RESEARCH IN
SEXUAL RESPONSE

1. The Sexual Response Cycle 3

2. The Research Population 9

FEMALE SEXUAL
RESPONSE

3. Female Extragenital Response 27

4. Female External Genitalia anatomy and

PHYSIOLOGY 38

5. The Clitoris 45
1. ANATOMY ANDPHYSIOLOGY 45
2. CLINICAL CONSIDERATIONS 56

xi
xii CONTENTS

6. The Vagina 68
1. ANATOMY AND PHYSIOLOGY 68
2. THE FUNCTIONAL ROLE IN REPRODUCTION 80
3. THE FUNCTIONING ROLE IN REPRODUCTION 88

7. The Artificial Vagina anatomy andphysiology 101

8. The Uterus physiologic and clinical

CONSIDERATIONS 111

9. The Female Orgasm 127

10. Pregnancy and Sexual Response 141

1. ANATOMY AND PHYSIOLOGY 141
2. CLINICAL CONSIDERATIONS 1 52

MALE SEXUAL
RESPONSE

11. Male Extragenital Reactions 171

12. The Penis 177

1. ANATOMY AND PHYSIOLOGY 177
2. CLINICAL CONSIDERATIONS 188

13. The Scrotum and the Testes anatomy and

PHYSIOLOGY 204
 Ylli
CONTENTS

14. The Male Orgasm (Ejaculation) 210

GERIATRIC SEXUAL
RESPONSE

15. The Aging Female 223

1. ANATOMY AND PHYSIOLOGY 223

2. CLINICAL CONSIDERATIONS 238

16. The Aging Male 248

1. ANATOMY AND PHYSIOLOGY 248
2. CLINICAL CONSIDERATIONS 260

GENERALITIES IN
SEXUAL RESPONSE

17. Similarities in Physiologic Response 273

18. Myotonia in Sexual Response 294

19. Study-Subject Sexuality 301

REFERENCES 317

GLOSSARY 337
INDEX 347
 RESEARCH IN
SEXUAL RESPONSE
 I
THE SEXUAL RESPONSE
CYCLE

In 1954 an investigation of the anatomy and physiology of

human sexual response was initiated within the framework of the
Department of Obstetrics and Gynecology of Washington Univer­
sity School of Medicine. A closely coordinated clinical-research pro­
gram in problems of human sexual inadequacy was instituted in
1959. Since January, 1964, these programs have been continued
under the auspices of the Reproductive Biology Research Founda­
tion. During the past decade the anatomy of human response to
sexual stimuli has been established, and such physiologic variables
as intensity and duration of individual reaction patterns have been
observed and recorded. Intensive interrogation (medical, social,
psychosexual backgrounds) of both laboratory-study subject and
clinical-research populations has been a concomitant of the basic
science and clinical investigative programs since their inception.
Material of significant behavioral content derived from these inter­
views will be presented in general rather than in statistical dis­
cussions.
Kinsey and co-workers published a monumental compilation of
statistics reflecting patterns of sexual behavior in this country from
1938 to 1952. These reports of human sexual practices obtained by
techniques of direct interrogation offer an invaluable baseline of
sociologie information. Future evaluation of the work may reveal
its greatest contribution to be that of opening the previously closed
doors of our culture to definitive investigation of human sexual
response.
Although the Kinsey work has become a landmark of sociologie
investigation, it was not designed to interpret physiologic or psy­
chologic response to sexual stimulation. These fundamentals of hu­
3
4 CHAPTER ONE

man sexual behavior cannot be established until two questions are

answered: What physical reactions develop as the human male and
female respond to effective sexual stimulation? Why do men and
women behave as they do when responding to effective sexual
stimulation? If human sexual inadequacy ever is to be treated suc­
cessfully, the medical and behavioral professions must provide
answers to these basic questions. The current study of human sexual
response has been designed to create a foundation of basic scientific
information from which definitive answers can be developed to these
multifaceted problems.
The techniques of defining and describing the gross physical
changes which develop during the human male’s and female’s sex­
ual response cycles have been primarily those of direct observation
and physical measurement. Since the integrity of human observa­
tion for specific detail varies significantly, regardless of the observ­
er’s training and considered objectivity, reliability of reporting has
been supported by many of the accepted techniques of physiologic
measurement and the frequent use of color cinematographic record­
ing in all phases of the sexual response cycle.
A more concise picture of physiologic reaction to sexual stimuli
may be presented by dividing the human male’s and female’s cycles
of sexual response into four separate phases. Progressively, the four
phases are: (1) the excitement phase; (2) the plateau phase; (3)
the orgasmic phase; and (4) the resolution phase. This arbitrary
four-part division of the sexual response cycle provides an effective
framework for detailed description of physiologic variants in sexual
reaction, some of which are frequently so transient in character as
to appear in only one phase of the total orgasmic cycle.
Only one sexual response pattern has been diagrammed for the
human male (Fig. 1-1). Admittedly, there are many identifiable
variations in the male sexual reaction. However, since these variants
are usually related to duration rather than intensity of response,
multiple diagrams would be more repetitive than informative. Com­
parably, three different sexual response patterns have been dia­
grammed for the human female (Fig. 1-2). It should be emphasized
that these patterns are simplifications of those most frequently ob­
served and are only representative of the infinite variety in female
sexual response. Here, intensity as well as duration of response are
 THE SEXUAL RESPONSE CYCLE 5

FIGURE 1-1
The male sexual response cycle.

factors that must be considered when evaluating sexual reaction in

the human female.
The first or excitement phase of the human cycle of sexual re­
sponse develops from any source of somatogenic or psychogenic
stimulation. The stimulative factor is of major import in establish­
ing sufficient increment of sexual tension to extend the cycle. If

FIGURE 1-2
The female sexual response cycle.
6 CHAPTER ONE

the stimulation remains adequate to individual demand, the in­

tensity of response usually increases rapidly. In this manner the ex­
citement phase is accelerated or shortened. If the stimulative ap­
proach is physically or psychologically objectionable, or is inter­
rupted, the excitement phase may be prolonged greatly or even
aborted. This first segment and the final segment (resolution phase)
consume most of the time expended in the complete cycle of human
sexual response.
From excitement phase the human male or female enters the
second or plateau phase of the sexual cycle, if effective sexual stimu­
lation is continued. In this phase sexual tensions are intensified and
subsequently reach the extreme level from which the individual
ultimately may move to orgasm. The duration of the plateau phase
is largely dependent upon the effectiveness of the stimuli employed,
combined with the factor of individual drive for culmination of sex
tension increment. If either the stimuli or the drive is inadequate
or if all stimuli are withdrawn, the individual will not achieve or­
gasmic release and will drop slowly from plateau-phase tension
levels into an excessively prolonged resolution phase.
The orgasmic phase is limited to those few seconds during which
the vasoconcentration and myotonia developed from sexual stimuli
are released. This involuntary climax is reached at any level that
represents maximum sexual tension increment for the particular oc­
casion. Subjective (sensual) awareness of orgasm is pelvic in focus,
specifically concentrated in the clitoral body, vagina, and uterus of
the female and in the penis, prostate, and seminal vesicles of the
male. Total-body involvement in the response to sexual tensions,
although physiologically well-defined, is experienced subjectively on
the basis of individual reaction patterns. There is great variation in
both the intensity and the duration of female orgasmic experience,
while the male tends to follow standard patterns of ejaculatory re­
action with less individual variation.
The human male and female resolve from the height of their
orgasmic expressions into the last or resolution phase of the sexual
cycle. This involutionary period of tension loss develops as a reverse
reaction pattern that returns the individual through plateau and ex­
citement levels to an unstimulated state. Women have the response
potential of returning to another orgasmic experience from any
 THE SEXUAL RESPONSE CYCLE 7

point in the resolution phase if they submit to the reapplication of

effective stimulation. This facility for multiple orgasmic expression
is evident particularly if reversal is instituted at plateau tension
level. For the man the resolution phase includes a superimposed re­
fractory period which may extend during the involutionary phase as
far as a lower excitement level of response. Effective restimulation
to higher levels of sexual tension is possible only upon termination
of this refractory period. With few exceptions, the physiologic abil­
ity of the male to respond to restimulation is much slower than
that of the female.
Physiologic residuals of sexual tension usually are dissipated
slowly in both the male and female unless an overwhelming or­
gasmic release has been experienced. Total involution is completed
only after all manner of sexual stimuli have been withdrawn.
It always should be borne in mind that there is wide individual
variation in the duration and intensity of every specific physiologic
response to sexual stimulation. Those that occur early in the
response cycle and continue without interruption during several
phases are obvious (penile erection or vaginal lubrication). How­
ever, some physiologic reactions are fleeting in character and may
be confined to one particular phase of the cycle. Examples are the
plateau-phase color changes of the minor labia in the female and
the coronal engorgement of the penis in the male.
In brief, the division of the human male’s or female’s cycle of
sexual response into four specific phases admittedly is inadequate
for evaluation of finite psychogenic aspects of elevated sexual ten­
sions. However, the establishment of this purely arbitrary design
provides anatomic structuring and assures inclusion and correct
placement of specifics of physiologic response within the sequential
continuum of human response to effective sexual stimulation.
The basic physiologic responses of the human body to sexual
stimulation are twofold in character. The primary reaction to sexual
stimuli is widespread vasocongestion, and the secondary response
is a generalized increase in muscle tension. The vasocongestion may
be either superficial or deep in distribution, and the myotonia re­
flected by voluntary or involuntary muscle contractions. The more
severe vasocongestive and myotonic reactions are confined to pla­
teau and orgasmic phases of the sexual cycle. There are multiple ex-
8 CHAPTER ONE

amples of these physiologic evidences of sex tension increment.

They will be considered in discussions of specific body or organ sys­
tem response, and, when presented individually, identified within
the framework of reference provided by the four phases of the sexual
response cycle.
Obviously, there are reactions to sexual tension that are confined
by normal anatomic variance to a single .sex. Also, basic differences
develop between the two sexes in the intensity and duration of es­
tablished reaction patterns. These differences will be underscored
in context during the review of organ systems. However, again and
again attention will be drawn to direct parallels in human sexual
response that exist to a degree never previously appreciated. At­
tempts to answer the challenge inherent in the question, “What do
men and women do in response to effective sexual stimulation?”,
have emphasized the similarities, not the differences, in the anat­
omy and physiology of human sexual response.
The question of why men and women respond as they do to
effective sexual stimulation is not answered in this text. Neither
the laboratory-study subject nor the clinical-research populations
are sufficiently representative of the general population to allow
definitive conclusions to be supported from behavioral material
drawn from these groups and reported in the text.
Material of behavioral content drawn from the combined re­
search populations will be presented as a contribution to the under­
standing of human sexual response patterns, but the prejudiced
source of this information always must be borne in mind. Until a
representative cross-section of the general population can be made
available to research interests, even admittedly prejudiced informa­
tion is of inordinate value in the study of human sexual behavior.
The widespread problems of human sexual inadequacy will not
be attacked effectively by either medical or behavioral personnel
until more definitive information is accumulated. Such data only
will become available as the mores of our society come to accept
objective research in human sexuality.
 Z
THE RESEARCH
POPULATION

A population of adult men and women who were willing to

serve as subjects in the reproductive biology laboratory provided
the opportunity for observations of anatomic and physiologic re­
sponse to effective sexual stimulation made and recorded during this
investigation. From these observations and from concomitant
psychosexual interrogation, conclusions have been drawn regarding
the sexual behavior of this selected population. Therefore, the
general classification, history of development, and specific function
of this group will be presented for evaluation.
Review of material presented by previous investigators will re­
veal an obvious prejudice in subject selection that unfortunately is
inherent in any attempt to investigate biologic or behavioral facets
of human sexual response. Cultural attitudes and residual sexual
taboos always have inhibited statistically ideal population sampling.
This study proves no exception to the general rule.
The investigation has underscored many examples of socially or
culturally oriented situations that could influence human sexual
response patterns. The possibility that the artificial atmosphere of
the research laboratory might alter physiologic as well as psycho­
logic sexual reaction patterns has been a constant concern. Natural
anxiety of individual subjects for personal anonymity and concern
with pressures of performance created problems that required
special handling. The development of a range of interview tech­
niques effective for all ages for both laboratory-study subject and
clinical-research populations occupied hours of early research time.
These are but a few of thé multifaceted problems faced during the
past eleven years.
In view of the investigative problems created by the technique of
9
IO CHAPTER TWO

working directly with sexually responding men and women, every

attempt will be made to emphasize in context inadequacies of ex­
perimental control. When possible, countermeasures were taken
to improve the sociologic, psychologic, and physiologic integrity of
recorded data. They also will be explained in context.
First, the two questions to be answered: What happens to the
human male and female as they respond to effective sexual stimula­
tion? Why do men and women behave as they do when responding
to effective sexual stimulation? In order to approach these problems,
preliminary concentration was focused on the development of ef­
fective techniques of interrogation, observation, and physical re­
cording. Once these technical tools were at hand, the next steps
were the constitution of an adequate study-subject population and
the integration of these volunteers into the investigative design.
The initial selection of individuals for study in the investigation
of human sexual response was made from the prostitute population.
This socially isolated group was regarded as knowledgeable, co­
operative, and available for study. Availability was the determining
factor during the initial stages of the program. It was presumed, at
that time, that study subjects from more conservative segments
of the general population would not be available (a presumption
which later was proved to be entirely false).
For the first twenty months of the program, a total of 118 fe­
male and 27 male prostitutes contributed their sociosexual, oc­
cupational, and medical histories to the investigation. Ultimately,
a small number of the total group (8 women and 3 men) were
selected for anatomic and physiologic study. The criteria for selec­
tion were obvious intelligence, diverse experience in prostitution,
ability to vocalize effectively, and, of course, a consistently high
degree of availability and cooperation.
Suggestions by this select group of techniques for support and
control of the human male and female in situations of direct sex­
ual response proved invaluable. They described many methods for
elevating or controlling sexual tensions and demonstrated innumer­
able variations in stimulative technique. Ultimately many of these
techniques have been found to have direct application in therapy
of male and female sexual inadequacy and have been integrated
into the clinical research programs. This small group also served
 THE RESEARCH POPULATION 11

as laboratory-study subjects during the trial-and-error periods re­

quired initially to devise and to establish the investigative tech­
niques subsequently employed throughout the study.
The interrogative material and experimental results derived from
the prostitute population have not been included in the material
being presented. Two factors influenced this decision: (1) The
migratory tendencies of this population discouraged the recording
of individual study-subject response patterns over extended periods
of time, and (2) the varying degrees of pathology of the reproduc­
tive organs usually present in this population precluded the pos­
sibility of establishing a secure baseline of anatomic normalcy.
Faced with the experimental necessity of developing a group of
study subjects whose reproductive viscera could be related to base­
lines of anatomic normalcy and from whom long-range cooperation
was possible, volunteers were sought from relatively selected social,
intellectual, and economic backgrounds.
The study-subject population as finally constituted for this in­
vestigation has been established from selected segments of a metro­
politan community. More specifically, it has been developed pri­
marily from and sustained by the academic community associated
with a large university-hospital complex. The concentration of study
subjects from upper socioeconomic and intellectual strata provided
by this major source of supply has not been offset by a statistically
significant number of lower-range family units obtained from out­
patient clinic sources.
There have been other sources of subject recruitment. A number
of family units, initially presenting clinical problems either of sex­
ual inadequacy or conceptive inadequacy, subsequently became a
part of the study-subject population. They provide a wide range
of sociogeographic and educational backgrounds. In recent years
as knowledge of the work in progress spread locally, volunteers of
all ages came from all social strata, and from a wide variety of
educational backgrounds. During the past seven years recruitment
has been limited primarily to specific project interests, such as the
geriatric or the pregnancy-sexual response programs. Just over 75
percent of all male and female study subjects volunteered their
services during this seven-year period. However, as has been ob­
12 CHAPTER TWO

vious from the outset, the study-subject population represents

many different forms of selectivity.
As discussed, the sample was weighted purposely toward higher
than average intelligence levels and socioeconomic backgrounds.
Further selectivity was established by an extensively , detailed intake
interview designed to determine willingness to participate, facility
of sexual responsiveness, and ability to communicate finite details
of sexual reaction. A physical examination sufficient to establish
essential normalcy of the reproductive viscera also was required.
All individuals with socioscxual aberrancy or grossly abnormal re­
productive viscera were eliminated, further emphasizing the degree
of selection inherent in the research population.
It would have been physically and financially impossible to main­
tain as a static force a study-subject population of the magnitude
of the one presently reported. Many family units cooperated to
the extent of recording their sexual response patterns, but were not
retained thereafter as active members of the study-subject group.
Other family units have remained available to the total program
for years. Their reactions to effective sexual stimulation have been
recorded with regularity to determine whether full familiarity with
the program, the recording techniques, the investigative personnel,
and the artificial environment of the research laboratory would in
time alter their basic sexual response patterns.
During the years of continued cooperation, the ages, marital
status, and even the parity of some female study subjects changed.
The statistics as reported represent the status of the individual at
the initial interrogation prior to activation in any of the research
programs. A total of 382 women have cooperated actively with the
investigation. The age range of female study subjects is from 18 to
78 years (Table 2-1). As might be expected, most of them (321
women, or 84 percent) were in the 18-40-year age bracket, with
the largest concentration of active participants in the 21-30-year
age group (182, or 47.6 percent). There have been two girls active
in the program under 21 years of age—an 18-year-old who had been
married three years, had one child, and worked with her husband as
a family unit, and a 20-year-old who was recruited specifically for
the artificial-vagina studies (see Chapter 7).
While to date the majority of the study-subject population has
 THE RESEARCH POPULATION 13

TABLE 2-1
Female Population of 382 Active Study Subjects *

Age No. Selected No. Interviewed

18-20 2 2
21-30 1821
31-40 137 346 460
41-50 27.
51-60 23
61-70 8 34 157
71-80 3]
Totals 382 619

* Data from prostitute population not included.

been female, 312 males have cooperated with the program on at

least one occasion (Table 2-2). Their ages have ranged from 21 to
89 years. The majority of cooperative male study subjects (231, or
74 percent) were 21 to 40 years of age, with the largest number of
active participants in the 21-30-age group (120, or 38.5 percent).
From an educational standpoint the research population has al­
ways been weighted toward a higher standard of formal training
than would be true for a cross-section of the total population.

TABLE 2-2
Male Population of 312 Active Study Subjects *

Age No. Selected No. Interviewed

21-30 120'
31-40 111 273 409
41-50 42.
51-60 19
61-70 14 39 245
71-80 4
81-90 2
Totals 312 654

* Data from prostitute population not included.

 CHAPTER TWO

Tables 2-3 and 2-4 list the educational backgrounds of the female
and the male study subjects respectively. For purposes of statistical
simplicity, listing in the High School column is dependent only
upon matriculation. There were no active study subjects whose
formal education did not include matriculation in high school.
Dropouts are not listed separately. Both college and postgraduate
training have been handled in similar fashion.
As would be expected, the level of formal education was con­
sistently higher for male than female study subjects. Particularly
was this level of education evident in study subjects past 50 years
of age. Obviously, the inordinately high percentage of study sub­
jects with exposure to postgraduate training is a direct reflection of
both the metropolitan area and the hospital-university complex
from which a dominant percentage of the total study-subject popu­
lation has been drawn.
Although the research population purposely was weighted toward
average or above-average intelligence, some of the study subjects
were of less favorable backgrounds. Thirty-seven family units were
drawn from a clinic population. The maximum of formal training
in this group, four years of high school education, had been
achieved by less than half these subjects.
There were 11 Negro family units, 3 of privileged and 8 of under­
privileged backgrounds, included in the study-subject population.

table 2-3

Education Among Female Study Subjects

Age No. High School * College * Postgraduate *

18-20 2 2 0 0
21-30 182 61 83 38
31-40 137 53 57 27
41-50 27 13 12 2
51-60 23 14 8 1
61-70 8 6 2 0
71-80 3 3 0 0
Totals 382 152 162 68

Listing dependent only upon matriculation (highest level)

 THE RESEARCH POPULATION 15

TABLE 2-4
Education Among Male Study Subjects

Age No. High School * College * Postgraduate *

21-30 120 25 49 46
31-40 111 19 41 51
41-50 42 5 17 20
51-60 19 1 7 11
61-70 14 1 9 4
71-80 4 0 3 1
81-90 2 0 2 0
Totals 312 51 128 133

* Listing dependent only upon matriculation (highest level).

In addition, two Negro women were evaluated without marital

partners. One was a surgical castrate and the other had an artificial
vagina. In view of the small number of Negro families in the study­
subject population, it is obvious that the population has, over the
years, been weighted toward the Caucasian rather than the Negro
race.
From onset, no attempt has been made to maintain an accurate
count of the number of male and female sexual response cycles ex­
perienced by study subjects in the environment of the research lab­
oratory. However, a conservative estimate of 10,000 complete cycles
of sexual resporlse for the total research population certainly could
be supported. Such an estimate would represent at least a 3:1 fe­
male dominance. Thus, a minimum of 7,500 complete cycles of
sexual response have been experienced by female study subjects
cooperating in various facets of the research program, as opposed to
a minimum total of 2,500 male orgasmic (ejaculatory) experiences.
Both married and unmarried men and women have been in­
cluded in the study-subject population of 382 women and 312 men.
Over the years, 276 married couples have worked actively in the
various programs. There have been 106 women and 36 men who
were not married at the onset of their active cooperation with the
program. Many had been married previously (81 women and 17
men) but were without a spouse immediately prior to joining the
16 CHAPTER TWO

TABLE 2-5
Reproductive Organ Pathology in Female Study Subjects

Age-Group Distribution
18-20 21-30 31-40 41-50 51-60 61-70 71-80 Total
Pathology
Cystoceles 0 1 5 3 2 2 0 13
Urethroceles 0 0 4 2 2 1 0 9
Rectoceles 0 2 4 3 2 2 0 13
Myomatous
uteri 0 1 3 6 2 2 1 15
Retroverted
uteri 0 17 13 6 6 3 0 45
Pelvic and labial
varicosities 0 0 9 4 5 1 0 19
Pelvic endo­
metriosis 0 3 2 1 0 0 0 6
Additional Data
Vaginal agenesis
(corrected) 1 5 1 0 0 0 0 7
Pregnancy
Primaparas 0 2 1 0 0 0 0 3
Multíparas 0 1 2 0 0 0 0 3
Total active
participants 2 182 137 27 23 8 3 382

study-subject group. Obviously, investigative programs oriented to

a specific sex, such as work with the artificial vagina, pathologic
clitoral hypertrophy, intravaginal contraceptive testing, or the ejac­
ulatory mechanism and testicular elevation reactions, did not neces­
sitate an active marital status for the study subjects involved.
It should be stated in context that early in the investigation, the
nonmarried group also provided opportunity for comparison-con­
trol studies with established marital units. The unrehearsed phys-v
iologic and anatomic response patterns of the unmarried were re­
corded and contrasted to the mutually conditioned and frequently
stylized sexual response patterns of the marital units. This tech­
nique for experimental control was abandoned as soon as it was
 THE RESEARCH POPULATION 17

established unequivocally that there is no basic difference in the

anatomy and physiology of human sexual response regardless of
the marital status of responding units.
While pelvic pathology such as that characteristic of the pros­
titute population arbitrarily was screened out of the study-subject
population, normally occurring anatomic variants in reproductive
viscera purposely were included in an effort to avoid reactive selec­
tivity within both female and male study subjects (Tables 2-5 and
2-6). Cystoceles, urethroceles, and rectoceles were present in parous
study subjects. Myomatous uteri, retroverted uteri, pregnancy-in-

table 2-6

Reproductive Organ Pathology in Male Study Subjects

Age-Group Distribution
21-30 51-40 41-50 51-60 61-70 71-80 81-90 Total
Pathology
Benign
prostatic
hypertrophies 0 0 3 2 1 0 1 7
Unilateral
testicular
atrophies 0 1 1 0 0 0 0 2
Undescended
testicle 1 0 0 0 0 0 0 1
Inguinal hernia
(nonsympto-
matic) 1 0 0 0 0 0 0 1
Inguinal hernia
(sympto­
matic) 0 1 0 0 0 0 0 1
Varicocele
(sympto­
matic) 0 1 0 0 0 0 0 1
Additional Data
Uncircumcised
penises 2 7 ' 6 8 8 2 2 35
Total active
participants 120 111 42 19 14 4 2 312
18 CHAPTER TWO

duced pelvic and labial varicosities, and pelvic endometriosis also

were present in the female population. In the male groups there
were benign prostatic hypertrophies, unilateral testicular atrophies,
an undescended testicle, a small, nonsymptomatic and a large,
symptomatic inguinal hernia and, finally, a large clinically sympto­
matic varicocele.
Nineteen women and 6 men had experienced major pelvic sur­
gery before joining the study-subject population (Tables 2-7
and 2-8). Seven women served as active study subjects in the arti­
ficial-vagina group (see Chapter 7). Six women cooperated actively
with the study of sexual response in a pregnant state, although 111
pregnant women (9 unmarried) responded to interrogation in
depth with material of behavioral content (see Part 2 of Chapter
10). There were 35 uncircumcised male study subjects (see Part 2
of Chapter 12).
The study-subject population of unusual interest has been the
geriatric group. There were 34 women (see Table 2-1) aged 51 to
78 years and 39 men (see Table 2-2) aged 51 to 89 years who co­

table 2-7

Surgical History of Female Study Subjects

Age-Group Distribution
Major Pelvic
Surgery 18-20 21-30 31-40 41-50 51-60 61-70 71-80 Total
Abdominal
hysterectomy 0 0 1 3 3 1 0 8
Vaginal
hysterectomy 0 0 0 0 1 1 0 2
Anterior and
posterior
colporrhaphy 0 0 0 0 1 0 0 1
Salpingo-
oophorectomy 0 0 1 1 0 0 0 2
Oophorectomy 0 2 1 0 0 0 1 4
Salpingectomy 0 1 0 0 0 0 0 1
Inguinal
herniorrhaphy 0 0 0 1 0 0 0 1
 THE RESEARCH POPULATION 19

TABLE 2-8

Surgical History of Male Study Subjects

Age-Group Distribution
Major Pelvic
Surgery 21-30 31-40 41-50 51-60 61-70 71-80 81-90 Total
Prostatectomy
Transurethral 0 0 1 1 0 0 0 2
Perineal 0 0 0 1 0 0 0 1
Inguinal
herniorrhaphy 1 1 0 0 1 0 0 3

operated actively with the research program. Five of the men were
married to women in the 41- to 50-year age group. These additional
couples were included arbitrarily in the geriatric population. Three
of these female partners had been surgically castrated and the re­
maining two women were two and three years postmenopausal at
the outset of experimental cooperation. The arbitrary decision to
include these five couples in the geriatric group brought to 39 the
number of aging married couples evaluated in depth for anatomic
and physiologic patterns of sexual response. Even though the num­
ber of active geriatric participants is small and represents a high
degree of selectivity, their contribution has been large, for their
cooperation has extended over four years of concentrated investiga­
tion of geriatric sexual response.
There never has been an adequate number of study subjects
available to the investigative programs. There are many reasons for
the restricted size of the research population. As might be expected,
the major reason for the statistically inadequate number of study
subjects is the problem of insufficient research funding. Some pro­
grams were restricted in number of participants on the basis of
anatomic scarcity; for instance, the artificial-vagina studies. Others
were limited by psychosocial restraints. The geriatric research is an
excellent example of this particular problem. Inevitably, the in­
vestigation’s total orientation to human sexual response is a de­
limiting factor in itself.
No attempt will be made to provide statistical analyses of the
20 CHAPTER TWO

sexual-behavior content elicited from detailed intake interviews.

When compared to the Kinsey data collected 15 to 25 years ago, the
material returned from a total of 654 male and 619 female inter­
views in a selected population is too meager statistically to be of
significance. If the total sociologic import of the massive Kinsey
contribution is to be realized, the work must be repeated in similar
exhaustive detail and not suborned by attempts at inadequate
statistical comparison. Therefore, behavioral content will appear
only in the format of the chapters of general clinical discussion and
the degree of selection of the subject matter again will be empha­
sized in context.
Of major import is the unique opportunity created by the re­
search environment to observe, to record, and to evaluate the
patterns of physiologic and psychologic response to effective sexual
stimulation in a small, arbitrarily selected segment of male and
female society to a degree never possible previously in medical or
behavioral environment. Rather than material returned from inter­
views or questionnaires being the lone source from which to draw
conclusions concerning human sexual behavior, the material in the
chapters oriented to clinical reaction has been drawn from direct
observation of sexual response—interviews in depth of -behavioral
content, discussions of the individual’s sexual response patterns,
laboratory recording and analysis of reactive patterns, and so on.
Clinical chapters such as those dealing with geriatric sexuality,
sexuality and pregnancy, and sexuality of male and female study­
subject populations will be compilations of interrogative material
of behavioral content. In addition, observation and physiologic
recording of their sexual response patterns will be reported.
Finally, and possibly most important, is the information gleaned
from eleven years of opportunity to work directly with the human
male and female responding to effective sexual stimulation. It
constantly should be borne in mind that the primary research in­
terest has been concentrated quite literally upon what men and
women do in response to effective sexual stimulation, and why
they do it, rather than on what people say they do or even think
their sexual reactions and experiences might be.
Further, modes or means of sexual stimulation will be described
without reservation at this point and not constantly referred to
 THE RESEARCH POPULATION 21

in the body of the text. Recorded and observed sexual activity of

study subjects has included, at various times, manual and me­
chanical manipulation, natural coition with the female partner in
supine, superior, or knee-chest position and, for many female study
subjects, artificial coition in supine and knee-chest positions. No
study subject has been able to fantasy to orgasm under observa­
tion.
Hundreds of complete cycles of sexual response have been ac­
complished under artificial coition with female study subjects in
supine or knee-chest positioning. This research technique was cre­
ated and has been used for three purposes. First, it provides op­
portunity for observation and recording of intravaginal physiologic
response to sexual stimuli [215]. Second, the technique is em­
ployed to establish the effectiveness of intravaginal, mechanical,
or chemical contraceptives without months or years of field trial
wherein reported results of necessity are based upon the tragedy
of pregnancy failure [129, 130, 134, 135]. Third, artificial coital
techniques are used clinically to replace surgery in the creation of
artificial vaginas in women born with vaginal agenesis (see Chap­
ter 7). This use of the technique was suggested by the work of
Frank andXJeist [77, 78].
The artificial coital equipment was created by radiophysicists.
The penises are plastic and were developed with the same optics as
plate glass. Cold-light illumination allows observation and record­
ing without distortion. The equipment can be adjusted for physical
variations in size, weight, and vaginal development. The rate and
depth of penile thrust is initiated and controlled completely by
the responding individual. As tension elevates, rapidity and depth
of thrust are increased voluntarily, paralleling subjective demand.
The equipment is powered electrically.
Orientation to this equipment obviously was necessary for study
subjects with established coital and/or automanipulative experi­
ence. The orientation periods provided opportunities for evaluat­
ing subjective fantasy and conditioning processes employed by
study subjects for sex tension increment.
In view of the artificial nature of the equipment, legitimate issue
may be raised with the integrity of observed reaction patterns.
Suffice it to say that intravaginal physiologic response corresponds
22 CHAPTER TWO

in every way with previously established reaction patterns observed

and recorded during hundreds of cycles in response to automanipu­
lation.
Homosexual material, although recorded in both behavioral and
physiologic context for both sexes, has not been included in this
text. The returns from this facet of human sexual response are too
inadequate at present to warrant consideration. At the present
pace investigative maturity will not be reached in this program for
at least another four to five years.
Once selected as study subjects, males and females were ex­
posed to a controlled orientation program before assuming active
participation as members of the research population. Detailed
medical, social, and sexual histories were obtained from each study
subject by both male and female interrogators. The technique of
dual-sexed interrogation was designed to satisfy two purposes. First
was the necessity to orient a prospective study subject to the fact
of bisexual supervision of all investigative procedures, and second
was the demand for security of factual reporting. Material of sexual
connotation has been elicited from study subjects more effectively
and accurately by interview teams with both sexes represented than
by single-sexed interrogation [132, 133, 210, 216]. The exposure
to the prostitute population emphasized the advantages of this
technique. History-taking also served secondarily as a step in prep­
aration for active participation in the program. It acquainted the
study subject with the investigative personnel and established in
his or her mind the investigators’ nonjudgmental attitudes and
their authoritative roles.
The next step in the orientation program was to demand that
potential study subjects undergo physical examinations to rule
out any gross pathology, particularly of the reproductive organs.
The individuals considering active cooperation with the program
then were exposed to the research quarters. All equipment was
exhibited and its function explained to the uninitiated. Sexual
activity first was encouraged in privacy in the research quarters and
then continued with the investigative team present, until the study
subjects were quite at ease in their artificial surroundings. No
attempt was made to record reactions or introduce other members
of the research personnel to the reacting unit, until the study
 THE RESEARCH POPULATION 2J

subjects felt secure in their surroundings and confident of their

ability to perform. They rapidly gained confidence in their ability
to respond successfully while subjected to a variety of recording
techniques. Finally, this period of training established a sense of
security in the integrity of the research interest and in the absolute
anonymity embodied in the program.
Once total confidence was attained, the study subjects were
directed to the particular phase of the overall program in which
their cooperation was considered to be of greatest value. These
areas have included the specific and long-continued recording of
anatomic and physiologic response to effective sexual stimulation,
pregnancy sexuality, geriatric sexuality, etc. Frequently, one re­
cording session for a family unit was sufficient to demonstrate
conclusively the anatomic variations and physiologic reactions that
will be described in this text. In other instances family units have
been immersed in multiple facets of the investigative program and
have cooperated actively for many years.
FEMALE SEXUAL
RESPONSE
 3
FEMALE EXTRAGENITAL
RESPONSE

ihe human female’s physiologic response to sexual stimulation

is not confined to the reproductive viscera. Sexual tensions involve
many areas other than the primary or secondary organs of re­
production. Although previous investigators [56, 67, 76, 143, 144]
have described extragenital reactions, the extent of influence of
increasing or unresolved sexual tensions upon the corporate body
structure has not been appreciated. A description of specific organ
or system response may serve to highlight this influence of sexual
tensions on the total body economy.
Physiologic reactions to sexual stimulation are superficial and/
or deep vasocongestion and both generalized and specific myotonia.
The vasocongestive reactions relate to any phase of the sexual
cycle, while muscle tensions usually become clinically obvious dur­
ing the plateau phase. An example of superficial vasocongestion
is the sex flush appearing on body surfaces, while deep vasocon­
gestion is demonstrated by the development of the orgasmic plat­
form. Target organs such as the breasts provide evidence of a
combination of both superficial and deep vasocongestion. Muscle
groupings which reflect a generalized tension response to sexual
stimulation are those of the hands, feet, and abdomen, while
the bulbospongiosus and ischiocavernosus muscles and the rectal
sphincter provide examples of specific muscle tension.
This chapter will be devoted to evidence of physiologic response
to effective sexual stimulation in other than the target organs of
female reproduction. The four phases of the cycle of sexual response
will be employed as a descriptive aid.
27
28 CHAPTER THREE

THE BREASTS

EXCITEMENT PHASE

Nipple erection is the first evidence of the breasts’ response to

sex tension increment (Fig. 3-1). This erective reaction occurs as
the result of involuntary contraction of muscular fibers within the
structure of the nipple [94]. Frequently the nipples do not achieve
full erection simultaneously. One nipple may become fully erect
and tumescent, while the other lags in erective rapidity and tu­
mescent size. Inverted nipples may reverse their quiescent station
to assume a position of semierection, or if the inversion is ir­
reducible there may be no nipple indication of the breast’s reaction
to sexual stimulation.
Full erective response may increase nipple length by o. 5-1.0 cm.
and base diameter by 0.25-0.5 cm. over unstimulated measure­
ments. Large, protruding nipples usually have relatively less capac­
ity for size increase than do the more normal-sized nipples. Ex­
cessively small nipples have little physiologic capacity to respond
to sexual stimulation with a measurable increase in size.
A second physiologic alteration developing during the excitement

FIGURE 3-1
The breasts in the female sexual response cycle.
 FEMALE EXTRAGENITAL RESPONSE 29

phase is that of increased definition and extension of the venous

patterns of the breast. If the breast is of sufficient size, venous en­
gorgement of the inferior surfaces occurs, but may not be well
defined until somewhat later in the cycle. The larger breasts usually
display the most definitive expansion of venous pattern. Engorge­
ment of the vascular tree of the breast rarely extends centrally
as far as the areola, since there is fairly rapid venous drainage to
the axillary and internal mammary veins [54, 299].
As sexual tensions progress toward plateau-phase levels, there
is an obvious increase in the actual size of the breasts. This size
increment results from the organs’ deep vasocongestive reaction.
When the responding woman is in an erect position, the en­
gorgement is easily visualized in the lower or inferior portion of a
pendulous breast. When the responding woman is supine, the
overall increase in breast size is more apparent. Tumescence of the
female breast with sexual excitement was first described by Dickin­
son [56] over thirty years ago.

PLATEAU PHASE

Marked areolar engorgement develops late in the excitement

phase (see Fig. 3-1 ). The areolae become so tumescent with plateau­
phase tensions that they impinge upon the erect nipples, creating
an illusion that the responding woman partially has lost nipple
erection. This impression is corrected as resolution-phase areolar
detumescence again reveals the erect nipples.
Before the woman experiences the final physiologic surge toward
orgasm, the unsuckled breast will have increased in size by one-
fifth to one-fourth over unstimulated, baseline measurements. The
breast that has been suckled usually does not demonstrate as
definitive a size increase as the unsuckled breast. This anatomic
variant may be the result of the marked hypertrophy of venous
drainage which milk production develops in the suckled breast.
Suckling increases venous drainage and tends to minimize the
deep vasocongestive effects of sexual tension.
When more than one child has been suckled, the breasts rarely
demonstrate significant increase in size under the influence of
sexual stimulation. Apparently the increase in breast size stimu­
3° CHAPTER THREE

lated by sexual tensions not only is related to the physiologic

response of vasocongestion but also may be implemented by the
fibrous-tissue elements which invest breast lobules as supportive
aids [94]. Overdistention of the breast so frequently seen in the
early phases of milk production tends to impair the effectiveness
of these supportive fibrous-tissue elements. It is understandable,
therefore, that women who have suckled children frequently show
little or no increase in breast size under sex tension influence.
As the woman elevates from excitement-phase to plateau-phase
levels of sexual tension, a pink mottling frequently appears over
the anterior, lateral, and, ultimately, the inferior surfaces of the
breasts. Actually, this maculopapular rash first appears over the
epigastrium and spreads to the breast surfaces as the plateau phase
is firmly established. This superficial vasocongcstive reaction of the
breast will be considered in detail in the discussion of the sex­
flush phenomenon.

ORGASMIC PHASE

There is no specific breast reaction to the experience of orgasm.

Nipple erection and areolar tumescence have been established, the
vascular tree stands out in bold relief, the nonsuckled breast is
increased significantly in size over its unstimulated baseline, and
the sex flush is well established. Maturity of superficial and deep
vasocongestive responses is concentrated in a reactive peak during
the orgasmic experience.

RESOLUTION PHASE

Advent of the resolution phase is signalled by the rapid dis­

appearance of the sex flush and the simultaneous detumescence
of the areolae (see Fig. 3-1). With areolar detumescence the
nipples appear to regain full erection. The impression is created
that they are undergoing a secondary erective reaction, either from
new stimulative influence or retained stimulative effect. This re­
action has been termed a “false erection” and is simply the result
of early detumescence of the grossly engorged areolae which occurs
well before nipple erection subsides.
 FEMALE EXTRAGENITAL RESPONSE 31

As a general rule, the nonsuckled breasts lose their deep vaso-

congestion slowly. Frequently, the increment in breast volume
is retained for five to ten minutes after the orgasmic phase has
been terminated, while superficial venous patterns on the breast
surfaces may persist even longer. Erect nipples may undergo com­
plete involution before the venous patterns return to their nor­
mally ill-defined state. This persistence of both superficial and
deep vasocongestive influences, particularly evident in the non­
suckled breast, may be the result of plateau-phase overdistention
of the plexus venosus areolaris (circulus of Haller) [94]. This over­
distention results in slowed venous drainage into the internal
mammary veins during the resolution phase. (For discussion of
the pregnant and lactating breast, see Part 1 of Chapter 10.)

THE SEX FLUSH

The protean character of the sex-flush reaction to effective sexual

stimulation has not been considered previously. Its generalized
distribution was emphasized when illumination necessary for suc­
cessful laboratory cinematography increased the skin temperature
and more clearly defined the sex flush. Both intensity and distribu­
tion patterns of the sex flush vary among individuals, but as a rule
the severity of the flush reaction may be considered a direct
indication of the intensity of the sexual tensions experienced by
the responding woman.
This maculopapular type of erythematous rash first appears over
the epigastrium either late in the excitement or early in the plateau
phase of the sexual cycle. The sex flush then spreads rapidly over
the breasts, first appearing on the anterior and superior surfaces
of the breasts and then on the anterior chest wall. The lateral and
then the medial breast surfaces become involved. Finally, as or­
gasm is imminent, an extension of the flush is often noted on the
undersurfaces of the breasts.
On occasion most of the body surfaces of sexually responding
women have given evidence of this superficial vasocongestive re­
action during the plateau phase of the sexual cycle. The sex flush
32 CHAPTER THREE

may be observed spreading over the lower abdomen, the shoulders,

and even the antecubital fossae as sexual tensions mount. With
impending orgasm, this measles-like rash even may spread over
the anterior and lateral borders of the thighs and over the buttocks
and the entire back.
The sex flush reaches a peak of color concentration and its
widest distribution late in the plateau phase and terminates ab­
ruptly with orgasmic experience. The flushed, strained features of
the human female as she reaches for orgasmic release of her over­
whelming sexual tensions have been described graphically in the
past [30, 88, 141, 144, 305]. It now is evident that the vascular
flush previously described as confined to the face and anterior
chest wall frequently may have widespread body distribution.
The sex flush extends over the body surfaces of susceptible
individuals, paralleling in intensity the severity of impending or­
gasmic experience. Approximately 75 percent of all women evalu­
ated demonstrated the sex flush on occasion. It should be recalled
that the women recorded in the study had well-established sexual
response patterns with significant prior orgasmic experience. The
figure of 75 percent for sex-flush appearance among female study
subjects represents, in all probability, a higher incidence than that
to be observed in the general population.
The sex flush disappears from the different body sites in almost
opposite order from its sequential appearance. The maculopapular
rash disappears quickly from the back, buttocks, lower abdomen,
arms, and thighs. It is much slower to resolve from the chest,
breasts, neck, face, and finally from its initial appearance site
over the epigastrium.

MYOTONIA

Myotonia, which becomes clinically obvious late in the excite­

ment phase and during plateau-phase levels of sexual tension, is
both generalized and specific in character. Usually muscles contract
with regularity or in spasm in an involuntary manner, but con­
traction frequently may be voluntary depending upon coital po­
 FEMALE EXTRAGENITAL RESPONSE 33

sitioning. For example, carpopedal spasm [119, 144, 271, 319], a

spastic contraction of the striated musculature of the hands and
feet, frequently is present late in plateau or during orgasm for the
female in supine coital positioning or during automanipulation.
Carpopedal spasm is reflected involuntarily by fingers and toes that
are not devoted voluntarily to clutching responses. (A detailed
discussion of both male and female myotonia during sexual re­
sponse has been undertaken in Chapter 18.)

URETHRA AND URINARY BLADDER

Recurrent observation of the urethra has shown occasional in­

voluntary distention of the external meatus during orgasm. This
dilatation of the urethral meatus is of minimal degree and occurs
with no established regularity. The meatus returns to its normal
constricted state before contractions of the vaginal orgasmic plat­
form have ceased.
The urge to void during or immediately after intercourse has
been reported previously [69, 93, 102, 319]. In most instances study
subjects who complained of postcoital dysuria had a high, firm
perineum and nulliparous constriction of the vaginal outlet. These
nulliparous structures combine to hold and direct the penis along
the anterior vaginal wall during mounting and active coition. Thus
the posterior wall of the urinary bladder reflexly is irritated sub­
sequent to repeated penile thrusting. Only with this particular
type of outlet structuring was bladder or urethral tenesmus de­
scribed as a coital or postcoital complication. The clinical symp­
toms resulting from this situation have been known to the medical
profession for years and given the slang term of “honeymoon
cystitis.”
Three other study subjects, two with clinically symptomatic
urethroceles and one with a symptomatic cystocele and second-
degree uterine descensus, also have complained on occasion of
postcoital dysuria. Since all three women have a constant level of
residual urine in the bladder, the urge to void, particularly after
either long-continued or severe coital activity, is readily understood.
34 CHAPTER THREE

THE RECTUM

Voluntary contraction of the external rectal sphincter together

with the gluteal musculature may be employed during both excite­
ment and plateau phases of sexual response. Many women use
this stimulative technique when driving for sex tension increment.
Involuntary contraction of the rectal sphincter occurs only dur­
ing an orgasmic experience. Although this reaction does not occur
with consistency, it is a significant indication of the intensity of
orgasm. During a more intense orgasmic response, the external
rectal sphincter may contract two to five times. The contractions
develop at o.8-second intervals, as do those of the orgasmic plat­
form in the outer third of the vagina (see Part 1 of Chapter 6).
In short, the contractions of orgasm described for the orgasmic
platform frequently are paralleled by simultaneous contractions
of the perineal body and the external rectal sphincter. External
rectal-sphincter contractions occur most frequently during an or­
gasm elicited by automanipulation but occasionally have been
observed during coition.

HYPERVENTILATION

Hyperventilation develops late in the plateau phase of the

female’s sexual cycle, lasts through the entire orgasmic experience,
and terminates early in the resolution phase. Respiratory rates over
40 per minute have been recorded at the apex of severe orgasmic
experience. With a minimal-intensity orgasm lasting 3 to 5 seconds,
clinically obvious hyperventilation may not occur.

TACHYCARDIA

The heart rate usually is elevated significantly during late plateau

and orgasmic phases of the sexual cycle. Rates from 110 to 180+
beats per minute have been recorded. Higher heart rates reflect
more variation in orgasmic intensity for the female than for the
 FEMALE EXTRAGENITAL RESPONSE 35

RATE 100
RATE U0

LEAD II
MANIPULATION
CONT.
RATE 134 7 RATE 140
, ■, —11

■■ 1 1/2 MIN. LATER V

I 1 MIN.LATER

RATE 15a

RATE ITS RATE 175

IMMEDIATE RESOLUTION
KGIN ORGASM PHASE
2 1/2 MIN. LATES
EMD ORGASM
LEAD 11

RS (HUTTON PHASE CONTIMJED (2 MIN. LATES)

RATE 126

RES0LUT10N PHASE CONTINUED (2 MIN. LATER)

RATE 98

FIGURE 3-2
Electrocardiogram (Lead II) of female study subject. Note cardiac
rate of 175/min. late in plateau and during orgasm.

male. The highest cardiac rates have been returned during female
masturbatory sequences rather than during coition (Fig. 3-2).

BLOOD PRESSURE

Elevations of systolic pressure of 30 to 80 mm. Hg have been

recorded from female study subjects late in plateau or during
36 CHAPTER THREE

orgasmic experience. Diastolic pressure elevations are usually in

the range of 20 to 40 mm. Hg. With minimal-intensity orgasmic
experience, diastolic pressure readings essentially may be unaf­
fected.
There have been several attempts to evaluate cardiorespiratory
response to sex tension increasement in the past [22, 67, 151, 152,
220, 282]. Specifics of female cardiorespiratory response to elevated
sexual tensions will be published in a separate consideration of
both general body and target-organ physiology.

PERSPIRATORY REACTION

Many women have described a sensation of being excessively

warm or feeling cold as they resolve their sexual tensions. Fre­
quently, resolution of the sex flush occurs coincidentally with the
appearance of a widespread film of perspiration. An involuntary
perspiratory reaction may develop during the resolution phase re­
gardless of the degree of physical activity demanded of the re­
sponding woman. This reaction has been described frequently
during the past thirty years [67, 239, 278, 319].
A filmy sheen of perspiration may appear over the back, thighs,
and anterior chest wall as the immediate postorgasmic woman
recovers conscious interest in her environment. Perspiration has
been noted to run from the axillae and also become an evident
surface coating of the entire body from shoulders to thighs. The
soles of the feet and palms of the hands are areas of perspiratory
concentration for some women. Perspiration appears on the fore­
heads and upper lips of women whose faces have been mottled
and swollen in the usual patchy manner immediately prior to
orgasmic tension release.
Approximately one-third of female study subjects display a ten­
dency toward the perspiratory reaction. It appears simultaneously
over all body sites in the immediately postorgasmic time sequence
and is the first indication of resolution of the superficial vaso-
congestive response of the skin (sex flush) to effective sexual
stimulation. For instance, the breasts may be covered with perspira­
tion, and still demonstrate disappearing vestiges of the sex-flush
 FEMALE EXTRAGENITAL RESPONSE 37

phenomenon. The degree of obvious perspiratory coating of the

body surfaces depends on opportunity for evaporation and/or ab­
sorption by clothing or bedding materials. The severity of the re­
action when it occurs also parallels directly the intensity of the
orgasmic expression.
If orgasmic-phase levels of sexual tension are not experienced, a
generalized perspiratory reaction rarely occurs during the resolution
phase. If a sex flush develops during the woman’s plateau phase
and she does not achieve orgasmic-phase release, the flush fades
rapidly (once sexual stimulation is discontinued), usually resolving
without evidence of perspiratory response other than on the palms
of the hands or soles of the feet.
It constantly must be bome in mind that physiologic response
to sex tension increment is a protean reaction. In addition to the
selected responses highlighted in this chapter, generalized vaso-
congestion and myotonia involve many body areas and organ
systems other than the target organs. Future investigation will
establish specifics of response in such areas as the organs of special
sense, the endocrine system, and the hypothalamic and higher
cortical centers.
 4

FEMALE EXTERNAL
GENITALIA
ANATOMY AND PHYSIOLOGY

Th e human female’s external genitalia include the labia majora,

the labia minora, and the clitoris. The anatomy, physiology, and
psychodynamics of clitoral response will be presented in Chapter 5.
A consideration of the function of Bartholin’s glands, located
in the labia minora, has been included in this discussion. The
glands are intimately associated anatomically with the external
genitalia, since they are imbedded in the labia minora. Both the
external genitalia and Bartholin’s glands respond to sexual stimula­
tion through an interdependency on mutual neuroactivation (Fig.
4-1).

LABIA MAJORA

When unstimulated sexually, the major labia normally meet in

the midline and provide positive protection for the subjacent
structures—the minor labia, the vaginal outlet, and the urinary
meatus. Obstetric trauma may cause loss in the integrity of major­
labial midline accommodation and a subsequent loss of protec­
tion to the vaginal outlet. Thus, the response patterns of the major
labia to effective sexual stimulation may be influenced markedly
by the patient’s obstetrical history. For this reason the labial
response patterns will be discussed for both nulliparous and mul­
tiparous women. As sexual tensions rise for the nullipara during
the excitement phase, the major labia thin out and flatten against
the perineum. There is also a slight elevation of the labia in an
38
 FEMALE EXTERNAL GENITALIA 39

FIGURE 4- 1
The human female external genitalia.

upward and outward direction away from the vaginal outlet. This
labial flattening and anterolateral elevation or displacement usually
are completed late in the excitement phase or soon after plateau­
phase levels of sexual tension are achieved.
The anatomic displacement of the major labia may be caused
by protrusion of the rapidly engorging minor labia and preliminary
vasocongestion of the external third of the vagina. There is an
alternative possibility. The flattening and anterolateral elevation
of the major labia away from the vaginal outlet may be an in­
voluntary neurophysiologic attempt to remove any exterior im­
pediment to the anticipated mounting process. There are no
changes in the anatomy of the labia majora either late in plateau
or during the orgasmic phase of the sexual cycle.
During the resolution phase the major labia return to their
normal thickness and midline positioning. Labial involution occurs
rapidly if the woman undergoes an orgasmic experience. If only
plateau-phase levels of sexual tension are attained, an extended
resolution phase usually is experienced, and the separated and
engorged major labia may be slow to return to midline positioning.
Additionally, if the nulliparous woman is long maintained in
excitement or plateau phase, the separated labia majora become
4° CHAPTER FOUR

severely engorged with venous blood and sometimes even develop

edema. Frequently this severe labial vasocongestion may persist
for several hours after cessation of all sexual stimulation.
For the multiparous woman (particularly one with labial vari­
cosities), the labia majora react to elevated sexual tensions in a
somewhat different manner. Instead of flattening and undergoing
excitement-phase anterolateral elevation against the perineum, the
labia majora become markedly distended with venous blood. Oc­
casionally, during an extended plateau phase, a two- to threefold
increase in labial diameter has been demonstrated. If the vaso-
congestive increase in diameter occurs, there is no flattening or
elevation of the swollen labia against the perineum; they hang
pendulous and swollen as a partial curtain to the vaginal outlet.
There is, however, a slight lateral movement away from the mid­
line, so that even the swollen vasocongested major labia of a multi­
parous woman do not interfere with the normal mounting process.
In fact, a restricted but discernible mounting invitation still occurs
as an involuntary response to effective sexual stimulation regardless
of the degree of multiparity of the individual.
In a varicosity-distressed woman, labial vasocongestion may per­
sist through a two- to three-hour resolution phase before complete
detumescence, presuming only plateau-phase levels of sexual ten­
sion have been attained. If an orgasm is experienced by these
women, detumescent involution of labial vasocongestion is much
more rapid. Understandably, the more advanced the varicosity
involvement of the major labia, the more severe the vasocongestive
reaction of the labia under sex tension influence.

LABIA MINORA

Aside from changes in the clitoris, the most definitive changes

that develop in the external genitalia during a complete cycle of
sexual response appear in the labia minora. With a well-established
excitement phase the labia minora of both nulliparous and mul­
tiparous women expand markedly in diameter. When sexual ten­
sions reach plateau-phase levels, the labia minora increase at least
two, occasionally three, times in diameter. With expansion in
 FEMALE EXTERNAL GENITALIA 41

diameter, the minor labia protrude through the protective curtain

of the thinning major labia, and in so doing may be partially
responsible for major labial separation and anterolateral elevation.
The increase in minor labial diameter adds at least 1 cm. to the
clinical length of the vaginal barrel during coition with the ex­
ception of the posterior wall of the vaginal outlet (the fourchette).
Once the excitement-phase vasocongestive increase in diameter
has been completed, the minor labia are prepared for one of the
most unique but specific physiologic reactions occurring in the
human female during the cycle of sexual response. Vivid color
changes develop in the engorged minor labia during the plateau
phase of the sexual response cycle. These color changes may be
equated with the parity of the individual. When the nulliparous
woman reaches a plateau phase of sexual tension, the minor labia
undergo a color change which ranges from a pink to a bright red
color. This florid coloration diffuses along both sides of the vaginal
outlet, usually including the clitoral hood in its progression. The
multiparous individual also evidences an obvious color change
which varies from the bright red to a deep wine color. As a rule
the darker the color change in the minor labia, the more severe
the degree of pelvic and labial varicosity involvement.
So specific are these plateau-phase color changes that the minor
labia have been termed the “sex skin” of the sexually responding
woman. No premenopausal woman has been observed to reach
plateau-phase levels of sexual tension, develop the “sex skin” color
changes, and then not experience an orgasm. In order to support
this statement it must be presumed that the particular form of
effective sexual stimulation which produced the sex-skin color
changes is continued without major alteration. (The term sex skin
should not be confused with terminology referring to circumperi-
neal changes in female monkeys and apes during estrus [11].)
Many women have progressed well into plateau-phase levels
of sexual response, had the effective stimulative techniques with­
drawn, and been unable to achieve orgasmic-phase tension release.
These women, if sufficiently excited, may have developed the sex­
skin color changes. When an obviously effective means of sexual
stimulation is withdrawn and orgasmic-phase release is not
42 CHAPTER FOUR

achieved, the minor-labial coloration will fade rapidly, long before

the vasocongestive increase in diameter is resolved.
It is obvious that the sex skin (labia minora) provides satis­
factory clinical evidence of the degree of sexual tension experienced
by the individual. When the sex-skin reaction develops, the woman
has reached plateau-phase levels of physiologic response to her
sexual tensions. Generally, the more brilliant and definitive the
color change, the more intense the individual’s response to the
particular means of sexual stimulation. It should be emphasized
that the development of the sex-skin reaction is clinically pa­
thognomonic of impending orgasmic-phasc expression. No woman
ever has been observed to attain orgasmic release of sexual tensions
without first demonstrating the specific minor-labial color changes.
During the resolution phase, the tension-induced coloration of
the sex skin quickly devolves from deep or bright red to light pink,
generally within 10 to 15 seconds after orgasmic expression. The
second stage of color loss of the minor labia (pink to unstimulated
colorless state) is also relatively rapid but does not occur with
uniform regularity. The sex skin undergoing final or secondary
loss of sex tension color has a rather blotchy appearance.
When the minor labia have achieved a plateau-phase color
change, at least a twofold increase in diameter has developed. To­
gether with the vasocongested outer third of the vagina (orgasmic
platform) the minor labia form an engorged distal vaginal barrel
and provide supportive containment for the penile shaft. In es­
sence, the changes in the labia (majora and minora) that plateau­
phase levels of sexual tension develop result in opening the vaginal
outlet by removing the natural anatomic protection from the
vaginal orifice. In addition, the sex-skin coloration (minor labia)
signifies intense female sexual tensions and is clinically pathog­
nomonic of impending orgasm, if the effective stimulative tech­
niques are maintained.

BARTHOLIN’S GLANDS

Bartholin’s glands are vulvovaginal glands located in each of the

minor labia. They have ductal outlets on the inner surfaces of the
 FEMALE EXTERNAL GENITALIA 43

labia, immediately adjacent to the vaginal introitus. The glands

secrete a mucoid material that for many years has been presumed
to contribute sufficient lubrication for successful and painless
vaginal penetration [30,119, 228, 268, 305, 318, 319].
It is true that Bartholin’s glands do respond to sexual stimulation
by secretory activity (Fig. 4-2). However, this secretory activity
develops only late in excitement-phase or early in plateau-phase
levels of sexual tension. The nulliparous study subjects rarely
produce more than a drop of the mucoid material from each duct.

FtGUKE 4-2
Specific secretory activity of Bartholin s gland at the plateau phase.
44 CHAPTER FOUR

The multiparous woman occasionally develops 2 or even 3 drops

of material. Under observation, however, there never has been
sufficient secretory material produced to accomplish more than
minimal lubrication of the vaginal introitus.
Basic vaginal lubrication develops in a transudation-like reaction
through the walls of the vagina. This lubricating material appears
early in the excitement phase, a matter of seconds after the onset
of any form of sexual stimulation. This material normally is pro­
duced in such copious quantity that the vaginal barrel and outlet
are quickly and effectively lubricated (see Part 1 of Chapter 6).
Bartholin’s gland activity is stimulated most effectively by long-
continued coital connection, particularly if the female partner is
maintained in late excitement-phase or plateau-phase levels of
sexual tension. In this situation, male coital stroking continued
for lengthy periods of time stimulates the Bartholin’s glands to
contribute significantly to introital lubrication, but they never pro­
duce sufficient material to effect lubrication of the vaginal barrel.
During automanipulative episodes there frequently is no evidence
of Bartholin’s gland secretory activity.
Bartholin’s gland secretions have been assigned the role of
reducing vaginal acidity to promote greater sperm longevity during
intravaginal containment [119, 325]. However, the material se­
creted is so minute in amount when compared to that produced by
the mechanism of vaginal lubrication that the concept is mechani­
cally and chemically impossible. It is true that there is a recordable
elevation of vaginal pH during episodes of long-continued sexual
stimulation, but this change in vaginal acidity is the result of the
production of vaginal lubrication and not Bartholin’s gland se­
cretory material (see Part 3 of Chapter 6).
In summary, increased secretory activity of Bartholin’s glands
is a negligible factor in vaginal-barrel or even introital lubrication.
Not only is a minimal amount of material produced, but also the
plateau-phase timing of such secretory activity rules out a role as
the primary mechanism of vaginal lubrication.
 THE CLITORIS

i. ANATOMY AND PHYSIOLOGY

The clitoris is a unique organ in the total of human anatomy.

Its express purpose is to serve both as a receptor and transformer
of sensual stimuli. Thus, the human female has an organ system
which is totally limited in physiologic function to initiating or
elevating levels of sexual tension. No such organ exists within the
anatomic structure of the human male.
Conceptualization of the role of the clitoris in female sexual
response has created a literature that is a potpourri of behavioral
concept unsupported by biologic fact. Decades of “phallic fallacies”
have done more to deter than to stimulate research interest in
clitoral response to sexual stimulation. Unfortunately, the specific
roles previously assigned clitoral function in female sexual response
were designated by objective male consideration uninfluenced by
and even uninformed by female subjective expression.
In the past, anatomic dissection, microscopic examination, and
surgical ablation of the clitoris have established the organ as a
homologue of the male penis [94, 262, 278]. The clitoris (Fig. 5-1)
consists of two corpora cavernosa enclosed in a dense membrane
primarily of fibrous-tissue origin. This capsule has recently been
shown to contain elastic fibers and smooth-muscle bundles [49].
The fibrous capsules unite along their medial surfaces to form
a pectiniform septum which is well interspersed with elastic and
smooth-muscle fibers. Each corpus is connected to the rami of
the pubis and ischium by a crus. The clitoris is provided (as is the
penis) with a suspensory ligament which is inserted along the
anterior surface of the midline septum. In addition, two small
muscles, the ischiocaverndsus muscles, insert into the crura of the
clitoris and have origin bilaterally from the ischial rami.
The dorsal nerve of the clitoris is very small and is the deepest
45
46 CHAPTER FIVE: PART ONE

lschioca\
mut Minor labial hood

Clitoral glans
Sjfm>
Clitoral shaft

CHh

Urethra

FIGURE 5-1
The clitoris in retraction (lateral view).

division of the pudendal nerve. It terminates in a plexus of nerve

endings within the substance of the glans and the corpora caver­
nosa. Dahl described both myelinated and unmyelinated fibers of
the somatic and vegetative nervous systems [48]. Pacinian cor­
puscles are distributed irregularly throughout the autonomic system
nerve fibers both in the glans and the corpora but usually have
greatest concentration in the glans [157, 158].
The pacinian corpuscles are concerned primarily with propri­
oceptive stimulation. The blood supply to the clitoris is derived
from the deep and dorsal clitoral arteries, which in turn are
branches of the internal pudendal artery. The arterial supply to
and venous return from the clitoris follow the distribution patterns
described for the penis (see Part 1 of Chapter 12). Although the
blood supply has distribution patterns similar to that of the penis,
clitoral vascularity obviously is accomplished from vessels of smaller
capacity for fluid volume.
Anatomic dissection was supplemented by reported clinical men­
suration of the female phallus only forty years ago. Clitoral glans
size has been established at an average of 4 to 5 mm. in both the
transverse and the longitudinal (less accurate) axis. One hundred
adult females were used in Dickinson and Pierson’s [59] first
sample. Dickinson later described clitoral position with relation
to the distance between the crural origins on the anterior border
of the symphysis and the urethral meatus. A mean of 2.5 cm. was
reported [56]. Marked variation has been recorded in the length of
 THE CLITORIS 47

the clitoral body (glans and shaft). Frequently overlooked has

been the possibility of an endocrine source for instances of hyper­
trophy of the organ observed clinically. Exact descriptions of points
of origin of the clitoral crura on the anterior border of the sym­
physis or of any constant relation of crural origin to urethral
meatus are an anatomic impossibility.
Aside from academic interest, Dickinson’s expressed purpose in
accumulating these data was to encourage clinical attempts to es­
tablish the physiology of clitoral function in female sexual re­
sponse. In order to amplify his pioneer efforts, certain fundamental
questions of clitoral reaction to sexual stimuli must be answered:
(1) What anatomic changes occur in the clitoris during periods of
sexual stimulation? (2) Are there consistent physiologic patterns
of clitoral response that can be related to the descriptive frame­
work of the four phases of the cycle of sexual response? (3) Does
the clitoral body develop different response patterns during coition
as opposed to those resulting from manipulation of the mons or
other erogenous areas or to pure psychogenic stimulation? (4) What
clinical application can be developed from the basic material
accumulated to answer the first three questions? (5) Are clitoral
and vaginal orgasms truly separate anatomic and physiologic
entities? The questions relating to anatomy and physiology (Nos.
1-3) are approached immediately following, and the clinical ques­
tions (Nos. 4 and 5) are approached in Part 2 of this chapter.
The first two questions will be explored in sequence in order
to define clitoral anatomic reaction and physiologic response to
sexual stimuli within the descriptive framework of the four phases
of the female cycle of sexual response [212, 214].
It should be reemphasized that there normally is marked varia­
tion in the anatomic structuring of the clitoris. Clitoral glandes
frequently have been measured at 2 to 3 mm. in transverse di­
ameter, yet a glans measuring 1 cm. in transverse diameter is
still within normal anatomic limits. There also is marked variation
in points of origin of the crural and suspensory ligaments. These
ligaments originate on the anterior surface of the symphysis but
vary from the lower to the upper border. The clitoral shaft
(crura and corpora) may be quite long and thin and surmounted
by a relatively small-sized glans, or short and thick with an
48 CHAPTER FIVE: PART ONE

enlarged glans. Frequently the reverse of these shaft-and-glans

combinations has been observed. Clinical mensuration of clitoral
shaft length has been so unreliable that results will not be reported.
The first pelvic response to sexual stimulation is the production
of vaginal lubrication (see Part 1 of Chapter 6). This material
appears on the walls of the vaginal barrel within 10 to 30 seconds
from the onset of any form of sexual stimulation. Clitoral reaction
does not develop as rapidly as the production of vaginal lubrication.
Consequently the widespread belief that the clitoris responds to
sexual stimulation with a rapidity equal to that of penile erection
is fallacious. This physiologic misconception may have developed
from the realization that anatomically the clitoris is a true homo­
logue of the penis. It was a natural error to assume that similar
anatomic structures would demonstrate parallel response patterns
in a relatively equal time sequence.
The rapidity of clitoral response depends upon whether the
stimulative approach is direct or indirect. The only direct approach
is manipulation of the clitoral body or the mons area. There are
numerous indirect stimulative techniques: manipulation of other
erotic areas, coition, fantasy. If, for example, only breast or vaginal
stimulation is employed (without direct clitoral contact), clitoral
response will follow established patterns. However, there is a dis­
tinct delay in the onset of these patterns as opposed to the rapid
reaction developed from direct stimulation of the clitoral body or
the mons area.

EXCITEMENT PHASE

There is a clitoral response to sexual stimulation which occurs

in every responding female during the excitement phase (Fig. 5-2)
regardless of whether there is clinically obvious tumescence of
the glans. The superficial integument of the unstimulated clitoral
glans is wrinkled and moves without restriction over the underlying
glans tissue in manner similar to the integument of the un­
stimulated glans penis, but with less freedom than the integument
of the scrotum (see Chapter 13). When any form of sexual
tension develops, the clitoral glans always increases in size to a
 THE CLITORIS 49

CL ¡TORAL
SHAFT
Retraction
Reoction,
Giant and Shaft
CL ¡TORAL
HOOD Chtoroi Hood

CLITORAL
GLANS Labia!
Engorgement
MINOR
LABIUM

I ni
UNSTIMULATED EXCITEMENT PLATEAU
BASELINE PHASE PHASE

FIGURE 5-2
The clitoris in the female sexual response cycle. The orgasmic phase
is omitted because of lack of information.

degree sufficient to develop close apposition between the sub­

jacent tissues and the loosely applied, superficial integument. The
vasocongestive reaction is of such finite nature that it usually
cannot be noted by unsupported clinical observation. This ana­
tomic response to increasing sexual tension has been established
with aid of colposcopic magnification (6-40X). Microscopic tu­
mescence of the clitoral glans always develops with sexual tension,
regardless of whether this vasocongestive process continues into
a clinically observable (macroscopic) tumescent reaction.
There is no way of anticipating from observation in an un­
stimulated state whether or not a clitoral glans will develop a
clinically obvious tumescence under sexual influence. When in­
crease in size of the glans does occur, this reaction pattern develops
with total consistency. Variations in tumescent reactions relate
only to the rapidity and extent of increase in size of the glans in
response to direct manipulation, as opposed to slower and less
extensive glans tumescence in response to breast manipulation,
active coition, or fantasy.
More than half of the study subjects did not develop clinically
obvious tumescence of the clitoral glans. When macroscopic tumes­
cence does occur, the degree of vasocongestion ranges from a
barely discernible increase in diameter to a twofold expansion of
the glans. This tumescent reaction of the glans has been confused
with the penile erective process and has been mistermed “erection
50 CHAPTER FIVE: PART ONE

of the clitoris” [58, 97]. Total clitoral-body erection has not been
observed unless there has been an obvious pathologic hypertrophy
of the organ in its unstimulated state. Generally, the smaller the
clitoral glans, the less frequently there is a clinically demonstrable
tumescent reaction. However, some of the smaller organs have
demonstrated the greatest relative size increases, while many of
the larger clitorides have provided no gross evidence of a tumescent
reaction.
When observable tumescence of the glans occurs, it does not
develop until sexual tensions have progressed well into the excite­
ment phase of the sexual response cycle. The clitoris engorges in
a time sequence that parallels that of vasocongestion of the minor
labia. It may be recalled that the minor labia of the sexually
responding human female increase in size to a minimum of twice
their unstimulated diameter and provide external extension for the
expanding vaginal barrel (see Chapter 4). A similarly responding
male has long since achieved full penile erection and, quite pos­
sibly, a moderate degree of elevation of at least one testicle (see
Chapter 13).
Once observable tumescence of the clitoral glans develops, the
engorgement persists throughout the remainder of the sexual cycle,
or for as long as any significant degree of sexual stimulation is
maintained.
As the anatomic structuring of the corpora cavernosa would
suggest, the shaft of the clitoris also undergoes an excitement­
phase vasocongestive reaction. There is definitive increase in di­
ameter of the shaft which is a constant development regardless
of shaft size. The vasocongestive increase in shaft diameter occurs
simultaneously with the development of any macroscopic tumes­
cent reaction of the glans. However, the clitoral shaft increases
in diameter whether or not the glans reacts with clinically obvious
tumescence.
In addition to a constant diameter increase, shaft elongation
can occur. However, most clitorides go through vasocongestive
glans reactions without developing clinically observable shaft elon­
gation. Although objective observation admittedly is very difficult,
an elongation reaction of the clitoral shaft has been firmly estab­
lished in less than 10 percent of the observed orgasmic cycles.
Shaft elongation develops only after the normal vasocongestive in-
 THE CLITORIS 51

crease in shaft diameter has been stabilized. Elongation of the shaft

has been observed only during direct manipulation of the mons
area and not in response to the stimulation of other erotic areas of
the body, fantasy, or active coition. It also should be emphasized
that shaft elongation is confined to excitement-phase levels of
sexual response, as discussion of plateau-phase clitoral response
patterns will make evident.

PLATEAU PHASE

The most significant physiologic reaction of the clitoris to effec­

tive sexual stimulation occurs in the plateau phase of the sexual
cycle (see Figs. 5-1, 5-2) and develops with universal consistency.
The entire clitoral body (shaft and glans) retracts from the normal
pudendal overhang positioning. The crura and suspensory ligaments
of the clitoris have major anatomic functions in this pattern of
physiologic response. The ischiocavernosus muscles also contribute
actively to retraction of the clitoral body, as opposed to their
function during male ejaculation (see Chapter 14). It should be
emphasized that the exact roles of the crura, suspensory ligaments,
and various muscle bundles in clitoral retraction have not been
determined with total conviction.
Clitoral reaction to plateau-phase levels of sexual tension occurs
in a constant pattern. The shaft and glans of the clitoris withdraw
from normal pudendal-overhang positioning and retract against the
anterior border of the symphysis. Any portion of the clitoral glans
that normally projects from the clitoral hood in a sexually un­
stimulated state is withdrawn deeply beneath the protective fore­
skin as the retraction reaction progresses. In the immediate pre-
orgasmic period the clitoral body (shaft and glans) is extremely
difficult to observe clinically. At this time the retraction of the
clitoral shaft normally is so advanced that there is at least a
50 percent overall reduction in the length of the total clitoral body.
The degree of individual clitoral-body retraction has been estimated
with the aid of direct colposcopic observation.
During the plateau phase, clitoral-body retraction develops in
relation to mode and effectiveness of sexual stimulation. During
coition or breast manipulation, clitoral retraction develops late in
the plateau phase as an indication of preorgasmic levels of sexual
52 CHAPTER FIVE: PART ONE

tension. With manipulation of the mons area, retraction of the

clitoral shaft develops more rapidly, frequently early in the plateau
phase, and may indicate sensate response to tactile stimuli rather
than imminence of orgasmic experience.
Obviously, psychic components of sexual response patterns can­
not be equated objectively for each orgasmic cycle under investiga­
tion. However, it would be a major mistake to presume that
psychogenic influences do not contribute to either degree or rapid­
ity of clitoral response to effective sexual stimulation. No woman
who can fantasy to advanced plateau stages of sexual tension has
been available to the investigation, so there is no information as
to the degree of clitoral retraction possible in response to purely
psychosexual stimulation.
Retraction of the clitoral body during the plateau phase is a
reversible reaction. If high sexual tension levels are allowed to fall
by deliberate reduction or withdrawal of stimulative techniques,
the retracted shaft and glans will return to the normal pudendal-
overhang position. With return to effective sexual stimulation,
clitoral-body retraction will recur. This clitoral reaction sequence
may develop repetitively during long-maintained plateau phases.
Such a situation would exist when a woman who cannot quite
achieve orgasmic expression insists on long-continued or repetitive
return to stimulative activity in attempts to obtain release from
her demanding sexual tensions.

ORGASMIC PHASE

No specific orgasmic-phase reaction of the clitoris has been

established. In fact, due to the severity of the normal clitoral
retraction beneath the minor labial hood, the clitoral glans has
never been available to direct observation during an orgasmic
experience.

RESOLUTION PHASE

After an orgasmic episode the return of the clitoris to normal

pudendal-overhang positioning occurs within 5 to 10 seconds after
cessation of orgasmic platform contractions (see Part 1 of Chapter
 THE CLITORIS 53

6). Retraction of the clitoral body is reversed even more rapidly

than detumescence of the orgasmic platform and as swiftly as
the sex-skin discoloration disappears from the minor labia (see
Chapter 4). To provide further concept of this rapid clitoral-body
“release,” a parallel might be drawn to the male reaction pattern.
The relaxation of the retracted clitoral shaft and the return of the
glans to the normal pudendal-overhang positioning occurs in a
parallel time sequence with the primary-stage involution of male
penile erection after ejaculation (see Part 1 of Chapter 12).
When an observable tumescence of the clitoral glans has de­
veloped during the excitement phase, subsequent resolution-phase
detumescence of the glans is a relatively slow process. This is
particularly true for the individuals who demonstrate as much as
a twofold vasocongestive increase in glans size. Although termina­
tion of the clitoral retraction reaction occurs very rapidly, continued
tumescence of the glans and vasocongestion of the shaft frequently
have been observed to last 5 to 10 minutes after orgasmic expres­
sion. Occasionally some women have demonstrated continued
venous engorgement of the clitoral shaft or glans for 15 to 30
minutes after an orgasmic experience.
Those individuals who achieve plateau-phase levels of sexual
response but do not obtain orgasmic-phase release of the ac­
cumulated sexual tensions occasionally maintain venous engorge­
ment of both clitoral shaft and glans for a matter of hours after
termination of all sexually stimulative activity.

PATTERNS OF CLITORAL RESPONSE

With the answers to the first two questions established and

available as anatomic and physiologic baselines, the third question
may be approached with more security. Does the clitoris develop
different response patterns during coition as opposed to manipula­
tion of the mons or other erogenous areas or to pure psychogenic
stimulation?
Clitoral response was observed during natural coital activity in
three positions: female supine, superior, and knee-chest; during
artificial coition in female supine and knee-chest positions; and
during both manual and mechanical manipulation of the mons and
54 CHAPTER FIVE: PART ONE

other erogenous areas. In female supine position, during natural

coition, it was impossible to establish accurate observations of
clitoral reaction patterns. The information returned from female
supine positioning was developed by artificial coital techniques.
Conversely, artificial coition was a technical impossibility in fe­
male superior coital positioning, so information of clitoral-body
reaction patterns in this position was returned only from natural
coital activity. Regardless of positioning and type of coition, or
erogenous areas manipulated, the reactions of the clitoris to success­
ful sexual stimulation followed the physiologic response patterns
detailed in preceding portions of this chapter.
When women developed clinically obvious tumescence of the
clitoral glans subsequent to mons manipulation, they achieved
similar degrees of vasocongestion during coition in the three
described positions. Conversely, none of the female study subjects
developed glans tumescence during coition without demonstrating
similar or more severe degrees of glans vasocongestion during mons
area stimulation. When the mons was manipulated directly, the
observable tumescent reaction of the glans occurred earlier in the
excitement phase than when this vasocongestive reaction developed
during coital activity.
Vasocongestive increase in diameter of the clitoral shaft occurs
in all women regardless of the presence or absence of an observable
glans tumescence. This reaction developed earlier in the excitement
phase when direct mons area manipulation was employed than
when the study subjects were responding to coital stimulation.
The presence or absence of a clitoral shaft-elongation reaction
could not be determined during active coition.
Three women were able to achieve orgasmic response by breast
manipulation alone, in addition to their ability to react with
orgasmic success to mons manipulation and to coition. Only one of
the three women demonstrated an observable excitement-phase
tumescent reaction of the clitoral glans during mons manipulation,
coition, or breast stimulation. There was obvious delay in this
secondary vasocongestive reaction during breast automanipulation
when compared with the rapid development of glans tumescence
during direct manipulation of the mons area.
As anticipated, the retraction reaction of the clitoral body (glans
 THE CLITORIS 55

and shaft) developed during the plateau phase for all three breast
manipulators. The reaction paralleled in time sequence that
achieved during intercourse (late plateau, preorgasmic phase) and
obviously was delayed as compared to the more rapid response
patterns (early plateau phase) elicited by direct mons manipula­
tion.
Unfortunately, as mentioned earlier, study subjects available to
the investigation did not include individuals who could fantasy to
orgasm. Therefore, observations of clitoral-body reaction patterns
subsequent to psychogenic sexual stimulation have been limited
to excitement-phase levels of sexual response. This level of sexual
tension has been created frequently by providing suggestive litera­
ture for the study subjects. A clinically obvious tumescent reaction
of the clitoral glans could be demonstrated in only a few of the
women who normally developed this reaction during somatogenic
stimulation. When clinical tumescence of the glans did occur, it
developed long after there was obvious production of vaginal lu­
brication and paralleled a vasocongestive increase in the size of the
minor labia. A minimum of a half-hour of exposure to stimulative
literature was necessary to produce an observable glans tumescence
in any woman.
The microscopic vasocongestive reaction of the clitoral glans
which provides close apposition between integument and under­
lying glans tissues occurred in approximately 75 percent of the
women who were exposed to suggestive literature. Fewer than one-
third of the responding women produced a demonstrable increase
in clitoral shaft diameter and no shaft-elongation reaction was
observed.
The only variations in clitoral response developed from psy­
chogenic forms of sexual stimulation, natural or artificial coition,
and manual or mechanical manipulation of the mons or other
erogenous areas have been in the rapidity and intensity of phys­
iologic reaction.
56 CHAPTER FIVE: PART TWO

2 . CLINICAL CONSIDERATIONS

Clinical error has dominated the assignment of clitoral function

in sex tension increment for the human female. Therefore, a
detailed consideration of the dual capacity of the clitoris, as both
a receptor and transformer of sexual stimulation, is in order. The
definitive role of the clitoris in sexual response must be appreciated
if female sexual inadequacy ever is to be treated effectively.
Five questions have been raised and must be answered if the
role of the clitoris in human female sexuality is to be established.
Three of these five questions have been discussed in Part 1 of
this chapter. Two questions remain: (4) What clinical application
can be developed from the basic material accumulated to answer
the first three questions? (5) Are clitoral and vaginal orgasms
truly separate anatomic and physiologic entities? Attempts to
answer these two questions have directed investigative interest
toward a clinical evaluation of clitoral influence upon female
sexual response.
While the literature contains innumerable discussions of the role
of the clitoris in female sexuality, authoritative opinion has reached
essential accord only in the view that the primary function of the
organ is to stimulate female sexual tensions. In order to accomplish
its clinical purpose, the clitoris functions in the dual capacity of
both receptor and transformer of sexual stimuli regardless of
whether these stimuli originally have been somatogenically or
psychogenically oriented. This concept will be discussed later.
In the past, attempts have been made to assign to clinical
variants in clitoral anatomy and physiology specific influence on
the total of female sexual response. Eleven years of investigation
have failed to support these concepts. Both the size of the clitoral
glans and the total clitoral body’s positioning on the anterior
border of the symphysis have been assigned roles of major in­
fluence in female sexual response [8, 144, 268, 319, 330]. However,
Dickinson and Pierson [54, 59] originally expressed the conviction
that there is no relation between the size of the clitoris and the
effectiveness of its role in female sexual stimulation. Direct ob­
 THE CLITORIS 57

servation of thousands of sexual response cycles has confirmed

their opinion.
Historically, the anatomically oriented concept that clitoral size
has a direct relation to the effectiveness of the individual female’s
sexual performance has been fostered by our “phallic fallacy”
literature and has no foundation in fact. The diameter of the
unstimulated clitoral glans measured at the juncture of the glans
and shaft has varied in the study-subject population from 3 mm.
to 1 cm. In this group there has been absolutely no relationship
established between the size of the glans and the rapidity and
intensity of the individual’s ability to respond to effective sexual
stimulation. Conversely, there also has been similar variation in
clitoral glans size among women treated for inadequacy of sexual
response during the past seven years. Regardless of the type of
somatogenic or psychogenic approach to sexual stimulation, clitoral
glans size has played no definitive part in the effectiveness of the
individual’s sexuality.
Consideration of the anatomic positioning of the clitoris has
paralleled any discussion of clitoral size in relation to degree of
sexual response. Clitoral placement on the anterior border of the
symphysis has been assigned a role of major influence on female
response during coition [57, 319, 330]. A low implantation has
been presumed to improve the sexuality of the individual female
due to the possibility of increased direct contact between the
penis and clitoral glans. Regardless of clitoral-body positioning
the penis rarely comes in direct contact with the clitoral glans
during active coition. In fact, clitoral retraction, which always
develops during the plateau phase and elevates the clitoral body
from its normal pudendal-overhang positioning, further removes
the glans from even the theoretical possibility of direct penile
contact.
Specific physiologic reactions, like anatomic variants of the clit­
oris, also have been assigned major roles in elevating female sexual
tensions [8, 56, 64, 65, 140, 144, 305, 306, 319, 330]. Studies
in depth of both the study-subject population and women under­
going treatment for sexual' inadequacy have failed to support these
contentions. Whether the clitoris develops an obvious tumescence
of the glans or elongation of the shaft has little to do with the
5« CHAPTER FIVE: PART TWO

degree of the individual woman’s response to effective sexual

stimulation. Tumescence of the glans and shaft elongation have
been observed in women during multiple orgasmic sessions as well
as in women who have not been able to achieve orgasmic levels
of sexual tension. Clitoral-body retraction occurs during the plateau
phase whether or not an orgasmic experience is to follow. In brief,
sexually responding women achieve orgasmic levels of sexual ten­
sion without regard to variables in the basic anatomy and phys­
iology of the clitoris.
Dickinson [ 56] insisted that women with histories of decades of
masturbatory activity did not develop a consistent hypertrophy
of the clitoris. While this general concept certainly is acceptable,
there are minor exceptions that should be noted. Observations
of individuals over the past decade have removed any doubt that
frequent, severe masturbatory activity occasionally may produce
measurable increases in the diameter of the clitoral glans and
questionable increases in the length of the clitoral shaft. When
recordable clitoral glans hypertrophy develops over a period of
years, the women usually are found to employ extensively one or
more of the mechanical methods for clitoral stimulation. Ob­
viously, long-continued androgenic influence (adrenal hyperplasia,
testosterone ingestion, etc.) must be ruled out first in these cases.
It may be recalled that there are reports of African tribes that
measure female sexuality in terms of clitoral length and labial
hypertrophy [249]. From infancy, female members of such tribes
deliberately are manipulated for countless hours to stimulate the
development of these artifacts. These girls have been reported to
obtain an obvious hypertrophy of the clitoris and the labia, if
not by puberty, at least during their early teens. Although the fact
of manipulative hypertrophy is established, there is no reliable
information relating the hypertrophy directly to excessive levels
of female sexuality. It is possible that methods used to attain a
culturally desirable condition of adornment can simultaneously
increase individual sexual responsiveness.
Although anatomic placement and physiologic reaction preclude
any consistency of direct clitoral glans stimulation during coition,
the significant influence of secondary stimulation should not be
overlooked. The fact that the clitoral glans rarely is contacted
 THE CLITORIS 59

directly by the penis in intravaginal thrusting does not preclude

the coital development of indirect clitoral involvement. Clitoral
stimulation during coitus in the female supine position develops
indirectly from penile-shaft distention of the minor labia at the
vaginal vestibule. A mechanical traction develops on both sides of
the clitoral hood of the minor labia subsequent to penile distention
of the vaginal outlet. With active penile thrusting, the clitoral
body is pulled downward toward the pudendum by traction exerted
on the wings of the clitoral hood. However, there is not sufficient
excursion developed by coital traction on the clitoral body to allow
direct penis-to-clitoris contact.
When the penile shaft is in the withdrawal phase of active
coital stroking, traction on the clitoral hood is somewhat relieved
and the body and glans return to normal pudendal-overhang po­
sitioning. However, the rhythmic movement of the clitoral body
in conjunction with active penile stroking produces significant
indirect or secondary clitoral stimulation.
It should be emphasized that this same type of secondary
clitoral stimulation occurs in every coital position when there is
a full penetration of the vaginal barrel by the erect penis. Anatomic
exceptions to this statement are created by any significant path­
ologic gaping of the vaginal outlet, such as might be occasioned
by childbirth injury. If the vaginal outlet is too expanded to allow
strong traction on the minor-labial hood by the thrusting penis,
minimal clitoral excursion will occur and little if any secondary
stimulation will develop.
Only the female superior and lateral coital positions allow direct
or primary stimulation of the clitoris to be achieved with ease.
In these positions the clitoris can be stimulated directly if apposi­
tion between male and female symphyses is maintained. There
also remains the constant factor of secondary clitoral stimulation
provided by traction on the minor-labial hood during active coition
in these positions. The influences of both direct and indirect
stimulation are essentially inseparable in these coital positions.
Clitoral response may develop more rapidly and with greater in­
tensity in female superior coition than in any other female coital
position.
In the knee-chest coital position no direct stimulation of the
6o CHAPTER FIVE: PART TWO

clitoris is possible. Yet glans tumescence, when it occurs, and

clitoral-body retraction, which is a constant factor, occur in the
response patterns established for the supine or superior coital
positions. The intensity of physiologic reaction usually is less
pronounced than in either supine or superior coital positioning.
Obviously, active coition develops psychogenic as well as physi­
ologic response patterns, both of which contribute to indirect or
secondary clitoral stimulation. It will remain for more sophisticated
methods of neurophysiologic and psychologic investigation to assign
individual spheres of influence to these multiple influences which
create the total picture of indirect stimulation of the receptor
organ developed by active coition.
In essence, stimulation of the clitoris (receptor organ) develop­
ing during active coition is the secondary or indirect result of
penile traction on the minor labial hood. This traction occurs
regardless of female coital positioning, anatomic variations in clit­
oral size, or crural origin on the pubic rami.
The importance of development by marital units of specific
coital techniques to facilitate clitoral stimulation has been em­
phasized repeatedly in the literature [15, 68, 144, 150, 163, 193,
278, 305, 319, 330]. The clinical fallibility of these suggestions
now is obvious. Unless the male partner makes a specific effort
to bring the shaft of the penis in direct apposition to the total
mons area, the clitoris is not stimulated directly by penile thrust
with the female in the usual supine position. An overriding coital
position is difficult for the male partner to maintain as sexual
tensions increase, particularly if the female does not have parous
relaxation of the vaginal outlet. The nulliparous woman may not
be able to retain the penis in an awkward pelvic override position
without complaining of vaginal outlet or rectal discomfort.
An additional objection to the male-override position is that it
precludes full vaginal penetration at the apex of the penile thrust.
Thus the mutual coital stimulation of vaginal engulfment for
the male and cul-de-sac distention for the female are lost to the
sexual partners. Intensity of vaginal exteroceptive and proprio­
ceptive response can be dulled for the female partner by any
awkward attempt to provide direct clitoral glans contact.
The primary focus for sensual response in the human female’s
 THE CLITORIS 61

pelvis is the clitoral body. The clitoris responds with equal facility
to both somatogenic and psychogenic forms of stimulation, and is
truly unique in the human organ system in that its only known
function is that of serving as an erotic focus for both afferent
and efferent forms of sexual stimulation. How, then, does the
clitoral body function in its role as receptor and transformer to
sexually invested stimuli?
At the outset it should be made perfectly clear that although
stimuli are characterized as somatogenic or psychogenic in origin
and the roles of the clitoris as receptor and transformer, this does
not imply that any form of stimulation is or can be purely somato­
genic in character. All stimuli are appreciated, delineated, and
referred by higher cortical centers. The term somatogenic relates
only to physical activity. This form of clitoral stimulation can
vary from heterosexual manual manipulation to automanipulative
use of bedding material or thigh pressure. Thus the use of the terms
somatogenic stimuli or transformer role connotes initiation or
approach rather than any concept of discriminatory ability.
Sexual stimuli may be derived from either somatogenic or psy­
chogenic origins. The clitoral response patterns will vary depending
upon the initial involvement of either afferent or efferent pathways.
When the clitoral body reacts directly to automanipulative tech­
niques or secondarily to coital activity, these stimuli (initially
somatogenic but with an obvious psychogenic overlay) are received
through the afferent nerve endings in the clitoral glans and shaft.
Clitoral-body response to this type of stimulation could, from a
clinical point of view, be termed receptor in character.
The pacinian corpuscles within the large nerve bundles con­
ceivably play an important role in relaying afferent impulses created
by somatogenic forms of stimulation. As Krantz [156] so ably has
shown, there is marked variation in quantity and quality of nerve
endings and in the number of pacinian corpuscles located within
the individual clitoral glans and shaft. Since the assigned role
of the pacinian corpuscles is that of proprioceptive response to
deep pressure (receptor role), the great variety in female auto­
manipulative techniques ranging from demand for severe pressure
to insistence upon the lightest touch may be explained.
Little is known of the neurologic pathways that lead from
Ô2 CHAPTER FIVE: PART TWO

stimulated afferent nerve endings in the clitoral body. Although

a reflex center in the sacral portion of the spinal cord has been
identified in the male animal by Semans and Langworthy [285],
no similar response center has been described for the human
female. It may be that the entire reflex arc involving the spinal
cord and the higher cortical centers constantly is caught up in
the continuum of response to dominantly somatogenic forms of
sexual stimulation. Particularly is this concept plausible when it
is realized that regardless of the effectiveness of the somatogenically
oriented stimuli, the psychogenic overlay inherent in any approach
to female sexual stimulation is of constant import. Therefore, the
possibility of a pure reflex-arc response to afferent stimulation is
reduced with the realization that psychogenic stimulation of the
higher cortical centers and the resultant direct, efferent, trans­
former response in the clitoris is an undeniable factor in the
sexual response of the human female.
The clitoral body functions as a receptor organ in an objective
expression of sensual focus, as well as the subjective end-point
(transformer) of neurogenic pathways. The result of efferent stimu­
lation of the clitoris, be it psychogenically or somatogenically
initiated, has been recorded in the detailed consideration of the
anatomy and physiology of the clitoral body’s response to varying
intensity of sexual stimulation (see Part 1 of this chapter). How­
ever, the functional role (that of serving clinically as a transformer
or subjective organ of sensual focus) has not been considered
previously.
The subjective, or transformer, response of the clitoris to any
form of effective sexual stimulation, such as reading of pornography,
direct manipulation, coital connection, etc., has been vocalized
by women in many ways. Some vocally identify a subjective sensa­
tion of deep pelvic fullness and warmth (possibly vasoconcentra-
tion), others a feeling of local irritation, expansive urge, need
for release, etc. (possibly glans enlargement). The clinical or func­
tional response of the clitoris as a transformer of efferent forms
of stimulation is to create in turn a subjective urge or tension
increment and, ultimately, a higher cortical need for release. It is
impossible to delimit this functional clitoral role of sensual focus
because vocalization of the sensual response patterns varies from
 THE CLITORIS 63

woman to woman. The transformer role also differs between

clitoris and penis (see Part 2 of Chapter 12). Suffice it to say
that the clitoris, serving as a receptor and transformer organ, has a
role as the center of female sensual focus, and the functional
response it creates easily is identifiable by any sexually oriented
woman.
Any clinical consideration of clitoral response to effective sexual
stimulation must include a discussion of masturbation. The tech­
niques of and reactions to direct manipulation of the clitoral body
(glans and shaft) or the mons area vary in each woman. Ob­
servations of higher animal patterns of foreplay first sensitized
investigators to the clinical importance of effective autostimulative
techniques by emphasizing the obvious response that such effective
foreplay can develop in the female of the species [10, 76].
Marriage manuals discuss at length the importance of clitoral
manipulation as the basis of adequate coital foreplay. Most discus­
sions of initiation and elevation of female sexual tensions have
included the questions of why and when to stimulate the clitoris.
To date there has been little consideration of the infinitely more
important questions of how to manipulate the clitoris and how
much stimulation usually is required. Direct observation of hun­
dreds of women using mechanical and manual masturbatory tech­
niques through repetitive orgasmic experiences has emphasized
the fundamental importance of the questions, “How?” and “How
much?”
No two women have been observed to masturbate in identical
fashion. However, there is one facet of general agreement. Women
rarely report or have been noted to employ direct manipulation
of the clitoral glans. In those isolated instances when the tech­
nique is used it is limited to the excitement phase only and fre­
quently a lubricant is applied to this normally quite sensitive
tissue. Additionally, the clitoral glans often becomes extremely
sensitive to touch or pressure immediately after an orgasmic ex­
perience, and particular care is taken to avoid direct glans contact
when restimulation is desired.
Those women who manipulate the clitoris directly concentrate
on the clitoral shaft. Usually they manipulate the right side of the
shaft if right handed, and the left side if left handed. Occasionally,
64 CHAPTER FIVE: PART TWO

women have been observed to switch sides of the shaft during

stimulative episodes. A relative degree of local anesthesia may
develop if manipulation is concentrated in just one area for ex­
tended periods of time or if too much manipulative pressure is
applied to any one area.
Women usually stimulate the entire mons area rather than con­
centrating on the clitoral body. Regardless of whether the clitoris
is stimulated by direct means or indirectly through mons area
manipulation, the physiologic responses of the clitoris to elevated
sexual tensions are identical. Most women prefer to avoid the
overwhelming intensity of sensual focus that may develop from
direct clitoral contact. Instead, mons area manipulation produces
a sensual experience that although somewhat slower to develop
is, at orgasmic maturity, fully as satiating an experience as that
resulting from direct clitoral shaft massage. Mons area manipula­
tion also avoids the painful stimuli returned to many women when
the clitoris is manipulated directly either with too much pressure
or for too lengthy periods of time.
The concept of the mons as an area of severe sensual focus is
supported by the clinical observation that after clitoridectomy,
masturbation has been reported to be as effective a means of
sexual stimulation as before surgery [23]. Manipulation usually has
been confined to the mons area, although sometimes concentrated
on the scarred postsurgical site.
Evidence of the extreme tactile sensitivity of the entire perineum
in addition to the clitoral body and the mons area has been
presented by the Institute for Sex Research [144]. During the
Institute’s gynecologic observation, the minor labia were deter­
mined to be almost as perceptive to superficial tactile sensation
as the clitoral glans. The Institute also considers the minor labia
to be fully as important as the clitoris or mons as a source of
erotic arousal. While the tactile sensitivity of the minor labia is
without question, stimulation of the labia does not provide the
human female with the extremes of sensual stimuli that massage
of the clitoral shaft or mons area produces.
Another observation of female automanipulative technique
should be considered for its clinical import. Most women continue
active manipulation of the clitoral shaft or mons area during their
 THE CLITORIS 65

entire orgasmic experience. This female reaction pattern parallels

their coital pattern of demand for continued active male pelvic
thrusting during the woman’s orgasmic experience. This female
demand for continued stimulation during the actual orgasmic ex­
pression is in opposition to the average male’s reaction to his
ejaculatory experience. Most males attempt the deepest possible
vaginal penetration as the first stage of the ejaculatory response
develops. They maintain this spastic, deep vaginal entrenchment
during the second phase of the ejaculatory experience rather than
continuing the rapid pelvic thrusting characteristic of preorgasmic
levels of sexual tension (see Part 2 of Chapter 12).
The human female frequently is not content with one orgasmic
experience during episodes of automanipulation involving the cli-
toral body. If there is no psychosocial distraction to repress sexual
tensions, many well-adjusted women enjoy a minimum of three
or four orgasmic experiences before they reach apparent satiation.
Masturbating women concentrating only on their own sexual
demands, without the psychic distractions of a coital partner,
may enjoy many sequential orgasmic experiences without allowing
their sexual tensions to resolve below plateau-phase levels. Usually
physical exhaustion alone terminates such an active masturbatory
session.
There is a specific clitoral-body reaction to effective sexual stimu­
lation that has created a state of confusion for the average male
sexual partner. This physiologic response to sexual tension has been
termed the retraction reaction. The entire clitoral body is elevated
high on the anterior border of the symphysis (away from its
normal pudendal-overhang positioning) during both the plateau
and orgasmic phases of the female sexual response cycle (see
Part 1 of this chapter).
This physiologic reaction to high levels of female sexual tension
creates a problem for the sexually inexperienced male. The clitoral-
body retraction reaction frequently causes even an experienced
male to lose manual contact with the organ. Having lost contact,
the male partner usually ceases active stimulation of the general
mons area and attempts manually to relocate the clitoral body.
During this “textbook” approach, marked sexual frustration may
develop in a highly excited female partner. By the time the clitoral
66 CHAPTER FIVE: PART TWO

shaft has been relocated, plateau-phase tension levels may have

been lost. Not infrequently the female partner, frustrated by male
ineptitude, may not recover from her psychophysiologic distraction
sufficiently to avoid the frustrating, vasocongestive pelvic distress
occasioned by orgasmic inadequacy.
It is important to reemphasize the fact that the retracted clitoral
body continues to be stimulated by traction or pressure on the
protective clitoral hood. Once plateau-phase clitoral retraction has
been established, manipulation of the general mons area is all that
is necessary for effective clitoral-body stimulation.
Most marriage manuals advocate the technique of finding the
clitoris and remaining in direct manual contact with it during
attempts to stimulate female sexual tensions. In direct manipula­
tion of the clitoris there is a narrow margin between stimulation and
irritation. If the unsuspecting male partner adheres strictly to
marriage manual dictum, he is placed in a most disadvantageous
position. He is attempting proficiency with a technique that most
women reject during their own automanipulative experiences.
As stated previously, no two women practice automanipulation
in similar fashion. Rather than following any preconceived plan for
stimulating his sexual partner, the male will be infinitely more
effective if he encourages vocalization on her part. The individual
woman knows best the areas of her strongest sensual focus and
the rapidity and intensity of manipulative technique that provides
her with the greatest degree of sexual stimulation.
Finally, a brief consideration of the fifth and last of the questions
raised about the role of the clitoris in female sexuality: Are clitoral
and vaginal orgasms truly separate anatomic entities? From a
biologic point of view, the answer to this question is an unequivocal
No. The literature abounds with descriptions and discussions of
vaginal as opposed to clitoral orgasms [14, 24, 42, 53, 63, 83, 84,
115, 116, 153, 159, 177, 277, 324, 331]. From an anatomic point
of view, there is absolutely no difference in the responses of the
pelvic viscera to effective sexual stimulation, regardless of whether
the stimulation occurs as a result of clitoral-body or mons area
manipulation, natural or artificial coition, or, for that matter,
specific stimulation of any other erogenous area of the female body.
With the introduction of artificial coital techniques, the reactions
 THE CLITORIS 67

of the vagina during coition became available to direct observation

and repeatedly have been recorded through the medium of cin­
ematography. These vaginal reactions first had been observed dur­
ing sexual response cycles stimulated by manipulation of the mons
area and clitoral body [203, 205, 207]. During artificial coition the
reactions of the vaginal barrel initiated under direct stimulation
conformed in exact detail to the vaginal response patterns which
developed subsequent to the indirect stimulation of mons area
or clitoral-body manipulation.
Three study subjects available to the investigative program have
demonstrated the facility of orgasmic response to breast stimulation
alone, as well as to coital, clitoral-body, or mons area manipulation.
Identical vaginal response patterns were observed for these three
study subjects from all the above-described modes of stimulation.
Conversely, what of clitoral-body reaction to direct or indirect
stimulation? The physiologic responses that develop in the clitoral
glans and shaft during the four phases of the sexual cycle are the
same regardless of whether the clitoral body is responding to direct
or indirect stimulation. For research purposes the definition of
indirect or direct clitoral-body stimulation has been oriented to
clinical considerations alone.
Direct stimulation results from manual or mechanical manipula­
tion of the clitoral shaft or glans. Indirect stimulation develops
from mons area manipulation or the stimulation of any other
erogenous area of the female body, such as the breasts. In addition,
the clitoral body may be stimulated indirectly by natural or artificial
coition with the female partner in the supine, superior, or knee­
chest position. All of these techniques have been used in order to
record clitoral-body response patterns. These patterns are identical
and vary only in intensity of reaction to the effectiveness of the
stimulative technique, regardless of whether this technique is
described clinically as direct or indirect.
There may be great variation in duration and intensity of orgas­
mic experience, varying from individual to individual and within
the same woman from time to time. However, when any woman
experiences orgasmic response to effective sexual stimulation, the
vagina and clitoris react in consistent physiologic patterns. Thus,
clitoral and vaginal orgasms are not separate biologic entities.
 6
THE VAGINA

i. ANATOMY AND PHYSIOLOGY

The vaginal barrel performs a dual role, providing the primary

physical means of heterosexual expression for the human female
and serving simultaneously as an integral part of her conceptive
mechanism. Discussion in this part of the chapter will reflect the
anatomic and physiologic reactions of the vagina in its role as the
physical means by which the woman expresses sexual capacity.
A consideration of the efficiency of the vagina in conceptive physi­
ology will be presented in Parts 2 and 3 of this chapter. The duality
of the vaginal role should be emphasized. It is possible that the
efficiency of vaginal conceptive function is a physiologic measure
of the psychosomatic effectiveness of the vagina’s role as the
primary means of the female’s sexual expression.
To appreciate vaginal anatomy and physiology is to comprehend
the fundamentals of the human female’s primary means of sexual
expression. In essence, the vaginal barrel responds to effective
sexual stimulation by involuntary preparation for penile penetra­
tion. Just as penile erection is a direct physiologic expression of a
psychologic demand to mount, so expansion and lubrication of
the vaginal barrel provides direct physiologic indication of an
obvious psychologic mounting invitation.
When the role of the vagina as a sexual organ is evaluated,
the physiologic responses of the vaginal barrel to sex tension
increment come into primary focus. Indeed, the reactions of the
artificial as well as the natural vaginal barrel must be considered
(see Chapter 7). The anatomic alterations that develop within
the natural or artificial vaginal barrel, when it is functioning as
the primary means of female sexual expression, frequently are
oriented to specific levels of sexual tension. Therefore, these tension-
68
 THE VAGINA 69

induced anatomic variations will be described with relation to the

four phases of the cycle of sexual response.
It should be stated parenthetically that vaginal (natural or
artificial) response to sexual stimulation develops in a basic pat­
tern regardless of whether the stimuli originally are primarily
somatogenic or psychogenic in origin.

EXCITEMENT PHASE

The first physiologic evidence of the human female’s response

to any form of sexual stimulation is the production of vaginal
lubrication. Lubricating material appears on the walls of the va­
gina within 10 to 30 seconds after the initiation of any form of
effective sexual stimulation. There have been many efforts over the
years to discover the source of vaginal lubrication. The cervix has
been considered by many authors as the primary site of the lubri­
cating material [8, 21, 30, 54, 67, 144, 191, 239, 295, 308, 318,
319]. Bartholin’s glands (see Chapter 4) also have been allotted a
major role in the production of vaginal lubrication. Neither the
healthy cervix nor the Bartholin’s glands make any essential con­
tribution to the total of vaginal lubrication.
As sexual tensions rise, a “sweating” phenomenon may be ob­
served developing on the walls of the vaginal barrel (Fig. 6-1).
Individual droplets of transudation-like, mucoid material appear
scattered throughout the rugal folds of the normal vaginal ar­
chitecture. These individual droplets present a picture somewhat
akin to that of the perspiration-beaded forehead. As tensions in­
crease, the droplets coalesce to form a smooth, glistening coating
for the entire vaginal barrel. This “sweating” phenomenon pro­
vides complete lubrication for the vaginal walls early in the excite­
ment phase of the human female’s sexual response cycle and
certainly is the first evidence of the vaginal barrel’s physiologic
response to sexual stimulation. In a matter of seconds the sexually
responding woman may develop sufficient lubrication for coital
readiness.
Identification of the vagina’s lubricating mechanism has been
one of the most interesting aspects of the anatomic study of the
70 CHAPTER SIX: PART ONE

FIGURE 6-1
Schematic representation of vaginal lubrication.

human female’s sexual response cycle. Present information sug­

gests that this transudation-like material is the result of marked
dilatation of the venous plexus which encircles the entire vaginal
barrel. The bulbus vestibuli, plexus pudendalis, plexus uterovagi-
nalis, and, questionably, the plexus vesicalis and the plexus rectalis
externus are all involved in a fulminating vasocongestive reaction
about the walls of the vagina. Apparently the transudation-like
material which lubricates the vagina develops from the activation of
a massive localized vasocongestive reaction. It long has been es­
tablished that there are essentially no glandular elements in the
walls of the vagina [219]. Yet this transudation-like material ap­
pears readily, usually in copious amounts, early in the excitement
phase of the sexual response cycle. The biochemical constitution
of the lubricating material and its effect upon normal vaginal
chemistry are under present investigation.
In only one instance has any cervical activity of a secretory
nature been noted during directly observed intravaginal cycles of
sexual response. In this particular situation the study subject lost
 THE VAGINA 71

a mucus plug from the cervical outlet. She was in the thirteenth
day of a regularly recurring 28-day menstrual cycle. It was interest­
ing to note that although this thin, ovulatory-type mucus was ex­
truded from the cervical canal, the reaction occurred late in the
plateau phase of the sexual response cycle, long after vaginal
lubrication had been established.
In a consideration of the problem of vaginal lubrication, there
are two other items of information which should be presented.
First, a pronounced sweating phenomenon has been repeatedly
observed in women who have been subjected to complete hys­
terectomy and bilateral salpingo-oophorectomy. The ability to
lubricate with reasonable effectiveness, even in a state of complete
castration, mechanically eliminates the cervix from significant
consideration as a primary source of lubrication. Second, still further
verification that the cervix makes no contribution to vaginal
lubrication is provided by those women for whom artificial vaginas
have been created (see Chapter 7). They also produce an effective
degree of vaginal lubrication by means of the transudation-like
“sweating” mechanism.
In order to comprehend the distensive ability of the vaginal
barrel in response to sexual stimuli, it must be recalled that
anatomically the unstimulated vagina is a potential rather than
an actual space. Unless the woman is menstruating or subjected
to sexual stimulation, the anterior and posterior walls of the
vagina are essentially contiguous. Obviously, the minimal spacing
shown between the anterior and posterior vaginal walls in Figure
6-2, representing normal pelvic anatomy, is, in truth, inaccurate.
Obstetricians are well aware that the normal vagina is infinitely
distensible from a clinical point of view. The demands of child­
birth clearly establish that the collapsed state of the unstimulated
vaginal barrel is no measure of the vagina’s expansive potential.
As the excitement phase of sexual tension continues, further
anatomic evidence of psychologic mounting readiness develops
within the vagina (Fig. 6-3). Initially, there is a lengthening and
distention of the inner two-thirds of the vaginal barrel. Irregular
expansive movements of- the vaginal walls may be observed as
sexual tensions mount toward the plateau phase. Before termination
of the excitement phase, the vaginal barrel is markedly expanded.
?2 CHAPTER SIX: PART ONE

FIGURE 6-2
Female pelvis: normal anatomy (lateral view).

FIGURE 6-3
Female pelvis: excitement phase.
 THE VAGINA 73

The walls of the inner two-thirds of the vaginal barrel expand

involuntarily and then partially relax in an irregular, tensionless
manner. Slowly the demand to expand overcomes the tendency
to relax, and the clinically disterided vaginal barrel of the sexually
responding woman is established.
In addition to the expansive effect in the vaginal fornices, the
cervix and corpus are pulled slowly back and up into the false
pelvis as sexual tensions mount (see Chapter 8). This reaction,
together with the expansion of the fornices, contributes greatly
to the distention of the inner two-thirds of the vaginal barrel.
Cervical elevation creates a tenting effect at the transcervical depth
in the midvaginal plane. The slow, irregular elevation of the
cervix from the vaginal axis toward the false pelvis is dependent
upon normal anterior uterine positioning. If the uterus is in
marked 30 retroversion, for example, not only is there no cervical
elevation from the vaginal axis, but also the usual degree of mid-
vaginal expansion and posterior vaginal extension is reduced.
The sexually unstimulated vaginal barrels (Fig. 6-4) of 100
nulliparous study subjects have been measured repeatedly at a
2 cm. diameter in the transcervical plane (just anterior to the
resting cervix of an anteriorly placed uterus). As sexual tensions
mount, transcervical vaginal-wall expansion ranges from 5.75 to

<- 5.75-6.25 cm.—»

FIGURE 6-4
Nulliparous vaginal barrel: baseline measurements.
74 CHAPTER SIX: PART ONE

6.25 cm. Vaginal length (fourchette to posterior-fornix wall) of

the unstimulated nulliparous vagina has been recorded as ranging
from 7 to 8 cm. During excitement-phase response the vaginal
length measurement increases to 9.5-10.5 cm.
In an attempt to demonstrate the vagina’s essentially unlimited
clinical distensibility, the same transcervical vaginal-wall and vag­
inal-length measurements were taken within the 100 nulliparous
vaginas previously distended by an indwelling speculum (Fig. 6-5).
The speculum was placed at a fixed dilation of 2 cm. between the
anterior and posterior blades. The initial transcervical expansion
readings were now an average of 3-4 cm., and vaginal length was
recorded at an 8-9 cm. average. With excitement-phase response,
the transcervical expansion of the vaginal walls reached averages
of 6.75-7.25 cm., and vaginal-length extension was recorded at an
11-12 cm. average.
From these figures it is obvious that the more the vagina dilates,
the more further dilatation becomes possible. When the two sets
of figures are compared, a maximum increase of 3.75-4.25 cm. in
transcervical width and 2.5-3.5 cm. in length have been established
for the nulliparous vagina under the influence of excitement-phase

figure 6-5
Nulliparous vaginal barrel: speculum-dilated.
 THE VAGINA 75

levels of sexual tension. When the vagina is partially dilated by

an indwelling speculum, the transcervical-diameter increase under
the additional influence of effective sexual stimulation reaches a
maximum of 3.75-4.25 cm., and the length increase averages 3-4
cm. From these essentially similar figures it is obvious that under
sexual stimulation the inner two-thirds of the vagina expands and
the vaginal barrel lengthens in complete disassociation from pre­
viously established states of vaginal distention.
This experiment was not repeated with multiparous individuals.
The previously overdistended and obstetrically traumatized vaginas
of multiparous women do not provide a satisfactory norm from
which to measure significant vaginal distensibility other than on
an individual basis. From the examination of individual women,
however, the statement still can be supported that regardless of
prior degree of vaginal expansion or increase in barrel length, the
vagina will increase significantly in its measurable length and
transcervical width under effective sexual stimulation.
During the excitement phase the vaginal walls also undergo a
distinct color alteration. The purplish-red coloring of the normal
steroid-stimulated vagina slowly changes to the darker, purplish
hue of vasocongestion. This purple discoloration is patchy in
character during the early stages of the excitement phase, but as
plateau is achieved and pelvic vasocongestion becomes intense the
entire vaginal barrel perceptibly darkens.
As excitement-phase reactions progress toward plateau, there
is a flattening of the rugal pattern of the well-stimulated vaginal
wall. This thinning or stretching of the vaginal mucosa is ob­
viously a corollary of the involuntary expansion of the inner two-
thirds of the vaginal barrel.

PLATEAU PHASE

Vaginal alterations in response to effective stimulation are not

confined to the inner two-thirds of the vaginal barrel. There usually
is a minimal distention of the outer third of the vagina during
excitement phase. With attainment of plateau-phase levels of
7Ö CHAPTER Six: PART ONE

sexual tension, a marked localized vasocongestive reaction develops

in this specific area of the vagina (Fig. 6-6). The entire outer
third of the vagina, including the bulbus vestibuli, becomes grossly
distended with venous blood. This vasocongestion is so marked that
the central lumen of the outer third of the vaginal barrel is reduced
by at least a third from the distention previously established during
the excitement phase. Although this localized vasocongestion de­
velops as an involuntary response, it is a sure indication that
plateau-phase levels of sexual tension have been achieved. The
base of vasocongestion which encompasses the entire outer third
of the vagina, together with the engorged labia minora, provides
the anatomic foundation for the vagina’s physiologic expression of
the orgasmic experience. This area of plateau-phase vasocongestion
has been termed the orgasmic platform.
A minimal further increase in width and depth of the vagina
(measured respectively at the transcervical depth and the fornices)
occurs during the plateau phase. This is a negligible degree of
clinical distention compared to the expansive response established

Uterine
■/ Elevation

V Full
£1 Vaginal
Expansion
Clitoral
Body
Elevatioi

^Orgasmic Platform
Labia Minora Size Increase
(Sex Skin)

FIGURE 6-6
Female pelvis: plateau phase.
 THE VAGINA 77

during the excitement phase. The degree of expansion is not

standardized, so no attempt was made to measure it.
The production of vaginal lubrication reaches its full potential
during the excitement phase. The production rate actually slows
during the plateau phase, particularly if this level of sexual tension
is experienced for an extended period of time.

ORGASMIC PHASE

The degree of expansion of the inner two-thirds of the vagina

is not advanced beyond that attained during terminal stages of
the excitement or early in the plateau phase of the sexual cycle.
The basic reaction of the inner vaginal barrel is essentially ex­
pansive, however, rather than constrictive in character during the
actual orgasmic experience.
The specific response of the vaginal barrel to the explosive
physiologic entity of orgasm is confined to the orgasmic platform
in the outer third of the vagina (Fig. 6-7). This localized area

figure 6-7
Female pelvis: orgasmic phase.
78 CHAPTER SIX: PART ONE

of bulbar vasoconcentration contracts strongly in a regularly re­

curring pattern during the orgasmic expression. The contractions
have onset at o.8-second intervals and recur within a normal range
of a minimum of three to five, up to a maximum of 10 to 15 times
with each individual orgasmic experience. The intercontractile
intervals lengthen in duration after the first three to six contractions
of the orgasmic platform, and the measurable intensity of the
contractions progressively diminishes. The duration of the orgasmic
platform’s recurring contractions and the degree of the contractile
excursions vary from woman to woman and within the same
individual from one orgasmic experience to the next. These re­
current contractions in the outer third of the vagina are the only
physiologic responses of the vaginal barrel that are confined en­
tirely to the orgasmic phase of the sexual cycle.
At the highest tension levels (“status orgasmus”; see Chapter
9), the orgasmic platform may respond initially with a spastic
contraction lasting 2 to 4 seconds before the muscle spasm gives
way to the regularly recurrent o.8-second contractions described
above.

RESOLUTION PHASE

With onset of the resolution phase, retrogressive changes develop

first in the outer third of the vagina (Fig. 6-8). The localized
vasocongestive concentration established during the plateau phase
which served as a platform for the spasmodic contractions of
orgasm is dispersed rapidly. As the result of this loss of localized
vasocongestion, the central lumen of the outer third of the vagina
actually increases in diameter in the early stages of the resolution
phase.
Slowly the expanded inner two-thirds of the vaginal barrel
shrinks back to the collapsed, unstimulated state. This reaction
is not one of a uniformly completed collapse of the vaginal walls.
It is rather an irregular, zonal type of relaxation of the lateral and
posterior walls. The anterior wall and the cervix of the anteriorly
positioned uterus descend toward the vaginal floor rapidly, quickly
resolving the tenting effect in the transcervical diameter of the
 THE VAGINA 79

FIGURE 6-8
Female pelvis: resolution phase.

vagina. The return of the cervix to the vaginal axis from its ele­
vated position in the pelvis and the coordinated collapse of the
vaginal fornices frequently take at least three to four minutes to
complete after orgasmic-phase release of sexual tensions.
The deep-purple color of the vaginal mucosa, developed during
the plateau phase, returns to basic coloration in a slow retrogressive
process which frequently requires as long as 10 to 15 minutes for
completion. Normal rugal patterns, so typical of the hormonally
well-stimulated vaginal barrel, become more apparent as the ex­
pansive reaction of the inner two-thirds of the vagina and the
localized venous congestion of the outer third of the vagina
retrogress. In rare instances the production of lubrication has been
observed to continue into the resolution phase. This reaction con­
tinued beyond its normal stage of involution (late excitement or
early plateau phase) suggests remaining or renewed sexual tension.
Such individuals may be returned rapidly to orgasmic expression if
stimulation is renewed.
The vaginal barrel’s reaction to sexual tension has been con­
8o CHAPTER SIX: PART TWO

sidered in the restricted light of its role as the primary means

of the human female’s sexual expression. The rapidity and in­
tensity of the response mechanisms of lubrication production,
inner-barrel lengthening and expansion, transcervical tenting effect,
and vasocongestive development of the orgasmic platform always
parallel the degree of sexual tension experienced by the individual.
The vagina truly provides a direct physiologic reflection of female
psychosexual tensions, as it involuntarily prepares for and then ac­
commodates the act of copulation.

2. THE FUNCTIONAL ROLE

IN REPRODUCTION

In performing its dual role, the vaginal barrel simultaneously

functions as a physical means of the human female’s sexual ex­
pression and as an integral part of her conceptive mechanism. The
vagina’s anatomic and physiologic reflection of woman’s psycho-
sexual tensions has been reported in Part 1 of this chapter. Its
only established role in conceptive physiology, that of a seminal
receptacle, is the area of present consideration. Even the mechanism
of this functional role has not been understood because vaginal
physiology has been, and still remains, an essentially unexplored
field. The possible functioning role of the vagina as an organ of re­
production rather than purely a functional seminal receptacle will
be approached in Part 3 of this chapter.
Following the usual pattern of medical response to investigative
challenge, many relatively obscure physiologic reactions of the fe­
male reproductive tract have been the target for more definitive in­
vestigative effort than have the more obvious reproductive functions
of the vagina. For instance, direct observation of human ovulation
has been accomplished [60]; tubal motility has been identified
[61, 274, 326]; and implantation of the fertilized ovum in the
wall of the uterus has been described in detail [127, 261]. To
date, the vagina’s possible role as a functioning organ of reproduc­
tion and its role as a functional receptacle for seminal fluid have not
been considered in sufficient depth.
 THE VAGINA 81

The anatomic angulation of the vagina assumes primary impor­

tance when the organ is considered purely as a seminal receptacle.
The vaginal barrel normally angles about io° to 150 below the
horizontal pelvic line when a baseline is drawn from the vaginal
outlet to the curve of the sacrum (Fig. 6-9). When a woman is
in the supine coital position, the transcervical plane of the vagina is
at a slightly lower level than the midplane of the fourchette of a
nulliparous vaginal outlet. Therefore there is a natural gravita­
tional tendency for a seminal pool to develop on the posterior wall
of the inner half of the vaginal barrel. Obviously, there are numer­
ous variations in vaginal anatomy and physiology which either
improve, interfere with, or at times, even completely negate this
normal pooling tendency.
The male partner must ejaculate if conception is to occur sub­
sequent to coition (for exception see Chapter 14). Obviously, there
is no requirement for orgasmic experience from the female partner.
Women respond to coition with marked variation in sexual tension
development. The male partner may ejaculate within the seminal
receptacle while the female is in any of the four phases of the sexual
response cycle. Therefore, the discussion of the anatomy of the

/'

FIGURE 6-9
Female pelvis: vaginal-barrel angulation.
82 CHAPTER SIX: PART TWO

vagina as a functional seminal receptacle will be developed within

the established framework of the sexual response cycle.

EXCITEMENT PHASE

Vaginal response to excitement-phase levels of sexual stimula­

tion is confined to the inner two-thirds of the vaginal barrel. The
primary physiologic reaction is an involuntary expansion and length­
ening of the barrel. The vaginal wall lengthens in an anterior-pos­
terior plane and expands in transverse diameter at the midcervical
vaginal plane (see Fig. 6-3). With increasing tension, the ante­
riorly placed uterus is elevated into the false pelvis (see Chapter 8).
Consequently the cervix is withdrawn from its sexually unstimu­
lated positioning near the vaginal outlet, and elevated from the
vaginal floor. The phenomenon of cervical elevation produces a
bulbous or “tenting” expansion in the midvaginal plane. Thus,
involuntary distention increases the circumferential diameter of
the entire inner two-thirds of the vaginal barrel, with the greatest
effect concentrated at the transcervical plane.
Further discussion of the basic physiology of vaginal accommoda­
tion to the mounting process is presented in Part 1 of Chapter 12.

figure 6-10
Nulliparous perineum: seminal-pool containment.
 THE VAGINA 8?

There are both anatomic variants and physiologic reactions that

tend either to prevent or to encourage the escape of seminal fluid
from the vaginal receptacle. An anatomic variant that aids seminal-
fluid retention is the normally high, firm perineal support of the
nulliparous woman. A high, tight vaginal outlet tends to trap sem­
inal fluid in the vaginal depths with an actual damming effect
(Fig. 6-10). The weight of the penis seldom is sufficient to over­
come completely the constraining effort of the virginal perineum.
Conversely, an anatomic variant that encourages seminal-fluid
wastage is observed when the virginal perineum has been altered by
obstetric trauma (Fig. 6-11). A functional reproductive concern of
the woman with an obstetrically traumatized perineum is the fact
that a major portion of the total ejaculate may escape normal sem­
inal pooling in the transcervical depths of the vaginal barrel. With­
out the damming effect of the nulliparous perineum there is a tend­
ency toward immediate wastage of major portions of the seminal
fluid immediately following penile withdrawal.
Many women with obstetrically lacerated or flattened vaginal
outlets also develop an incipient or clinically defined rectocele. The
existence of this anatomic variant frequently counterbalances the
seminal-fluid-wastage tendency of the flattened vaginal outlet. The

figure 6-11
Parous outlet: seminal-fluid wastage.
»4 CHAPTER SIX: PART TWO

rectocele’s involuntary contribution toward seminal-fluid retention

is improved by elevated sexual tensions. Excitement-phase expan­
sion of the posterior vaginal wall is extended well beyond normal
limits by the existence of separation or laceration of the levator
sling (rectocele). The excessive expansion of the vaginal barrel at
the transcervical depth made possible by the rectocele improves the
vagina’s retention of seminal fluid. In other words, the tendency of
an anatomic variant to retain seminal fluid is improved by physio­
logic response to sexual stimulation.

PLATEAU PHASE

The major physiologic response of the vaginal barrel to plateau­

phase levels of sexual tension is the creation of the orgasmic plat­
form in the outer third of the vagina. This tension reaction is one
of marked vasoconcentration (see Part 1 of this chapter). The local­
ized vasocongestion creates a 50 percent constriction of the central
lumen in the outer third of the vagina when compared to excite­
ment-phase expansion in this area.
From an anatomic point of view, there is probably a greater
chance of conception if the parous female achieves only plateau­
phase levels of response during her sexual encounter, as opposed to

FIGURE 6-12
Plateau-phase orgasmic platform: seminal-pool containment.
 THE VAGINA 85

enjoying an orgasmic experience. If only plateau-phase levels of

tension are experienced, the orgasmic-platform vasocongestion will
be dissipated at a much slower rate than that expected in a post-
orgasmic sequence and consequently the physiologic aid in
seminal-pool containment will be of longer duration (Fig. 6-12).
If a woman does not obtain orgasmic release and must resolve tar­
get-organ vasocongestion from plateau-phase tension levels, the
orgasmic platform may not be lost for 20 to 30 minutes. Obviously,
the longer the external cervical os is exposed to an effectively con­
trived seminal pool the greater the possibility of conception.
The development of the orgasmic platform during advanced
stages of female sexual response is an example of physiologic sem­
inal-pool constraint. The orgasmic platform produces a stopperlike
effect in the outer third of the vagina. This transitory constriction
of the vaginal outlet helps retain seminal fluid within the trans­
cervical depth of the vaginal barrel. Fortunately for reproductive
interest, the orgasmic platform develops both in sexually responding
nulliparous and multiparous females. Thus the tendency of the
obstetrically traumatized woman to lose seminal fluid in the im­
mediate postejaculatory period may be overcome or at least partially
counterbalanced by the stopperlike effect of the orgasmic platform
(Fig. 6-13).

Seminal
pool

FIGURE 6-13
Parous outlet: orgasmic platform seminal-pool containment.
86 CHAPTER SIX: PART TWO

ORGASMIC PHASE

The physiologic constriction of the vaginal outlet which develops

as an orgasmic platform does not remain indefinitely. If the sexually
responding female experiences an orgasm, the localized vasocon-
gestion in the outer third of the vaginal barrel is lost rapidly during
her resolution phase.
With the anatomic variant of a retroflexed or retroverted uterus,
the cervix may point in the vaginal axis or may be placed in direct
apposition to the anterior vaginal wall. With the uterus in these
posterior positions and the woman in supine coital positioning,
the difficulty in establishing direct contact between the external
cervical os and the seminal pool on the expanded posterior vaginal
wall becomes obvious. If the uterus is fixed in severe third-degree
retroversion, vaginal expansion in the midcervical plane essentially
is unhampered. Only involuntary lengthening of the vaginal barrel
is impeded.
Intercourse with the female partner in a knee-chest position
will create a seminal pool on the anterior rather than the posterior
vaginal wall. The cervix of the retroverted or retroflexed uterus
has ready egress into such a seminal pool, if the recipient fe­
male remains in the knee-chest position after the male withdraws.
A few minutes will be sufficient to allow effective contact between
the external cervical os and the seminal pool created on the anterior
vaginal wall by the knee-chest coital technique.
If only a plateau phase of sexual response is reached in the knee­
chest position, the orgasmic platform created at this tension level
will assist in constraining the subsequently developed seminal pool.
If possible, orgasmic-phase response should be avoided for the fe­
male partner attempting to conceive in this position. Orgasmic
experience would dispel the orgasmic platform from the vaginal out­
let too rapidly to enable its constraining action on the seminal pool
to be particularly effective.

RESOLUTION PHASE

Since we are considering the vagina as a functional seminal re­

ceptacle, a description of the anatomy of vaginal reaction subse­
 THE VAGINA 87

quent to penile withdrawal is indicated. As the penis is withdrawn

and the female enters the resolution phase of her sexual response
cycle, there is a slow zonal relaxation of the expanded vaginal bar­
rel to previously unstimulated positioning. The anterior vaginal
walls and the cervix of the anteriorly placed uterus return to previous
positioning more rapidly than the posterior or lateral walls of the
vaginal barrel (Fig. 6-14). In this manner the cervix is quickly im­
mersed in any normally constrained seminal pool in the trans­
cervical depth of the vagina. That portion of the ejaculate not lost
during penile withdrawal usually is well contained within the trans­
cervical depths of the nulliparous vagina for a matter of hours, un­
less the individual female assumes other than a supine position.
There is an earlier loss of seminal fluid from the parous woman with
an obstetrically traumatized perineum. Here seminal fluid is lost
as soon as the orgasmic platform is resolved. Excessive pelvic ac­
tivity such as elevation to a sitting or standing position or even
changing position from side to side in bed will occasion further
loss of seminal fluid.
Two other variants, based on male postejaculatory behavior, tend
to dispel the local concentration of the intravaginal seminal pool
and should be noted briefly. If the sexual unit continues in quies­
cent coital connection after the male has completed his ejaculatory

figure 6-14
Cervical immersion in seminal pool. Resolution phase.
88 CHAPTER SIX: PART THREE

effort, the weight of the penis acts to flatten the posterior wall in
the outer third of the vagina. This will result in escape of seminal
fluid from the natural pooling in the transcervical depth of the
vagina. For the parous woman, penile weight also will tend to
overcome the constrictive effect of an orgasmic-platform residual
at the vaginal outlet.
Some males attempt to continue active coital thrusting after
ejaculation and before loss of full erection. This situation usually
develops when the male is trying to accomplish orgasmic release
for his tension-distressed partner. Seminal-fluid loss is excessive in
this instance. There is no opportunity for seminal-pool formation,
and during active penile stroking each withdrawal movement en­
courages further fluid escape.
Thus the efficiency of the vagina’s functional role as a seminal
receptacle is influenced primarily by the anatomic and physiologic
factors of vaginal angulation, sex tension-induced transcervical ex­
pansion, parity, obstetric trauma, orgasmic-platform constriction
of the vaginal outlet, and coital positioning. A secondary influence
on the vagina’s functional role is exerted by the male partner
through improper coital technique.

3. THE FUNCTIONING ROLE

IN REPRODUCTION

The possibility that the vagina has a functioning role as an

organ of reproduction rather than purely a functional role as a
seminal receptacle first was suggested by Sims seventy-five years
ago [297]. Unfortunately, minimal investigative interest has been
directed toward the analysis of multiple factors in the intravaginal
environment which, theoretically at least, either would be sup­
portive of or antagonistic toward spermatozoal migration. Sperma­
tozoa must be able to exist in the vaginal environment and migrate
through the vaginal barrel into the ovulatory cervical mucus if
postcoital conception is to occur.
Brief mention should be made of some of those who have
 THE VAGINA 89

devoted serious consideration to the possible role of the vagina

as a functioning organ of reproduction. In 1913 Huhner popular­
ized Sims’ original concept that microscopic examination of post-
coital cervical mucus was of primary importance in any fertility
examination. He described this postcoital examination of cervical
mucus as the Huhner test and established standards for the test
[121, 123, 124]. Subsequently, Séquy and colleagues [286, 287] re­
focused medical attention on Sims’ original suggestion of the im­
portance of timing postcoital examination of cervical secretions
to coincide with what we now know to be ovulatory receptivity
to the spermatozoa. Unfortunately, in 1930 Moench’s [226, 227]
tenet that there was little of consequence within the vagina to
influence longevity or motility of spermatozoa gained wide credence
within the medical profession. As a result of his influence, the
vagina was considered for many years to be only a functional, not
a functioning, part of the female reproductive system. It remained
for Rakoff [253, 254] and Lang [164, 165] to provide the present
impetus for investigation of vaginal conceptive physiology. Their
findings serve as a foundation for any investigative departure into
the functioning role of the vagina in reproductive physiology.
Vaginal environment is subject to influences from many sources.
The fact that the vaginal mucosa is a permeable two-way membrane
[179, 203] emphasizes the difficulty in establishing and maintaining
a stable environment. The potential factor of contamination
of the vaginal barrel by infectious agents [34, 35, 218, 264, 283]
must always be considered. (These fluctuating influences on vaginal
environment are mentioned only in passing, as space does not
permit a more definitive consideration. Only concerns of possible
sensitivity reactions and of acid-base response to seminal-fluid in­
fluence will be considered at this time. Recent publications [256,
272, 298] point up the functioning role of intra vaginal environ­
ment in reproductive physiology.)
Since Zweifel [333] first described the normally acid state of
vaginal discharge, the source of vaginal acidity and concerns of
in vitro pH influence upon seminal elements have been of interest
to numerous investigators [96, 236, 237, 243, 288, 289, 321]. Gener­
ally it has been accepted that normal vaginal acidity ranges from
a pH of 4.0 to 5.0. Significant pH elevation has been related to
90 CHAPTER SIX: PART THREE

cyclic luteal influence on the vaginal mucosa. This information

was made available by Rakoff [254], using a modification of the
Trussell and MacDougal technique [317] for estimating acidity
of the vaginal environment.
Cruickshank and Sharman [47] emphasized the many factors
which influence vaginal acidity. The pH of the vagina is a second­
ary reflection of the effective production of ovarian hormones.
Vaginal pH is developed and maintained by the sloughing of
mature cells of the superficial layers of the vaginal mucosa. These
cells under estrogenic influence contain a high concentration of
stored glycogen which is, in turn, metabolized to lactic acid within
the vaginal canal.
After Muschat and Randall [236, 237] pointed out hydrogen-ion
influence on motility of human spermatozoa, a number of ex­
periments have clarified optimum conditions for sperm motility
in an acid media such as that present in the normal vaginal en­
vironment. Voge [321] first reported that a pH of 4.9 to 6.4 def­
initely arrests sperm motility. He also pointed out that once
spermatozoa are exposed to a pH of 3.5 or below, revival of motility
by neutralization of the acid environment was not possible. It
remained for Shedlovsky [288, 289] to provide the most definitive
work in this field, when he completely immobilized spermatozoa
in less than one-half minute in a pH greater than 12.2 and in a
pH of less than 3.0.
Huhner adamantly defended the thesis that neither the viability
of spermatozoa in secretions of the female genital tract nor their
actual value for purposes of impregnation can be determined by
any chemical or physical test of the seminal specimen itself [122].
He suggested the possibility that the female genital secretions
might have even more power to preserve the vitality of spermatozoa
than the seminal fluid proper [123, 124]. His suggestion that there
might be a functioning role for the vagina in reproductive physi­
ology was amplification of Sims’ pioneer thinking on this subject.
Suffice it to say that there are many influences on sperm motility
and longevity which develop within, and are a natural part of,
vaginal environment. To date, most of these influences not only
are unexplored but are also without even hypothetical definition.
 THE VAGINA 91

The unfortunate part of all of these early studies is the fact

they were in vitro determinations, and no in vivo intravaginal
correlation was attempted. Laboratory climate and intravaginal
environment are completely separate entities. There is a specific
clinical application of information gathered by in vitro investigation
of the seminal fluid and its contents. For instance, the in vitro
studies [289] describing human spermatozoa! inability to be re­
activated after an exposure to a pH of 3.5 have been proved to have
no significant clinical application by in vivo observations. We
now know that a controlled vaginal environment normally will
maintain a pH ranging from 3.5 to 4.0. Controlled vaginal en­
vironment arbitrarily has been defined as a vaginal barrel without
pathogenic bacteria or fungi, and with no exposure to the neu­
tralizing effect of seminal fluid or menstrual flow for a 48-hour
period.
Another factor in vaginal environment which may have in­
fluence upon spermatozoal motility or longevity is vaginal lubrica­
tion. This is the substance that develops with sexual tension as
the first evidence of the human female’s excitement-phase response
to sexual stimulation (see Part 1 of this chapter). It appears on
the walls of the vagina within 10 to 30 seconds after reception of
either somatogenic or psychogenic sexual stimulation. The longer
foreplay is extended, and the longer coition is continued without
ejaculation, the greater the total production of the vaginal lubrica­
tion. The influence of lubricating material on vaginal acidity is
related directly to the amount produced and the duration of its
production [202, 206].
With vaginal acidity established in the 3.5 to 4.0 pH range,
approximately 30 minutes of lubrication production must occur
before influence on such a low pH is recordable. Elevation of a
baseline pH (3.5-4.0 in the unstimulated vagina) into the range
of 4.25-4.5 has been recorded repeatedly after relatively extended
periods of sexual activity. The responding female may experience
multiple orgasms or only achieve plateau-phase levels of sexual
tension during extended manipulative and coital episodes. The one
constant factor influencing the production of vaginal lubrication
is long-maintained stimulative activity, regardless of type employed,
whether or not orgasmic level of sexual response is obtained. This
ga c hap tk r six : rart thrk k

statement presumes, of course. that the female at least reaches

an excitement-phase level of sexual response.
Since the pH of lubricating material obviously has a higher
range than that encountered in a controlled vaginal environment,
it may be that this lubricating material also plan's a preordained
role in adjusting vaginal acidity to provide the most effective
enrironment possible for spennatozoal migration. It will be re­
called that there is a marked buttering power in seminal-fluid
content. How much the vaginal lubrication, through its influence
on baseline vaginal acidity, aids the inherent buffering power of the
seminal fluid to protect spermatic motilitv bv elevating vaginal
pH has not been determined.
Laboratory standards for fertile and infertile males haw been
established in accurate detail by MacLeod and his co-workers
[184-190]. His exhaustive efforts have provided the medical pro­
fession with a baseline for effective in vitro evaluation of male
fertility-. However, the clinician investigating an infertile family
unit may make a serious mistake by defining male fertility only
on the basis of an in vitro evaluation of a manually produced
seminal specimen. The in vitro evaluation of the male partner is
the step of primary importance and is of tremendous value, but
it is not the only step to be taken.
A second important step (which should be part of every evalua­
tion of an infertile family unit') is definition of spennatozoal vi­
ability and motility after intravaginal deposition of the ejaculate.
The Sims-Huhner type of marital-unit evaluation (microscopic
examination of postcoital ovulatory conical muons') should be just
as constant a part of the infertility work-up as the in vitro seminal
specimen examination [34. 211].
The immediate effect on vaginal environment created bv the
ejaculatory deposition of seminal fluid has not been fully appreci­
ated. In an attempt to illustrate this effect, measurements of
intravaginal pH were conducted after the technique popularized
by Rakoff ct aL [254]. Due to the immediacy of the buffering
effect of seminal fluid, glass measurement electrodes were stan­
dardized at a pH of 7.0 routinely. Therefore slightly higher readings
for baseline vaginal acidity were recorded during these experiments
than would represent the true value if the electrodes were standard­
 THE VAGINA 93

ized with a pH of 1.0. Despite this experimental inadequacy all

measurements of the pH of controlled vaginal acidity fell in the
3-5-3-9 range.
In order to prevent possible iritravaginal contamination a period
of vaginal control (3-7 days) was established for the family units
cooperating with the investigation. The vaginas all returned nega­
tive cultures for bacterial or fungal pathogens within a 48-hour
period before the experimental observations. Details of these ex­
periments have been reported [206, 208]. To avoid repetition,
the results reported will be restricted to those obtained from only
one of the experimental sessions.
As recorded in Figure 6-15, there was a total stimulation time
of 17 minutes (vaginal lubrication production) from the onset
of foreplay until the male’s ejaculatory experience. The first mea­
surement of vaginal acidity and examination of vaginal content
was initiated 9 seconds after intravaginal deposition of seminal
fluid. Readings of vaginal acidity were recorded at 10-minute inter­
vals for 2 hours, and then every hour for 10 hours. A concluding

FIGURE 6-15
Vaginal environment and seminal-fluid content (in vivo determina­
tions).
94 CHAPTER SIX: PART THREE

estimate of postejaculatory vaginal acidity was recorded 24 hours

after coition.
Neutralization of total vaginal acidity occurs immediately after
ejaculation. Although the major part of the seminal fluid usually
is delivered to the transcervical depth of the vagina, penile with­
drawal serves to spread portions of the ejaculate throughout the
vaginal barrel. A sufficient amount of seminal fluid escapes the
transcervical intravaginal pool to neutralize total vaginal acidity.
The buffering effect of this particular ejaculate was sufficient to
provide a residual influence on total vaginal acidity that lasted for
6 to 7 hours. For other family units the active neutralizing action
of the ejaculate has been recorded for as long as 16 hours.
In order to explore this aspect of the vagina’s functioning role
in reproductive physiology at the most plausible time, measure­
ments were taken on the thirteenth day of a regularly recurring
28-day menstrual cycle (see Fig. 6-15). This fertile study subject
(as well as other subjects) was determined to be in an immediate
preovulatory phase as defined by vaginal cytology [294]. There
was a three-day continence period for the family unit. The last
prior female orgasm had occurred three days previously, during
coition that was condom-controlled to avoid vaginal contamination.
An excessive amount of vaginal lubrication developed during the
experimental period and was designated as Grade 5 by the in­
vestigators (the highest possible grade). The study subject per­
sonally graded her orgasm at a level of 4, which is the highest
grading assigned to a single orgasmic experience (Grade 5 rep­
resents multiple orgasm). The female study subject achieved or­
gasm approximately three minutes before her male partner ejac­
ulated.
Further evidence suggesting a normal functioning role for the
vagina of this study subject was acquired during the three months
prior to the experimental period by evaluating spermatozoal mo­
tility in the vaginal environment. The Sims-Huhner tests of post-
coital ovulatory cervical mucus were consistently positive for this
family unit.
At the time of initial pH measurement a specimen of vaginal
content was obtained (see Fig. 6-15). This specimen of seminal
fluid microscopically showed many spermatozoa motile with good
 THE VAGINA 95

direction. The postcoital vaginal content was examined in similar

fashion every 15 seconds for the first postcoital minute. There­
after, specimens were obtained every minute for 5 minutes, and
again at the 10-minute interval. The vaginal content routinely
was examined at 1, 3, 6, 8, 10, and, finally, 24 hours postcoition.
All specimens were examined microscopically to evaluate sperma-
tozoal longevity and directional motility within the functioning
environment of the postcoital vagina. Spermatozoa continued mo­
tile with good direction until the 10-hour examination. At this
time and thereafter, all spermatozoa were nonmotile.
In substance, Figure 6-15 records the response of a functioning
vagina to the coital deposition of a fertile seminal specimen. The
chart is representative of 53 observations of fertile family units
conducted under similar conditions, and establishes a baseline
for comparison with infertile family units. Fertile family units
have been evaluated at various stages of the female partner’s men­
strual cycle. No significant variation in hydrogen-ion influence
on intravaginal spermatozoal longevity or directional motility has
been recorded from the immediate postmenstrual to late pre­
menstrual phases of the menstrual cycle. It also makes no dif­
ference in intravaginal spermatozoal motility or longevity whether
seminal fluid is deposited by coition or by insemination techniques.
A routine in vitro evaluation of all male partners was con­
ducted from 3 to 5 days after the experimental sessions with the
fertile family units. In every instance this examination was carried
out on the first seminal specimen produced, after that measured
in the family-unit investigation. In this way, the male partner’s
levels of fertility as described by these in vitro studies could be
compared with the family unit’s in vivo results.
In addition to the routine in vitro examinations (seminal-fluid
volume and viscosity; sperm count per cubic centimeter, directional
motility, longevity, and morphology), the seminal specimen was
subjected to a four-day check of hydrogen-ion concentration (Fig.
6-16). This technique was used to demonstrate the stable, almost
incredible buffering power inherent in seminal-fluid content. The
manually produced specimen was maintained at 37°C. over a
water bath without carbon dioxide contact. Dicrysticin was added
to the seminal fluid to control possible bacterial contamination. Al-
96 CHAPTER SIX: PART THREE

% ♦ I I ♦ ♦
Sperm
90 80 80 70-80 0
Motility
Lively, good direct sluggish dead

Continence: 3 days Morphology ■ 10% abnormal

Sperm count /cc. 151M Culture« ¿colonies while stoph.
Volume: 2cc. (37*C.) - Dicrysticin added
Viscosity- Normal

FIGURE 6-16
Seminal-fluid content (in vitro determinations).

though the specimen was obtained under the most sterile condi­
tions possible, routine anaerobic and aerobic cultures were taken as
a means of experimental control. In this instance, bacteriologic
examination described five colonies of Staphylococcus albus, which
for purposes of this study was considered to be nonpathogenic in
character.
Routine evaluation of this fertile semen specimen showed a
volume of 2 cc. and essentially normal viscosity. The inadequate
volume of the ejaculate was counterbalanced by the sperm count
which was reported as 151 million per cc. The abnormal spermato-
zoal morphology was estimated at 10 percent. Observation at eight
hours demonstrated spermatozoa still active; however, directional
motility was reduced significantly. The only basic difference be­
tween the in vitro and in vivo evaluation of this male’s fertile sem­
inal fluid was the fact that the spermatozoa were shown to live
longer under the somewhat controlled in vitro conditions. There
is, however, real doubt of the fertilizing ability of spermatozoa after
even six to eight hours of controlled in vitro containment.
Abnormal variants of conceptive physiology are being identified
 THE VAGINA 97

as investigative interest is directed toward the possible functioning

role of the vagina as a reproductive organ. The recently established
“lethal factor” exists in the vaginal environment and immobilizes
apparently healthy spermatozoa [208, 211]. This example of ab­
normal physiology, in its acute stage, produces an infertile state
for any family unit contending with the problem. Influence of the
“lethal factor” on vaginal conceptive physiology is shown in Figure
6-17, which records information returned from the evaluation of an
infertile family unit.
The Sims-Huhner test was negative on three separate occasions.
The experiment reflected in Figure 6-17 was conducted on the
fourteenth day of a regularly recurring 28-day menstrual cycle.
Vaginal cytology placed the female partner in an immediate pre­
ovulatory phase. There had been a seven-day continence period
for both partners. The period of vaginal control also was one week.
The last prior orgasm had been experienced seven days previously.
The female partner achieved only plateau-phase tension levels dur-

75-1 MEASUREMENT Ncl5 ? a

TIME Day of Cycle: !4th
Continence (M)7d. (F)7d
LPO (c)l/or (m) 7d.
Medication: None
Period Vog. Control' I week
Lubrication / 2 3 (t) S
Orgasm- i e 3 4—5-

Commenfs: Metier achieves orgosm with

coitus- Manipulation always
successful after ejaculotion-
Not corried out this time

Sims - Hühner Test persistently negative

Many Sperm
AH Dead (less than
—I — 7 min.}
Buffer 700
3.5- —r n i i r-
Ejaculation 7 0 20 40
Time- 9min Minutes TIME Hours
45 sec.

FIGURE 6-17
The “lethal factor”: vaginal environment and seminal-fluid content
(in vivo determination).
9» CHAPTER SIX: PART THREE

ing the experimental session. This individual has never achieved

the orgasmic phase of sexual response with coitus. However, man­
ual manipulation has always provided orgasmic release and is
routinely employed by this family unit after the male ejaculatory
experience. In order to provide for immediate measurement of post-
coital vaginal content, this technique of female sexual tension re­
lease was avoided. A Grade 4 degree of vaginal lubrication developed
during the experimental session.
As indicated in Figure 6-17, seminal-fluid influence upon total
vaginal acidity was measurable 16 seconds after the male partner’s
ejaculation. The buffering power of this particular seminal specimen
was exceptional. There was an immediate rise from the baseline
vaginal pH levels of 3.7 to 3.9 into the range of 6.5 to 7.2 pH. The
marked buffering effect of this particular seminal fluid against the
total vaginal acidity maintained the intravaginal environment at
6.5 pH level approximately 80 minutes after ejaculation. The pH
of the vaginal environment then fell slowly but steadily toward a
level of 4.0, which was recorded 9 hours after the male’s ejaculatory
experience. At the 24-hour check, vaginal acidity was just below the
3.7-3.9 pH levels recorded at the onset of the experiment.
Although there were many spermatozoa in specimens of vaginal
content taken subsequent to ejaculation, all spermatozoa were ob­
served to be completely immobile. Specimens were returned for ex­
amination following the time schedule described earlier in the
chapter in discussion of normal vaginal physiology. The influence
of the “lethal factor” was established even in the sample of vaginal
content removed just 16 seconds after intravaginal seminal deposi­
tion. Every additional sample of vaginal content demonstrated
immobile spermatozoa.
The in vitro evaluation of the male partner followed the family­
unit experimental session by four-and-a-half days (Fig. 6-18). The
manually produced seminal specimen showed a normal count
of 95 million per cc., a total volume of 5 cc., and a moderately
increased viscosity of the seminal fluid. The incidence of abnormal
spermatozoal forms was somewhat high (recorded in the 15 percent
range).
Initial examination of the seminal specimen showed 70 to 80 per­
cent directional motility. At the three-hour check, there continued
 THE VAGINA 99

Sperm ♦ I
Motility 60 0
dead
Continence1 4^ doys (c) Morphology* 157« abnormal
Sperm count/cc.: 95 M Culture: Few alpha hemolytic strep.
I colony while staph.
Volume: 5cc.
HgO (37*O-0icrysticin added
Viscosity* mod. increoeed

FIGURE 6-18
The “lethal factor”: seminal-fluid content (in vitro determinations).

to be 70 percent directional motility, and at eight hours 60 percent

directional motility. The 24-hour check showed all spermatozoa
immobilized. The specimen was produced under as aseptic condi­
tions as possible. However, anaerobic and aerobic cultures of the
ejaculate demonstrated a few colonies of alpha-hemolytic strepto­
cocci and one colony of Staph, albus. The bacteriology suggested
contamination rather than incidence of pathology.
Examination of the pH of the seminal specimen showed a drop
just below the 7.0 level at the 24-hour observation. The rest of the
four-day observation period demonstrated a slow rise in recorded pH
for this seminal specimen. The specimen was maintained at 37°C.
over a water bath without CO2 contact. Dicrysticin was added to
control possible bacterial contamination. Again the buffering power
of the seminal-fluid content was demonstrated in the manner es­
tablished and described above. This male would have to be judged
(by laboratory standards) as essentially a fertile individual.
In an evaluation of the family unit, it is obvious that their
particular conceptive concern is one of absolute spermatozoal im­
mobility which develops immediately subsequent to ejaculatory
100 CHAPTER Six: PART THREE

deposition of the seminal-fluid content in the vaginal environment.

This family unit represents definition of the instant lethal effect
of an intravaginal environment upon apparently normal sperma­
tozoa. Thus, there is proof positive of an obvious functioning role
for the vagina in conceptive and contraceptive physiology. There
will be a great deal more evidence of the vagina’s functioning role
in conception when more definitive research has been designed,
conducted, and reported. To date little has been done, and little
is known of the vagina’s conceptive functioning role despite the
obvious availability of the organ to investigative procedure.
 7
THE ARTIFICIAL VAGINA
ANATOMY AND PHYSIOLOGY

Anatomic and physiologic response patterns have been described

for the normal human vagina in its dual role as the functional
means of the human female’s sexual expression and as a function­
ing part of her reproductive mechanism. Of comparative interest,
from a functional point of view only, are the anatomic and physio­
logic response patterns of the artificial vagina.
The material to be presented has been accumulated from follow­
up evaluation of seven women, ages 19 to 34 years, who were
treated for vaginal agenesis (congenital absence of the vagina).
Five of these anomalies were resolved by surgery; two responded to
mechanical methods. There is no necessity for a description of
either the surgical or the mechanical techniques used in these cases,
since they have been described in detail by numerous authors in
previous publications [4, 31, 45, 72, 77, 78, 92, 183, 223, 281, 327,
328]. The method of creating an artificial vaginal barrel is inci­
dental, since the functional reaction patterns of artificial vaginas
are identical regardless of how they are constituted.
Psychosexual histories obtained from individual subjects will
be omitted. While the varied backgrounds which produced seven
vastly different modes of psychosexual orientation are of interest,
they are of no statistical value. Psychosexual concerns are not
relative to the physiology being presented, and an adequate over­
all interpretation of the sexually functional role of these vaginas can
be established on the basis of essentially identical physiologic re­
action patterns.
Since the anatomic and physiologic response patterns of the
artificial vagina are to be considered in comparison with those of
the normally constituted vagina, the four phases of the human fe­
male’s sexual response cycle will serve as a descriptive framework.
101
102 CHAPTER SEVEN

EXCITEMENT PHASE

Following the pattern of normal vaginal reaction, the first ana­

tomic evidence of an excitement-phase response to sexual stimula­
tion appears in the form of a mucoid material on the walls of the
artificial vagina. This lubrication appears in droplet formation in a
matter of 30 to 40 seconds after the onset of any form of somato­
genic or psychogenic sexual stimulation. Production of the lubricat­
ing material in clinically sufficient amounts usually takes longer
than in the normal vagina. Long-maintained sexual tension levels
or extensive foreplay usually is necessary for achievement of an
effectively lubricated vaginal barrel prior to coition. This slowed
rate of initial response should not be confused with totality of
performance for the artificially constituted vagina.
With the first few penile strokes the production of lubrication
is increased and coalescence of the material is accomplished rapidly.
The accelerated production of lubrication that develops in direct
response to active coition is a reactive tendency characteristic of the
artificial vagina. It should be stated, however, that some surgically
or mechanically created artificial vaginas are capable of lubricating
as well and as rapidly as any normally constituted vaginal barrel.
Two of the seven women under evaluation have been observed to
lubricate extensively and rapidly in response to sexual stimulation­
in fact, more effectively than many women with normally consti­
tuted vaginas. In any event, the phenomenon of lubrication makes
an artificially constituted vagina a highly functional seminal recep­
tacle readily available for normal coition.
Speculation as to the actual physiologic source of vaginal lubri­
cation continues to be of some gynecologic interest. Just as with
the normal vagina, sexual tensions produce marked dilatation of
the venous plexus concentration which encircles the entire artificial
vaginal barrel. The mucosa of the artificial vagina has been estab­
lished as a functioning two-way membrane, as is normal vaginal
mucosa. At present there is no clinical contraindication to the pre­
sumption that spontaneous lubrication of the artificial vaginal
barrel comes from the same source and, in all probability, has
 THE ARTIFICIAL VAGINA 103

the same chemical constituents as that of the normal vaginal

barrel [202].
It should be stated parenthetically that in five of the clinically
resolved cases of vaginal agenesis lubrication has been observed to
be more effective during the luteal than the estrogenic phase of re­
curring hormonal cycles. Since only seven cases of vaginal agenesis
comprise the total number that have been evaluated to date, there
is no statistical significance to this observation.
As the excitement-phase continues, secondary anatomic reactions
to elevated sexual tensions develop within the artificial vagina just
as they do within the normal vagina. As previously described for
the normal vagina (see Part 1 of Chapter 6), there is a lengthening
and distention of the inner two-thirds of the vaginal barrel (Fig.
7-1). The area in question alternately expands spasmodically, and
then relaxes in a slow, tensionless manner essentially similar to that
of the normally constituted vagina.
In addition to lengthening of the vaginal barrel, there is an ob­
vious diameter increase in the inner two-thirds of the artificially

figure 7-1
Artificial vagina : excitement phase.
104 CHAPTER SEVEN

created vagina. However, elasticity of mucosal movement is reduced

significantly when compared to that of the normal vagina. Both
expansive and lengthening abilities develop more slowly without
the fluidity of movement and degree of excursion that normal
vaginal walls possess. Just as the normal vagina is a clinically po­
tential rather than an actual space, so the anterior and posterior
walls of the artificial vagina are collapsed together except when
under the influence of a significant degree of sexual tension.
The involuntary lengthening and distention of the artificial vag­
inal barrel has been measured in a manner similar to the technique
used for the normally constituted vagina. Due to the essential uni­
formity in physiologic response of the artificial vaginas, it is pos­
sible to report one study subject (Subject A) as representative of
the general response patterns for other individuals evaluated.
The vaginal length and midvaginal diameter of Subject A have
been measured repeatedly. These measurements have been taken
routinely from the fourchette to the depth of the vaginal barrel and
at the point of greatest expansion of the central diameter, which
usually develops approximately 2 cm. from the distal end of the
vagina (Fig. 7-2). When Subject A is stimulated sexually to ad­
vanced excitement-phase levels, the expanded central diameter

•"—3.5cm.—»

Unstimulated Stimulated
(Advanced Eicitement
Phase)

FrGURE 7-2
Artificial vagina: baseline measurement, Subject A.
 THE ARTIFICIAL VAGINA 105

measures approximately 3.5 cm. as opposed to the unstimulated

central diameter measurements of 1-1.5 cm- The artificial vaginal
barrel increases in length to an average of 8 cm. from an unstimu­
lated length of 6 cm.
Subject A also demonstrates the artificial vagina’s ability to effect
further vaginal-wall expansion under the influence of continued or
increased sexual stimulation (Fig. 7-3). With the anterior and
posterior speculum blades fixed at a constant 2 cm. separation,
the initial lateral wall (central diameter) expansion developed by
speculum placement was measured at 2.5-3 cm., as opposed to the
1-1.5 cm. the unstimulated state. The length of Subject A’s
artificial vaginal barrel was increased from 6 to 7.5 cm. by the place­
ment of an indwelling speculum before conscious sexual stimulation
was initiated.
When the subject was stimulated sexually to an advanced excite­
ment phase with an indwelling speculum in the vaginal barrel, the
point of greatest lateral wall expansion (central diameter) measured
3.5-4 cm. in width, while the length of the vaginal barrel was in­
creased to approximately 9 cm.
As a general rule, the more the artificial vagina is dilated, the
greater the potential for further dilatation. While the degree of dis-

—3.5-4cm.—►

2.5-3cm.
■-------- z" X
1
:

l
I
«
»
7. 5 cm.
1

A
Unstimulated Stimulated
(Advanced Excitement
Phase)

FIGURE 7-3
Artificial vagina: speculum-dilated, Subject A.
io6 CHAPTER SEVEN

tensive ability is not that of a normal vagina, certainly this inherent

functional response to female sexual tension remains a factor of
clinical significance. The artificial vagina under effective sexual
stimulation can accommodate any size of penis if there has been
successful surgical or mechanical development.

PLATEAU PHASE

When plateau-phase levels of sexual response are achieved, local­

ized vaginal vasocongestion is apparent. This reaction develops
with such severity that there is approximately a 50 percent occlusion
of the central lumen of the vaginal barrel. Just as an orgasmic plat­
form develops in the outer third of the normal vaginal barrel, so
an orgasmic platform constantly develops in the outer third of the
artificial vaginal barrel (Fig. 7-4).
The production of vaginal lubrication increases markedly during
the plateau phase, as opposed to the somewhat slowed production

figure 7-4
Artificial vagina: plateau phase.
 THE ARTIFICIAL VAGINA 107

rate of the normal vagina at this tension level. The highest rate
of lubrication production in the normal vagina is confined to the
excitement phase of the sexual response cycle. There is relatively
little increase in central diameter or length of the artificial vaginal
barrel during the plateau phase of sexual response.
The labia minora of women with an artificial vagina turn the
sex-skin color of bright red, just as do the labia minora of the
normal nulliparous women, when an advanced plateau phase of
sexual excitement is attained (see Chapter 4). When this sign of
impending orgasm occurs (presuming that effective sexual stimula­
tion is continued), orgasm is sure to follow in women with an arti­
ficial vagina, just as it does in women with the normally consti­
tuted vaginal barrel.

ORGASMIC PHASE

The characteristic physiologic expression of orgasm in both arti­

ficial and normal vaginas is the onset of regularly recurring contrac­
tions of the orgasmic platform (Fig. 7-5). This platform, created
by plateau-phase vasocongestion, contracts strongly and in a regu­
larly recurrent pattern during the orgasmic phase of the female
sexual cycle. The contractions have a frequency rate, at onset,
of approximately 0.8 second. The intercontractile intervals slow
as the orgasmic experience progresses. Orgasmic-platform con­
tractions of artificial vaginas have been measured by gross pressure­
gradient techniques. They recur with slowly increasing intercon­
tractile intervals on an average of from 5 to 10 times. The
physiologic contractions of the orgasmic platform increase in num­
ber in direct parallel to the severity of the experience.
The orgasmic response of the individual with an artificial vagina
includes involuntary contractions of the entire perineal body. Not
only the outer third of the vagina but also the external rectal
sphincter and the lower abdominal musculature contract in or­
gasmic-phase expression. The superficial and deep transverse peri­
neal, the bulbospongiosus, the levator ani, and the lower portions
of the rectus abdominis muscles are the muscles of primary re­
sponse. Once the artificially created vagina becomes available to
io8 CHAPTER SEVEN

FIGURE 7-5
Artificial vagina: orgasmic phase.

heterosexual function, both voluntary and involuntary muscular

control develops with normal physiologic responsiveness.
The one completely characteristic reaction of orgasmic-phase
response in artificial vaginas, never observed in normal vaginas, is
a marked color change which occurs throughout the entire vaginal
barrel. Vivid discoloration of the barrel appears with sudden onset
during the actual orgasmic experience. This phenomenon of orgas­
mic color change has been recorded by cinematography.
The mucosa of the artificial vagina varies in color from gray to
purplish-red in a sexually unstimulated state. During an orgasmic
experience, the mucosal color changes to a bright red. This flash of
red is startling both in suddenness of onset and in vividness of
coloration. The more intense the color change, the more intense is
the orgasmic experience. This orgasmic color reaction has never
been identified in normal vaginas during hundreds of directly ob­
served sexual response cycles. The trigger mechanism for this
marked vasocongestive reaction to orgasmic experience has not
been defined.
 THE ARTIFICIAL VAGINA 109

RESOLUTION PHASE

Following the involutional pattern established for the normal va­

gina, the retrogressive changes of the resolution phase in the arti­
ficial vagina occur in reverse order of their original development
(see Part 1 of Chapter 6). The first resolution-phase responses are
loss of the localized vasoconcentration in the outer third of the va­
gina (orgasmic platform) (Fig. 7-6) and involution of the sex­
skin discoloration of the labia minora. Actually, the sex-skin dis­
coloration disappears more rapidly than does the orgasmic platform
in women with an artificial vagina.
The walls of the artificial vaginal barrel slowly shrink back to the
unstimulated baseline measurements. Just as the expansion reac­
tion of the artificial vagina is delayed in time sequence, when com­
pared to that of the normal vagina, so the return of artificial vaginal
walls to an unstimulated collapsed positioning occurs at a much
slower rate than that recorded for the normal vagina.

figure 7-6
Artificial vagina: resolution phase.
no CHAPTER SEVEN

The orgasmic color change is slow to resolve. Residual discolora­

tion frequently can be demonstrated for as long as 10 to 15 minutes
after women with an artificial vagina have experienced physiologic
release from sexual tensions.
If the artificial vaginal barrel has been created successfully either
by surgical or mechanical means, the social catastrophe of vaginal
agenesis may be resolved. The artificial vaginal barrel, once success­
fully constituted, is a thoroughly effective coital mechanism. Gen­
erally, reactions to effective sexual stimulation are somewhat de­
layed in rapidity and intensity, when compared to those of the
normal vaginal barrel. The successfully created artificial vagina rap­
idly and effectively assumes its proper functional role as the primary
physical means of the human female’s sexual expression.
The psychosexual problems that develop subsequent to the crea­
tion of an artificial vagina have not been dealt with in this chapter.
Prior publication has discussed at some length the psychosocial
concerns of three women with a successfully constituted artificial
vagina [209]. Since there were only seven study subjects available,
statistical support was insufficient for a generalized psychosexual
discussion. A consideration of the psychosexual and social problems
inherent in the clinical condition of vaginal agenesis will be
presented at a later date.
 8
THE UTERUS
PHYSIOLOGIC AND CLINICAL
CONSIDERATIONS

Despite the milestone of the Reynolds contribution [261], rela­

tively little is known of human uterine physiology in those areas
not related directly to states of pregnancy or hormonal influence
on the myometrium. Due to the technical difficulties inherent in
working objectively with the human uterus, information available
usually has been developed in a fragmentary manner. For example,
the cyclic influence of ovarian hormones on the secretory activity
of the glands in the uterine endometrium is well established [149],
yet the biochemical constitution of the material secreted by these
glands remains an unresolved problem. Moreover, areas of potential
influence for this material either locally within the uterine cavity or
distally in some target organ such as an ovary have not been estab­
lished.
A similar picture reflects the levels of knowledge of uterine-body
response to sexual stimulation. Finite details of uterine-body reac­
tion to sexual stimuli will not be established until the problem is
attacked by a more definitive program of physiologic investigation
than has been possible. Sufficient inroads have been made by the
combined techniques of basic physiologic recording and direct clini­
cal observation to establish certain truths in the culturally resis­
tant area of uterine response to sexual stimulation. The uterus has
been observed to respond to sexual stimulation as a composite or­
gan. In addition, individual reaction patterns for the corpus and
the cervix have been recorded and observed. The four phases of
the cycle of sexual response will be employed to facilitate a dis­
cussion of reactions of the organ as a whole and of those of its
composite parts.
111
112 CHAPTER EIGHT

The first phase of uterine response to sexual stimulation has been

established by considering the organ as a whole rather than by
focusing on either of its component parts, the corpus or the cervix.
This total-uterine-body reaction develops at excitement-phase levels
of sexual tension and is related directly to uterine- positioning in the
female pelvis. The following description of uterine-body reaction
to sexual stimulation presumes an anteriorly placed or midposi­
tioned uterus and does not apply to the organ in retroverted or
retroflexed pelvic positioning.

UTERINE-ELEVATION REACTION

As excitement-phase levels of sexual tension progress toward the

plateau, the entire uterus elevates from the true into the false pelvis.
Under direct observation, the cervix is removed from its normal
resting position in direct contact with the posterior vaginal floor,
not far from the vaginal introitus. The cervix slowly retracts from
its resting position in a posterior and superior plane as the vaginal
walls expand under the influence of sex tension increment (Fig.
S-r).
As the entire uterus elevates into the false pelvis, the cervix, to­
gether with the involuntarily expanding anterior and lateral vaginal
walls, creates a tenting effect in the transcervical depth of the vag­
inal barrel (see Part 1 of Chapter 6). The elliptical expansion in
the midvaginal plane resultant from cervical elevation and ante­
rior, lateral, and posterior vaginal-wall dilatation creates an ana­
tomic basin for a theoretical seminal pool (see Part 2 of Chapter 6).
Full uterine elevation is not accomplished until the plateau phase
of sexual response has been established. At this level of tension the
nulliparous cervix may be elevated almost into the false pelvis. With
the reaction of uterine elevation fully established, there is no fur­
ther total organ response to effective sexual stimulation during ter­
minal plateau phase or the orgasmic experience.
With onset of the resolution phase, the elevated uterus begins its
return to the unstimulated resting position in the true pelvis. This
return of the uterus from the false pelvis drops the cervix into the
anatomically contrived seminal basin in the transcervical depths
 THE UTERUS II3

FIGURE 8-1
Uterine-elevation reaction. Composite of sexual response cycle.

of the vagina. Early in resolution uterine descent progresses rapidly.

However, final return of the cervix to full apposition with the poste­
rior vaginal wall frequently takes as long as five to ten minutes.
Currently there is no acceptable physiologic explanation for the
phenomenon of uterine elevation in response to effective sexual
stimulation. The uterus has been theorized to elevate in response
to increased negative pressures in the abdominal cavity. In turn,
the increase in negative pressure has been presumed to be the
secondary result of the partial elevation and fixing of the dia­
phragms that usually develop in advanced excitement-phase levels
of sexual tension. This theory does not explain the onset of uterine
elevation early in the excitement phase, before any significant de­
gree of hyperventilation develops. However, negative abdominal
pressures may be a contributing factor to the final stages of uterine
elevation late in the plateau phase.
The cardinal ligament and the plica rectouterina also have been
suggested as possible contributors to the reaction of uterine eleva­
tion. Supporting this contention is the clinical observation that
n4 CHAPTER EIGHT

women with obstetrically traumatized uterine supports usually ele­

vate the uterus much more slowly and with significantly reduced
excursion, when compared to nulliparous women.
The generalized vasocongestive reaction in the pelvis (a constant
response to sex tension increment) also has been suggested as con­
tributing to uterine elevation through passive vasocongestion of the
broad ligaments. As these major supports of the uterus fill with
venous blood, there may be a resultant shortening and tensing of
these structures which secondarily could contribute to uterine ele­
vation.
Although there is no established physiologic reaction to account
specifically for uterine elevation, there also is no question that the
reaction occurs routinely in anteriorly placed uteri. The cervix has
been observed through full elevation reactions hundreds of times
with the use of artificial coital techniques, and the elevation reac­
tion also has been observed many times directly during automanip-
ulative episodes with the aid of an indwelling vaginal speculum.
The posteriorly positioned uterus (retroverted or retroflexed
uterus) does not elevate from the true into the false pelvis in re­
sponse to sexual stimuli. The posteriorly positioned uterus remains
in the true pelvis, although vaginal-wall expansion does occur in the
transcervical depth in the usual anterior, lateral, and posterior
planes (see Part 1 of Chapter 6). There is no physiologic explana­
tion for the lack of elevation of posteriorly placed uteri, particu­
larly those that move freely on pelvic examination and obviously
are not fixed in their posterior positions by adhesions or other
forms of pelvic pathology.
The reactions of the individual components of the uterus (corpus
and cervix) to advanced degrees of sexual stimulation constitute
the second phase of total uterine response. The cervix and the
corpus will be considered in sequence in discussing the reactive po­
tential of the uterus to sexual stimulation.

CERVICAL RESPONSE

The production of vaginal lubrication in response to sexual stim­

ulation has been identified with cervical secretory activity by many
authors [8, 21, 30, 54, 67, 144, 219, 239, 295, 308, 318, 319]. Dur-
 THE UTERUS 115

ing the past eleven years direct intravaginal observation of hun­

dreds of complete cycles of female sexual response has been pos­
sible. With one exception, the cervix never has been observed to
secrete material during any phase of the entire sexual response cycle.
The exception was created by a study subject who lost an ovulatory­
mucus plug from the external cervical os on the thirteenth day of
what developed into a 28-day menstrual cycle. Although it is true
that a thin, ovulatory-type mucoid material was discharged into the
vaginal barrel, this secretory activity developed only after the re­
sponding woman was well into the plateau phase of the particu­
lar response cycle, long after full lubrication of the vaginal barrel
had been established (see Part 1 of Chapter 6).
The only definitive response of the cervix to sexual stimulation
develops with resolution-phase timing during the sexual cycle. A
minimal dilatation of the external cervical os frequently has been
observed. This specific cervical reaction, if it is to occur, develops
immediately after an orgasmic experience. If the study subject does
not achieve orgasmic tension release, the gaping of the external
cervical os does not occur. When cervical os dilatation develops, 20
to 30 minutes of the resolution phase must intervene before a con­
strictive effect slowly closes the slightly patulous external os.
Positive identification of this reactive pattern has been confined
to the nulligravid cervix. It well may occur in the parous individual,
but the obstetric trauma resulting from passage of an infant’s head
and shoulders through the cervix obviates secure identification of
this reaction subsequent to childbirth. The external cervical os nor­
mally is slightly patulous and the entrance to the cervical canal
larger in the parous as opposed to the nulliparous woman. The de­
velopment of dilatation of the external cervical os early in the reso­
lution phase has been observed to parallel the intensity of the or­
gasmic response. Severe orgasmic experiences increase the frequency
of identification of the patulous response of the external cervical os
in the nulliparous woman.
It has been suggested that there may be clinical significance in
the resolution-phase response of cervical gaping. This reaction the­
oretically increases the opportunity for spermatozoal access to the
uterine cavity. While this physiologic possibility exists, the corpus
contractile patterns to be described later in the chapter preclude an
active role for cervical gaping in sperm migration. There is no ques­
116 CHAPTER EIGHT

tion that gaping of the external cervical os, when it develops, may
passively improve spermatozoal access to the cervical canal.

CORPUS RESPONSE

Clinical experiments have been conducted in attempts to evaluate

uterine reactive potential and to find support for the concept that
vasocongestion and myotonia are the physiologid bases of visceral
reaction to sex tension increment.

MYOTONIA

Uterine physiology has been investigated with both intrauterine

and abdominal electrode placements and acceptable physiologic re­
cording techniques. Both investigative techniques have returned
evidence of corpus irritability that increases from early in excite­
ment to late in the plateau phase and resolves into an identifiable
contraction pattern that has specific orgasmic-phase orientation and
resolves with resolution-phase timing. These specific contraction
patterns are repeated with each subjective orgasmic experience,
varying in excursion (graphic representation of intensity) and dura­
tion of recordable result. This phase of the total program of basic
physiologic investigation of human sexual response, involving not
only target-organ but general body reactions, has not been estab­
lished with sufficient statistical security for detailed presentation at
this time. Suffice it to say that there is an identifiable recurrent
pattern of uterine muscle contractility that is oriented specifically
to the orgasmic phase of the female sexual cycle.
Specific uterine muscle contractile patterns do not develop unless
the individual study subject undergoes an orgasmic experience that
is recognizable both by trained observers and by the individual in­
volved. Inevitably, the degree of excursion of recorded corpus con­
tractive response parallels the study subject’s subjective and the
observers’ objective evaluations of the physical and emotional in­
tensity of the orgasmic experience. A uterine contraction pattern
recorded with intrauterine electrodes during an orgasmic experi­
ence is presented in Figure 8-2. Typical corpus contractions of or-
 3>

FIGURE 8-2
Uterine contraction in orgasm (intrauterine electrode)
118 CHAPTER EIGHT

gasmic response start in the fundus, progress through the midzone,

and expire in the lower uterine segment. The contractile patterns
are suggestive of those developed by the uterine musculature dur­
ing the first stage of labor. However, the orgasmic-phase contrac­
tions are reduced in excursion, and contractile frequency is in­
creased.
It will be noted (see Fig. 8-2) that fundal contractile patterns
are initiated 2 to 4 seconds after subjective awareness of the onset of
an orgasmic experience. Comparably, it has been observed that the
orgasmic platform in the outer third of the vagina (see Part 1 of
Chapter 6 ) may respond initially to the more severe levels of sexual
tension (see “status orgasmus,” Chapter 9) by contractile spasm,
before this involuntary reaction is overcome by the regularly recur­
rent o.8-second orgasmic contractions. There is little doubt that the
female appreciates orgasmic response subjectively 2-4 seconds be­
fore she expresses this tension level physiologically. This lag between
subjective appreciation and physiologic release may be comparable
to the two stages of the male ejaculatory experience (see Chapter
14).
Although the number of experiments is not sufficient to allow
an empirical position, it is current belief that the corpus contraction
patterns initiated in response to automanipulative techniques are
of greater intensity and duration than those resulting from coitally
induced orgasmic experience. Certainly it is subjectively true that
study subjects report that usually the experience with orgasm in­
duced by masturbation is more intense than, although not neces­
sarily as satisfying as, that resulting from coition (see Chapter 19).
Although initiated during orgasmic expression, corpus contrac­
tions continue in irregularly recurring patterns and with progres­
sively reduced excursion as the individual woman is resolving from
her orgasmic experience. There is at present no clinical explanation
for the sensation of continued corpus contractions experienced at
orgasm by study subjects with surgically ablated uteri. The prob­
ability of a pattern of conditioned response must be considered as a
possible explanation of this subjective response.
The physiologic definition of uterine muscle contraction patterns
during orgasm offers a possible explanation for the clinical com­
plaints of cramping distress initiated during orgasmic response and
 THE UTERUS HQ

experienced by many women (particularly multíparas). The orgas­

mic contractions of the corpus also have been reflected subjectively
as painful stimuli in many instances by postmenopausal women
(see Part 2 of Chapter 15).

VASOCONGESTION

A decade ago during the prostitute phase of the sex research pro­
gram, investigators first were alerted to the extent that pelvic vaso-
congestion may be developed by long-continued sexual stimulation.
One individual underwent repeated pelvic examinations during a
six-and-a-half-hour working period and for six hours of observation
thereafter. During the working period multiple coital exposures
maintained the woman at excitement-phase levels of response.
There were five subjective plateau-phase experiences superimposed
on maintained excitement tension levels, but orgasmic relief was
not experienced.
Toward the end of the working period the uterus was increased
two to three times the unstimulated size; the broad ligaments thick­
ened with venous congestion; the walls of the vaginal barrel were
edematous and grossly engorged; and the major and minor labia
were swollen two to three times normal size. Pelvic examinations
and coital activity became increasingly painful toward the end of
the six-and-a-half-hour working period.
During the six-hour observation period gross venous engorge­
ment of the external and internal genitalia persisted—so much so,
in fact, that the woman was irritable, emotionally disturbed, and
could not sleep. She complained of pelvic fullness, pressure, cramp­
ing, moments of true pain, and a persistent, severe low backache.
After the termination of the observation period automanipulation
brought immediate relief from the subjective pelvic distress and
the low backache. The objective findings also disappeared rapidly.
Pelvic vasocongestion was reduced by an estimated 50 percent in
five minutes and had disappeared completely ten minutes after
the orgasmic experience.
Genital pain associated with long-maintained or continued sexual
excitement has been described in the literature occasionally [2, 98,
191, 239]. However, the mechanism initiating the pelvic pain had
120 CHAPTER EIGHT

not been established prior to the clinical observations of the unre­

solved vasocongestion just described. Pain and pressure stimuli are
produced by severe unresolved vasocongestion of the pelvic target
organs. This clinical distress, although much more severe than that
classically described by Taylor as chronic passive congestion of the
pelvis [310-312], has the same pathologic orientation.
Results of the early prostitute observations instigated an experi­
ment designed to investigate vasocongestive response in the female
pelvis during more moderate sexual activity. Over a four-year period
50 female study subjects cooperated with the program. They were
selected for ease of pelvic examination. Their ages ranged from 18
to 53 years. Thirty-one women were parous (13 had one child, 17
had two or three children, and one was a para 4); 19 women were
nulliparous. All women cooperated actively with the investigative
schedule on five different occasions. Two clinical observations were
conducted during the week immediately following a menstrual pe­
riod, two clinical observations were conducted during the week im­
mediately prior to anticipated menstruation, and one clinical ex­
periment was conducted at the height of the menstrual flow (usu­
ally the second or third day of menstruation). Results returned
from the menstrual-flow observations will be discussed later in the
chapter.
The premenstrual and postmenstrual observation weeks included
both an automanipulative session and an active coital session. The
study subjects were stimulated to plateau-phase levels of sexual
tension. Automanipulation or coition was continued until orgasm
was judged imminent by the study subjects. Pelvic examinations
were conducted before onset of each stimulative session and imme­
diately after arbitrary cessation of sexual stimulation late in the
plateau phase.
In every instance the 31 parous study subjects demonstrated a
significant increase in uterine size. Usually the uterus increased in
size from 50 to 100 percent over that described immediately prior
to the onset of sexual stimulation. In addition, those individuals
with any evidence of pelvic or labial varicosities demonstrated an
abnormal degree of venous engorgement of the broad ligaments.
Among the 19 nulliparous women the clinical results were not so
obvious. Only 7 nulliparous study subjects developed uterine size
 THE UTERUS 121

increase of a clinical magnitude that was obvious during the pelvic

examinations conducted late in- the plateau phase of the sexual cy­
cle. Four more nulliparous study subjects had suggestive uterine en­
gorgement, but since there was a question of positive clinical iden­
tification they were listed as nonreactive. The remaining 8 women
in the nulliparous group did not provide clinical evidence of uter­
ine size increase at plateau-phase levels of sexual tension.
When the uterus obviously was enlarged, the deep vasocongestive
response to sex tension increment developed both with automanip-
ulative and coital stimulation. The longer sexually stimulative ac­
tivity was continued before late plateau-phase levels of tension were
achieved, the more severe was the deep vasocongestive response of
the pelvic viscera.
Obviously, clinical examination of the pelvis is, at best, a crude
determinant of pelvic vasocongestion. Yet, in women easy to exam­
ine pelvically a uterine size increase of from 50 to 100 percent de­
veloping from a known baseline within a twenty-thirty-minute in­
terval should not be missed at routine examination. The clinical
impression persists, after conducting these experiments, that in all
pelves examined there probably was a significant increase in target­
organ size due to vasocongestion. There was no question of this fact
in the 31 parous study subjects; the 12 nulliparous subjects that
were judged nonreactive may have been determined nonreactive
only because the minimal degree of their pelvic visceral response
could not be established by the crude technique of pelvic examina­
tion.
After the routine plateau-phase pelvic checks, the study subjects
returned to sexual activity, and in approximately 75 percent of
the occasions accomplished orgasmic-phase release of their sexual
tensions. Examinations were conducted within a minute or two of
the orgasmic experience, continued at five-minute intervals for a
half-hour, and terminated at the hour interval. The nulliparous
women lost all demonstrable vasocongestion from the pelvic viscera
within 10 minutes after orgasm, while the multiparous study sub­
jects needed from 10 to 20 minutes after orgasm before all clinical
evidence of uterine vasocongestive size increase was dissipated.
When orgasm was not accomplished, clinically obvious uterine size
increase frequently remained for 30 to 60 minutes.
122 CHAPTER EIGHT

There no longer is any question that the uterus may and fre­
quently does increase in size during a sexual response cycle. Par­
ticularly is this reaction clinically obvious when the excitement
and plateau phases are extended in time sequence and the respond­
ing woman is parous. Thus, these experiments provide another ex­
ample of deep vasocongestion in a target organ. The uterus under
the influence of sex tension increment, together with the outer third
of the vagina (orgasmic platform), the minor labia, and the breasts,
reacts specifically to effective sexual stimulation by a marked vaso-
congestive increase in organ fluid content and consequently in or­
gan size.

UTERINE RESPONSE AND

SPERM MIGRATION

There have been numerous references to a sucking effect de­

veloped by the uterus and directed toward seminal-pool content
[69,103, 105,126, 325]. Usually the concept is expressed that during
orgasm the uterus develops some form of pressure and sucks the
seminal fluid through the external cervical os into the cervical canal,
and ultimately even into the endometrial cavity. Thus, in theory,
uterine activity mechanically would shorten the transportation in­
terval and the migratory distance for the spermatozoa elevated from
the vaginal seminal pool by this reaction.
Evidence assembled during the past decade raises grave ques­
tion as to the authenticity of this concept, so well established in
biologic thinking. As described earlier in the chapter, corpus con­
tractions start in the fundus, work down through the midzone, and
terminate in the lower uterine segment. In other words, orgasmic
uterine contractions are expulsive, not sucking or ingesting in char­
acter. Even if a negative pressure could be established in the uterus
with its normal direct tubal connection into the abdominal cavity,
corpus contractions would be expected to work from the midzone
up toward the fundus in order to establish a sucking effect. In an
attempt to evaluate this biologic concept, six study subjects were
selected for active cooperation in a brief clinical investigation. They
FIGURE 8-3
Check plate for cervical cap and radiopaque fluid. Note cervical im­
mersion line.
FIGURE 8-4
Cervix in contact with radiopaque material. Orgasmic phase.

figure 8-5
No evidence of sucking effect of uterus. Resolution phase (after 10
minutes).
 THE UTERUS 12?

were selected both for age and parity. There were two study subjects
in their midtwenties, one nulliparous, the other multiparous. A
similar selection was made of two study subjects in their midthirties,
and finally, of two women in their early forties.
A reasonable facsimile of seminal-fluid content with relation to
surface tension, specific gravity, and specific density was developed
in a radiopaque substance with a liquid base. Since the time inter­
val necessary for normal autolysis of seminal-fluid content is not
present during active coition, every attempt was made to have the
synthetic material correspond with immediately postejaculatory
seminal fluid. Due to autolysis, repeated examination of seminal-
fluid content provides constantly changing values. Baseline values
could not be established for fresh seminal fluid with security and,
therefore, no absolute parallel could be developed for the artificial
media employed. Therefore, interpretive values within an admitted
range of laboratory error arbitrarily were established for the sub­
stitute material employed. Average values of surface tension, specific
density, and specific gravity were developed in the liquid-based
radiopaque substance through the use of apple pectin.
The radiopaque substance was placed in a plastic cap and fitted
over the cervix of each of the six participating study subjects. After
the cap was placed, a radiographic check plate of the pelvis was
taken to assure immersion of the cervix in the experimental mate­
rial and to rule out the possibility of material spillage. Thereafter,
radiographic plates were taken simultaneously with the orgasmic
experience and after 10 minutes of the resolution phase. In none of
the six individuals was there evidence of the slightest sucking effect
on the media in the artificial seminal pool. Nor was there any evi­
dence of the material in the cervical canal or the uterine endometrial
cavity. All women were orgasmic during their experimental session.
The nulliparous woman in her middle twenties was selected as
representative of the six study subjects. A radiogram taken imme­
diately after the onset of automanipulation demonstrated the cervi­
cal cap in proper position and the line of cervical immersion (Fig.
8-3). This woman had an orgasmic experience within a five-minute
time interval. A radiogram was taken during the orgasm (Fig. 8-4).
The resolution-phase plate was taken 10 minutes after orgasmic re­
sponse (Fig. 8-5).
124 CHAPTER EIGHT

In order to establish physiologically acceptable experimental con­

ditions, all six individuals were evaluated at the time of expected
ovulation. In each instance ovulation was established by the tech­
niques of vaginal cytology [294]. While these clinical experiments
are relatively uncontrolled, there still is no evidence to support the
biologic concept of a sucking effect developed by the uterus during
orgasmic experience.
From a purely physiologic point of view, the sucking concept
cannot be supported by the mechanics of coition. If it is presumed
that the uterus develops a sucking effect during orgasm in order to
contribute actively to sperm migration, it must also be presumed
that the external cervical os has immediate and relatively constant
access to seminal-fluid content. During the woman’s orgasmic ex­
perience the corpus and cervix are elevated far from the posterior
vaginal floor. The penis frequently may intervene as a mechanical
blocking agent, or the male may remain unejaculated at the moment
of female orgasm. If ejaculation has occurred prior to female orgasm,
the seminal-fluid content may be collecting in the anatomic basin
on the posterior vaginal floor beneath the penis. Usually, the
anatomy involved makes exposure of the cervical os to seminal-
fluid content a virtual impossibility during active coition.
The biologic concept has been expressed that orgasm produces
a negative pressure in the uterus which persists for significant
lengths of time after active coition. If such a negative pressure or
sucking effect were to develop, presumably a 10-minute resolution­
phase radiogram would show some evidence of fluid migration into
the cervical canal or the lower uterine segment. There was no such
evidence in any of the six women checked. Thus it must be stated
that there is no definitive evidence to date to support the concept
of an active uterine role in aiding and abetting sperm migration
from vaginal deposition sites.

UTERINE RESPONSE
DURING MENSTRUATION

Many cultures abound with interdiction against sexual activity

during menstrual flow [41, 46, 70, 75, 79, 154, 266, 301]. While it
 THE UTERUS I25

certainly is not the province of this investigation to debate this point

along cultural or religious lines, it does remain the province of the
research to establish physiologic truth as opposed to cultural fiction.
Frequently it has been presumed that coital activity during men­
struation will lead to acute physical distress on the woman’s part.
During the past ten years no clinical evidence to support this con­
cept has been established. In short, from a purely physiologic point
of view, there is no contraindication to coition or automanipulation
during menstruation. Obviously, if the female partner is subjec­
tively distressed with the esthetics of coition during menstruation,
is currently experiencing a heavy menstrual flow, or has obvious
physical disability, she well may prefer to avoid coital connection.
These subjective and objective concerns, when present, should be
supported by full cooperation from her male partner.
There is the other side of the coin, however. Many women are
interested in and desire sexual activity during their menstrual pe­
riods. Three hundred and thirty-one women were menstruating reg­
ularly during their active period of cooperation with the sex-re­
search program. Each individual was questioned at length by inter­
view teams with both sexes represented as to her concerns with or
desires for sexual activity during her menstrual periods. Only 33
of these women objected to sexual activity during menstruation on
a basis of religious or esthetic concerns. The remaining high per­
centage of study subjects vocalized no objection to or specific inter­
est in sexual activity during their menstrual periods, providing they
(1) were not at a peak of menstrual flow, (2) felt well, and (3)
felt no esthetic aversion from the male partner. One hundred sev­
enty-three of the 331 women expressed personal interest in sexual
activity during menstruation, particularly during the last half of
the flow period.
Also of interest was the fact that 43 women described the fre­
quent use of automanipulative techniques with the onset of men­
strual flow as a personal method contrived for relieving minor to
major degrees of dysmenorrhea. These study subjects stated that
severe orgasmic experience shortly after onset of menstruation in­
creased the rate of flow, reduced pelvic cramping when present, and
frequently relieved their menstrually associated backaches. Obvi­
ously, these women have learned a technique for the release of the
126 CHAPTER EIGHT

cramping of excessive uterine irritability and the symptoms of pelvic

vasocongestion when present at menstrual onset.
As stated previously, 50 women cooperated with investigation of
uterine response to sexual stimulation during menstrual flow. Thirty-
one of these women were parous and 19 were nulliparous indi­
viduals. At research request, the women subjectively selected the
period of their heaviest flow for evaluation of uterine response. With
a speculum placed in the vagina to provide full view of the cervix
throughout the entire cycle, all 50 women achieved full orgasmic-
phase tension release by automanipulative techniques. Seventeen
of these women desired more than one orgasmic experience during
the experimental sessions. During the terminal stages of orgasmic
experience or within the first few seconds of the resolution phase,
menstrual fluid could be observed spurting from the external cervi­
cal os under pressure. In many instances the pressure was so great
that initial portions of the menstrual fluid actually were expelled
from the vaginal barrel without contacting either blade of the spec­
ulum. It should be recalled that an indwelling speculum holds the
cervix high and far from the vaginal outlet.
These observations provide further clinical evidence of uterine
contractile response to effective sexual stimulation. A strong expel­
ling force must be created in the corpus to extrude menstrual fluid
under the degree of pressure evidenced in these 50 clinical observa­
tions. Since the menstrual flow was extruded in spurts rather than
in continuous flow, the expulsive force can be presumed contractile
rather than spastic in character. It should be recalled that corpus
contractions initiated by orgasm have been recorded physiologically
to start in the fundus and work toward the lower uterine segment.
There now is objective clinical observation to support many wom­
en’s subjective contention that sexual activity during menstrual flow
markedly increases the flow on a temporary basis during an imme­
diate postcoital or postmanipulative time sequence. Additionally,
these observations support the concept of expulsive rather than
ingestive reactions of the corpus to effective sexual stimulation.
 9
THE FEMALE ORGASM

For the human female, orgasm is a psychophysiologic experience

occurring within, and made meaningful by, a context of psycho­
social influence. Physiologically, it is a brief episode of physical
release from the vasocongestive and myotonic increment developed
in response to sexual stimuli. Psychologically, it is subjective per­
ception of a peak of physical reaction to sexual stimuli. The cycle
of sexual response, with orgasm as the ultimate point in progres­
sion, generally is believed to develop from a drive of biologic-be­
havioral origin deeply integrated into the condition of human ex­
istence [55, 75,142,145,196, 246, 279].
Where possible, material presented reflects consideration of three
interacting areas of influence upon female orgasmic attainment pre­
viously recognized in attempts to understand and to interpret female
sexual response: (1) physiologic (characteristic physical conditions
and reactions during the peak of sex tension increment); (2) psy­
chologic (psychosexual orientation and receptivity to orgasmic at­
tainment); and (3) sociologie (cultural, environmental, and so­
cial factors influencing orgasmic incidence or ability) [12, 50, 65,
145, 290, 305, 322]. The quantitative and qualitative relationship
of these factors appears totally variable between one woman’s or­
gasmic experiences, and orgasm as it occurs in other women. Only
baseline physiologic reactions and occasional individually character­
istic modes of expression remain consistent from orgasm to orgasm,
reflecting the human female’s apparent tendency toward orienta­
tion of sexual expression to psychosocial demand.
Factual data pertaining to orgasm may be more meaningful when
placed in clinical context. However, in order to provide a point of
departure for nonsubjective interpretation of female orgasmic re­
sponse, most of the material will be related to recognizable base­
127
128 CHAPTER NINE

lines of physiologic response and psychosocial patterns of sexual

expression which can be duplicated within investigative context.
General impression rather than statistical data will be reflected
owing to the selected quality of the population and the research
atmosphere to which the female study subjects have been exposed
(see Chapter 2).

PHYSIOLOGIC FACTORS OF ORGASM

Female orgasmic experience can be visually identified as well as

recorded by acceptable physiologic techniques. The primary require­
ment in objective identification of female orgasm is the knowledge
that it is a total-body response with marked variation in reactive
intensity and timing sequence. Previously, other observers have rec­
ognized and interpreted much of the reactive physiology of female
orgasm [8, 18, 43, 44, 54, 69, 102, 116, 119, 169, 268, 278, 313,
314, 319]. However, definition and correlation of these reactions
into an identifying pattern of orgasm per se has not been estab­
lished.
At orgasm, the grimace and contortion of a woman’s face graph­
ically express the increment of myotonic tension throughout her
entire body [144]. The muscles of the neck and the long muscles
of the arms and legs usually contract into involuntary spasm. Dur­
ing coition in supine position the female’s hands and feet volun­
tarily may be grasping her sexual partner. With absence of clutch­
ing interest or opportunity during coition or in solitary response to
automanipulative techniques, the extremities may reflect involun­
tary carpopedal spasm. The striated muscles of the abdomen and
the buttocks frequently are contracted voluntarily by women in
conscious effort to elevate sexual tensions, particularly in an effort
to break through from high plateau to orgasmic attainment (see
Chapter 18).
The physiologic onset of orgasm is signaled by contractions of
the target organs, starting with the orgasmic platform in the outer
third of the vagina (see Part 1 of Chapter 6). This platform, created
involuntarily by localized vasocongestion and myotonia, contracts
with recordable rhythmicity as the tension increment is released.
 THE FEMALE ORGASM 129

The intercontractile intervals recur at 0.8 second for the first three
to six contractions, corresponding in timing sequence to the first
few ejaculatory contractions (male orgasm) of the penis (see Part 1
of Chapter 12). The longer contractions continue, the more ex­
tended the intercontractile intervals. The number and intensity of
orgasmic-platform contractions are direct measures of subjective
severity and objective duration of the particular orgasmic experi­
ence. The correlation between platform contractions and subjective
experience at orgasm has been corroborated by study subjects dur­
ing thousands of cycles. Vaginal spasm and penile grasping reac­
tions have been described many times in the clinical and nonpro­
fessional literature [21, 147, 191, 228, 257, 271, 318]. Orgasmic-
platform contractility provides an adequate physiologic explanation
for these subjective concepts.
Contractions of the orgasmic platform provide visible manifes­
tation of female orgasmic experience. To date, the precise mecha­
nism whereby cortical, hormonal, or any unidentified influence may
activate this and other orgasmic reactions has not been determined
(perhaps by creating a trigger-point level of vasocongestive and
myotonic increment).
Orgasmic contractions of the uterus have been recorded by both
intrauterine and abdominally placed electrodes (see Chapter 8).
Both techniques indicate that uterine contractions may have onset
almost simultaneously with those of the orgasmic platform, but
the contractive intensity of the uterine musculature is accumulated
slowly and contractions are too irregular in recurrence and duration
to allow pattern definition. Uterine contractions start in the fundus
and work through the midzone to terminate in the lower uterine
segment. With the exception of the factor of contractile excursion
(indication of intensity), physiologic tracings of uterine orgasmic
contractions resemble the patterns of first-stage labor contractions
[107]. Uterine contractile intensity and duration vary widely from
orgasm to orgasm. However, there is some early indication that
both factors have a positive relation to the parity of the individual
and the prior extent of her orgasmic experience, both incidental and
cumulative.
Involuntary contractions of the external rectal sphincter also may
develop during orgasm, although many women experience orgasm
130 CHAPTER NINE

without evidencing sphincter contraction. When the contractions

do occur, they parallel in timing sequence the initial intercontrac-
tile intervals of the orgasmic platform. The rectal-sphincter con­
tractions usually terminate before those of the orgasmic platform.
The external urethral sphincter also may contract two or three
times in an involuntary expression of orgasmic tension release. The
contractions are without recordable rhythmicity and usually are
confined to nulliparous premenopausal women.
The breasts evidence no specific response to the immediacy of
orgasm. However, detumescence of the areolae immediately subse­
quent to orgasm is so rapid that its arbitrary assignment purely as
a resolution-phase reaction has been cause for investigative concern.
Often areolar detumescence is evident shortly after subjective re­
port of orgasmic onset and usually develops simultaneously with
the terminal contractions of the orgasmic platform. As a final stage
of the rapid detumescent reaction, the areolae constrict into a cor­
rugated state. The nipples remain erect and are turgid and quite
rigid ( the false-erection reaction ).
Rapid detumescence of the vasocongested areolae, resulting in a
constricted, corrugated appearance, occurs only with orgasm and is
an obvious physical manifestation that provides for visual identi­
fication of female orgasmic experience. If orgasm does not occur
areolar detumescence is a much slower process, corrugation does
not develop, and the false-erection reaction of the nipples usually
is reduced in intensity.
The sex flush, a maculopapular rash distributed superficially over
the body surfaces, achieves its greatest intensity and its widest dis­
tribution at the moment of orgasmic expression. Subsequent to or­
gasmic experience, the sex flush disappears more rapidly than when
resolving from plateau-phase levels of erotic tension.
From a cardiorespiratory point of view, orgasm is reflected by
hyperventilation, with respiratory rates occasionally over 40 per
minute. Tachycardia is a constant accompaniment of orgasmic ex­
perience, with cardiac rates running from 110 to beyond 180 beats
per minute. Hypertension also is a constant finding. The systolic
pressures are elevated by 30-80 mm. and diastolic pressures by 20-
40 mm. Hg.
The clitoris, Bartholin’s glands, and the major and minor labia
 THE FEMALE ORGASM 131

are target organs for which no specific physiologic reactions to or­

gasmic-phase levels of sexual tension have been established.
Aside from ejaculation, there are two major areas of physiologic
difference between female and male orgasmic expression. First, the
female is capable of rapid return to orgasm immediately following
an orgasmic experience, if restimulated before tensions have
dropped below plateau-phase response levels. Second, the female
is capable of maintaining an orgasmic experience for a relatively
long period of time.
A rare reaction in the total of female orgasmic expression, but
one that has been reduplicated in the laboratory on numerous occa­
sions, has been termed status orgasmus. This physiologic state of
stress is created either by a series of rapidly recurrent orgasmic ex­
periences between which no recordable plateau-phase intervals can
be demonstrated, or by a single, long-continued orgasmic episode.
Subjective report, together with visual impression of involuntary
variation in peripheral myotonia, suggests that the woman actually
is ranging with extreme rapidity between successive orgasmic peaks
and a baseline of advanced plateau-phase tension. Status orgasmus
may last from 20 to more than 60 seconds, as reflected in Figure
9-1. The severe tachycardia (more than 180 per minute) and the
long-maintained (43 seconds), rapidly recurring contractile pat­
terns of the orgasmic platform are identified easily.
Of interest from both physiologic and psychologic points of view
is the recorded evidence of an initial involuntary spasm of the or­
gasmic platform, developing before the regularly recurring contrac­
tions of orgasmic expression. As indicated in Figure 9-1, the study
subject identified the onset of orgasm and vocalized this subjective
experience before the onset of regularly recurrent contractions of
the orgasmic platform. However, the initial spasm of the orgasmic
platform developed parallel in timing sequence with the subjective
identification of the orgasmic experience. To date, preliminary
spasm of the orgasmic platform has been recorded only in situations
of severe tension increment.
It is investigative impression that the inability to record initial
spasm of the orgasmic platform in all orgasmic experiences well
may reflect lack of effective experimental technique rather than
unimpeachable physiologic fact. Subjectively, the identification of
FIGURE 9-1
Status orgasmus (43 seconds): combination electrocardiogram and orgasmic platform recordings. (A) Late
excitement phase: (Top) Heart rate at 120/min. (Bottom) Orgasmic platform: onset of irritability. (B)
Orgasmic phase: (Top) Heart rate above 180/min. at peak. (Bottom) 25 regularly recurrent platform con­
tractions.
 THE FEMALE ORGASM 133

initial spasm of the orgasmic platform is a constant factor in

any full orgasmic experience. The subjective and objective correla­
tion of orgasmic experience will be discussed later in the chapter.
No preliminary spastic contraction of the uterine musculature
comparable to the initial spasm of the orgasmic platform has been
recorded to date. However, the work is in its infancy, and such a
preliminary spasm before onset of the regular, expulsive, fundal
contractions may, in fact, exist and be recorded in the future.
The subjective identification of orgasmic expression by the hu­
man female simultaneously with the initial spasm of the orgasmic
platform, but 2 to 4 seconds prior to onset of its regularly recur­
rent contractions, draws an interesting parallel with the human
male’s ejaculatory experience. When the secondary organs of repro­
duction contract (see Chapter 14), the male feels the ejaculation
coming and can no longer control it, but there still is a 2- to 4-
second interval before the seminal fluid appears at the urethral
meatus under the pressure developed by penile expulsive contrac­
tions. Thus the male’s psychosensory expression of ejaculatory in­
evitability may have counterpart in the female’s subjective identi­
fication of orgasmic onset. The initial spasm of the orgasmic
platform, before the platform and the uterus contract with regu­
larity, may parallel the contractions of the prostate and, question­
ably, contractions of the seminal vesicles before onset of the regu­
larly recurrent expulsive contractions of the penis.
Understandably, the maximum physiologic intensity of orgas­
mic response subjectively reported or objectively recorded has been
achieved by self-regulated mechanical or automanipulative tech­
niques. The next highest level of erotic intensity has resulted from
partner manipulation, again with established or self-regulated meth­
ods, and the lowest intensity of target-organ response was achieved
during coition.
While variations in the orgasmic intensity and duration of target­
organ response have been recorded and related to modes of stimu­
lation, there have been no recorded alterations in the basic orgas­
mic physiology. This finding lends support, at least in part, to many
earlier concepts of orgasmic response [7, 16, 28, 29, 36, 51, 57, 64,
66, 76, 140, 144, 193, 194, 245, 256, 292, 315]. The fundamental
physiology of orgasmic response remains the same whether the
134 CHAPTER NINE

mode of stimulation is heterosexual or artificial coition or mechani­

cal or automanipulative stimulation of the clitoral area, the breast,
or any other selected erogenous zone. It follows that orgasm result­
ing from fantasy also would produce the same basic physiologic
response patterns, although a woman capable of fantasying to or­
gasm has not been available for inclusion in the research popula­
tion. The ability of women to fantasy to orgasm has been reported
by other investigators [21, 58,144,147,152, 244, 267, 300].
With the specific anatomy of orgasmic-phase physiology reason­
ably established, the age-old practice of the human female of
dissimulating has been made pointless. The obvious, rapid detu­
mescence and corrugation of the areolae of the breasts and the de­
finable contractions of the orgasmic platform in the outer third of
the vagina remove any doubt as to whether the woman is pretend­
ing or experiencing orgasm. The severe vasocongestive reactions
reflecting higher levels of sexual tension cannot be developed other
than during involuntary response to sexual stimulation. For exam­
ple, the transitory but obvious increase in nulliparous breast size,
the sex flush, and the minor-labial sex skin reactions are all plateau­
phase phenomena that develop only in response to effective sexual
stimulation.

PSYCHOLOGIC FACTORS OF ORGASM

It is well to restate from time to time the necessity for maintain­

ing a concept of total involvement when any facet of human sex­
uality is to be considered. This is equally true when the study is
directed to areas of psychologic influence upon orgasmic achieve­
ment [144, 232, 291].
Female orgasm, whether it is attained within the context of an
interpersonal relationship (either heterosexual or homosexual) or
by means of any combination of erotically stimulative activity and/
or fantasy, remains a potpourri of psychophysiologic conditions
and social influence. Many theoretical as well as individually graphic
accounts of the female experience at orgasm have been offered in
the professional literature of many disciplines and are even more
widespread in general publications. This vast amount of published
 THE FEMALE ORGASM 135

quasiauthority depicts both objective and subjective female reaction

to orgasm with almost every possible degree of accuracy and inac­
curacy.
Without referring to the prior literature, a description of subjec­
tive response to orgasmic incidence has been compiled from re­
ports of 487 women, given in the laboratory in the immediacy of
the postorgasmic period, obtained through interview only, or de­
veloped from a combination of both sources. This composite is
offered as a baseline for a concept of the psychologic aspects of the
human female’s orgasmic experience.
The consensus drawn from the multiple descriptions has estab­
lished three distinct stages of woman’s subjective progression
through orgasm.

STAGE 1
Orgasm has its onset with a sensation of suspension or stoppage.
Lasting only an instant, the sensation is accompanied or followed
immediately by an isolated thrust of intense sensual awareness,
clitorally oriented, but radiating upward into the pelvis. Intensity
ranging in degree from mild to shock level has been reported by
many women within the context of their personal experience. A
simultaneous loss of overall sensory acuity has been described as
paralleling in degree the intensity and duration of the particular
orgasmic episode. Loss of sensory acuity has been reviewed fre­
quently in the literature [8, 30, 40, 69, 113, 114, 136, 144, 239, 251,
257, 271,308,319].
During the first stage of subjective progression in orgasm, the
sensation of intense clitoral-pelvic awareness has been described by
a number of women as occurring concomitantly with a sense of
bearing down or expelling. Often a feeling of receptive opening was
expressed. This last sensation was reported only by parous study
subjects, a small number of whom expressed some concept of hav­
ing an actual fluid emission or of expending in some concrete fash­
ion. Previous male interpretation of these subjective reports may
have resulted in the erroneous but widespread concept that female
ejaculation is an integral part of female orgasmic expression [67,
93, 319]-
136 CHAPTER NINE

Twelve women, all of whom have delivered babies on at least

one occasion without anesthesia or analgesia, reported that during
the second stage of labor they experienced a grossly intensified
version of the sensations identified with this first stage of subjective
progression through orgasm. Reports of this concept also have ap­
peared from time to time in the literature [66, 241].

STAGE 11

As the second stage of subjective progression through orgasm, a

sensation of “suffusion of warmth,” specifically pervading the pel­
vic area first and then spreading progressively throughout the body,
was described by almost every woman with orgasmic experience.

STAGE III

Finally, as the third stage of subjective progression, a feeling of

involuntary contraction with a specific focus in the vagina or lower
pelvis was mentioned consistently. Frequently, the sensation was
described as that of “pelvic throbbing.”
Women with the facility to express sensate awareness frequently
separated this final stage of subjective progression into two phases.
The initial phase was expressed as contractile, followed immedi­
ately by a throbbing phase, with both sensations experienced as
separate entities. The initial contractile feeling was described as
localized vaginally, subsequently merging with the throbbing sensa­
tion which, though initially concentrated in the pelvis, was felt
throughout the body. The “pelvic throbbing” sensation often was
depicted as continuing until it became one with a sense of the pulse
or heartbeat.
Only the two phases of this third stage of subjective progression
during orgasm afforded positive correlation between subjective re­
sponse and objective reaction. This correlation has been developed
from a composite return of direct interrogation of female study
subjects during investigative sessions. The phase of contractile sen­
sation has been identified as paralleling in time sequence the
recorded initial spasm of the orgasmic platform.
 THE FEMALE ORGASM 137

Regularly recurring orgasmic-platform contractions were appre­

ciated subjectively as pulsating or throbbing sensations of the va­
gina. Although second-phase sensations of pulsation coincided with
observable vaginal-platform contractions, consciousness of a pul­
sating sensation frequently continued beyond observable platform
contractions. Finally this pelvic-throbbing sensation became one
with a subjective awareness of tachycardia described frequently as
feeling the heartbeat vaginally. Subjective awareness of orgasmic
duration was somewhat dependent upon the degree of intensity
of the specific orgasm.
Rectal-sphincter contraction also was described by some anatomi­
cally oriented or hypersensitive women as a specific entity during
intense orgasmic response.
Observation supported by subjective report indicates that a rela­
tive norm of orgasmic intensity and duration is reflected by ap­
proximately five to eight vigorous contractions of the orgasmic plat­
form. A level of eight to twelve contractions would be considered
by observer and subject to be an intense physiologic experience.
An orgasmic expression reflected by three to five contractions usu­
ally is reported by the responding female as being a “mild experi­
ence” unless the woman is postmenopausal (see Chapter 15). These
physiologically recordable levels of orgasmic intensity never must
be presumed arbitrarily to be a full or consistent measure of the
subjective pleasure derived from individual orgasmic attainment
[182,197,259].
Pregnancy (particularly during the second and, at times, the third
trimester) has been noted to increase general sensitivity to the
overall sensate effects of orgasm (see Part 2 of Chapter 10). To
date, an increase in contractile intensity of the pregnant woman’s
orgasmic platform as compared to that in her nonpregnant state
has not been corroborated by physiologic tracings. Orgasmic con­
tractions of the uterus recorded during the second and third tri­
mesters consistently have been reported as subjectively more in­
tense sensations than those of nonpregnant response patterns. Of
interest from an objective point of view is the fact that tonic spasm
of the uterus develops in response to orgasmic stimulation and has
been recorded during the third trimester of pregnancy.
138 CHAPTER NINE

SOCIOLOGIC FACTORS IN ORGASM

In our culture, the human female’s orgasmic attainment never

has achieved the undeniable status afforded the male’s ejaculation.
While male orgasm (ejaculation) has the reproductive role in sup­
port of its perpetual acceptance, a comparable regard for female
orgasm is still in limbo. Why has female orgasmic expression not
been considered to be a reinforcement of woman’s role as sexual
partner and reproductive necessity? Neither totem, taboo, nor re­
ligious assignment seems to account completely for the force with
which female orgasmic experience often is negated as a naturally
occurring psychophysiologic response.
With orgasmic physiology established, the human female now
has an undeniable opportunity to develop realistically her own sex­
ual response levels. Disseminating this information enables the
male partner to contribute to this development in support of an
effective sexual relationship within the marital unit [62, 235]. The
female’s age-old foible of orgasmic pretense has been predicated
upon the established concept that obvious female response increases
the male’s subjective pleasure during coital opportunity. With need
for pretense removed, a sexually responding woman can stimulate
effectively the interaction upon which both the man’s and woman’s
psychosocial requirements are culturally so dependent for orgasmic
facility.
Impression formed from eleven years of controlled observation
suggests that psychosocially oriented patterns of sexual expression
evolve specifically in response to developing social and life cycle de­
mands. When continuity of study-subject cooperation permitted
long-range observation and interrogation, it was noted that major
changes in social baseline were accompanied by actual changes in
sexual expression. For the female study subjects, changes involving
social or life-cycle demands frequently resulted in a reorientation
of sexual focus. This was manifest in alterations in desired areas of
stimulation, preferred actions of partner, and reported fantasy [118,
144, 198]. Often variations in coital and masturbatory techniques
were observed.
These alterations usually appeared gradually, although, depend­
 THE FEMALE ORGASM 139

ing upon the impact of the social change involved, there were occa­
sions of sudden onset. To date, physiologically measurable intensity
in orgasmic response has shown no specific parallel to onset or
presence of these psychosocial influences. This may indicate that
physiologic capacity, as influenced by purely biologic variations, re­
mains a dominant factor in orgasmic intensity and facility [64, 76,
231, 316]. Reported levels of subjective pleasure in orgasm did, of
course, parallel reports of desirable or undesirable social change.
It became evident that laboratory environment was not the de­
termining factor in the success or failure of female study subjects’
orgasmic attainment. Rather it was from previously established
levels of sexual response that the individual female was able to cope
with and adapt to a laboratory situation [76, 161, 170, 178, 221].
There were no particular personality trends toward high- or low-
dominance individuals among the participating female research
group. The women’s personalities varied from the very shy through
the agreeably independent, and histories reflected sexual-partner
experience ranging from single to many. The ability to achieve or­
gasm in response to effective sexual stimulation was the only con­
stant factor demonstrated by all active female participants. This
observation might be considered to support the concept that sexual
response to orgasm is the physiologic prerogative of most women,
but its achievement in our culture may be more dependent upon
psychosocial acceptance of sexuality than overtly aggressive be­
havior [17, 50, 57, 69, 100, 142, 194, 199, 300].
Many existing psychologic theories find support in the physio­
logic data emerging from this study [33, 81, 111, 166, 182, 233,
247]. However, it must be recalled that these data have been pre­
sented primarily as impression, due to the selectivity of the re­
search group and, in many instances, the absence of a statistically
significant number of recorded reactions. There always is great
temptation to connect theory to considered fact, when subjective
reports of the research population are placed as an overlay on the
observed and recorded physiologic reactions. If recall by interro­
gated subjects of early sexual feeling and of manipulative activity,
often to a remembered peak of experience, is to be given credence,
sexual response well may be viewed as an instinctual activity arising
from an undifferentiated sexual state. Although molded and trans­
140 CHAPTER NINE

mitted genetically, sexual response, in this concept, would be sub­

ject to both immediate and continued learning processes [20, 71,
74, 82,101,160,167,181, 229, 332].
Unreported observations [131] suggest that infant sexual re­
sponse as an undifferentiated state is not beyond possibility [82,
172]. Certainly, elaboration of sexual behavior in early childhood
of less restricted cultures has been reported [32, 67, 76, 109, 155,
192, 228]. The development of sexual responsiveness to orgasmic
level, identifiable subjectively, must be a cumulative result of inter­
action between the individual female’s hereditary endowment and
the psychosocial influence to which it is exposed. The element of
time must be assumed to be a finally determining factor, as it ac­
crues the experience of social and psychosexual maturation [112,
160,180, 275].
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 empha­
sizing an acute awareness of the vital, certainly the primary influ­
ence, exerted by psychosocial factors upon human sexuality, par­
ticularly that of orgasmic attainment of the female [1, 53, 55, 76,
114, 145, 195, 313]. Although the basic physiology of female or­
gasm never would have evolved from behavioral theory or socio­
logic concept, it equally is obvious that physiologic detail is of value
only when considered in relation to these theories and concepts.
When completed, psychosocial evaluation of the study-subject pop­
ulation will be published in another book.
 IO

PREGNANCY AND
SEXUAL RESPONSE

i. ANATOMY AND PHYSIOLOGY

Female sexuality as it may be enhanced or repressed by the state

of pregnancy has been a subject of conjecture for generations. The
taboos and sanctions dealing with this problem have been ap­
proached in number only by those which relate sexuality to men­
strual flow. Many of these taboos and sanctions have been pre­
sumed based upon established biologic fact, when in reality they
have developed from sources ranging from obscure speculation to
that extreme of prejudice, restricted individual experience [14, 125,
171, 266, 280, 301, 309].
One hundred and eleven women aged 21 to 43 years agreed to
cooperate with a subjective investigation of female sexual response
as affected by pregnancy. Seventy-nine husbands of these women
also cooperated with the program. The subjective material returned
from team interviews will be presented in Part 2 of this chapter in
a discussion format.
Greater value has been placed upon the objective results returned
from a small group of six study subjects who cooperated with an
anatomic and physiologic evaluation of sexual response during preg­
nancy and the postpartum period. The pertinent data relating to
these study subjects are listed in Table 10-1. All women in this
experimental group were married, and Subjects B, C, E, and F
had taken active parts in various phases of the program before preg­
nancy. Study subjects B and E had cooperated with physiologic
investigations of uterine contractile response to sexual stimuli prior
to attempting pregnancy (see Chapter 8). The contractile patterns
recorded from their nonpregnant uteri have been available for com-
141
142 CHAPTER TEN: PART ONE

TABLE 10-1

Pregnant Study Subjects

Study
Subject
Subject Age at Gravidity Formal Prior to
Identification Conception and Parity * Education t Pregnancy
Grav. I
A 21 Para 0 High school No
Grav. Ill
B 21 Para 1 High school Yes
Grav. I
C 24 Para 0 College Yes
Grav. Ill
D 27 Para 2 College No
Grav. II Postgraduate
E 31 Para 0 school Yes
Grav. IV
F 36 Para 3 High school Yes

* Status with current pregnancy.

t Listing relates to reported matriculation (highest level).

parison with those returned from experiments conducted in uterine

contractile physiology during the three trimesters of pregnancy.
Study subjects A and D first became active participants early
in their pregnancies, A at seven weeks and D after eight and one-
half weeks of amenorrhea.
Techniques of sexual stimulation have been natural and artificial
coition and manual and mechanical automanipulation.
In describing the effects of a state of pregnancy upon female
response to sexual tensions, no attempt will be made to present
finite detail other than of target organs. The study subject group of
six women is entirely too small to allow authoritative consideration
of general body reactions. The target organs have been defined ar­
bitrarily as the breasts and internal and external genitalia. Changes
wrought in these organs by sexual stimulation superimposed upon
alterations resultant from a state of pregnancy will be considered
within the established framework of the four phases of the cycle of
 PREGNANCY AND SEXUAL RESPONSE M3

sexual response. Since stages of pregnancy also may influence target­

organ response, physiologic alterations subsequent to sexual stimu­
lation will be related to the three trimesters of pregnancy and the
postpartum period.

THE BREASTS

In the human female’s body some of the earliest changes reflect­

ing pregnancy occur in the breasts. Tumescence develops in the
areolae as an early indication of conceptive influence. The breasts
rapidly increase in size during the first trimester due to significant
increases in the vascular and glandular beds. Venous drainage
patterns are defined clearly on breast surfaces early in the first tri­
mester and continue through pregnancy and into the postpartum
period.
The onset of tenderness along lateral breast surfaces and rapid
size increase are the particular trademarks of the newly pregnant
woman who has borne no children. When the nulliparous woman
responds to sexual stimuli in the first trimester of her pregnancy,
venous congestion of the breasts is more obvious than in a non­
pregnant state. Hundreds of observations of nonpregnant women
have established the fact that nulliparous breasts undergo a transi­
tory 20-25 percent increase in size in response to plateau-phase
levels of sexual tension (see Chapter 3). The same relative size in­
crease usually develops in the nulliparous breast as a normal physio­
logic change by the end of the first trimester of pregnancy. When
the vasocongestive reaction to sexual stimuli is superimposed upon
the definitive increase in breast size resulting from a state of preg­
nancy, the nullipara’s subjective complaint of severe breast tender­
ness during advanced stages of sexual tension early in pregnancy
is understandable. Breast pain occasioned by sex tension increment
frequently is localized in turgid nipples and engorged areolar ele­
ments.
During the second and third trimesters of pregnancy there usu­
ally is marked reduction in the nullipara’s complaint of breast
tenderness, whether it is solely the result of pregnancy or subse­
quent to the transitory venous congestion of superimposed sexual
M4 CHAPTER ten: PART ONE

tension. By the time the conical nursing-shape characteristic of late

third trimester has been achieved, breast volume has been increased
by approximately one-third compared to that in the nonpregnant
state. High levels of sexual tension frequently do not provide fur­
ther obvious increase in breast size at this stage of pregnancy. How­
ever, reactions of nipple erection and areolar tumescence remain
constant through all three trimesters of pregnancy.
During the second or third month of the postpartum period,
breast reaction to sexual stimuli is related to the nursing phe­
nomenon. If the normal postpartum milk production has been de­
pressed artificially through hormonal control or by constrictive
breast binding, there is little physiologic response of the breasts
other than nipple erection, even to plateau-phase levels of sexual
tension. The woman with suppressed milk production may be six
months past her delivery date before any definitive vasocongestive
reaction can be observed in the breasts in response to sexual stimu­
lation.
Nursing breasts, normally increased in volume, do not demon­
strate a consistent size increase even at plateau-phase levels of sex­
ual tension. However, the nursing mother responding to sex tension
increment frequently initiates an unusual reaction pattern. Many
women lose breast milk in uncontrolled spurts when responding to
sexual stimuli. Milk has been observed to run from both nipples
simultaneously during and immediately subsequent to an orgasmic
experience. Usually full flow of milk is restricted from the breast
more recently nursed. Involuntary loss of milk control has been ob­
served during both coital and automanipulative activity.
Since only six women cooperated actively during and immedi­
ately after their pregnancies, no suggestion of statistical significance
can be derived from clinical observation. Three of the six women
did nurse after their deliveries, two of them for a four-month and
one for a six-month period. Two of these women frequently dem­
onstrated involuntary loss of milk control during orgasmic experi­
ence. They also reported the experience of similar reaction patterns
outside the laboratory. The third study subject in the nursing
group did not lose milk control during orgasmic response either
during episodes of active cooperation with the research program or
in private reactive experience.
 PREGNANCY AND SEXUAL RESPONSE 145

THE GENITAL ORGANS

A state of pregnancy markedly increases the vascularity of the

pelvic viscera. Obviously, the mechanism of fetal support creates
gross vasoconcentration in the female pelvis. Any superimposed
physiologic response to sexual stimulation even further increases
this massive pelvic vasocongestion.
All six of the study subjects became consciously aware of in­
creased levels of sexual tension toward the end of the first or during
the early stages of the second trimester. The sex tension increment
reached extremely high levels during the second and continued well
into the third trimesters of their pregnancies. Four of the six women
described occasional cramping and aching in the midline of the
lower abdomen during and immediately subsequent to orgasmic
experience in the first trimester of pregnancy. Two women also
complained of low backache as a residual of the orgasmic cramping
episodes. Although none of the six women spotted vaginally or
developed any clinical threat of pregnancy wastage, the subjective
awareness of increased uterine irritability subsequent to effective
sexual stimulation was of particular moment.
During the second trimester, all six study subjects described
strong sexual drives marked by increased interest both in coital
and manipulative activity and were observed in fulminating orgas­
mic experiences. Two subjects who had never been multiorgasmic
in prior sexual experience described and demonstrated the onset of
this high-tension response for the first time during the second tri­
mester of their pregnancies. The other four study subjects have
positive histories for multiorgasmic response both in pregnant and
nonpregnant states. Discussions of reactions of external and in­
ternal genitalia to sex tension increment during states of pregnancy
will be restricted primarily to variations from the norms of physio­
logic response established for the nonpregnant state (see Part 1
of Chapter 6).

EXCITEMENT PHASE

The human female’s external genitalia and the internal organs

of reproduction alter significantly during pregnancy, when com­
146 CHAPTER TEN: PART ONE

pared to their norms in the nonpregnant state. Variations in pelvic

viscera, in reaction to pregnancy, primarily are related to intensity
of generalized pelvic vasocongestion. Therefore, it is understand­
able that the vasocongestive response of the internal and external
genitalia to sexual stimuli is a much more significant factor in
pregnancy than is the development of myotonia.
During the excitement phase the reaction of the labia majora in
the nullipara follows the usual patterns (described in Chapter 4).
For multiparous women, however, there is a tendency for the major
labia to be excessively engorged with blood and frequently quite
edematous. Although they undergo involuntary lateral withdrawal
from the vaginal outlet in the routine mounting invitation, the
elevation and flattening reactions of the major labia usually are ab­
sent after the first trimester of pregnancy. This restriction in reactive
potential probably results from a marked increase in vasoconges­
tion of the entire pelvis associated with the pregnant state.
In response to excitement-phase levels of sexual tension, the
minor labia usually become markedly engorged and at least two to
three times enlarged. This vasocongestive response to sex tension
increment continues throughout the first two trimesters of preg­
nancy. In the third trimester the minor labia normally are so chron­
ically engorged with both venous blood and interstitial edema fluid
that further specific distention subsequent to sex tension influence
is difficult to demonstrate.
Toward the end of the first trimester all six study subjects de­
scribed a definitive increase in the production of vaginal lubrication
that continued throughout pregnancy. Since four of the six women
had worked with the sex-research program prior to pregnancy, ob­
jective measurement of lubrication production was possible. Vaginal
lubrication developed more rapidly and more extensively for these
four women during pregnancy than had been their pattern in non­
pregnant response to sexual stimulation. Usually, pregnancy-ori­
ented increase in lubrication production was greater in the multi­
parous subjects as opposed to those women carrying their first term
pregnancies.
All six study subjects complained of a light mucoid discharge that
became apparent toward the end of the first trimester and continued
throughout pregnancy. It may be that the gross venous engorgement
 PREGNANCY AND SEXUAL RESPONSE I47

of the vaginal barrel accompanying states of pregnancy provides

such an increase in vaginal lubrication that there is more or less
constant, low-grade production of this material, even when the
individual is not exposed consciously to sexual stimuli. Such a re­
action would be presumed the result of pelvic venous congestion
contributing to the transudate-like product of vaginal lubrication.
By the end of the first trimester of pregnancy all uteri normally
are so enlarged that they have become abdominal organs. This
physiologic distention and elevation of the pregnant uterus includes
those that are normally retroverted or retroflexed. One subject had
a retroverted uterus that moved forward and elevated to become an
abdominal organ by the end of the first trimester of pregnancy.
After the uterus is elevated into the abdomen, vaginal expansion
and distention in response to sexual stimuli continues in the same
fashion as in the nonpregnant state. The exception is that the de­
finitive tenting phenomenon in the transcervical vaginal depth,
which occurs subsequent to excitement-phase uterine elevation in
the non-pregnant state, cannot be demonstrated. Once the preg­
nant uterus becomes an abdominal organ, there is a normal
physiologic “tenting” which develops in the anterior vaginal wall
to such a degree that further direct response to sexual stimuli
cannot be established with security.
There has been no evidence of secretory activity at the cervical os
during sexual excitation in any of the six pregnant study subjects
during the three trimesters of pregnancy.

PLATEAU PHASE

The minor labial sex-skin reaction occurs routinely in every fe­

male, pregnant or nonpregnant, if orgasm is to follow.
As plateau-phase tension levels are established, a marked venous
engorgement of the outer third of the vagina normally develops as
the orgasmic platform (see Part 1 of Chapter 6). In the nulliparous
pregnant study subjects, localized vaginal engorgement became so
severe when excitement or plateau phases were prolonged signifi­
cantly that 75 percent of the vaginal lumen was obtunded by this
massive vasocongestion. For the multiparous pregnant study sub­
jects, the orgasmic platform developed to such an extent that fre­
148 CHAPTER TEN: PART ONE

quently the vaginal barrel appeared completely obtunded, with the

lateral vaginal walls meeting in the midline in severe vasocongestive
response to sexual tensions. The more advanced the state of preg­
nancy, the more severe the venous engorgement of the entire
vaginal barrel, and the more advanced the secondary development
of the orgasmic platform in response to sexual stimulation.
The uterine-elevation reaction (see Chapter 8) cannot be dem­
onstrated once the uterus becomes an abdominal organ. Uterine
vasocongestive increase in size or vasocongestion of the broad liga­
ments cannot be identified as specific reactions to sex tension in­
crement after pregnancy has been established. This does not mean
that these reactions do not occur to varying degrees. The gross ex­
pansion of the uterus and the passive vasocongestion of the broad
ligaments associated with normal pregnancy (particularly during
the second and third trimesters) preclude identifying these reactions
with the crude clinical techniques currently available.

ORGASM

Orgasmic-platform contractions can be identified as specific phys­

iologic evidence of orgasmic experience during both the first and
second trimesters of pregnancy. During the third trimester the or­
gasmic platform in the outer third of the vagina may be so con­
gested with venous blood and the entire vaginal barrel so edematous
that intensity of contractions during orgasmic experience appear
minimal to direct observation. Although the woman subjectively
feels contractile response of the orgasmic platform, the entire area
may be so overdistended that objective evidence of contractile
efficiency is reduced markedly.
During the third trimester of pregnancy, particularly during the
last few weeks before term, the uterus instead of contracting reg­
ularly during orgasmic experience may go into tonic spasm. Spastic
uterine contractions have been observed occasionally in the labora­
tory and timed to continue for as long as one minute in response to
orgasmic stimulation. Listening to the fetal heart tones at this time
may return evidence of a slowed heart rate, but this reaction is
transitory in character. No further evidence of fetal distress has
been demonstrated. Two study subjects evidenced regularly recur­
 PREGNANCY AND SEXUAL RESPONSE I49

ring uterine contractions for as long as a half-hour after orgasmic

experience in the last month of pregnancy. Obviously, the uterus is
normally highly irritable at this time, particularly in the nulliparous
woman. When regularly recurrent uterine contractions associated
with orgasmic experience are superimposed upon the basic uterine
irritability of the last stages of pregnancy, a spastic uterine contrac­
tion may be the result.

RESOLUTION PHASE

Resolution-phase reaction during pregnancy differs severely from

that in the nonpregnant state, in that the vasocongested pelvis fre­
quently is not relieved completely with orgasmic experience. The
further pregnancy progresses, the less effective is vasocongestive
disbursement subsequent to orgasm. Direct observation of the six
pregnant study subjects revealed continued major and minor labial
engorgement and a congested vaginal barrel that included residuals
of the orgasmic platform, as opposed to the usual complete disburse­
ment of this localized vasocongestion subsequent to orgasm in the
nonpregnant state.
In resolution during the second trimester, it may take from 10 to
15 minutes after orgasm for the increased labial and vaginal-barrel
vasocongestion developed by sex tension increment to be lost from
the primigravid pelvis, and 30 or 45 minutes from the multiparous
pelvis. As previously stated, during the third trimester vasoconcen-
tration in the pelvis may not be relieved completely regardless of
the severity of the orgasmic experience. This residual vasocongestion
often is subjectively translated into a continuation of sexual stimula­
tion.
The lack of clinical relief of chronic pelvic vasocongestion sub­
sequent to orgasmic expression may account for the fact that during
the second and third trimesters of pregnancy the six study subjects
noticed subjectively higher sexual tension levels than they had en­
countered in nonpregnant states. The study subjects repeatedly
stated that orgasmic experience, although objectively most severe
and subjectively quite satisfying, did not relieve their sexual tension
levels for any significant length of time. Obviously, their compara­
i5o CHAPTER TEN: PART ONE

tive focus was subjective recall of comparable orgasmic response

situations in nonpregnant states.
The massive vasocongestion of the pelvic viscera associated with
a state of pregnancy further is increased by sex tension increment
even late into the third trimester of pregnancy. Postorgasmic dis­
bursement of the pelvic vasoconcentration, a normal resolution­
phase reaction in nonpregnant states, is slowed and usually tran­
sitory during pregnancy. Residual pelvic vasocongestion, together
with the pelvic pressures resultant from second- and third-trimester
uteri, may account for the high levels of maintained sexual tensions
frequently described for these stages of pregnancy.

POSTPARTUM PHYSIOLOGY

All six study subjects had uncomplicated deliveries, all babies

were reported to be in good physical condition, and the six subjects
rejoined the investigative program between the fourth and fifth
weeks after delivery. As noted earlier, three subjects nursed through
the fourth postpartum month. All subjects were reevaluated three
times after delivery: when they rejoined the program, between the
sixth and eighth postpartum weeks, and at the end of the third
postpartum month. A pelvic check with the first evaluation at four
to five weeks showed the episiotomies to be well healed, the cer­
vices closed, and the uteri still abdominal organs. The nursing sub­
jects, as would be expected, had smaller, better involuted uteri than
the nonnursing women. From the first evaluation at four to five
weeks to the last observations at the third postpartum month,
major physiologic changes developed in the pelves.
Although four of the six study subjects reported significant levels
of eroticism at the first check, the physiologic reactions of their
target organs were reduced both in rapidity and intensity of re­
sponse. Vasocongestive reactions of the major and minor labia
were mature, once they developed, but they frequently were de­
layed in development well into the plateau phase. Vaginal lu­
brication developed slowly and in reduced quantity. Vaginal dis­
tention in the inner two-thirds of the barrel also was reduced in
rapidity of development and in the degree of excursion when
compared to previously established patterns of reactivity. Under
 PREGNANCY AND SEXUAL RESPONSE 151

direct observation the walls of the vagina were quite thin at this
time. Normal rugal patterns were flattened or absent and the
vagina was light pink in color and appeared almost senile to direct
observation. Particularly was this steroid-starvation pattern true
for the three nursing mothers. Since the uteri were still abdominal
organs and a residual of pregnancy-incurred venous congestion re­
mained in the broad ligaments, no true clinical picture of supra­
vaginal vasocongestive response to sex tension increment could
be obtained during these examinations.
At plateau-phase tension levels the orgasmic platform developed
in the outer third of the vagina, but there was significant reduction
in the extent of reaction. During the last trimester of pregnancy,
75 to 100 percent of the vaginal lumen had been obtunded by the
development of the orgasmic platform; at the four-to-five-week
postdelivery check not more than one-third of the vaginal barrel
was obtunded by the orgasmic platform immediately prior to or­
gasmic experience. The sex-skin reaction of the minor labia was
present in all women immediately prior to orgasm, but there was
significant reduction in the vividness of the color change.
With orgasm, contractions of the orgasmic platform were reduced
in intensity and duration of recurrence. Although the study subjects
reported subjective satisfaction from orgasmic experience, the or­
gasmic-platform contractions were reduced markedly in physiologic
intensity during the actual orgasmic experiences.
At the six-to-eight-week check there was little variation from
the findings during the first examinations.
Early postpartum response to sex tension increment has provided
an exception to the general rule that physiologic response patterns
parallel in intensity the psychosexual tension levels. Through the
first six to eight postpartum weeks, sexual tensions frequently were
described at nonpregnant levels, particularly among the nursing
mothers, but intensity and duration of physiologic response during
coital and manipulative opportunity were diminished. Thus there
is a suggestion that states of steroid starvation may have more
effect on physiologic patterns of performance than on psychologic
levels of tension.
At the end of the third postpartum month an entirely different
picture was presented. All six study subjects gave evidence of return
152 CHAPTER TEN: PART TWO

of ovarian hormone production although the nonnursing group

was ahead of the three nursing mothers. Vaginal rugal patterns were
reestablished, and uteri had returned to normal pelvic positioning.
The major and minor labia responded readily to sexual stimuli
following response patterns established for women in a nonpregnant
state (see Part 1 of Chapter 6). Lubrication developed in expected
quantity and with usual rapidity. The vaginal barrels expanded at
the transcervical depth and extended in length in the nonpregnant
manner.
In response to plateau-phase tension levels, uterine elevation and
vasoconcentration of the broad ligaments could be identified. Uter­
ine size increase could not be determined with security. The orgas­
mic platform developed to normal degree, obtunding approximately
50 percent of the vaginal outlet. The sex-skin reactions of the minor
labia again developed a vivid coloration in the immediate preorgas-
mic period.
With orgasm, the orgasmic platforms evidenced increased con­
tractile intensity and the contractions recurred from eight to twelve
times, well within usual patterns of nonpregnant response.
Subjectively, the study subjects could not define significant dif­
ference between the orgasmic experiences of the three-month check
as opposed to those developed during the four-to-five-week check.
Physiologically, however, there was no question of increased inten­
sity and duration of the third month’s experiences as opposed to
those developed four to five weeks after delivery.

2. CLINICAL CONSIDERATIONS

The pregnancy year (three trimesters and the immediate post­

partum period) contributes to elevations and depressions of both
male and female sexuality that represent excursions well beyond
the response levels usually encountered in nonpregnant states.
Eroticism in pregnancy has not been investigated to a degree
sufficient to establish response patterns acceptable as baselines by
either the biologic or behavioral disciplines. In an attempt to
 PREGNANCY AND SEXUAL RESPONSE 153

highlight this wide gap in the knowledge of human sexual response,

limited studies with both objective and subjective focus have been
conducted. The physiology of human sexual response as affected
by pregnancy has been presented in Part 1 of this chapter. The
subjective concerns of the pregnant woman and the involved man
in relating a state of pregnancy to sexual response are of current
interest. This discussion provides a baseline from which a defini­
tive study of human sexual behavior during pregnancy may be
developed.
Material returned from this phase of the investigation must be
accepted at the level of clinical impression rather than considered
as statistically suggestive or presumed established fact. The num­
ber of women interrogated in depth is too restricted and the sample
too biased to represent an adequate cross-section of the population.
In presenting material, clinical import will be given precedent over
subjective report. A more definitive study of pregnancy and sexual
response will be presented in the near future.
Interrogative opportunity was solicited from 113 pregnant
women. Of the women originally approached, 111, aged 21 to 43
years, agreed to cooperate with a subjective investigation of female
eroticism as affected by pregnancy. During the first trimester initial
interviews were scheduled toward the end of the second month.
In the second trimester the sixth month was the review month,
and for the third trimester review was conducted at the end of
the eighth month of pregnancy. The postpartum review was held
in the third month after delivery. The initial interview concentrated
upon psychosocial, sexual, and medical backgrounds. The review
periods primarily were sexually focused. All interviews were con­
ducted by a team of both sexes.
Subjective material has fallen into patterns that relate to age,
parity, trimester of pregnancy, postpartum period, current state of
health, social pressures, and, of course, successful termination of
pregnancy.
As shown in Table 10-2, the 111 pregnant women have been
grouped by age and parity. A total of 43 of these women, 7 of
whom were unmarried, were primigrávidas and expected to cany
to full term. Thirty-seven women were carrying a second pregnancy
to term; 2 of these women were unmarried. Finally, 24 women
154 CHAPTER TEN: PART TWO

TABLE 10-2
Ages and Parity of 111 Pregnant Women
Interviewed

Ages (Yr.)
Parity 21-30 31-40 41-43 Totals
0 35 8 0 43
1 25 11 1 37
2 14 8 2 24
3 2 3 2 7
Totals 76 30 5 111

were attempting to carry a third pregnancy, and 7 a fourth, to

full term. There were 76 women between 21 and 30 years old;
30 women between 31 and 40; and 5 women were between 40
and 43 years of age at the onset of the current pregnancy.
The statistics of previous pregnancy wastage and current preg­
nancy conclusion in the 111 women are listed in Table 10-3.
Three of the 43 women attempting their first full-term pregnancy
aborted toward the end of the first trimester, and 1 woman
became severely toxemic and lost a stillborn infant three weeks
from term. Three of the 37 attempting a second full-term preg­
nancy aborted before the end of the first trimester, and 1 mis­
carried at the fifth month. Finally, 2 of the 24 women attempting
a third full-term pregnancy aborted before the end of the first
trimester, 1 woman miscarried, and 1 lost an infant from con­
genital malformations and infection approximately one month
postdelivery. None of the 7 women attempting a fourth pregnancy
had obstetric difficulty.
In brief, of the total of 111 women interviewed during the
second month in the first trimester, 8 women lost pregnancies
shortly after their initial interview and 2 women lost pregnancies
during their second trimester. This pregnancy wastage brought to
101 the number of women cooperating throughout the interroga­
tion (included among the 101 women were the 2 women with
pregnancy loss at term and in the postpartum period).
 TABLE IO-3

Pregnancy Wastage in m Pregnant Women Interviewed

No. Fetal Deaths

Previous Conceptions Current Conception

3rd 3rd
Trimester: Trimester:
1st Trimester 2nd Delivery 1st Trimester 2nd Delivery
Trimester and Trimester and
Parity No. Abortion C-AB* Miscarriage Postpartum Abortion C-AB * Miscarriage Postpartum

0 43 12 7 2 0 3 0 0 1
1 37 7 3 1 2 3 0 1 0
2 24 6 2 0 2 2 0 1 1
3 7 2 0 0 0 0 0 0 0
Totals 111 27 12 3 4 8 0 2 2

C-AB = Criminal abortion.

156 CHAPTER TEN: PART TWO

Seventy-nine husbands offered cooperation with team interroga­

tion, and did so at the end of the third postpartum month after
all review with their wives had been completed. Nine of the 101
women were unmarried. Thus 79 of a possible 92 husbands co­
operated with the investigation. The age among the men inter­
rogated ranged from 25 to 49 and averaged 31 years, 7 months.
Formal education averaged three years and two months of college.
The educational range was from incomplete high-school attendance
to postgraduate degree.
The subjective material returned from interrogation of the co­
operating women relates primarily to parity and trimester of preg­
nancy and will be presented in the framework of these arbitrary
standards. The average age of the 101 women was 27 years, 8
months, and the average level of formal education was two years
and three months of college exposure. As with the husbands, the
actual range of formal education varied from incomplete high­
school attendance to postgraduate degree.
Subjective material returned from repeated interviews with the
6 study subjects who cooperated with the physiologic investiga­
tion of sexual response in pregnancy (see Part 1 of this chapter)
is not included in the material contributed by the 101 women
who cooperated only at interview level.

FIRST TRIMESTER

During the first trimester, great variation was reported in levels

of eroticism and effectiveness of sexual performance among the
women interviewed. Reports ranged from voluntary rejection of
all physical forms of sexual activity during the entire pregnancy
to deliberate prostitution. In essence, the first-trimester response
related closely to parity and to social stratum.

NULLIPAROUS WOMEN

Of the 43 women who were attempting a first, full-term preg­

nancy, 33 reported reduction in sexual tensions and in effectiveness
of sexual performance. Many of these women were contending
 PREGNANCY AND SEXUAL RESPONSE I57

with nausea, and all were affected with sleepiness and symptoms
of chronic fatigue.
Twenty-six of the 43 nulliparous women reported fear of injury
to the conceptus (frequently not vocalized to their partner) as
affecting the freedom of their physical response in coital activity
during the first trimester. Two of these women had been urged to
avoid coition during the first trimester by their physicians.
There were 7 unmarried women in the sample who were under­
going their first pregnancy. Two of these women continued coital
connection throughout pregnancy and the postpartum period with
the man who reportedly fathered the child. Three of the 7 women
had occasional coital opportunities during the pregnancy. One girl
rejected both intercourse and automanipulation for the duration of
the pregnancy after a diagnosis was established, and one woman
turned to prostitution during her first trimester, admittedly for
financial gain, but with the expressed hope that excessive sexual
activity early in the pregnancy would induce an abortion. Each of
these 7 women reported little or no eroticism during their first
trimester of pregnancy. They were overwhelmed with the social
aspects of their circumstance. Concern for their financial security,
plans for the baby, and concern for their own personal care during
the pregnancy weighed heavily during this trimester. These socio­
economic concerns also were expressed by the two women with the
semipermanent male-partner connections.
Among the remaining 10 members of the nulliparous group,
6 described no apparent change in their sexual interest or effective­
ness of their sexual performance. Only 4 nulliparous women re­
ported a significant increase in sexual interest and elevated de­
mand for increased rate of performance immediately after the
diagnosis of pregnancy was established.

PAROUS WOMEN

As a group, the 68 parous women generally noted very little

change in their levels of sexual interest or effectiveness of per­
formance during the first trimesters of their pregnancies as opposed
to their recalled levels of response for a three-month period im­
mediately prior to conception. Exceptions to this statement were
158 CHAPTER TEN: PART TWO

7 women who were involved with nausea and vomiting of preg­

nancy. All of these women described similar gastrointestinal in­
volvement and similar marked loss of sexual interest during the
first trimesters of previous pregnancies. Only 4 of 68 women re­
ported an increase in sexual drive or improved sexual performance
that was apparent by the end of the second month of pregnancy
when the interrogations were conducted.

SECOND TRIMESTER

During the second trimester, sexual patterns generally reflected

a marked increase in eroticism and effectiveness of performance
regardless of the parity or ages of the women interrogated. This
evidence of elevated sexuality was reported by the women not
only as interest in sexual encounter but also as planning for sexual
encounter, fantasy of sexual encounter, and sex-dream content.
There also was an increased demand for a considered effectiveness
of sexual performance.
Of the 101 women reviewed toward the end of the second
trimester, 82 described a significant improvement in basic sexuality
not only over that recalled from the first trimester of pregnancy
but well beyond their concept of previously established norms of
performance in nonpregnant states.
Of the 19 women who described no improvement in sexual
interest or performance 11 were nulliparous and 8 were parous.
Of these, 4 women (3 nulliparous) described extremely low levels
of sexual interest in their past histories, had never been orgasmic,
and could not define change in sexual interest or demand during
their entire pregnancies. These women also had described them­
selves as sexually unaffected by pregnancy during interrogation
in the first trimester.
Two women in the parous group were having their second
illegitimate pregnancies. Both of these women were living in their
concept of common-law marriage. They described marked increase
in sexual interest and performance during the second trimester.
Five of the 7 women illegitimately pregnant with their first
 PREGNANCY AND SEXUAL RESPONSE 159

pregnancy had no opportunity for regular coition. However, 4 of

these women described marked increase in sexuality. Although
socially denied the opportunity of regular coition, they masturbated
with a greatly increased frequency as compared not only to first-
trimester activity but also to their pattern in the nonpregnant state.
Their socioeconomic concerns were relatively under control, and
their personal fears, if not dispelled, at least were neutralized.
Among these 4 women was the girl who had prostituted herself
during the first trimester of pregnancy. Although currently denied
social opportunity for regularly recurring intercourse, she described
marked subjective sexual drive for the first time and multiorgasmic
performance on coital occasion. In addition she instituted auto-
manipulative techniques on a regularly recurring basis for the first
time in her life.
One girl, as previously described, rejected any form of sexual
performance throughout her entire pregnancy and the postpartum
period. She did describe constantly recurring erotic dreams and
occasions of erotic fantasy during the second trimester.

THIRD TRIMESTER

Interviews were conducted approximately one month before the

estimated date of confinement. In the nulliparous group there was
a significant reduction in coital frequency compared to reported
incidence in the second trimester. However, there was the major
restraint of medical intervention. Intercourse was contradicted by
medical advice for 31 of the 40 nulliparous women who attained
the third trimester of pregnancy. Continence was prescribed for
periods varying from four weeks to three months prior to delivery.
There also were multiple reports of a variety of somatic complaints.
The sleepiness of the first trimester returned, and the second-
trimester symptoms of irritability, abdominal fullness, pelvic ten­
sion, and backache increased in severity. Although admittedly
strongly influenced by medical restriction, 33 of the 40 nulliparous
women reported that they personally gradually lost interest in
sexual activity during the third trimester.
i6o CHAPTER TEN: PART TWO

Intercourse also was contradicted by medical authority for 46

of the 61 parous women reviewed during the third trimester of
their pregnancies. Again the period of coital restriction ranged
from three months to four weeks before the estimated date of
confinement. Forty-one of the 61 members of this parity group
described a significant reduction in eroticism and frequency of
sexual performance as the estimated date of confinement ap­
proached. The subjective loss of sexual tension was related by
parous women to exhausting physical demands more than to medi­
cal influence. Frequently parous women admitted that contending
with existing children and their own physical distresses magnified
by the advanced stage of pregnancy kept them in such a state
of chronic exhaustion that they seldom sought the opportunity for
active sexual performance. When directly approached, however,
their effectiveness in and capacity for sexual performance frequently
surprised the women themselves.
Sixty-eight of the 77 women for whom coition was interdicted
medically expressed concern with the prescribed period of sexual
continence and its possible effect upon their husbands’ sexual
requirements. Seventeen of the nulliparous and 32 of the parous
women reported that they made deliberate attempts to relieve
their husbands during the period of prescribed continence.
Of interest were the observations of 8 nulliparas and 12 multi­
paras relating to husbands’ loss of sexual interest in them person­
ally. They stated that their husbands’ withdrawal from sexual
encounter had onset late in the second or early in the third tri­
mester of pregnancy. By this time they had become obviously preg­
nant, with large abdomen, swollen face, thickened ankles, and all
of the other gross physical signs of approaching confinement.
They expressed concern over this apparent lack of male interest in
their physical being, and the fear that the current rejection might
have some degree of permanent residual. All but 3 women thought
that their husbands avoided them on the basis of (1) their physi­
cal appearance, (2) concern for their personal comfort, or (3)
fear of injuring the fetus, and they were content to wait for
the release of delivery. The 3 women expressed specific knowl­
edge of their husbands’ interest in other sexual outlets at this
time.
 PREGNANCY AND SEXUAL RESPONSE 161

POSTPARTUM PERIOD

Postpartum interviews were conducted in the third month after

delivery. Female eroticism reported in the postpartum period had
no sure relationship to parity or age of the woman, but could be
related directly to the act of nursing. Forty-seven of the 101 women
(19 in the formerly nulliparous group, 28 in the parous group)
described low or essentially negligible levels of sexuality during the
reviews conducted early in the third postpartum month. A variety
of reasons for lowered sexual tensions were presented. Excessive
fatigue, weakness, pain with attempted coition, and irritative
vaginal discharge were but a few of these reasons. The area of
greatest expressed concern was personal fear of permanent physical
harm if coital activity were resumed too soon after delivery.
The remainder of the group (21 formerly nulliparous and 33
parous women) reported varying levels of sexual interest. These
reports ranged from rapid return to nonpregnant sexual tension
levels within two to three weeks after delivery to significantly higher
levels of tension than in the nonpregnant state, described as a
group by the nursing mothers (24 women). Aside from constant
concern by the entire group for the possibly injurious effects of
too rapid return to coital activity, the only real deterrent to early
sexual activity in this group was perineal pain or vaginal-barrel
irritation after coition.
Interestingly, 11 women described significantly increased sexual
pleasure derived from the tenderness of the episiotomy area or
the tightness of the postpartum vaginal barrel. A major factor
in the rapid return of eroticism among this group of women was
the continued feeling of congestion and fullness in the pelvis that
had been present in the second and third trimesters, which they
associated with sex tension increment. The postpartum pelvis is in
truth chronically congested with venous blood, so the subjective
sensations described by these women are readily understandable.
Ten women from the previously nulliparous group and 14 from
the parous group were successful in nursing their babies for at least
two months after delivery. The highest level of postpartum sexual
interest in the first three months after delivery was reported by
1Ó2 CHAPTER TEN: PART TWO

this group of nursing mothers. Not only did they report sexual
stimulation (frequently to plateau tension levels and, on three
occasions, to orgasm) induced by suckling their infants, but as a
group they also described interest in as rapid return as possible
to active coition with their husbands. There was a heavy overlay
of guilt expressed by 6 of the 24 women who admittedly were
stimulated sexually by the suckling process. They were anxious
to relieve concepts or fears of perverted sexual interest by recon­
stituting their normal marital relationships as quickly as possible.
This concept has been reported previously [53, 263, 296] and is
only confirmed by this investigation.
Of interest were the expressed concerns of 8 previously nul-
liparous and 17 parous women after voluntarily rejecting nursing
opportunity during the postpartum period. A major factor leading
to nursing refusal was verbal rejection of the concept of nursing
by 16 husbands. Thirteen of these women expressed fear of loss
of their figures and were not sufficiently reassured by medical
authority to consider nursing in a positive vein. The remainder
of the concerns ranged from personal rejection of the process as
degrading to the fear expressed by 6 women of the high levels of
eroticism stimulated by the suckling process. These 6 women were
multiparas and had attempted nursing with previous pregnancies.
The fact that for at least four weeks after delivery all women are
essentially castrates so far as ovarian function is concerned had
no predictable influence on the reported levels of their eroticism
or sexual performance. If negligible or absent ovarian-steroid pro­
duction is assumed to play an all-important role in female sexuality,
women in the immediate postpartum period would be expected
to have low or absent levels of sexual interest until the ovaries
resume sex-steroid secretion in normal physiologic sequence four
to six weeks after delivery.
Obviously, as reported above, such was not the case. States of
steroid starvation could have contributed to the excessive fatigue,
exhaustion, and emotional instability that were reported as dis­
tressing symptoms among the low-sex-tension groups. However,
the nursing women, normally contending with the longest delay
in physiologic return of ovarian-steroid production, also had the
highest levels of reported postpartum eroticism. There is no doubt
 PREGNANCY AND SEXUAL RESPONSE 163

that ovarian steroids have a role in female sexuality. That steroid

levels play the all-important role, as has been presumed by so
many in the past, obviously is false. Money and Lloyd have sup­
ported the concept of steroid fallibility [175, 232].
The incidence of masturbation during the postpartum period
was essentially negligible, as only 5 women reported any recourse
to or need for this form of relief. Two of these women were among
the group that had delivered illegitimate pregnancies.
Fifty-eight of the 101 women reviewed during the postpartum
period reported concern for their husbands’ sexual tensions during
the postpartum period of continence. Particularly were they con­
cerned when postpartum continence was added to whatever pre­
delivery-continence period had been established. Those women
that had provided active relief for their husbands during third-
trimester continence periods did so again after delivery. Three
women in the parous and one in the previously nulliparous group
had not approached their husbands before delivery, but during the
postpartum period they assumed an active role in providing release
for these men.
With the exception of the women for whom intercourse was
interdicted medically for three months and the members of the
nonmarried group, all women interviewed returned to full coital
activity within six weeks to two months after delivery. Despite
the fact that intercourse was prohibited for at least six weeks by
most medical authority, there frequently was return to coital
activity within three weeks of delivery by higher-tensioned women
or by wives attempting to respond to male demand. Particularly
was an early return to coition the pattern for those women actively
nursing. The women that tended to follow physicians’ prescribed
periods of continence were those who had regained little of their
own erotic interest.

MALE REACTIONS

As noted earlier in the chapter, 79 of the total of 92 available

husbands cooperated with bisexual interrogation at the end of the
third postpartum month, after all interrogative connection with
164 CHAPTER TEN: PART TWO

their wives had been terminated. Their stated ages ranged from
25 to 49 years. Eight of the men reported previous marriages,
and six had children by these marriages. Therefore, all experience
could not be related to current or previous pregnancies by present
wives. For the sake of brevity, only material relating to the last
trimester of pregnancy and the postpartum period will be presented.
Thirty-one of the men stated in retrospect that they had with­
drawn slowly, almost involuntarily, from active coital demand
upon their wives toward the end of the second or early in the
third trimester. As described earlier in the chapter, 20 of the 31
wives involved noted and reported their husbands’ apparent loss
of coital interest. The husbands gave no consistent reasons for
withdrawal other than fear of causing physical injury to fetus or
to wife. Eighteen men stated that they really weren’t interested,
and “don’t know why.” Only 5 of the men described the stig­
mata of pregnancy (swollen abdomen, thickened legs, etc.) as
personally objectionable. Two men stated that their wives had
not maintained personal cleanliness to the degree that was their
pattern in the nonpregnant state and that they had lost sexual
interest as a consequence.
Seventy-one of the men were married to women whose physicians
had prohibited intercourse for periods varying from four weeks to
three months prior to the estimated date of confinement. Twenty-
one of these men stated that they understood, agreed with, and
honored the prohibition. Twenty-three men did not understand
the reason for the prescribed continence period, were not sure
the doctor had said it, or wished that he had explained it to them
as well as their wives. Twelve of the men reported that they had
sought release outside of the home when denied conjugal opportu­
nity by medical proscription.
The major concern expressed after delivery by the entire group
was how soon active intercourse could be reinstituted without caus­
ing physical harm or emotional distress in their wives. None of the
husbands had any clear idea of female postpartum physiology or
psychology despite a liberal sprinkling of postgraduate degrees.
Several husbands of the high-tensioned postpartum women
were concerned with an early return to sexual encounter that was
established despite medical interdiction. They stated that the
 PREGNANCY AND SEXUAL RESPONSE 165

active demand for coition two to three weeks postpartum had

been instituted by their wives.
The 12 men that sought release outside the marriage during the
predelivery continence period continued to do so after delivery.
Six more husbands described extramarital activity during the
postpartum continence period. From 3 of these men came the
declaration that this was the “first time.”

CLINICAL CONCERNS

The study of female sexuality in pregnancy has highlighted

material of basic obstetric relevance. This material is presented
to suggest that little is known and frequently a great deal pre­
sumed in clinical areas relating to the pregnant woman’s physi­
ologic and psychologic patterns of sexual response.
For years, Javert [127, 128] has been concerned with the possible
relation between female orgasmic experience during coition and
pregnancy wastage in the first trimester. He has emphasized the
importance of avoiding coital activity during the first trimester
of pregnancy for individuals with a positive obstetric history of
three successive abortions. However, there has been no similarly
expressed concern for the severe uterine contractions that result
from an orgasmic experience induced by manipulative activity
during the first trimester of pregnancy.
Observations and physiologic recording of uterine contractile
response to sexual stimuli in the nonpregnant state suggest that
the uterus may contract with more intensity during an orgasmic
experience accomplished by manipulative stimulation than from
active coition (see Chapter 8). Similar investigation involving the
six study subjects in the first trimester of pregnancy tends to
support this clinical assumption (see Part 1 of Chapter 10). All
six women subjectively described more severe uterine contractile
response during an orgasm induced by manipulation than in
orgasmic response to coital stimulation. If it is true that coitally
induced orgasmic experience and the consequent uterine contractile
response have a tendency to induce pregnancy wastage, particularly
among susceptible women, it also must be considered highly
166 CHAPTER TEN: PART TWO

probable that masturbatory activity will create the same tendency

toward pregnancy wastage for the susceptible multiple aborter.
Although both professional and lay literature [27, 95, 250, 295]
has carried discussions of the problem of pregnancy wastage re­
sulting from coition, warnings of the possibility of pregnancy wast­
age subsequent to successful erotic stimulation by manipulative
techniques have not been given similar publicity.
Late in the third trimester of pregnancy, when the fetal present­
ing part enters the true pelvis and cervical effacement begins,
there will be some reduction in the elevation of the anterior
vaginal wall in response to sexual stimulation. This is purely a
mechanical effect and does not reflect lack of expansive ability
of the reacting tissues. With the presenting part deeply engaged in
the true pelvis, the cervix is brought into the vaginal axis. At this
stage, consistent, direct penile-cervical contact is probable during
active coition. Some postcoital spotting may result from direct
contact between the erect penile glans and the vasocongested
predelivery cervix. If spotting or frank bleeding occurs, coition
should be interdicted.
There are legitimate clinical concerns with both coition and
automanipulation at or near term. It probably is true that the
contractions of orgasm at or near term can send a woman into
labor. Certainly this reaction has been verbalized sufficiently to
be of some possible clinical significance. Four women, uninvolved
in the research program, have reported the onset of labor im­
mediately subsequent to orgasmic experience [131]. In three in­
stances, orgasmic response was initiated by coital stimulation. In
one situation, the contractions initiated by multiorgasmic auto­
manipulation continued into full-fledged labor with delivery. In
all four cases the women were within 18 or less days of the
expected date of confinement. Three women were having a first
and one a second delivery. No obstetric distress was encountered.
Whether or not premature labor can or has been induced by
orgasmic response is of major clinical moment. There is no secure
information available on this subject.
Insofar as the clinical problem of infection resultant from coition
is concerned, this problem applies not only to the last few weeks
but also to any stage of pregnancy, or for that matter, to the non­
 PREGNANCY AND SEXUAL RESPONSE 167

pregnant state. The interdiction of coition during the latter part

of the third trimester based only upon fear of infection for mother
or child is a residual of the preantibiotic days in medicine and
largely can be negated. Infection of the vaginal barrel immedi­
ately prior to labor certainly is controllable medically. In like
manner, full protection can be and is provided the newborn
infant.
The uterus remains an abdominal organ for approximately six
weeks after delivery. Bleeding from the placental site on the wall
of the uterus usually continues for two to four weeks postpartum.
Incisions in the perineum and posterior vaginal wall (episiotomy)
made to aid in the delivery of the child usually are well healed
within two to three weeks. Therefore, from a purely physiologic
point of view, there is no contraindication to coition once the
postpartum vaginal bleeding has stopped and any incisions or tears
in the vaginal outlet have healed.
The whole problem of coition during the third trimester of
pregnancy and the postpartum period should be individualized.
As described, late in the third trimester there is possible direct
penile contact with a relatively unyielding cervix when the pre­
senting fetal part is deeply engaged in the pelvis. Yet many
women, particularly multíparas, go through the entire third trimes­
ter without deeply engaging the presenting part until in active
labor. There is no real contraindication to coition in this situation
insofar as damage to the pregnancy on a purely mechanical basis
is concerned.
Although the female may be physiologically capable of resuming
coition early in the postpartum period, she may or may not be
psychologically ready to do so. Again the problem should be
considered by medical authority on an individual basis. Many
women are anxious to return to coital connection as soon as
physically possible. They should be encouraged in this regard.
There are those women who prefer longer periods of continence.
Their situation should be discussed, personal reasons examined,
fears explained away, and a firm understanding between both
members of the marital unit established. Frequently, blanket
medical interdiction of coital activity for arbitrarily established
168 CHAPTER TEN: PART TWO

periods of time both before and after delivery has done far more
harm than good.
A more thorough investigation of problems of sexual activity
for both husband and wife late in the third trimester and early
in the postpartum period is in order. Physicians often fail to take
into account the factor of long-term male continence. Six weeks
before and six weeks after delivery usually are proclaimed restricted
periods by medical interdiction. Many male partners first break
marital vows during this three-month period. If such a degree of
sexual continence is in order, the situation should be explained to
the marital partners, and concerns with automanipulation also
should be discussed. If continence is not indicated, a healthy
marriage may be preserved by individualizing each case. Many men
accustomed to regular ejaculatory release find three months an
excessive period of continence and may elect not to tolerate such
degrees of personal restraint.

The material presented in this chapter reflects the influence of

pregnancy upon female eroticism. Although the sample obviously
is prejudiced these reports suggest that parity and trimester of
pregnancy exert the greatest influence upon female sexual response
before delivery, and that nursing in the postpartum period usually
initiates rapid return of female interest in sexual performance.
Male concern with the relation of a state of pregnancy to marital-
unit sexuality has been approached casually and needs further
amplification. Possibly of significance is the suggestion that medical
authority should individualize rather than arbitrarily assign pre-
partum and postpartum periods of continence.
MALE SEXUAL
RESPONSE
 11

MALE EXTRAGENITAL
REACTIONS

lhe human male’s physical reaction to elevated levels of sexual

tension is not confined to the primary or secondary organs of repro­
duction. Physical evidence of sexual tension develops throughout
the entire body. Just as with the female, physiologic response to
effective sexual stimulation follows two basic patterns—first, wide­
spread vasocongestion (superficial and deep) and second, myotonia
(generalized and specific). Physical reactions other than those in­
volving the organs of reproduction are of sufficient magnitude to
merit separate consideration.

THE BREASTS

There is no consistent anatomic response of the male breast to

sexual stimulation. However, frequent nipple erection and addi­
tional nipple tumescence have been demonstrated by male study
subjects. If nipple erection is to occur, it usually develops late in
the excitement phase and lasts throughout the remainder of the
sexual cycle. Tumescence of the erect nipples is evidence of plateau­
phase levels of sexual stimulation. Nipple erection has been ob­
served in 60 percent of the study subjects and additional tumescence
in 7 of 10 males who attain full nipple erection. However, late ex­
citement or early plateau vasocongestive reactions of increased
venous pattern or areolar tumescence have not been observed in
the sexually responding male.
There are no specific male breast reactions during the late plateau
or orgasmic phases of the sexual response cycle. If both primary
erection and secondary tumescence of the nipples are established,
171
172 CHAPTER ELEVEN

it may be many minutes or even more than an hour after ejaculation

before resolution-phase nipple retraction is accomplished.
Nipple erection and tumescence usually develop without direct
contact. As a source of erotic stimulation male breasts and nipples
seldom are manipulated directly during heterosexual activity. How­
ever, breast stimulation does constitute a significant segment of
male homosexual activity. As a result, the nipples and even the
anterior chest wall develop erotogenic qualities seldom found in
the heterosexually oriented male.

SEX FLUSH

The human male develops the same maculopapular sex flush

described for the human female (see Chapter 3). A statement of
statistical rate of appearance will be omitted, however, since the
flush occurs with wide variation within the same individual as well
as between different individuals. Although an overall observation of
25 percent incidence was noted throughout the study, correlation
with individual tendency or individual circumstance did not seem
sufficiently pertinent to record.
When the sex flush occurs in the male, it arises from the epi­
gastrium and spreads over the anterior chest wall. The neck, face,
and forehead progressively are involved. Occasional evidence of the
flush appears on the shoulders, forearms, and thighs of particularly
susceptible males. When fully developed, the maculopapular sex
flush resembles the measles rash. While this flush may appear late
in the excitement phase in a situation of rapid tension elevation, it
usually develops after the plateau phase is well established. There­
after it spreads rapidly as the highly stimulated male progresses to­
ward an orgasmic experience.
The appearance of this measles-like rash in any phase of the
cycle provides evidence of high levels of sexual tension. For example,
a man may experience a complete cycle of sexual response without
manifesting a sex flush. During a subsequent opportunity much
higher levels of sexual tension may develop and the sex flush may
become quite evident. The actual occurrence and timing of onset
of the male sex flush seem to be influenced by both environmental
 MALE EXTRAGENITAL REACTIONS 173

and psychogenic factors. Evidence of this is suggested when re­

corded incidence is higher in a heated rather than a cool room and
in situations of extreme anticipation rather than routine perfor­
mance.
During the refractory period of the male’s resolution phase the
sex flush disappears with extreme rapidity. It disappears initially
from the shoulders and extremities, secondarily from the diaphragm
and anterior chest wall and, finally, from the neck, face, and fore­
head.

MYOTONIA

Myotonia becomes clinically obvious late in excitemcnt-phase and

during plateau-phase levels of sexual tension and is both generalized
and specific in character. Usually muscles contract with regularity
or in spasm in an involuntary manner, but contraction frequently
may be voluntary, depending upon coital positioning.
Carpopedal spasm [144, 203, 239] rarely has been observed with
the male in the usual superior coital position (see Chapter 18). The
physical activity associated with this position necessitates employ­
ment of voluntary musculature of the trunk, pelvis, and extremities
and usually precludes development of involuntary striated-muscle
spasm in the extremities. If the male is in supine position during
coition, carpopedal spasm occurs frequently. This involuntary spasm
of the striated musculature of the hands and feet is an indication
of high levels of sexual tension. Carpopedal spasm has been ob­
served more frequently during male masturbatory episodes than
during intercourse, regardless of body positioning.
A detailed discussion of both male and female myotonia during
sexual response has been undertaken in Chapter 18.

THE RECTUM

The external rectal sphincter contracts irregularly subsequent to

direct stimulation in both the excitement and plateau phases of
the sexual response cycle. During the ejaculatory experience the
174 CHAPTER ELEVEN

sphincter also contracts involuntarily. Orgasmic contractions of the

sphincter recur in regular patterns with an o.8-second intercontrac-
tile interval. They occur simultaneously with the expulsive contrac­
tions of the periurethral musculature, but do not recur more than
two to four times. Resolution-phase relaxation of extemal-sphincter
muscle tension occurs before the expulsive contractions of the penile
urethra have been completed.

CARDIORESPIRATORY REACTIONS

HYPERVENTILATION

Hyperventilation developing during the late plateau and the or­

gasmic phases of the sexual response cycle is a normal occurrence.
The physiologic intensity and the duration of the hyperventilative
reaction frequently are indicative of the degree of sexual tension.
The reaction usually continues through the orgasmic phase and
resolves in the refractory period of the resolution phase. Respiratory
rates peaking at over 40 per minute have been recorded repeatedly
during orgasm.

TACHYCARDIA

The heart rate of the responding male increases in direct parallel

to his rising sexual tensions. During plateau-phase levels of sexual
tension the heart rates of male study subjects have been recorded
in a range of 100-175 beats per minute. The slower the initial heart
rate at resting stage, the lower the rate during sexual stimulation.
Orgasmic-phase recordings have ranged from 110 to 180+ beats per
minute. Electrocardiograph tracings must be studied with a mag­
nifying glass to count the beats per minute at the extremely high
levels of cardiac contractility. These rates occur regardless of the
technique of sexual stimulation (Fig. 11-1 ).

BLOOD PRESSURE

Elevations in systolic blood pressure ranging from 40 to 100 mm.

Hg. have been recorded from male study subjects during coition and
 MALE EXTRAGENITAL REACTIONS 175

1 HIM. LATER

FIGURE 11-1
Male study-subject, electrocardiogram (Lead V): cardiac rates during
sexual stimulation.

automanipulation. Diastolic pressure elevations have ranged from

20 to 50 mm. Hg.
In the past there have been several attempts to evaluate the
problems inherent in the cardiorespiratory response to sex tension
increment [22, 67, 151, 152, 220, 282]. Clinicians daily face the
problem of advising the patient recovering from an acute episode
of coronary artery occlusion. One of the immediate problems is that
176 CHAPTER ELEVEN

of the family unit’s interest in returning to an active sexual relation­

ship. How much cardiac strain develops in response to sexual ten­
sions? Is coition more of a strain on the cardiac patient than is
masturbation? Are there sex techniques that will place less strain
on the heart, yet relieve the individual and the family unit of their
tension increment? These are but a few of the questions that
medicine must answer.
A report on male cardiorespiratory response to sexual tensions
will be published in the future, with detailed consideration given
to both general body and target-organ physiology.

PERSPIRATORY REACTION

Many males evidence an involuntary sweating reaction immedi­

ately after ejaculation. This perspiratory reaction may develop
whether or not there has been obvious physical exertion during the
sexual encounter, and whether or not a sex flush has appeared.
Usually this perspiratory reaction is confined to the soles of the feet
and the palms of the hands, but may appear on the trunk and oc­
casionally may involve the head, face, and neck of the responding
male. If perspiration appears on body surfaces, it does so during
the refractory period of the resolution phase. Occasionally the per­
spiratory reaction develops so rapidly that its appearance is con­
comitant with the final ejaculatory contractions of the penis. Ap­
proximately one-third of all male study subjects developed the
perspiratory reaction.
Human physiologic response to sexual stimuli is above all else a
protean reaction. The examples of reaction in specific body areas
or organ systems recorded in this chapter should not distract from
the concept that the entire body is involved by sex tension incre
ment. As the tensions elevate, so do the reactions of vasocongestion
and myotonia, until the trigger point of physiologic release, orgasm,
is attained.
 I 2

THE PENIS

i. ANATOMY AND PHYSIOLOGY

The anatomy and physiology of penile-erection response to sexual

stimulation have been considered exhaustively in the literature
[19, 94, 142, 276, 299, 329]. This material will be presented in
detail sufficient only to establish orientation to the male’s primary
reproductive viscera.
The morphology of the penis provides ideal support for the pri­
mary physiologic response to sexual stimulation, vasocongestion.
The penis is formed of three cylindrical bodies of erectile tissue
(Fig. 12-1). Two of the cavernous cylinders, the corpora cavernosa
penis, lie parallel to each other and just above a third cylinder of
erectile tissue, the corpus spongiosum, which, in addition to erectile
tissue, contains the urethra. The corpus spongiosum is expanded at
its base to form the urethral bulb and distally to form the glans
penis. The two corpora cavernosa and the corpus spongiosum are
each surrounded by an individual fibrous coat, the tunica albuginea,
and all three corpora are enclosed in dense fascial capsules.
At the base or root of the penis the corpora cavernosa penis di­
verge to form the crura, two processes which are attached directly
to rami of the pubis and ischium (the pubic arch). Each of the
crura is sheathed by the ischiocavernosus, a skeletal muscle. The
corpus spongiosum also is encapsulated by a skeletal muscle, the
bulbospongiosus muscle.
The two corpora cavernosa and the corpus spongiosum form the
erectile tissue of the penis, receiving arterial blood from branches
of the internal pudendal arteries. These branches are (1) the dorsal
arteries of the penis found near the dorsal surface of the penis in
the tunica albuginea; (2) the cavernous arteries running longitu­
dinally through each corpus cavernosum penis; and (3) two bul­
bourethral arteries that run longitudinally through the corpus spon-
177
178 CHAPTER TWELVE: PART ONE

FIGURE 12-1

The penis: normal anatomy (lateral view).

giosum just ventral to the urethra. Terminal branches from these

arteries, the helicine arteries, end in small capillaries that open
directly into the cavernous spaces (Fig. 12-2).
Venous return is by two pathways, the superficial dorsal vein
which drains the entire corpus spongiosum including the glans
and the urethral bulb, and the deep dorsal vein that drains the
corpora cavernosa.
The cavities of the three corpora cavernosa serve as erectile tissue.
There are many compartments separated by bands or cords of
fibrous and smooth-muscle tissue called trabeculae. These compart­
ments are interspersed with arterioles the intima of which sup-

Dorsal Dorsal ortsry ond nerve

FIGURE 1 2-2

The penis: normal anatomy (transverse view).

 THE PENIS 179

posedly contains ridges which in a contracted state act to constrict

partially the blood flow entering the cavernous sinuses. When the
arterioles are dilated, the flow of blood into the penis is increased
and the sinuses are filled. The veins of the penis are believed to
possess valves that slow down the return of blood from the penis
[87, 148]. Previously, contraction of the ischiocavernosus muscle
was believed to aid in erection by secondary venous constriction,
but little support is given now to this concept [108].
The return of the erect penis to a flaccid state probably is much
more the result of active constriction of the arterioles than of any
other action. The trapped blood then escapes from the cavernous
sinuses despite any existent passive constriction of the veins.
Dilatation of the penile arteries and subsequent penile erection
are the result of stimulation of the splanchnic nerves. Erection is
lost when the sympathetic nerve supply causes constriction of the
penile arteries. A center for reflex erection is believed to exist in
the sacral portion of the spinal cord [110, 285]. Obviously, stimula­
tion of erection primarily is directed from the higher cortical cen­
ters [10, 25, 238, 307,320].
The erotic component of the male genitalia has been concen­
trated in external pelvic anatomy. The penis, scrotum, and rectum
are markedly sensitive to sexual stimulation, while the prostate,
seminal vesicles, vas deferens, etc., have little or no sensual focus
(Fig. 12-3). These structures respond to effective sexual stimulation
both by vasocongestion and by elevated muscle tension. It should
not be presumed, however, that every incidence of increased vaso­
congestion or of muscle tension evidenced by male genitalia neces­
sarily reflects states of elevated sexual tension. While recurrent erec­
tion and detumescence of the penis usually are evidence of waxing
and waning sexual tensions, there are other causes for penile erec-
tive response that should be considered in context before attention
is focused specifically on penile reaction to sexual stimulation. The
penile erection that adolescent and mature males frequently evi­
dence upon awakening has been observed on multiple occasions.
Partial penile erection subsequent to stress on the perineal muscula­
ture, such as that resulting from lifting unusually heavy loads or
straining at stool, has been recorded. Involuntary penile erection
18o CHAPTER TWELVE: PART ONE

FIGURE 12-3
Male pelvis: normal anatomy (lateral view).

also has been demonstrated repeatedly clinically in such pathologic

conditions as phimosis with irritative proprioceptive stimulation of
the glans, and benign prostatic hypertrophy with secondary penile
stimulation resultant from chronic urinary retention.
Recently, regularly recurrent penile erection has been recorded
during the observed sleep of male experimental subjects [131].
In younger males dream erections recur regularly despite ejaculatory
experience in an immediate presleep sequence. However, if the
male is in his late thirties or beyond, an ejaculatory experience im­
mediately before observed sleep reduces the incidence of dream
erections, particularly in the first few hours of the sleep sequence.
Hyperinvolution of the penis beyond resolution-phase levels of
detumescence has been observed clinically on numerous occasions.
Penile involution following exposure to cold (e.g., swimming in
cold water) is well established. In situations of acute exhaustion
consequent to severe physical strain, the penis usually is smaller
than its normal flaccid size. Advancing age or surgical castration
may and frequently does produce a secondary involution of the
 THE PENIS 181

penis which permanently reduces organ size below previously estab­

lished normal states for the individual involved.
Unpublished data also suggest that the penis of the secondarily
impotent male attains states of pathologic hyperinvolution (when
compared to previously established norms), after two to four years
of unremitting impotence [131]. Particularly does hyperinvolution
become clinically obvious immediately following attempted and
failed sexual encounter. Clinical observations tend to support the
possibility that penile hyperinvolution, like penile erection, al­
though frequently developed on a reflex basis, may also respond
directly to higher cortical centers.
Since neither the physiology of penile hyperinvolution nor of
penile response to asexual stimuli has been investigated, these
problems cannot be explored at this time. A consideration of penile
response to sexual stimuli will provide a baseline upon which future
studies of these reactions can be based.
The initial physiologic response of the human male to effective
sexual stimulation is erection of the penis. This reaction is the
neurophysiologic parallel to the human female’s production of
vaginal lubrication [202]. Both reactions occur with equal facility,
regardless of whether the source of sexual stimulation is initially
somatogenic or psychogenic in origin (see Chapter 17).
During eleven years of direct investigation of human sexual
response, penile erection has been observed in males of all ages,
ranging from baby boys immediately after delivery to men in their
late 8o’s. Penile erection in the neonate is considered to be evi­
dence of specific vasocongestion and of increased neurogenic and
myogenic irritability as might be stimulated by a severe crying spell.
Penile reactions of aged men usually are so varied that descriptions
of response patterns have been individualized (see Part 1 of Chap­
ter 16). The mere fact that full penile erection could be obtained
and an ejaculation produced by an 89-year-old man during epi­
sodes of active cooperation as a study subject is considered worthy
of report.
In order to facilitate clinical consideration of penile response to
sexual tensions, the cycle of sexual response again will serve as a
framework upon which descriptions of anatomic and physiologic
reaction can be placed in proper continuity.
182 CHAPTER TWELVE: PART ONE

EXCITEMENT PHASE

The human male’s first physiologic response to effective sexual

stimulation is penile erection (Fig. 12-4). There may be only a
minimum degree of sexual tension present before this response
pattern has been completed. After full penile erection has been at­
tained, the excitement phase may extend for the briefest of inter­
vals or for a matter of many minutes in direct parallel to the inten­
sity of or variation in any form of successful sexual stimulation.
Penile erection has been maintained by study subjects for ex­
tended periods by carefully controlling variation and intensity of
stimulative techniques. Erection has been partially lost and sub­
sequently rapidly regained many times during an intentionally pro­
longed excitement phase. With variation from intense somatogenic
stimulation to complete recession of such activity, penile tumes­
cence may increase or decrease repeatedly over long periods of time
without either the achievement of full penile vasodistention or
total loss of vasocongestion.

FIGURE 12-4
Male pelvis: excitement phase.
 THE PENIS 183

Psychosensory diversion has been created frequently in the

laboratory during excitement-phase response. Penile erection may be
impaired easily by the introduction of asexual stimuli, even though
sexual stimulation is continued simultaneously. Despite constantly
maintained somatogenic penile stimulation, a sudden loud noise,
vocalization on an extraneous subject, or an obvious change in
lighting, temperature, or attendant personnel may result in partial
or even complete loss of penile erection.

PLATEAU PHASE

The penis that apparently has achieved full erection during ex­
citement phase undergoes a minor involuntary vasocongestive in­
crease in diameter as the orgasmic (ejaculatory) phase approaches
(Fig. 12-5). This additional plateau-phase tumescence is confined
primarily to the corona glandis area of the glans penis.
A color change also may develop in the glans penis late in the
plateau phase of the sexual cycle. There may be a deepening of the

figure 12-5
Male pelvis: plateau phase.
184 CHAPTER TWELVE: PART ONE

mottled reddish-purple color of venous stasis. This preejaculatory

color change, when well established, is reminiscent of the preorgas-
mic discoloration of the minor labia of the human female. However,
the color change of the corona glandis is not a constant occurrence,
nor as well defined, when it does develop, as the minor-labial sex­
skin reaction of the human female (see Chapter 4). Approximately
20 percent of all male study subjects have demonstrated the coronal
color change. It should be emphasized, however, that some men
may develop a coronal color change during one cycle and not during
a subsequent sexual encounter. The appearance of the coronal
color change has been too variable to allow objective conclusions
to be drawn as to its relation to severity of response or the in­
fluence of such variables as type of stimulation, length of conti­
nence, etc., on its appearance or intensity.

ORGASMIC PHASE

The orgasmic-phase penile ejaculatory reaction (Fig. 12-6) de­

velops from regularly recurring contractions of the sphincter ure-

FIGURE 12-6
Male pelvis: orgasmic phase.
 THE PENIS 185

thrae, bulbospongiosus, ischiocavernosus, and transverse superficial

and deep perineal muscles. The ejaculatory contractions involve the
entire length of the penile urethra and force the seminal-fluid con­
tent from the prostatic and membranous portions of the urethra to
and through the urethral meatus. The seminal fluid is expelled the
full length of the penile urethra under severe pressure created by
the involuntary but coordinated contractions of these muscle group­
ings.
The intercontractile intervals of the initial penile contractions
have been timed at a rate similar to that of the orgasmic-platform
contractions which develop in the vagina during the female’s orgas­
mic experience. Expulsive penile contractions start at intervals of
0.8 second. After the first three or four major expulsive efforts the
penile contractions are rapidly reduced in frequency of recurrence
and in expulsive force. Minor contractions of the penile urethra con­
tinue for several seconds in an irregularly recurrent manner, pro­
jecting a minimal amount of seminal fluid under little if any expul­
sive force. The terminal intercontractile intervals are extended to
several seconds in duration.

RESOLUTION PHASE

Resolution-phase penile detumescence develops in two distinct

stages (Fig. 12-7). The primary stage of penile involution, occur­
ring early in the refractory period of the resolution phase, reduces
the penis from full erection to approximately 50 percent larger than
its unstimulated, flaccid state. This primary stage of penile de­
tumescence usually occurs with extreme rapidity. Secondary-stage
penile involution, which ultimately returns the penis to its normal,
unstimulated size, may be an extended involutionary process which
lasts well past the refractory period of the resolution phase.
The primary stage of penile involution usually is prolonged when
the excitement or plateau phases of the particular sexual cycle have
been extended by direct intent. Many males learn to restrain or
delay their ejaculatory reaction until their sexual partner is satiated.
Satiation on the woman’s part may represent several complete cycles
of sexual response with the consequent demand for maintained
186 CHAPTER TWELVE: PART ONE

FIGURE 12'7

Male pelvis: resolution phase.

penile erection for extended periods of time. When an erection is

maintained for many minutes, particularly during long-continued
intravaginal containment, advanced degrees of penile vasoconges-
tion frequently continue after the actual ejaculatory experience.
Thus, the primary stage of penile involution, usually a rapid process,
may be extended indefinitely and second-stage penile involution sub­
sequently delayed. No acceptable physiologic explanation can be
offered at present for this clinical observation.
The rapidity with which total penile (two-stage) involution is
accomplished frequently is dependent on the existence and intensity
of extraneous stimuli. The detumescent process is slowed during
the second stage when residual sexual stimulation persists, and is
speeded when the stimuli are asexual in character. If the penis is
removed from the vagina immediately following an ejaculatory ex­
perience, full detumescence is accomplished much more rapidly
than if the postejaculatory penis remains in the stimulative vaginal
barrel. If the male simply maintains close physical proximity to his
female sexual partner, the secondary stage of penile detumescence
may be quite prolonged. With opportunity for long-continued
bodily contact with a sexual partner, the penis may not complete a
 THE PENIS 187

second-stage detumescence and revert to its normal flaccid state for

many minutes after an ejaculatory experience.
If the resolution-phase male walks about, talks on any extraneous
subject, or is otherwise diverted in an asexual manner, secondary­
stage penile involution occurs with relative rapidity. For example,
if the male attempts to urinate immediately after an ejaculatory
experience, the involuntary mental concentration directed toward
the urinary process will shorten both primary and secondary stages
of penile detumescence. Actual urinary effort always will increase
the rate of penile detumescence, since the male cannot urinate with
the penis in full erection. If the penis is still somewhat enlarged
(secondary-stage involution) at the onset of micturition, the penis
usually is in a completely flaccid state by the time the act is com­
pleted.
Finally, the physiologic response of the penile urethra to sexual
tensions should be described. Obviously, the urethra lengthens dur­
ing active penile erection. As excitement-phase progresses toward
plateau, the lumen of the penile urethra undergoes at least a two­
fold increase in transverse diameter. As the plateau phase of sexual
tension is experienced, this increase in penile urethral diameter ap­
proaches threefold magnitude at the base of the urethra where the
urethral bulb is located (Fig. 12-8). Late in the plateau phase there

figure 12-8
The penis: erect (ventral view).
188 CHAPTER TWELVE: PART TWO

is further transitory distention of the urethral bulb that varies in

degree from man to man. This preorgasmic rapid distention of the
urethral bulb is pathognomonic of impending orgasm and is a re­
action of such magnitude as to be obvious to direct observation.
The penile urethra contracts in rhythm parallel to that of the
total penile body during the ejaculatory process.
The urethral meatus usually becomes slightly patulous in its
transverse axis during the excitement phase of the male’s sexual
response cycle. There is no further plateau- or orgasmic-phase dila­
tion of the meatus. Direct observation of the urethral meatus pro­
vides no clue to the imminence of an ejaculatory experience. The
urethral meatus loses its patulous transverse distention immediately
after ejaculation.
During the refractory period of the resolution phase loss of in­
creased urethral diameter and shrinkage of the overdistended ure­
thral bulb occur before loss of increased urethral length can be
determined.

2. CLINICAL CONSIDERATIONS

The functioning role of the penis is as well established as that

of any other organ in the body. Ironically, there is no organ about
which more misinformation has been perpetrated. The penis con­
stantly has been viewed but rarely seen. The organ has been ven­
erated, reviled, and misrepresented with intent in art, literature, and
legend through the centuries. These intentional misrepresentations
have varied in magnitude with the culture. Our culture has been
influenced by and has contributed to manifold misconceptions of
the functional role of the penis. These “phallic fallacies” have
colored our arts and, possibly of even more import to our culture,
influenced our behavioral and biologic sciences.
The twofold functioning role of the penis providing for both uri­
nary release and seminal-fluid deposition has been accepted through­
out recorded history. Why, with the functioning role unquestion­
ably established, should the functional role of the penis have been
 THE PENIS 189

shrouded so successfully by “phallic fallacy” concepts? This, indeed,

is one of the great mysteries of biologic science.
The functional role of the penis is that of providing an organic
means for physiologic and psychologic increment and release of
both male and female sexual tensions. The penis as an organ of
male sensual focus can be related to the functional role of the
clitoris (see Part 2 of Chapter 5) in the total of female sexual re­
sponse. The gross difference between these two organs is that the
clitoris serves only in a functional role, and the penis has both a
functioning and a functional capacity.
Objective material relating to the functional role of the penis has
been accumulated from over 2,500 directly observed sexual response
cycles experienced by 312 male study subjects whose ages range
from 21 to 89 years. Subjective material has been returned from
team interrogation of 654 men screened as study-subject appli­
cants before the 312 active participants were selected. Material
for anatomic consideration has been developed from direct evalua­
tion of penile and scrotal content plus rectal examination for pros­
tate and seminal-vesicle anatomy. These examinations were con­
ducted routinely on all males who became active members of the
study-subject population.
Additional material of both physiologic and psychologic content
has been returned from investigation of human sexual inadequacy.
This clinical-research program has been running concurrently with
the basic-science investigation of human sexual response for the
past seven years.

CIRCUMCISION

Thirty-five of the 312 male members of the study-subject popula­

tion were uncircumcised. Although approximately one-quarter of
the male study subjects were beyond 40 years of age, more than
half (19) of the uncircumcised males were found in this age group­
ing. The fact that only 16 out of a total of 231 male members of
the study-subject population between the ages of 21 and 40 years
were uncircumcised is representative of the medical trend toward
urging routine circumcision of the newborn male infant. More than
190 CHAPTER TWELVE: PART TWO

95 percent of all deliveries in this country now are hospital deliver­

ies, and circumcision is recommended as a routine neonatal pro­
cedure. The uncircumcised male, particularly one born in an urban
area, indeed, is becoming a rarity in our society.
The phallic fallacy that the uncircumcised male can establish
ejaculatory control more effectively than his circumcised counter­
part was accepted almost universally as biologic fact by both cir­
cumcised and uncircumcised male study subjects. This concept was
founded upon the widespread misconception that the circumcised
penile glans is more sensitive to the exteroceptive stimuli of coition
or masturbation than is the glans protected by a residual foreskin.
Therefore, the circumcised male has been presumed to have more
difficulty with ejaculatory control and (as many study subjects be­
lieved) a greater tendency toward impotence.
A limited number of the male study-subject population was
exposed to a brief clinical experiment designed to disprove the false
premise of excessive sensitivity of the circumcised glans. The 35
uncircumcised males were matched at random with circumcised
study subjects of similar ages. Routine neurologic testing for both
exteroceptive and light tactile discrimination were conducted on the
ventral and dorsal surfaces of the penile body, with particular atten­
tion directed toward the glans. No clinically significant difference
could be established between the circumcised and the uncircum­
cised glans during these examinations.
A clinical observation specifically relating to the uncircumcised
penis may explain in part this lack of excessive sensitivity of the
circumcised as opposed to the uncircumcised glans. Frequently
during coition and occasionally during automanipulation the fore­
skin of the uncircumcised male retracts from the glans as the fully
erect penis reacts to plateau-phase levels of sexual tensions. The fore­
skin retracts in direct relation to the degree of freedom of its move­
ment over the subjacent glans with the penis in a flaccid state.
When a minor to moderate degree of phimosis is present, foreskin
retraction occurs only after long-continued coital connection. Only
6 of the 35 uncircumcised study subjects failed to demonstrate sig­
nificant exposure of the glans during or immediately subsequent to
active coition. Foreskin retraction usually does not develop as fre­
 THE PENIS 191

quently, or progress as far, during automanipulation as during

coition. This fact probably is related to the manipulative techniques
employed. These will be discussed later in the chapter.
Since 29 of the 35 uncircumcised males developed a significant
degree of foreskin retraction during active coition, obviously the
uncircumcised glans frequently is exposed directly to exteroceptive
stimuli resultant from intravaginal containment just as is the cir­
cumcised glans. Thus from a physiologic point of view, a retained
foreskin probably contributes little if anything to the individual
male’s ejaculatory control.

PENILE FALLACIES

Another widely accepted “phallic fallacy” is the concept that the

larger the penis the more effective the male as a partner in coital
connection. The size of the male organ both in flaccid and erect
state has been presumed by many cultures to reflect directly the
sexual prowess of the individual male. Dickinson [56] was one of
the first to record dimensions of the penis with some degree of ob­
jectivity. He supported Loeb’s report [176] that the normal range
of penile length varies from 8.5 to 10.5 cm. in the flaccid state,
with the general average in the 9.5 cm. range. The range of
normalcy suggested by these measurements also has been supported
by measurements returned from examinations of individual mem­
bers of the male study-subject population [131].
The delusion that penile size is related to sexual adequacy has
been founded in turn upon yet another phallic misconception.
It has been presumed that full erection of the larger penis provides
a significantly greater penile size increase than does erection of the
smaller penis. This premise has been refuted by a small group
of men selected from the study-subject population for clinical
evaluation. Forty men whose penises measured 7.5-9 cm. in length
in the flaccid state were compared to a similar number of study
subjects whose penises in the flaccid state measured 10-11.5 cm.
Measurement was crudely clinical at best and can only be presumed
suggestive and certainly not specific in character. The length of the
1Ç2 CHAPTER TWELVE: PART TWO

smaller penises increased by an average of 7.5-8 cm. at full (plateau­

phase) erection. This full erection essentially doubled the smaller
organs in length over flaccid-size standards. In contrast, in the men
whose organs were significantly larger in a flaccid state (10-11.5
cm.), penile length increased by an average of 7-7.5 cm. in the
fully erect (plateau-phase) state.
These measurements of full penile erection are so crudely clinical
that they have been adjusted arbitrarily to the nearest 0.5 cm. to
facilitate presentation. In each instance, measurement was taken
from the anterior border of the symphysis at the base of the penis
along the dorsal surface to the distal tip of the glans. All 80 penises
were measured on three different occasions both in flaccid and erect
states by the same individual. Only one investigator conducted this
clinical measurement so that any idiosyncrasy of measurement tech­
nique would be common to all results. One of the measurements
of penile erection was taken during automanipulation, and two
measurements were initiated immediately upon withdrawal of the
plateau-phase penis from active coition. Measurement of an erect
penis was not attempted until the final engorgement of late plateau
phase had been accomplished. Since full penile engorgement is a
short-term process before ejaculation intervenes, measurement fre­
quently was rushed and, therefore, additionally unreliable. While
the information returned obviously is not definitive, there certainly
is no statistical support for the “phallic fallacy” that the larger penis
increases in size with full erection to a significantly greater degree
than does the smaller penis. The difference in average erective size
increase between the smaller flaccid penis and the larger flaccid
penis is not significant.
Of clinical interest is the fact that the greatest observed penile-
size increase from flaccid to erect state occurred in a male study
subject with an average flaccid measurement of 7.5 cm. (not in­
cluded in the experiment reported above). The increase in size
from flaccid to erect state was just over 9 cm. This penis more
than doubled in length when reacting from flaccid to erect state.
The smallest increase in size from flaccid to erect state was ob­
served in one of the larger organs. This penis measured just under
11 cm. in its flaccid state, yet at full erection only 5.5 cm. had been
added to the length of this larger organ. At full plateau-phase
 THE PENIS 193

erection the two organs were measured at identical lengths on

three separate occasions.
As Piersol has stated [248], the size of the penis has less constant
relation to general physical development than that of any other
organ of the body. This statement has been made in recognition
of yet another “phallic fallacy.” It has been presumed by many
cultures that the bigger the man in skeletal and muscular develop­
ment, the bigger the penis, not only in a flaccid but also in an
erect state. Detailed examination of the study-subject population
of 312 men aged 21 to 89 years supported Piersol’s contention that
there is no relation between man’s skeletal framework and the
size of his external genitalia. The largest penis in the study-subject
population, measuring approximately 14 cm. long in the flaccid
state, was in a man 5 feet, 7 inches tall weighing 152 pounds. The
smallest penis, measuring just over 6 cm. in the flaccid state, was
in a man 5 feet, 11 inches tall weighing 178 pounds.
Although there is little to support the concept that erective size
is proportionally greater for the larger than the smaller penis,
there remains the theoretical concern of the man with the small
penis as to his potential coital effectiveness. Even with erective
ability of the smaller penis (less than 9 cm.) presumed equal to
that of the larger penis (more than 10 cm.), the smaller penis in
the flaccid state usually remains somewhat smaller in an erect state.
The factor that constantly is overlooked in theoretical discussions
of penile coital effectiveness is the involuntary accommodative re­
actions of the vagina in its functional role under coital stimulation
as a seminal receptacle (see Part 2 of Chapter 6).

VAGINAL FALLACIES

The vagina is infinitely distensible from a clinical point of view.

If mounting occurs early in the excitement phase, before involun­
tary expansion in length and transcervical diameter has developed
fully, the woman may experience immediate difficulty in accom­
modating an erect penis, particularly a large organ. Presuming
sufficient physical distress does not occur with intromission to dis­
pel the woman’s sexual tensions, involuntary vaginal expansion con­
194 CHAPTER TWELVE: PART TWO

tinues rapidiv. Full accommodation usually is accomplished with

the first few thrusts of the penis, regardless of penile size. If intro­
mission occurs early in the woman's sexual response cycle, the
fully erect smaller penis can and does function as a dilating agent as
effectively as a larger penis.
With advanced excitement or early in plateau phase, the vagina
normally overextends in length and overexpands at transcervical
depth (see Part 1 of Chapter 6). This elliptical vaginal expansion,
creating an anatomic basin for the imminent seminal pool, accounts
for some loss of exteroceptive stimulation of the distal half of the
fully inserted penis and reduces vaginal sensate focus for the fe­
male. Before the orgasmic platform in the outer third of the vagina
develops sufficiently to provide increased exteroceptive and pro­
prioceptive stimulation for both sexes, the overdistended excite­
ment-phase vagina gives many women the sensation that the fully
erect penis (regardless of size) is “lost in the vagina.”
The obstetrically traumatized vaginal barrel increases accom­
modative difficulties for many women. Some vaginas are perpetually
enlarged as the result of tears of pelvic fascia and musculature
caused bv childbirth, resulting in secondary cystoceles, rectoceles.
and chronic cul-de-sac distention. In addition to sustaining the fas­
cial and muscle tears these women also may have lost muscle tone
throughout the pelvic area, as Kegel has emphasized repeatedly
[138. 139]. These traumatized vaginas so overexpand late in ex­
citement or during plateau phases that the resultant enveloping
rather than supporting and constricting vaginal barrels inevitably
reduce susceptibility to exteroceptive and proprioceptive stimuli for
copulating women much more than for their male partners. This
local reduction in sensate focus is more than counterbalanced by
the psychologic stimuli initiated by the act of copulation (see Chap­
ter 9).
Female concept of vaginal anatomy often provides a female
counterpart to the fallacies occasioned by male anatomic miscon­
ceptions. There are occasional women with exceptionally large or
small vaginas, just as there are occasional men with an exception­
ally large or small penis [131]. The large vagina reacts as an ob­
stetrically traumatized vagina and expands involuntarily far be­
 THE PENIS 195

yond the point of physiologic demand. Only one exceptionally large

vagina was identified among the study-subject population of 382
women. This anatomic anomaly rendered immediate accommoda­
tion regardless of the size of the artificial penis introduced. A nor­
mal-sized penis could be accommodated in this large vagina with­
out an obvious reaction. Therefore, there was little involuntary dis­
tention or “tenting” of the vaginal walls. With a twice-normal-sized
penis introduced, the large vagina evidenced the involuntary accom­
modation reaction, expanding and extending in the usual manner.
This woman’s constant complaint was that during coition the penis
seemed lost in the vagina and provided little direct exteroceptive
stimulation during thrusting episodes.
There were two instances of an exceptionally small vagina within
the study-subject group. These two women, when responding to
plateau-phase levels of sexual tension, could accommodate either
a large or a small penis, but experienced constant difficulty if mount­
ing was attempted before sexual tensions had reached high levels
of response. Early attempts frequently incited sufficient pain to dis­
pel incipient or real sexual tensions. These women had difficulty
accommodating any penis, regardless of its size, unless they were
highly excited.
In the same category of potential distress are women who have
undergone long periods of continence or are postmenopausal. In
both situations there may be some shrinking of the vaginal barrel.
These vaginas usually will respond slowly to stimulation at a first
coital opportunity, reacting in fashion similar to that of the excep­
tionally small vagina described above. It becomes obvious that
penile size usually is a minor factor in sexual stimulation of the
female partner. The normal or large vagina accommodates a penis
of any size without difficulty. If the vagina is exceptionally small, or
if a long period of continence or involution due to aging intervenes,
a penis of any size can distress rather than stimulate, if mounting
is attempted before advanced stages of female sexual tension have
been experienced.
Observation of the accommodation reactions within the human
vagina has been made possible by the techniques of artificial coition
developed during the past five years.
ig6 CHAPTER TWELVE: PART TWO

THE FUNCTIONAL ROLE

As a center of sensual focus, the clitoris serves both as a receptor

and transformer of sexual stimuli (see Part 2 of Chapter 5). The
penis is primarily a receptor of sexual stimuli, but there is also a
transformer role for the penis in sexual response. The functional
role of the penis is established through both exteroceptive and
proprioceptive stimulation. As a receptor of sexual stimuli, the penis
well may be as responsive to superficial stimuli as is the clitoris in
the female. However, since the penis plays both active and passive
roles in human sexual activity, as opposed to the more constant
receptor or passive role of the clitoris, it is difficult to compare the
two organs purely from a subjective standpoint.
Obviously the penis not only serves the male as a receptor and
transformer of stimuli but also provides exteroceptive stimulation in
its erect state for the female partner during coition. When the penis
responds to sexual stimuli with an erective reaction, the physiologic
fact of full erection and the proprioceptive stimuli that full erection
develops for the male increases the pelvic focus of the male’s sexual
interest. The vasoconcentration that results in full penile erection
serves in effect as a transformer mechanism by which the effective­
ness of initial sexual stimuli is increased many times in the male’s
consciousness. As opposed to the female, in whom the clitoris in its
psychophysiologic role of transformer projects the warmth of vaso-
congestive sensual demand throughout the pelvic viscera, the male’s
sensual focus usually is directed solely to the full, tense demand of
the erect penile organ. Thus the penis serves as a psychophysiologic
transformer of sensual stimuli through the proprioceptively stimu­
lating process of erection. This is the first phase of the role of the
penis as a transformer for sexual stimuli.
The second phase in the transformer role is developed by either
vaginal or manual containment of the fully erect penile shaft.
Regardless of whether the male is stimulated by intromission or by
automanipulative techniques, the shaft of the penis is enclosed and
thereby subjected to further sensory stimulation that primarily is
exteroceptive in nature. The male’s sexual tensions elevate from
late excitement into plateau phase and toward ejaculatory demand
 THE PENIS 197

as a result of proprioceptive stimuli plus successive contact and

pressure stimuli created either by the thrusting of the engorged
penile shaft within the accommodating vaginal barrel or by manual
constriction of the penile shaft with manipulative techniques.
Both penile containment and thrusting provide stimuli, fun­
damentally exteroceptive in character, that are transformed through
higher cortical centers into those levels of sensual focus that
ultimately develop ejaculatory demand. The actual mechanism that
triggers the male into an ejaculatory process is no better understood
than that mechanism that provides the female with orgasmic release
of her vasocongestion and myotonia. In both cases, however, the
clitoris and the penis not only act initially as receptors for both
objective and subjective sensual stimuli but also express their roles
as transformers of sexual stimuli fundamentally by means of
psychophysiologic orientation and responsiveness to proprioceptive
stimuli.

AUTOMANIPULATION

During the discussion of the role of the clitoris in female

sexuality, a clinical consideration of masturbatory techniques was
presented (see Part 2 of Chapter 5). Similarly, a discussion of the
penis in its functional role in male sexuality should include consider­
ation of automanipulative techniques. Genital manipulation occurs
in earliest infancy in both sexes. The pleasing sensation of genital
play in infancy is translated by most men into the active pleasure
of tension release engendered by genital manipulation during
puberty or the teenage years. The instance of a positive masturba­
tory history was placed at 92 percent of the total male population
by Kinsey and his associates [142]. Their figures generally have been
supported in this country and abroad by many similar reports
[57, 99, 117, 255, 269]. The age most frequently recalled by the 312
members of the male study-subject population for onset of active
masturbatory practices centered around the fourteenth or fifteenth
year. Some men described masturbatory patterns starting at the
age of 9 or 10, others not until 16 or 18 years. However, by far the
greatest onset frequency was concentrated during the immediate
198 CHAPTER TWELVE: PART TWO

postpubertal years. It may be recalled that all members of both

study-subject populations described a positive history of masturba-
tory facility (see Chapter 2).
Just as the female, males develop completely individual mastur-
batory techniques and overt response patterns. This despite the
fact that a much higher percentage of boys observe their friends in
masturbatory activity than do girls of similar age groups. Some men
use the lightest touch on the ventral surface of the penis, some use
strong gripping and stroking techniques that for many individuals
would be quite objectionable, if • not painful. Frequently men
prefer stimulation of the glans alone, either confining manipulation
to the ventral surface of the penis on or near the frenulum or using
the simple finger technique of pulling at or stimulating the entire
glans area. These are the exceptions, however, since most men
manipulate the shaft of the penis with stroking techniques that
encompass the entire organ and vary from man to man in desired
rapidity, excursion, and tightness of manual constriction.
Uncircumcised males have not been observed to concentrate
specifically on the glans area of the penis. Normally they follow the
usual pattern of confining manipulative activity entirely to the
penile shaft. Stroking techniques rarely move sufficiently distal on
the shaft of the penis to encounter more than the coronal ridge of
the glans even late in plateau phase just before ejaculation. For this
reason the foreskin (even in those males with marked mobility of
this tissue over the subjacent glans) rarely is retracted from the
total glans area. Usually only that area of the glans immediately
surrounding the urethral meatus is exposed prior to ejaculation.
This is obviously a different picture from that occasioned by active
intercourse. With full vaginal containment the foreskin not tightly
attached to subjacent tissue usually retracts freely from a major
portion of the glans during active male coital thrusting before
ejaculation.
As the male reaches late plateau levels of sexual tension, the
rapidity of manipulative excursion increases, until most men are
stroking the penile shaft as rapidly as possible. However, with the
onset of the ejaculatory process marked variation has been observed
in male manipulative technique. During ejaculation most of the
study subjects either cease completely or markedly slow the manual
 THE PENIS 199

excursion along the penile shaft. Many of the study subjects grip
the penile shaft spastically (usually just beneath the glans) and
continue this spastic constrictive pressure during the entire ejac­
ulatory process. This reaction may represent an involuntary response
pattern similar to that developed during active coition. Many men
plunge the penis into deepest possible vaginal containment as ejac­
ulation develops and cease all active pelvic thrusting during the
ejaculatory process.
A few study subjects manipulate the penile shaft actively during
the ejaculatory process, although almost universally slowing the
rapidity of and easing the constrictive tension of the stroking tech­
niques. These men observed during active coition usually avoid
spasmodic, deep vaginal containment of the penis with onset of
ejaculation and continue coital thrusting during their entire ejac­
ulatory process. No accurate check has been made of this reactive
mannerism, but it is estimated that not more than 10 percent of the
male study-subject population continued active stroking, either
manipulative or coital in origin, during their ejaculatory response.
Many men have reported the penile glans to be quite sensitive
to any pressure or containment immediately subsequent to ejacula­
tion. A few of the study subjects develop such a degree of glans
sensitivity that they involuntarily protect it against any form of
stimulation. These men reject any pattern of continued intravaginal
containment after ejaculation because even the low-grade exterocep­
tive stimulation of the static vaginal barrel is sufficient to distress.
Certainly, care is taken by males with postejaculatory glans sensi­
tivity to avoid any continuation of penile stroking after automanip-
ulative orgasm. The sensitivity of the penile glans (like the sensitiv­
ity of the clitoral glans) in the immediate postorgasmic period rarely
is appreciated by the opposite sex. Significant clinical distress de­
velops for these individuals when the male attempts continued
stimulation of his female partner or the female continues active
manual stroking or pelvic thrusting immediately subsequent to the
male’s ejaculation. Vocalization of postorgasmic glans sensitivity
in either marital partner will clear up this potential clinical distress
in short order.
From the point of view of sensate focus, the male usually is not as
effectively stimulated sexually by manipulation of the scrotal sac and
200 CHAPTER TWELVE: PART TWO

its subjacent content as is the female from stimulation of the labial

area or the vaginal introitus. While male study subjects responded
during the neurologic examination to the lightest touch of the
scrotal sac to the same degree that they did to similar stimulation
of the penile shaft, they have not described comparable sensual
pleasure derived from stimulation of the two areas. Obviously, this
lack of scrotal sensual focus is at variance with the focus of sensual­
ity returned from stimulation of the labial areas and the vaginal
introitus expressed by the women examined by the Kinsey gyne­
cologists [144].
It is obvious that the sensual focus of the entire male reproductive
viscera is limited primarily to the penile shaft and glans. This
is opposed to the female, who has not only a high level of sensual
focus concentrated in the clitoral shaft and glans but also major
levels of sensual focus in the labia, at the vaginal outlet, and in
the vaginal barrel. The sensitivity of the rectum to stimulation
was adjudged essentially equal between the two sexes by gross
clinical observation. It must be remembered, however, that material
of homosexual content has not been included in this review.

FEARS OF PERFORMANCE

“Phallic fallacies” relating to the functional role of the penis

frequently devolve from the culturally conceived role for the male
partner in human coition—that of actively satisfying the female
partner.
The “fear of performance” developing from cultural demand
for partner satisfaction has been in the past uniquely the burden of
the responding male. Inevitably fear provides a breeding-ground for
misconception. Among the male members of the study-subject
population and males interrogated as applicants, phallic fallacies
of subjective orientation were related to decades of life experience
more than to any other single factor.
Since a criterion for membership in the study-subject population
was ejaculatory experience in both masturbatory and coital situa­
tions, no members of the study group had to contend personally
with performance fears developed from primary impotence. Ques­
 THE PENIS 201

tioning related to this type of subjective concern among this selec­

tive population exposed beliefs that primary impotence was only
the result of a complete homosexual orientation or elicited vague
replies that “something must be wrong with the glands.” Delu­
sions resulting from the fears of performance with which the
primarily impotent male must contend almost on a daily basis
were undeveloped to the total group of interrogated males and,
therefore, cannot be dealt with objectively.
For the men forty years or younger, fears of performance centered
about questions of excessive ejaculatory experience and concerns
for premature ejaculation. The problem of too frequent ejaculation
was associated in the minds of many study subjects with possible
loss of physical strength and not infrequently was presumed to be
a basis for emotional instability if not severe neurosis. These mis­
conceptions have grown from the culturally centered fear that
frequent or excessive masturbation may lead to mental illness.
No study subject could provide a secure personal concept of what
constituted frequent or excessive levels of masturbation, nor could
anyone describe an instance known to them, even by report, of
mental illness resulting from masturbation. The superstition that
physical or mental deterioration results from excessive masturbation
is firmly entrenched in our culture, if returns from the team ques­
tioning of the total male group of study-subject applicants are
any criterion.
Reported masturbatory frequency in the male study-subject group
ranged from once a month to two or three times a day. Every
male questioned expressed a theoretical concern for the supposed
mental effects of excessive masturbation, and in every case “exces­
sive levels” of masturbation, although not defined specifically, were
considered to consist of a higher frequency than did the reported
personal pattern. One man with a once-a-month masturbatory
history felt once or twice a week to be excessive, with mental illness
quite possible as a complication of such a frequency maintained
for a year or more. The study subject with the masturbatory
history of two or three times a day wondered whether five or six
times a day wasn’t excessive and might lead to a “case of nerves.”
No study subject among the 312 questioned in depth expressed
202 CHAPTER TWELVE: PART TWO

the slightest fear that his particular masturbatory pattern was

excessive regardless of stated frequency.
There is no established medical evidence that masturbation,
regardless of frequency, leads to mental illness. Certainly there is
no accepted medical standard defining excessive masturbation. It
is true, of course, that many severely neurotic or acutely psychotic
men masturbate frequently. If a high-frequency pattern of mas­
turbatory activity exists, it may be but one of a number of symp­
toms of underlying mental illness rather than in any sense the
cause of the individual distress. The vague concept of excessive
masturbatory activity is a phallic fallacy widely accepted in our
culture, relating specifically to the functional role of the penis in
male sexuality.
Problems of premature ejaculation also disturbed the younger
members of the study-subject population. These fears of perform­
ance were not associated with problems of erection; rather, they
were directed toward the culturally imposed fear of inability to
control the ejaculatory process to a degree sufficient to satisfy the
female partner. These expressed fears of performance were con­
fined primarily to those study subjects who had attained college or
postgraduate levels of formal education. Only 7 of the total of 51
men whose formal education did not include college matriculation
expressed the slightest concern with responsibility for coital-partner
satisfaction. These men felt that it was the female’s privilege to
achieve satisfaction during active coition if she could, but cer­
tainly it was not the responsibility and really not the concern of
the male partner to concentrate on satisfying the woman’s sexual
demands. Out of a total of 261 study subjects with college matricu­
lation, 214 men expressed concern with coital-partner satisfaction.
With these men ejaculatory control sufficient to accomplish partner
satisfaction was considered a coital technique that must be acquired
before the personal security of coital effectiveness could be es­
tablished.
The fear of performance reflecting cultural stigmas directed
toward erective inadequacy was that associated with problems of
secondary impotence. These fears were expressed, under interroga­
tion, by every male study subject beyond forty years of age, irre­
spective of reported levels of formal education.
 THE PENIS 203

Regardless of whether the individual male study subject had

ever experienced an instance of erective difficulty, the probability
that secondary impotence was associated directly with the aging
process was vocalized constantly. The fallacy that secondary im­
potence is to be expected as the male ages is probably more firmly
entrenched in our culture than any other misapprehension. While
it is true that the aging process, with associated physical involution,
can reduce penile erective adequacy, it is also true that secondary
impotence is in no sense the inevitable result of the aging process.
This factor has been firmly established by the aging members
of the study-subject population (see Part 2 of Chapter 16). In
addition, the clinical-research program of the Reproductive Biology
Research Foundation has established the fact that most secondary
impotence associated with the aging process can be transitory in
character.
In most instances, secondary impotence is a reversible process
for all men regardless of age, unless there is a background of specific
surgery or physical trauma.
The functional role of the penis in male sexuality has not been
established with the security of the organ’s functioning role. It
has been severely obscured by “phallic fallacies” of cultural origin.
Further definitive research in the physiology of male sexual re­
sponse will make the greatest contribution toward identifying and
reversing these misconceptions. It is inevitably true that the psy­
chology of human sexual response can best be appreciated when
the physiology has been established. The numerous “phallic fal­
lacies” dealt with in this chapter are but a few of the many present
in our culture. They represent major concerns of a highly selective
group of male study subjects and applicants, and not necessarily
the fears of a cross-section of the male population.
 I?

THE SCROTUM AND

THE TESTES
ANATOMY AND PHYSIOLOGY

lhe scrotum and the testes respond to sexual stimulation, as do

all other male primary and secondary organs of reproduction, with
both localized vasocongestion and increased myotonia. In a sexu­
ally unstimulated state the thin scrotal integument (skin and tunica
dartos) characteristically hangs in multiple folds or creases and
moves freely over the subjacent scrotal content. The scrotum
is morphologically homologous to the labia majora of the human
female. However, there is not the mature female’s tendency toward
localized deposition of fatty tissue.

THE SCROTUM

The scrotum responds to sexual stimulation in specific reaction

patterns that reflect the severity of the stimulative response. There­
fore, descriptions of these reaction patterns can be related to the
four phases of the cycle of sexual response.

EXCITEMENT PHASE

As sexual tensions rise there are notable tensing and thickening

of the scrotal integument accomplished both by localized vaso­
congestion and by contraction of the smooth-muscle fibers of the
dartos layer (see Fig. 12-4). The unstimulated scrotal patterns
of multiple folding and free movement rapidly are lost. Con­
striction of the scrotal integument produces a significant decrease
204
 THE SCROTUM AND THE TESTES 2O5

in the internal diameter of the scrotal sac. There also is a marked

restriction in free testicular movement in other than a perpendicular
plane.
The constricted scrotal sac with its resultant loss of internal
diameter contributes secondary support to the reaction of testicular
elevation during advanced stages of the excitement phase. If ex­
citement-phase levels of sexual tension are maintained for long
periods without the usual progression toward plateau-phase levels
of intensity, the constricted and congested scrotal sac may relax.
When relaxation occurs scrotal folding reappears, and partially
elevated testes may return to the scrotal depths. This loss of
scrotal physiologic responsiveness may develop even though full
penile erection is maintained. Ultimately, if sexual tensions ac­
cumulate and plateau-phase levels of response develop, the con­
gestive and constrictive reactions of the scrotal sac may be re­
established rapidly.

PLATEAU AND ORGASMIC PHASES

Occasionally an obvious thickening and tensing of the scrotal

integument develops as a continuing reaction into plateau-phase
levels of sexual tension, but only if the excitement phase has
been of exceptionally short duration (see Figs. 12-5, 12-6). There
are no specific scrotal sac reactions to either plateau- or orgasmic-
phase levels of sexual tension.

RESOLUTION PHASE

During the resolution phase the scrotal integument responds

to loss of sexual tensions in two diametrically opposed patterns.
Either reaction pattern usually is specific for the individual male.
The most frequent reaction is characterized by rapid loss of the
congested, tense appearance of the scrotum and an early reappear­
ance of the patterns of integumental folding or creasing so charac­
teristic of the sexually unstimulated male (see Fig. 12-7). Approxi­
mately 25 percent of human males demonstrate a pattern of slow
resolution with delayed loss of the scrotal integument’s tension-
induced congestion and constriction. Retained definitive thickening
ao6 CHAPTER THIRTEEN

of the integument frequently has been observed to last for one to

two hours after an ejaculatory experience. The concomitant con­
striction of internal diameter of the sac may delay (five to twenty
minutes) bilateral testicular return to fully relaxed positioning in
the scrotal depths.
As stated, the individual male usually adheres to either rapid
or slow scrotal involution, but three individuals have demonstrated
both response patterns. For these three men, the longer that ten­
sion-induced congestion and constriction of the scrotal sac are
maintained before orgasmic release, the more slowly detumescence
and relaxation of the scrotal sac will develop during the resolution
phase of the sexual response cycle.
No specific color change of the scrotal integument has been
observed during any phase of the sexual response cycle.

THE TESTES

EXCITEMENT PHASE

The testes evidence specific reaction patterns during each of the

four phases of the sexual response cycle. As excitement-phase levels
of tension develop, there is a specific elevation of both testes
toward the perineum (see Fig. 12-4). This physiologic response
to sex tension increment has been observed during previous in­
vestigations [3, 144, 213]. Testicular elevation is accomplished
by shortening of the spermatic cords. The cremasteric musculature
which invests the spermatic cord produces this physiologic response
through an entirely involuntary contractile process.
Actually, only partial elevation of the testes is accomplished
during the excitement phase, unless there is to be a fulminating
completion of the sexual response cycle. The testes in addition to
their ascent toward the perineum undergo a change in their axis
of suspension during the process of elevation. The superior pole
of the ascending testis rotates anteriorly, and as a consequence, once
the testis is elevated completely, the posterior testicular wall ul­
timately comes in direct contact with the male perineum. Actually
this modest (30° to 350) anterior rotation has onset late in the
 THE SCROTUM AND THE TESTES 207

excitement phase and is completed during the terminal portions

of the plateau phase of the individual sexual response cycle.
If excitement-phase levels of sexual tension are maintained for
more than 5-10 minutes and there is no immediate interest in
escalating the sexual tensions to plateau-phase levels, the con­
tracted cremasteric musculature of the spermatic cords relaxes and
the testes together with the relaxed scrotal sac (see previous
description) return to their unstimulated suspended positioning.
Cremasteric muscular tension usually cannot be maintained over
indefinite periods of time. Therefore, the testes frequently may
return to their unstimulated low-scrotal positioning despite the
fact that excitement-phase levels of sexual tension are maintained,
and an accompanying penile erection may be continued indefi­
nitely. The sexually responding male may go through several epi­
sodes of partial elevation and subsequent descent of the testes
during a voluntarily extended excitement phase before sufficient
sexual tensions accumulate to establish a plateau-phase level of
sexual response and with it the resultant complete testicular eleva­
tion.
Observation of the phenomenon of preejaculatory testicular
elevation finally has provided an adequate explanation of the
physiologic intent of the well-established clinical entity of the
cremasteric reflex [162]. However, it should be emphasized that
partial testicular elevation should not be considered purely as
a physiologic response to sexual tension. Under controlled labora­
tory conditions, testicular elevation (approximately half-way to
the perineum) has been observed as a response to a chilled en­
vironment and also has been produced as an immediate response
to the stimuli of both fear and anger.

PLATEAU PHASE

As male sexual tensions rise through plateau-phase toward or­

gasmic-phase release, the specific reaction of testicular elevation
progresses until the final preejaculatory positioning in tight apposi­
tion to the male perineum is attained (see Fig. 12-5). Repeated
demonstrations have established the fact that the phenomenon
of testicular elevation is of extreme physiologic importance. If
208 CHAPTER THIRTEEN

the testes do not undergo at least partial elevation the human

male will not experience a full ejaculatory sequence. Some males,
particularly after the age of fifty, do ejaculate from a partially
rather than a fully elevated testicular positioning. When ejaculation
from partially elevated testicular positioning occurs, there is marked
reduction in ejaculatory pressure. This variation in response pattern
will be discussed in detail during the consideration of the influence
of age upon the human male’s sexual response patterns (see Part 1
of Chapter 16).
When the testes do rise to a position of close apposition to
the male perineum, an orgasmic phase is certain to follow if
effective sexual stimulation is maintained. Full testicular elevation
is pathognomonic of impending ejaculation.
The left testicle, which usually (85 percent of the time) has
the lower scrotal sac positioning in a sexually unstimulated state,
obviously must move through the widest excursion during testicular
elevation. The left testis also has been observed to react frequently
to the stimulus of sexual tensions independently of the right
testicle. Many males accomplish final elevation of the right testicle
against the perineum late in excitement or early in a plateau-phase
sequence, while the left testicle still continues to move up and
down in restricted excursion from partial to complete elevation
within the congested and constricted scrotal sac. The left (lower)
testicle frequently docs not establish full perineal apposition until
immediately prior to the ejaculatory sequence.
There is yet another physiologic response of the testicles to
elevated sexual tensions that has not been described heretofore.
This reaction consists of an observable increase in testicular size.
Direct palpation of the testes supports the clinical impression that
this is yet another deep vasocongestive phenomenon. Testicular
size increase usually is not apparent until late excitement or early
plateau phase. The testes achieve approximately a 50 percent size
increase over their sexually unstimulated noncongested state, be­
fore the orgasmic phase is experienced. Some males have been
observed to develop almost a 100 percent increase in testicular
size, particularly if the individual sexual response cycle is of ex­
ceptional duration. As a rough rule of thumb, it can be stated
that the longer the plateau-phase levels of sexual tension are main-
 THE SCROTUM AND THE TESTES log

tained without orgasmic phase release, the more severe is the deep
vasocongestion of the testes and the more obvious is the resultant
testicular size increase.

ORGASMIC PHASE

No specific orgasmic phase reaction of the testes has been

recorded (see Fig. 12-6). Suspicion persists, however, that this
is merely an expression of lack of effective observation and physi­
ologic recording techniques rather than a factual determination.
Specifically, the testes have not been felt nor observed to contract
during the ejaculatory process. To date, finite physiologic recording
of testicular contractile potentials has not been attempted.

RESOLUTION PHASE

Resolution-phase loss of vasocongestive increase in testicular size

and full descent of the testes into the depths of a relaxed scrotum
(see Fig. 12-7) may develop as either a rapid or a slow involu-
tionary pattern, just as has been described for the scrotal sac
relaxation. There is marked specificity of response pattern for the
individual male, but wide variation of involutionary reaction from
man to man. However, the general clinical pattern of target-organ
vasocongestion again applies. The longer the plateau-phase levels
of sexual tensions are experienced and resultant testicular size
increase is maintained, the slower is full testicular detumescence
during the resolution phase.

The specific physiologic reactions of scrotum and testes to sex

tension increment have been considered in this chapter. Again
evidence has been developed of both superficial (scrotal integu­
ment) and deep (testicular size increase) vasocongestion and both
generalized (scrotal constriction) and specific (testicular elevation)
myotonia. Application of this material will be developed in a
future publication relating to clinical consideration of problems of
human sexual inadequacy.
 14
THE MALE ORGASM
(EJACULATION)

lhe human male’s orgasmic experience (ejaculation) can be ap­

proached from the same three disciplinary foci that have been
employed in Chapter 9 in an attempt to interpret the human
female’s orgasmic experience. These foci are: (1) physiologic
(characteristic physical conditions and reactions during the peak
of sex tension increment); (2) psychologic (psychosexual orienta­
tion and receptivity to orgasmic attainment); and (3) sociologie
(cultural, environmental, and social factors influencing orgasmic
incidence or ability) [12,145, 322].
In the past the progressive chain of physiologic events that
comprise the human male’s orgasmic episode has been considered
in detail. However, there has been little attempt to present an
analysis of psychologic components and to correlate objective and
subjective elements of the experience. During the cycle of human
sexual response, the male reaction for which there is no com­
parable female counterpart is, of course, the emission of seminal
fluid. The physiology of this orgasmic process has been established
and will be reviewed but briefly. The male’s subjective progression
through orgasm will be considered in more depth as correlation
between physiologic and psychologic components of the experience
is attempted. Sociologie aspects of male orgasm will be examined
in context.
Preliminary to the discussion of male orgasmic response, a
characteristic plateau-phase reaction should be mentioned. Fre­
quently a preorgasmic secretory emission has been observed. It
is mucoid in character, usually totals no more than two or three
210
 THE MALE ORGASM (EJACULATION) 211

drops, and escapes involuntarily from the urethral meatus. Oc­

casionally, developing as an individual reactive characteristic or
during long-maintained plateau-phase tension levels, the mucoid
emission has reached levels of 0.5-1 cc. in total volume. Frequently,
actively motile spermatozoa have been demonstrated in micro­
scopic examinations of this preejaculatory fluid emission.
There has been no attempt to establish percentage incidence
for the preejaculatory material in the male study-subject population
because many males secrete the material so irregularly. As stated,
it appears most frequently during voluntarily lengthened plateau­
phase experiences. For example, in active coition a man may
practice voluntary ejaculatory control at plateau-tension levels
through several of his female partner’s orgasmic cycles. Other
similar situations tend to increase both frequency of occurrence
and secretory volume of the preejaculatory mucoid material. They
are automanipulative activity voluntarily maintained at plateau­
phase tension levels for lengthy periods without ejaculatory release,
and fellatio conducted in similar manner and with similar intent.
From a physiologic point of view, it is interesting to note that
the plateau-phase timing of the male’s preejaculatory emission is
essentially the same as the plateau-phase secretory activity of
Bartholin’s glands in the female sexual cycle. The source of the
mucoid material produced by the sexually responding human
male has been allocated questionably to Cowper’s glands (see Fig.
12-3). The chemical composition of either of these plateau-phase
secretions has not been identified.
No relationship has been established between incidence or
amount of the preejaculatory mucoid material and the volume or
specific content of the true seminal emission. To date, there is
insufficient information to correlate the incidence of large num­
bers of active spermatozoa in the preejaculatory secretion with
high levels of fertility as reflected by in vitro evaluations of
seminal-fluid content. There also is no statistically secure parallel
between the presence or absence of a preejaculatory emission and
a higher or lower seminal plasma volume [131]. In short, the physi­
ology and biochemistry of the male’s preejaculatory emission are
essentially unexplored areas.
212 CHAPTER FOURTEEN

PHYSIOLOGY OF ORGASM

The actual expulsion of seminal-fluid content from the accessory

or secondary organs of reproduction (prostate, seminal vesicles,
ejaculatory duct, etc.) into the prostatic urethra and the progres­
sion of the fluid content under pressure through the full length
of the penile urethra to the urethral meatus are the physiologic
expression of male orgasmic experience. The act of ejaculation
usually involves activity of the highest cortical levels but also
may be purely reflex [no, 168, 206, 260, 285]. The ejaculatory
process may be divided physiologically into two separate stages.
Stage I consists of expulsion of seminal-fluid substrate from the
accessory organs of reproduction into the prostatic urethra (see
Fig. 12-3). Stage II includes the progression of seminal-fluid con­
tent from the prostatic portion of the urethra through both the
membranous and the penile segments of the urethra to the urethral
meatus (see Fig. 12-1 ).

STAGE I

The first stage of the ejaculatory process is initiated by accessory­

organ contractions previously described as commencing with the
vasa efferentia of the testes [224]. These secondary contractions
are presumed to continue through the epididymis to the vas
deferens which finally contracts in close parallel with the seminal
vesicles [225]. Regularly recurring prostatic contractions have been
palpated rectally in study subjects during ejaculation. This physi­
ologic reaction of the prostate gland also has been recorded by
an independent observer [265].
As many as six separate fractions of the seminal fluid have
been identified [284]. Initially, seminal-fluid content is developed
from expulsion of prostatic fluid into the prostatic urethra. Then
contents of the ampulla (outlet of the vas deferens) are discharged
into the prostatic urethra, accompanied by simultaneous expulsion
of seminal-vesicle content. During the course of the ejaculatory
episode prostatic fluid is delivered to the seminal-fluid content
 THE MALE ORGASM (EJACULATION) 213

repeatedly by regularly recurring contractions. As stated, these

expulsive contractions of the prostate can be palpated rectally.
As seminal fluid collects in the prostatic urethra, there simul­
taneously is a two- to threefold involuntary expansion of the
urethral bulb (sec Fig. 12-8). This expansion develops in anticipa­
tion of the second-stage expulsive urethral contractions.
At the onset of the ejaculatory experience, the intact internal
sphincter of the urinary bladder normally closes or remains sealed,
thereby preventing seminal-fluid content from entering the bladder
in a retrograde ejaculatory sequence. This specific internal-sphincter
constriction also has the function of retaining any urinary content
within the bladder and avoiding any intermingling of urine and
seminal plasma [120].

STAGE 11

The second stage of the ejaculatory process is initiated by

relaxation of the external sphincter of the bladder, which allows
the seminal-fluid content to flow into the distended bulb and
penile urethra. The seminal plasma is propelled from the prostatic
urethra along the penile urethra by the perineal musculature, the
bulbospongiosus and ischiocavernosus muscles, and the sphincter
urethrae. The urethral bulb also contracts regularly as an aid
to the propulsive mechanism. The first two or three ejaculatory
contractions of the penile urethra project seminal-fluid content
under such pressure that initial portions of the ejaculate may be
expelled 12-24 inches from the urethral meatus if the penis is
unencumbered by vaginal containment. The anatomy of seminal-
fluid deposition within the vaginal barrel is discussed in Part 2 of
Chapter 6.
Alterations in ejaculatory physiology reflecting the influence of
the aging process are presented in Part 1 of Chapter 16.
The physiology of repeated ejaculation should be considered
briefly. Many males below the age of 30, but relatively few
thereafter, have the ability to ejaculate frequently and are subject
to only very short refractory periods during the resolution phase.
One male study subject has been observed to ejaculate three times
within 10 minutes from the onset of stimulative activity. The
214 CHAPTER FOURTEEN

seminal-fluid volume progressively was reduced in amount with

each ejaculatory episode. This example, of course, marks the excep­
tion to the basic rule of severe male psychophysiologic resistance
to sexual stimuli (refractory period) immediately after an ejacula­
tory experience (see Fig. 1-1).
From the standpoint of physiologic strain, there is no information
available to date that would indicate any residual physical distress
from repeated ejaculation that might be expected to develop in
a healthy male. The act of ejaculation, while obviously a part of
the total of physiologic strain of orgasmic experience, has not
been observed to create residual physical distress. There is a wide­
spread concept that ejaculation, whether accomplished through
masturbation or coition, is detrimental to the physical condition of
men in athletic training programs. To date, there is no physiologic
evidence to support this concept.
From a physiologic point of view the male orgasmic experience
is one of total-body involvement through the processes of vaso-
congestion and myotonia. Specific orgasmic reactions of body
areas and organ systems have been outlined in Chapter n and
need not be repeated here. It is important, however, to reemphasize
constantly the protean character of orgasmic experience in the
male as well as the female. The male’s ejaculatory reaction fre­
quently draws attention from, and tends to obscure the degree
of, total-body involvement developed by an orgasmic interlude.

PSYCHOLOGY OF ORGASM

The two-stage physiologic process of ejaculation can be cor­

related specifically with the male’s subjective progression through
the orgasmic experience.
Subjective material has been returned from interrogation of 417
males with ages ranging from 18 to 89 years. Many of these men
(164) have been or are actively with the research program as co­
operating study subjects. Eighty-nine other men have been study­
subject applicants. Additionally, material has been drawn from 65
sexually inadequate males seeking relief from their clinical distress.
Finally, 99 infertile males were selected from the conceptive-
 THE MALE ORGASM (EJACULATION) 215

physiology research program. Their qualifying factor was physi­

ologic evidence of excessively high or low ejaculate volume. The
discussion to follow represents a consensus of the opinions ex­
pressed and sensations described by these voluntarily cooperative
males.

STAGE 1

In the human male a sensation of ejaculatory inevitability de­

velops for an instant immediately prior to, and then parallels in
timing sequence, the first stage of the ejaculatory process (acces­
sory-organ contractions). This subjective experience has been
described by many males as the sensation of “feeling the ejacula­
tion coming.” From onset of this specific sensation, there is a
brief interval (2 to 3 seconds) during which the male feels the
ejaculation coming and no longer can constrain, delay, or in any
way control the process. This subjective experience of inevitability
develops as seminal plasma is collecting in the prostatic urethra
but before the actual emission of seminal fluid begins. The two-
to threefold distention of the urethral bulb developing in the
terminal portions of the plateau phase also may contribute pro-
prioceptively to the sensation of ejaculatory inevitability [213,
290].

STAGE II

During the second stage of the ejaculatory process (propulsion

of seminal-fluid content from prostatic urethra to the urethral
meatus), the male subjectively progresses through two phases:
First, a contractile sensation is stimulated by regularly recurring
contractions of the sphincter urethrae. Second, a specific apprecia­
tion of fluid volume develops as the seminal plasma is expelled
under pressure along the lengthened and distended penile urethra.
Phase 1. The contractile effect varies in intensity of subjective
appreciation from onset to termination of the expulsive process.
The severity of the first two or three expulsive contractions of the
penile urethra and the slowed, almost tensionless, final contractions
of the ejaculatory process create entirely different contractile sen­
216 CHAPTER FOURTEEN

sations. The first few forceful contractions frequently develop a

relative degree of secondary anesthesia along the barrel of the
penile urethra, so that the final portions of the seminal volume
propelled by relatively tensionless contractions may escape without
the male’s sensate awareness of the emission. When the male is
subjectively aware of the final tensionless contractions, there is no
associated level of pleasure response similar to that identified with
the first strong expulsive contractions.
Phase 2. The subjective appreciation of volume of seminal-fluid
content is best exemplified by the severe orgasmic experience re­
lated to an initial ejaculation after a period of continence as op­
posed to the subjectively milder orgasmic episode associated with a
second ejaculation developing in a short interval after a first emis­
sion. If a male has been continent for several days, there generally
is a larger volume of seminal fluid ejaculated compared to that re­
turned after a few minutes of continence [131, 187]. The larger fluid
volume is appreciated subjectively as a more sensually pleasurable
sensation than is the lower volume ejaculate. Obviously, there
must be recurrent ejaculations for the male subjectively to appreci­
ate volume differences.

There is more to learn of the male’s subjective appreciation

of seminal-fluid volume. A larger ejaculate volume may account
in part for the male’s relatively greater pleasure in an initial
ejaculatory episode after a significant period of continence than
in a repeated orgasmic experience at the termination of his first
refractory period. This subjective reaction pattern is in opposition
to reported orgasmic response patterns for the human female. When
female study subjects were interrogated in the laboratory after
multiorgasmic experiences, the second or third orgasmic episode
usually was identified subjectively as more satisfying or more
sensually pleasurable than the first orgasmic episode. When male
study subjects were multiejaculatory in the laboratory, inevitably
the first ejaculatory episode was reported as the most satisfying
experience.
It should be emphasized that the first-phase sensation of con­
tractile response and the second-phase appreciation of fluid volume
blend as the second stage of the male’s ejaculatory experience
 THE MALE ORGASM (EJACULATION) 217

progresses. The contractile sensation is the dominant of the two

factors, as it is experienced initially and continues to be of sub­
jective import during and after seminal-fluid volume appreciation
has developed and subsided. The final sensate focus in the ejacula­
tory experience is on contractions of the penile urethra recurring
irregularly and with rapidly diminishing intensity.
The subjective progression of the two phases of contraction
and fluid volume through Stage II of the male orgasmic experience
is directly comparable to the sensations of contraction and throb­
bing that form the two phases of Stage III of the human female’s
subjective progression through orgasmic experience (see Chapter
9)-
There are marked differences in both objective and subjective
orgasmic experience for the aging male as opposed to his younger
counterpart. These differences have been considered in detail in
Chapter 16.
In contrast to the fact that orgasmic experience of the human
female can be interrupted by extraneous psychosensory stimuli,
the male orgasmic experience, once initiated by contractions of
the accessory organs of reproduction, cannot be constrained or
delayed until the seminal-fluid emission has been completed. Re­
gardless of intensity of extraneous sensory stimuli, the male will
carry the two-stage ejaculatory process to completion.

SOCIOLOGIC FACTORS IN
ORGASMIC ACHIEVEMENT

As opposed to the evasive literature reflecting sociologie in­

fluences upon the female orgasmic expression, there is little literary
concern for the male’s orgasmic experience. There are two major
reasons for this lack of sociologie concern with ejaculation. Of
primary importance is the fundamental demand of the life cycle
for male ejaculation. This one factor has provided acceptance of
the ejaculatory process per se by all cultures. Obviously, there
have been cultural attempts to control ejaculatory frequency and
to direct ejaculatory occasion, but not to repress the ejaculatory
218 CHAPTER FOURTEEN

process. This one factor of ejaculatory necessity has relieved the

male of the psychosocial pressures that have been imposed upon
the female’s orgasmic experience.
The second reason for lack of sociologic concern with the
male’s orgasmic experience is the fact that cultural pressures have
been directed toward other target areas. For the male, these pres­
sures have centered about the physiologic processes of penile
erection and not ejaculation. Thus, cultural demand has played
a strange trick on the two sexes. Fears of performance in the
female have been directed toward orgasmic attainment, while in
the male the fears of performance have related toward the attain­
ment and maintenance of penile erection, and orgasmic facility
always has been presumed.
It is evident that man’s sexual inadequacy is not related directly
to his ability or inability to attain orgasmic release of sexual
tensions. Psychosocial influences certainly create clinical states of
male sexual inadequacy, but rarely are they directed specifically
toward the orgasmic experience. Rather the major clinical dis­
tresses of primary and secondary impotence obviously have direct
relation to the psychophysiologic concerns of attainment and/or
maintenance of penile erection and do not relate to the actual
ejaculatory process. It also is obvious that the psychosocial concern
of premature ejaculation, although directly related to the male’s
orgasmic episode, hardly represents an expression of orgasmic
inadequacy. Therefore, these physiologic reflections of psychosocial
imbalance, arbitrarily termed sexual inadequacies, have been con­
sidered in Part 2 of Chapter 12 in a brief discussion of the
clinical concerns of the penile erective process.
There is a rare clinical exception to the concept that male
sexual inadequacy culturally is not related directly to orgasmic
attainment. Five men have been referred to the conceptive-physi-
ology section of the reproductive-biology research program during
the last 18 years with the primary complaint of conceptive in­
adequacy. These five men have not had difficulty in erective
attainment, nor has there been any inadequacy in maintenance,
once penile erection was achieved. In fact, their difficulties are
exactly on the opposite side of the coin. Their conceptive and
psychosocial problems have centered on the physiologic fact that
 THE MALE ORGASM (EJACULATION) HQ

they cannot ejaculate with the penis contained in the vagina. These
men can and do maintain coital connection for 30 to 60 minutes
at any given opportunity, but they are not able to ejaculate
intravaginally.
Three of the five wives are multiorgasmic as result of the
constant opportunity at long-maintained coition. Coital connec­
tion is terminated by the female partner’s admission of sexual
satiation. The remaining two wives, although having proved re­
sponsive capacity, had some loss of responsive interest developing
from concern about the considered partner abnormality.
All five of these men, ranging in age from 28 to 41 years, have
a masturbatory history reflecting some regularity of automanipula-
tive or partner release. In addition, they report occasional nocturnal
emissions. Of interest is the fact that they describe only excitement­
phase levels of sexual tension developing during or immediately
after the extended coital episodes. They find little or no interest
in tension release associated directly with coition. Usually their
psychosexual tension demands elevate and are expressed as com­
pletely separate sexual episodes. Their ejaculatory demand rarely is
above three or four times a month. Only one of the five men
has described four occasions of ejaculatory success with women
other than his marital partner. There has been no more than
one episode of success with each woman despite repeated attempts.
Three of the men have had no ejaculatory success with other
partners, although multiple exposure is described, and one man
has denied extramarital experimentation. Positive homosexual
histories have been obtained from only two of the five men, with
only one of the men active at the time of consultation with the
research program.
These men and their wives were referred initially because of
problems of conceptive inadequacy. The primary marital-unit con­
cern was for conception, not ejaculation. Since these problems
have been resolved in three of the five families by using the
husband’s seminal content in insemination techniques, these men
remain of interest more from a psychosexual point of view than
as problems in conceptive physiology.
While the psychosocial implications of this relatively rare in­
stance of male orgasmic inadequacy are striking, they have no
220 CHAPTER FOURTEEN

place in the current restricted discussion. These clinical problems,

together with those of primary and secondary impotence and
premature ejaculation, will be discussed in detail in future publica­
tions directed toward psychosocial background and the diagnosis
and treatment of human sexual inadequacy. Suffice it to say that
these five men prove exceptions to the basic concept that the
human male’s failures in sexual expression rarely have psychologic
or physiologic focus on the actual orgasmic (ejaculatory) experi­
ence. Inherent in the expression of this concept is the major
difference in the psychosocial approach of our culture to male and
female sexual inadequacy.
In essence, orgasm for the male, a two-stage experience, can
be identified by a chain of specific physiologic reactions and by
correlated patterns of subjective progression. Cultural concerns for
male sexual performance do not focus on orgasmic attainment.
GERIATRIC SEXUAL
RESPONSE
 I 5"

THE AGING FEMALE

i. ANATOMY AND PHYSIOLOGY

The anatomy and physiology of female sexual capacity and

performance during and after the menopausal years have not
been investigated previously. As might be expected, the cooperation
of women in this age group is not elicited easily. It will require
at least another decade to obtain the cooperation of aging women
in numbers sufficient to provide biologic data of statistical sig­
nificance. Current material is presented to suggest clinical im­
pression rather than to establish biologic fact.
The number of older women (menopausal and postmenopausal)
who have cooperated with the overall investigative program are
listed and separated into ten-year age groups in Table 15-1. The
oldest woman in the female population was 78 years at the time
of her evaluation. Altogether, 61 women past 40 years (34 of these
were past 50 years) of age have cooperated with the investigative
program during the past decade.
Since patterns of sexual response have been established for pre­
menopausal women using the four phases of the sexual cycle as
an arbitrary descriptive mechanism, older women’s sexual response
patterns will be described in similar fashion. Physiologic variations
from younger women’s established reaction patterns will be em­
phasized in context.
This technique of comparing the sexual reactions of older and
younger women should not be presumed to suggest physiologic
abnormality for the reactions of older women. Norms of sexual
response have been established independently for aging women
without regard to reactive potentials of younger women. The
technique of age-group comparison will serve merely to emphasize
changes in the physiology of sexual response that are related to
223
224 CHAPTER FIFTEEN: PART ONE

TABLE 15-I

Age Distribution of 61 Female Menopausal

and Postmenopausal Study Subjects

Age Distribution No. Active Participants

41-50 27
51-60 23
61-70 8 34
71-80 * 3
Total 61

* Oldest study subject was 78 years old.

the aging process. The primary purpose of this report is to

highlight the previously undcscribed sexual response patterns of
the aging human female.

EXTRAGENITAL REACTIONS

THE BREASTS

Excitement Phase. Nipple erection occurs in the aging female

following exactly the patterns described for her younger counterpart
(see Chapter 3). This reaction is the first external evidence of ele­
vated sexual tensions and, presuming the nipples are not inverted,
occurs shortly after the onset of any form of effective sexual stimu­
lation. Members of the 60- and 70-year age groups demonstrated
facility in the nipple erective response, just as their younger
counterparts always have done. Apparently, this elastic-tissue ac­
tivity is not destroyed by the aging process. There are, of course,
smooth-muscle fibers in the nipple that contribute to the erective
reaction, but the facility of nipple response cannot be credited to
smooth-muscle contractility alone.
The vasocongestive increase in breast size, often evident under
sex tension influence in the younger female who has not suckled,
undergoes progressive involution in reactive effectiveness as the
 THE AGING FEMALE 225

human female ages. Sixteen of the 27 members of the 41-50-year

age group repeatedly demonstrated obvious increase in breast size
as excitement-phase levels of sexual tension were established. Of
this group of 16 women, only 4 had suckled babies. However, in
the 51-60-year age group there was a marked reduction of the vaso-
congestive reactive potential of the breasts. Only 5 of the 23
members of this age group demonstrated a clinically obvious
increase in breast size during the excitement phases of their
sexual response cycles. Yet 15 of the 23 members of this age
group had not nursed. None of the 11 women over the age of
60 showed any clinically obvious increase in breast size as their
sexual tensions mounted, and 6 of these 11 women gave no
history of prior suckling. Thus, the clinical impression has been
created that as the human female ages, some degree of the
normal vasocongestive reaction of the breasts to elevated sexual
tensions is delimited by the aging process. Had the study subjects
been younger women, there would have been a much higher per­
centage of vasocongestive increase in breast size, particularly among
those women who had not suckled babies.
In those aging women that demonstrated obvious increment
in breast size, the swollen superficial venous patterns and slow
increase in breast volume (ultimately one-fifth to one-fourth size
increase) followed exactly the reaction patterns of the younger
age groups.
Plateau Phase. Engorgement of the areolae, a constant finding
during late excitement and early plateau phases of sexual response
in younger women, also develops in their aging counterparts. How­
ever, the intensity of the reaction usually is diminished. In younger
women plateau-phase areolar tumescence is of such magnitude that
it impinges upon the fully erect nipple, giving the impression that
a significant degree of nipple erection is lost. Although areolar
tumescence develops in women past 50 years of age, the reaction
is of minor intensity and there is no impression of loss of nipple
erection. Of clinical interest is the fact that women beyond 50
years of age may demonstrate an areolar tumescent reaction in
one breast and not the other. This phenomenon has been observed
22Ô CHAPTER FIFTEEN: PART ONE

rarely in younger women, but has been seen frequently in the

older age group.
Fourteen of the 27 members of the 41-50-year age group
showed a pink mottling over the anterior, lateral, and/or inferior
surfaces of the breasts immediately prior to orgasmic release of
their sexual tensions. Three of the 23 members of the 51-60-year
age group reacted in similar fashion. None of the women past
the age of 60 demonstrated the sex tension flush over the breasts
during the plateau phase of the sexual cycles.
Orgasmic Phase. There is no specific breast reaction to the
experience of orgasm. This is true for the younger as well as the
older woman.
Resolution Phase. The first resolution-phase reaction is the loss
of the sex tension flush if it has occurred. Shortly thereafter, oc­
casionally occurring simultaneously, is detumescence of the areolae.
This reaction progresses rapidly because of the limited extent of the
areolar tumescent reaction. Most of the women in the 50-, 60-, and
70-year age groups retain obvious nipple erection for a matter of
hours after an orgasmic experience. Loss of nipple erection after or­
gasmic release of sexual tension is usually a much more delayed
process in postmenopausal as compared to the premenopausal
years. However, postorgasmic nipple erection may be an indication
of continuing sexual interest following insufficient orgasmic tension
release. This distress occurs in the sexually responding woman of
any age. Therefore, definition of such etiology for retained nipple
erection only can be determined from direct interrogation of the
individual woman involved.
As a general clinical observation, it may be stated that the
more pendulous and slack the breasts of women of any age, the
more resistant the breasts are to the vasocongestive size increase
of sexual excitement. This observation has particular application
to the postmenopausal woman. As a direct result of the aging
process, a significant degree of elasticity is lost from breast tissues,
causing sagging and flattening. As hormone levels fall there usually
is measurable loss in integral breast tissue and actual breast
dimensions. Therefore, reduction in or absence of vasocongestive
response in the sagging, flattened breast becomes even more evident
with the passing years.
 THE AGING FEMALE 327

SEX FLUSH

The superficial vasocongestive skin response to increasing sexual

tensions develops in approximately 75 percent of women under
the age of 40. It does not occur so frequently in older women. Only
14 of the 27 members of the 41-50-year age group showed the
mottled maculopapular type of erythematous rash which first ap­
pears over the epigastrium late in the excitement phase or shortly
after plateau phase has been achieved. Only 3 of the 23 members
of the 51-60-year age group evidenced the sex flush at any time
during their evaluation, and none of the women past the age of
60 years demonstrated the flush.
When the flush appeared, it spread in the normal fashion over
the breasts, appearing first on the anterior and superior breast sur­
faces and then on the anterior chest wall. In most of the women
the flush continued to spread over the shoulders, neck, face, and
forehead. In only one individual (41-50-year age group) was the
sex flush of sufficient degree to be noted over the back, abdomen,
and extremities. In short, the development of the sex flush in the
aging female is limited in occurrence and is restricted to the
epigastrium, anterior chest, neck, face, and forehead, as opposed
to the rather protean distribution seen in the younger woman
(see Chapter 3).

MYOTONIA

General muscle-tension elevation in response to sexual stimuli

decreases as the woman ages. There obviously is less tension
created during voluntary muscle contraction, and specific examples
of involuntary striated-muscle spasm, such as carpopedal spasm,
are quite rare. The exception to this general rule is created by
a woman of 60 or 70 years responding to sexual stimuli as part
of a regularly recurring opportunity of exposure to sexual episodes.

URETHRA AND URINARY BLADDER

As in younger women, there is a minimal involuntary distention

of the external urinary meatus during an intense orgasm experi­
228 CHAPTER FIFTEEN: PART ONE

enced by older women. Menopausal and postmenopausal women

have been observed through many cycles of sexual response during
which the actual orgasmic phase was of moderate or minimal
intensity. In these situations gaping of the urinary meatus usually
did not occur. However, when the orgasmic experience was of
high intensity or the woman moved from one orgasmic experience
to a second or even a third in rapid succession, gaping of the urinary
meatus was observed frequently.
Many postmenopausal women complain of burning on urination
within the first few hours after coition, particularly if coital con­
nection is continued for extended lengths of time. This clinical
distress, identified in younger women as “brides’ cystitis,” develops
from mechanical irritation of the urethra and the bladder produced
by the normal thrusting movement of the penis. As the woman
moves through her postmenopausal years the lining of the vagina
becomes very thin and atrophic. Instead of having the thick, rugal
pattern of the hormonally well-stimulated premenopausal vagina,
the walls of the postmenopausal vaginal barrel are tissue-paper-thin
and, therefore, cannot protect the subjacent structures of the
urethra and bladder by absorbing the mechanical irritation of
active coition. Therefore, irritation of the urethra and bladder
occurs with some regularity and may do so with a high degree of
frequency if the aging female does not lubricate well. It is not
unusual, then, to find many older women having to contend with
a sense of urinary urgency shortly after coital connection and
being forced frequently to urinate immediately after coition. Some
of these individuals even may complain of urinary burning and
frequency for as long as two or three days after an episode of
extended coital connection.
One woman aged 57 described rare occasions of involuntary
loss of urine during coition with a particularly forceful male
partner. The same individual also loses urinary control with cough­
ing and sneezing. She has clinical evidence of both a cystourethro-
cele and rectocele. She has been catheterized on two occasions
immediately after voiding and demonstrated retention of 75-90
cc. of residual urine in the bladder. This instance of coitally con­
nected urinary loss is a reported fact. Urinary incontinence has
not been observed in the research laboratory.
 THE AGING FEMALE 229

THE RECTUM

Contraction of the rectal sphincter during orgasm is generally

an indication of the intensity of the specific orgasmic response.
Regularly recurring rectal contractions usually are seen in younger
women during episodes of multiorgasmic experiences. Suggestive
of the possibility of a generalized reduction in the intensity of
orgasmic expression as a part of the aging process is the fact
that orgasmic-phase rectal contractions have been observed only
three times in women beyond the age of 51 years. In each
instance the orgasmic phases obviously were associated with severe
tension levels, and in two of the three instances immediate return
to a second orgasmic experience was anticipated and executed.

THE EXTERNAL GENITALIA

The clitoris and the minor and major labia vary in responsiveness
to sexual tensions as the human female ages. Clitoral response
continues into the 70-year age groups in patterns similar to those
established for the premenopausal female. On the other hand,
reactions of the minor and major labia reflect involutionary changes
that appear to be inherent in the aging process.

THE CLITORIS

All of the 61 women past the age of 40 who have cooperated

in the research effort demonstrated the usual clitoral response
patterns of younger women (see Part 1 of Chapter 5). It should
be reemphasized that for all ages there is normally marked variation
in the anatomic structure of the clitoral body and glans. Clitoral
glandes measure 3-4 mm. to 1 cm. in transverse diameter, and
both measurements must be considered within the normal limits
of anatomic structuring. The rapidity of clitoral reaction to sexual
stimulation depends upon whether there is direct manipulation of
the mons area or the sexually stimulative activities are focused on
other erotic areas of the body (see Part 2 of Chapter 5). If stimula­
tion of the clitoris is other than by direct area contact, there is
230 CHAPTER FIFTEEN: PART ONE

distinct delay in reaction time as opposed to the speed with

which the clitoris reacts to direct stimulation.
Excitement Phase. Clinically obvious tumescence of the clit-
oral glans was observed during excitement-phase levels of sexual re­
sponse in only 14 of the 61 women past 40 years of age. In younger
women, approximately 25 of these 61 women would have been ex­
pected to demonstrate an obvious tumescence of the clitoral glans.
Of the 14 aging women who did show clitoral glans tumescence, 9
were in the 41-50-year age group, 4 were in the 51-60-year age group,
and one woman was 67 years of age.
The response of vasocongestive increase in clitoral-shaft diameter
which has been established as a reactive constant in premeno­
pausal age groups also was a constant factor in physiologic response
of menopausal and postmenopausal women. As sexual tensions
rise through excitement toward plateau-phase levels of response,
the shaft of the clitoris thickens, providing a diameter increase
that in some women exceeds twofold.
Plateau Phase. As plateau-phase levels of sexual tension are es­
tablished and the aging female approaches orgasmic-phase release,
the clitoris elevates away from its pudendal-overhang positioning,
retracting the exposed glans beneath its minor-labial hood in the
manner described for younger women (see Part 1 of Chapter 5).
This retraction of the clitoral shaft and glans and flattening of the
entire shaft on the anterior border of the symphysis (a constant
plateau-phase response of younger women) continue unabated as
the human female ages. The retraction reaction, when completed,
reduces clitoral-body length by approximately 50 percent in the
immediate preorgasmic period.
Orgasmic Phase. There is no established orgasmic-phase reac­
tion of the clitoris, regardless of age of the human female.
Resolution Phase. Clitoral-body retraction is terminated with
extreme rapidity. Lengthening of the shaft returns the clitoris to its
normal pudendal-overhang positioning immediately after orgasmic
experience. In those few instances in which obvious tumescence of
the clitoral glans was established, tumescence was lost within a
few seconds after the aging female’s orgasmic experience.
 THE AGING FEMALE 231

THE MAJOR LABIA

The flattening, separation, and elevation of the major labia

that develop in response to elevated sexual tensions, particularly
in the nulliparous woman, are lost as the woman ages. This
reaction normally separates and elevates the labia in an upward
and outward direction away from the vaginal outlet (see Chapter
4). Only three women in the 41-50-year age group demonstrated
the major-labia elevation reaction. None of the women past the
age of 51 showed this response to excitement-phase or even plateau­
phase levels of sexual tensions.
The major labia lose fatty-tissue deposits as the reduced hormone
levels of the postmenopausal years affect female anatomy. With
the loss of major-labial body content also goes some loss of elastic
tissue. Therefore, it was not unexpected that the major-labial
elevation reaction would be basically altered in the advanced
years.

THE MINOR LABIA

The minor labia of younger women undergo a vasocongestive

thickening during advanced excitement-phase levels of sexual re­
sponse which extends the vaginal barrel by approximately 1 cm.
This vasocongestive reaction is reduced when the human female
ages. Minor labial thickening and expansion still was obvious in 18
of the 27 members of the 41-50-year age group, and in 7 of the
23 members of the 51-60-year age group. None of the 11 women
past the age of 61 years evidenced this vasocongestive reaction.
The minor-labia reaction of younger women, specific to the
plateau phase of the sexual cycle, is a definitive color change
that ranges from a cardinal-red to a burgundy-wine color and
occurs in the immediate preorgasmic phase of the sexual response
cycle. This sex-skin reaction of the minor labia is pathognomonic
of impending orgasm in the premenopausal human female (see
Chapter 4).
As the human female ages, there is an obvious loss in the
consistency of the minor-labial sex-skin reaction. All the women
232 CHAPTER FIFTEEN: PART ONE

in the 41-50-year age group demonstrated the sex tension color

change immediately prior to orgasmic experience. Nineteen of
the 23 members of the 51-60-year age group also underwent the
minor-labial color change immediately prior to orgasmic experience.
Only 2 of the 8 members of the 61-70-year age group demonstrated
the color change, and only one of the 3 members of the 71-80-year
age group still retained this vasocongestive responsiveness of the
minor labia. These elderly women are the only women observed
through orgasm who did not demonstrate the preorgasmic color
change of the minor labia.

Bartholin’s glands

The secretory activity of Bartholin’s glands is somewhat slowed

by the aging process, but not until the human female is well
into the postmenopausal years. It may be recalled that Bartholin’s-
gland secretory activity in younger women develops only during
the plateau phase of the sexual response cycle (see Chapter 4).
Even then it is produced only if plateau-phase tension levels are
maintained for extended periods of time or if coital connection
purposely is continued for many minutes. Normally, the amount
of secretory material is very small, usually a drop or two of the
mucoid substance, and its only known use is to lubricate the
vaginal outlet during long-maintained coital connection.
All 27 members of the 41-50-year age group demonstrated Bar­
tholin’s gland secretory activity during the plateau phase of at
least one of their observed cycles of sexual response. However,
such secretory activity was present in only 12 of the 51-60-year
age group, in 3 of the 61-70-year age group, and was not observed
in the 71-80-year age group. Since Bartholin’s gland activity is
extremely difficult to demonstrate, it may well be that there were
cycles of sexual response in which individuals did produce this
mucoid material and the secretory activity was overlooked. In
older women there not only was a marked reduction in demon­
strable secretory activity, but the amount of material produced
also was significantly reduced when compared to that developed
by younger women.
 THE AGING FEMALE 233

THE REPRODUCTIVE VISCERA

THE VAGINA

The aging woman’s vagina undergoes specific involutionary

changes which should be described in some detail before attempt­
ing to establish the differences in vaginal response to sexual ten­
sions between younger and older women. After the woman has
undergone the normal menopausal involution of ovarian sex-
steroid production, changes develop in the target organs, i.e., the
labia, vagina, uterus, breasts, etc. The well-stimulated healthy
vagina of the 30-year-old woman has an entirely different appear­
ance from that of the steroid-starved woman in the 61-70-year age
group. After the ovaries cease or grossly reduce sex-steroid produc­
tion, the walls of the vaginal barrel begin to involute. Instead of
having the well-corrugated, thickened, reddish-purple appearance
of the well-stimulated vagina, the walls of the senile vaginal barrel
become tissue-paper-thin, lose the rough, corrugated look, and
change to a light pinkish color. The very thin walls of the senile
vagina almost give the impression that they can be seen through.
In addition to a thinning of the mucosa with aging, there is
shortening of both vaginal length and width (at the transcervical
level). The vaginas of the 11 women past the age of 60 who co­
operated with the research program measured 4.5-6 cm. in length
and 1-1.5 cm. ¡n width (transcervical level) of the vaginal barrel,
as opposed to a measurement of 7-8 cm. in length and approxi­
mately 2 cm. in width established previously for normally men­
struating women (see Part 1 of Chapter 6).
In addition to loss of length and width during the aging process,
the vagina also loses some of its expansive ability, as might be
anticipated from the reported loss of vaginal-wall thickness. The
involuntary neuromuscular response to sexual tensions which re­
sults in expansion in vaginal length and in transcervical width
obviously is influenced by states of sex-steroid starvation. One
woman, aged 62, has been with the experimental program for
nine years. No sex-steroid replacement therapy has been adminis­
tered despite several years of steroid-withdrawal symptomatology.
234 CHAPTER FIFTEEN: PART ONE

The vaginal barrel has lost length, transcervical width, and a sig­
nificant degree of involuntary ability to expand under sex tension
influence.
Excitement Phase. As excitement-phase levels of sexual tension
are achieved, the first evidence of physiologic response is, of course,
the production of vaginal lubrication. This primary evidence of fe­
male sexual tension is affected significantly by advancing years.
Once the individual female is approximately five years past the ces­
sation of her menses, the rate and the amount of lubrication pro­
duction diminish to an obvious degree. This is a general rather than
a specific statement of fact, for there have been and are individual
exceptions to this rule.
In younger women, vaginal lubrication is well distributed
throughout the vaginal barrel within 10-30 seconds of the onset
of any form of effective sexual stimulation. Once the individual
female is beyond the midfifties, and particularly when she is
beyond 60 years of age, it may take from one to three minutes
before any definitive production of vaginal lubrication can be ob­
served, despite the fact that the woman obviously is responding
with real anticipation and pleasure to the particular form of
sexual stimulation employed.
Three women represent the observed exceptions to the rule of
delayed lubrication production for the aging female—two in the
61-70-year age group, and one of 73 years. All three women con­
sistently respond to sexual stimulation with rapid production of
vaginal lubrication in a manner expected from a 20-30-year-old
woman. For these three women lubrication diffuses throughout
the vaginal barrel and covers the minor labia in short order. This
rapid, full production of lubrication occurs despite the fact that
in all three instances the vaginal mucosa is very thin and atrophic.
The only possible explanation for these exceptions to the general
rule of slowed lubrication production with aging is the interesting
fact that these three women (two in the 60- and one in the 70-
year age group) have maintained active sexual connections once
or twice a week throughout their mature lives. They are the only
ones in the over-6o-years age groups to have maintained coital
connection at such a frequency level.
Excitement-phase involuntary expansion of the inner two-thirds
 THE AGING FEMALE 235

of the vaginal barrel is reduced as has been described, in degree

and in rapidity of reaction during the postmenopausal years. How­
ever, the vagina does respond to the direct stimulation of actual
mounting opportunities with an expansive ability in excess of
that demonstrated during orgasmic cycles induced by manipula­
tion. As opposed to this older-age response pattern, the younger
female expands the inner two-thirds of the vagina almost as well
with manipulative activity as she does during active coition.
Plateau Phase. Since the inner two-thirds of the vaginal barrel
expands more slowly as the woman ages, this reaction may be ob­
served as frequently at plateau levels of sexual response as during
the excitement phase. This is in opposition to younger women’s re­
actions. Most vaginal expansion in length and in transcervical
width has been accomplished before plateau-phase levels of sexual
tension have accumulated.
The major physiologic response to plateau-phase levels of sexual
tension is the development of the orgasmic platform in the outer
third of the vagina (see Part 1 of Chapter 6). This reaction occurs
in all women at all ages and subsequent to any and all forms of
effective sexual stimulation. Local vasocongestion in the outer
third of the vagina is reduced significantly in intensity after senile
involution of the vaginal walls and constriction of the vaginal
barrel have developed. One woman aged 62, with nine years of
cooperation with the program, now develops an orgasmic platform
that is approximately one-half as extensive a reaction as the
platform produced during her middle fifties.
Once the orgasmic platform is developed fully, the central
lumen of the senile vagina is constricted to a degree proportional
to that of younger women. This is a constant reaction despite
the reduced local vasocongestion. The marked constriction of the
vaginal lumen probably is due to the fact that there is reduction
of the total vaginal-barrel volume and its involuntary expansive
qualities with senile involution of the vaginal walls and surround­
ing tissues.
Orgasmic Phase. The characteristic physiologic reaction to or­
gasmic levels of sexual tension is contraction of the orgasmic plat­
form. In older women contractions develop in fashion identical to
those of younger women with the exception that the orgasmic
236 CHAPTER fifteen: PART ONE

phase generally is reduced in duration when compared to that of

20-30-year-old women. Postmenopausal orgasmic-platform contrac­
tions usually recur from 3 to 5 times, as opposed to the response
pattern of younger women, whose orgasmic platform contractions
recur normally from 5 to 10 times (see Part 1 of Chapter 6). There
are exceptions to the general rule, as evidenced by the three
women mentioned previously, two in their sixties and one in her
seventies, who have maintained regularly recurring coital connec­
tions during their entire mature lives. These three women have
orgasmic-platform contractions that have been observed to recur
from 4 to 6 or even 7 times, as opposed to the 3 or 4 platform con­
tractions of women of the same age whose opportunity for sexual
expression has been delimited by physical or social circumstances.
As is true for younger women, contractions of the orgasmic
platform develop in the older female regardless of whether clitoral
area manipulation, active coition, or stimulation of any other
erotic area is used to develop orgasmic-phase response.
Resolution Phase. The expanded inner two-thirds of the vagina
shrinks back to a collapsed unstimulated state with marked rapid­
ity. This is a rapid involution of the entire vaginal barrel rather
than the irregular zonal type of reaction that slowly drops the cervix
of the anteriorly placed uterus into the transcervical depth of the
vagina in the younger woman. This rapidity of vaginal-wall collapse
in older women as opposed to the slower involution of the younger
woman well may be the result of the increasing rigidity and
lack of elasticity in the senile vaginal barrel. The orgasmic-platform
vasocongestion is lost even more rapidly than in younger women.
This rapid rate of involution again may result from generalized
reduction in the extent of pelvic vasocongestive response to sexual
tension.

THE CERVIX

As is true for younger women, there never has been evidence

of cervical secretory activity in postmenopausal women during
any of the four phases of the sexual response cycle.
During resolution, a slight patulousness of the nulliparous ex­
ternal cervical os has been demonstrated frequently in the younger
 THE AGING FEMALE 237

female. This dilatation of the external cervical os never has been

observed in any woman who is more than five years past the
cessation of menses.

THE UTERUS

As the human female experiences endocrine starvation during

her involutionary years, the cervix and the uterus respond to the
deprivation of sex-steroid stimulation by shrinking in size, with
the greatest evidence of involutionary change in the corpus, or
body, of the uterus. If the uterus is anteriorly placed, there is
some elevation of the senile corpus as excitement and plateau
phases develop in the sexually responding older woman. Thus,
a minor tenting effect develops at the transcervical depth of the
vaginal barrel. Uterine elevation is not as marked as that seen
in younger women. The tenting effect in the woman now 62 years
of age who has been with the program for nine years is much
less marked in extent, and the degree of uterine elevation is re­
duced significantly when compared to the severity of these reac­
tions when she first joined the program. Uterine elevation, if it
is to occur in older women, develops either in advanced excitement
or any time during a plateau-phase of sexual tension. This is further
evidence of aged women’s delayed reaction time when compared
to the usual pattern for the younger age groups. With premeno­
pausal women, uterine elevation essentially is completed by the
time plateau-phase levels of sexual tension have been established.
No evidence of vasocongestive uterine enlargement has developed
in any of the postmenopausal women.
As senile pelvic involution progresses after ovarian-steroid pro­
duction is no longer adequate for target-organ protection, the
uterus shrinks in size so that when the average woman is five
to ten years past cessation of flow, the uterus and cervix are
essentially equal in length. For this reason it has been impossible
to place intrauterine electrodes successfully, and orgasmic-phase
contractility of the senile uterus has not been recorded, as it has
been for younger women (see Chapter 8). However, several of
the women in the 60-70-year age group have responded to the
238 CHAPTER FIFTEEN: PART TWO

stimulation of orgasm with the clinical suggestion of uterine con­

tractility reported as severe cramping pain. One individual in the
60-year age group describes the uterine contractions of orgasm as
“almost like labor pains except that they occur more rapidly.”
There seems to be little doubt that the factor of uterine contractility
with orgasm remains in senile women. The severity, the duration,
and the degree of recurrence of these contractions obviously varies
tremendously from individual to individual and within the same
individual depending upon the intensity of the orgasm. There is
no definitive information available at present as to the physiologic
response of the senile uterus to effective sexual stimulation.

In brief, significant sexual capacity and effective sexual per­

formance are not confined to the human female’s premenopausal
years. Generally, the intensity of physiologic reaction and duration
of anatomic response to effective sexual stimulation are reduced
through all four phases of the sexual cycle with the advancing
years. Senile involution of the target organs (breasts, labia, vagina,
uterus) is evidence of postmenopausal states of sex-steroid starva­
tion. Regardless of involutional changes in the reproductive organs,
the aging human female is fully capable of sexual performance
at orgasmic response levels, particularly if she is exposed to regular­
ity of effective sexual stimulation. Steroid starvation has the pri­
mary influence of reducing rapidity and intensity of physiologic
response. When reduction in psychologic tension levels develops it
usually is secondary to considered loss of physiologic capacity and
not a direct effect of steroid starvation.

2 . CLINICAL CONSIDERATIONS

Theoretical knowledge and clinical experience related to sexual

problems of the aging are totally inadequate to meet the require­
ments of men and women who currently are living within the
framework of our newfound longevity. Any counselor facing prob­
lems created by the sexual tensions of menopausal or postmeno­
 THE AGING FEMALE 2J9

pausal women finds himself seriously handicapped by the lack of

a well-established body of literature on the subject.
Reports of the aging female’s sexual activity have been limited
largely to studies of the menopausal or immediate postmenopausal
years. Possibly this investigative concentration on the climacteric
age of 45 to 55 years has been stimulated by women’s tendency
to seek relief at this time from a variety of psychophysiologic
problems. In order to establish the aging-female component of
the study-subject population, 157 intake interviews were conducted
with women beyond 51 years of age. One hundred fifty-two of
these women contributed detailed sociosexual histories in response
to team interrogation. From this material, together with that
accumulated from seven years of clinical therapy of sexual in­
adequacy, the behavioral concepts expressed in this chapter have
been drawn. Only 34 of the original 157 women interviewed co­
operated actively in the investigative program (see Part 1 of this
chapter). The age distribution of the 152 women past 51 years
of age and the level of their formal education are listed in Table
15-2. The subjects provided histories separately to both the male
and female members of the interview team.
The degree of influence of sex-steroid withdrawal upon female
sexual adjustment during the menopausal and postmenopausal
years has not been established, although it is a popular practice
to assign to the physiologic fact of steroid starvation most of
the physical ills and psychosexual problems associated with these

TABLE 15-2

Age and Education of 152 Geriatric Female Study Subjects

Education
Age by No. Grade High Graduate
Decade Subjects School School College School
51-60 98 -2 62 29 5
61-70 37 1 28 6 2
71-80 17 3 11 3 0
Totals 152 6 101 38 7
240 CHAPTER FIFTEEN: PART'TWO

years. Many facets of the relationship between states of steroid

starvation and female sexual response remain to be defined.
There are several mechanical factors occasioned by endocrine
imbalance which result indirectly in painful coition during the
postmenopausal years. Many women who have never been dis­
comforted by sexual activity complain of physical distress during
or shortly after coital connection in the immediate postmenopausal
years. Coition may become severely painful during the penetration
phase, or extended coital connection may be followed by vaginal
burning, pelvic aching, or vague lower abdominal distress. Fre­
quently, coition is followed by burning and irritation on urination.
These symptoms of dyspareunia and dysuria may continue for
24 to 36 hours after sexual connection.
The symptoms of acquired dyspareunia and dysuria usually result
from a marked thinning of the vaginal mucosa and a reduction
in involuntary distensibility of the entire vaginal barrel. The natural
ability to lubricate the vaginal barrel and introitus effectively may
be reduced or the reaction time slowed for women beyond their
middle fifties (see Part 1 of this chapter).
Thinning of the vaginal walls, reduction in length and trans­
cervical diameter of the vaginal barrel, and shrinking of the major
labia, leading to constriction of the vaginal outlet, result from
sex-steroid starvation as ovarian function fails. These specific in­
dications of postmenopausal physiologic involution of ovarian
function may be corrected easily with adequate endocrine-replace­
ment therapy [52, 80, 86, 200, 201]. The return of physical capacity
for effective sexual performance should be considered the indirect
result of removing the physical roadblocks of target-organ (vagina)
senility, rather than the primary result of direct hormone stimula­
tion of lagging sexual tensions.
Even more necessary for maintained sexual capacity and effective
sexual performance is the opportunity for regularity of sexual
expression. For the aging woman, much more than for her younger
counterpart, such opportunity has a significant influence upon her
sexual performance. Three women past 60 years were repeatedly
observed to expand and lubricate the vagina effectively despite
obvious senile thinning of the vaginal walls and shrinking of the
 THE AGING FEMALE 241

major labia. These women have maintained regular coital con­

nection once or twice a week for their entire adult lives.
Frequently, women from five to ten years postmenses who
experience infrequent coition (once a month or less) and who do
not masturbate with regularity have difficulty in accommodating
the penis during their rare exposures to coition. It also is true
that many younger women deprived of coital opportunity for
long periods of time may have to contend with a slowed rate
of vaginal lubrication and restricted vaginal-barrel expansion during
a first return to coital connection. However, their difficulties are
far less pronounced than those of older women in similar cir­
cumstances of coital deprivation, and their full physiologic response
to coital stimulation is established far more rapidly.
There is another manifestation of steroid imbalance in the
sexual response patterns of the aging human female. As women
age and lose their sex-steroid levels, uterine contractions occurring
with orgasm frequently become painful. The actual degree of
distress varies from time to time and from woman to woman,
but when experienced, this painful uterine cramping develops
during as well as subsequent to orgasmic expression. While these
uterine contractions occur in women of all ages experiencing
orgasmic response, younger women rarely have accompanying phys­
ical discomfort that reaches a level of clinical distress.
Beyond 60 years of age some women are so distressed with
these contractions that they purposely avoid orgasmic experience
and even coital connection if possible. The pain from the con­
tractions is relieved by combinations of estrogen and progesterone,
if both are supplied continuously in a balanced combination to
the distressed postmenopausal woman. Neither hormone used
singly will relieve severe degrees of uterine contractile distress.
It should be emphasized that only pain of the contractions is
lost by adequate hormone replacement. The uterine contractions
continue to occur regularly with orgasmic expression.
Thus the simple fact remains that if opportunity for regularity
of coital exposure is created or maintained, the elderly woman
suffering from all of the vaginal stigmas of sex-steroid starvation
still will retain a far higher capacity for sexual performance than
242 CHAPTER FIFTEEN: PART'TWO

her female counterpart who does not have similar coital oppor­
tunities.
As has been seen, endocrine starvation has an indirect influence
upon, but certainly not absolute control over, female sexual capacity
or performance. Steroid starvation also has an indirect influence
upon female sexual drive. However, sex drive is but one in the
total of physical and psychosocial factors influenced by the aging
process.
It has become increasingly evident that the psyche plays a
part at least equal to, if not greater than, that of an unbalanced
endocrine system in determining the sex drive of women during
the postmenopausal period of their lives. If endocrine factors
alone were responsible for sexual behavior in postmenopausal
women (whether menopause occurs by surgical or natural means),
there should be a relatively uniform response to the physiologic
diminution and ultimate withdrawal of the sex hormones. How­
ever, there is no established reaction pattern to sex-steroid with­
drawal. For instance, clinical symptoms of menopausal distress
vary tremendously between individuals, and, for that matter, within
the same individual as the demand arises for increased physical
or mental activity [204].
Elevation of sexual responsiveness rarely results directly from
the administration of estrogen or estrogen-like products. Estrogenic
compounds frequently do improve sex drive in an indirect contri­
bution above and beyond the original intended purpose of insuring
a positive protein balance in the aging female. A woman previously
experiencing a healthy libido may become relatively asexual while
contending with such menopausal discomforts as excessive fatigue,
flushing, nervousness, emotional irritability, occipital headaches,
or vague pelvic pain. This individual’s personal eroticism may be
restored to previously established response levels following the
administration of estrogenic preparations. The obviously increased
sex drive well may have developed secondary to relief of the
woman’s multiple menopausal complaints, rather than as a pri­
mary or direct result of the actual adjustment of the individual’s
sex-steroid imbalance [201].
Personality studies of menopausal or postmenopausal women
are more prevalent in the literature than are endocrine studies.
 THE AGING FEMALE 243

In the opinion of Stern and Prados [302] there is no correlation

between the intensity of the type of physical symptoms usually
related to hormonal withdrawal (hot flushes, for instance) and
the severity of emotional disturbances occasioned by steroid star­
vation. They do feel, however, that among the many complaints
presented by menopausal women the physical complaint of pelvic
pain is the most intimately associated with the more severe forms
of psychic maladjustment. Rosenzweig [270] suggests that emo­
tional disturbance during the menopause may represent a reaction
of frustration to the representation of the menopause as the failure
of the whole life cycle in respect to procreation. Shorr [293] came
to the conclusion that the emotional complications of the meno­
pause are basically psychoneurotic in nature and are almost always
exacerbations of similar disorder patterns developed earlier in the
patient’s life. Certainly, absence of a sense of well-being and
general physical discomfort frequently present in the menopausal
woman only would tend to heighten and reactivate established
psychoneurotic behavior patterns of sexual origin. The average
woman’s psychosomatic symptoms fluctuate to the greatest extent
in the menopausal years. It is to be expected that the sex drive,
with its multiple related tensions, would reflect the instability of
this age group.
During the climacteric either a return to or escape from the
reproductive drive has been demonstrated by many women. Helene
Deutsch [53] has stated that during the preclimacterium many
women develop an overwhelming desire to become pregnant once
more, demonstrating in this manner an apprehensive feeling about
the “closing of the gates.” Other women welcome the advent of
the climacteric with genuine pleasure but do not demonstrate an
increased sex drive until menopause obviously is well established.
These women usually have been burdened with either an excessive
number of children or a financial situation too insecure to guarantee
adequate family protection. They develop a resultant “freedom
from fear of pregnancy” as the menses terminate.
Many a woman develops renewed interest in her husband and
in the physical maintenance of her own person, and has described
a “second honeymoon” during her early fifties. This expression of
unleashed sexual drive occasioned by the alleviation of the “preg­
244 CHAPTER FIFTEEN: PART TWO

nancy phobia” is one of the most frequently occurring factors

responsible for increased sexual tensions evident in the 50-60-year
age group. Noteworthy is the obvious fact that the renewed hus­
band-interest of the pregnancy-phobic individual' reflects a baseline
of pleasure and stability in the sexual relationship.
When the women who demonstrate the “freedom from fear”
complex are added to those concerned with the “closing of the
gates,” the frequently increased levels of sexual activity during the
late forties and early fifties noted by many observers is partially
explained. It should be emphasized, however, that the woman
who increases her sexual activity basically from a desire to con­
ceive rarely has major interest in the sexual relationship per se.
Thus, the marked increase in sexual activity of these two groups
does not reflect parallel increase in sex drive.
Absolute contraceptive security has not been available in the
past to women who are presently in the menopausal and post­
menopausal age groups. Therefore, the pregnancy phobias, when
they have developed, have been thoroughly understandable. When
the 20-30-year-old women of today are in their late forties and
early fifties, the expected increase in sex drive concomitant with
release of pregnancy fears well may be a thing of the past. In
today’s society the young wife need have no fear of unwanted
pregnancy, provided her religion tolerates the practice of contra­
ception and she can afford to purchase the effective contraceptive
materials presently available.
It also should be recalled that women beyond 50 years of age
usually have resolved most of the problems associated with the
raising of a family. Once the exhausting physical and extensive
mental demands of brood protection have been obviated by the
maturing of the family group, it is only natural that new directions
are sought as outlets for unexpended physical energy and re­
awakened mental activity. Thus, a significant increase in sexual
activity marks the revived sex drive of these middle-aged women.
Frequently this is the time for casting about for new sexual
partners or for the development of variations of or replacements for
long-established unsatisfying sexual practices.
The Kinsey group has noted that a large part of the sex drive
during the postmenopausal age is related directly to the sexual
 THE AGING FEMALE 245

habits established during the procreative years [144]. The inter­

view material suggests that a woman who has had a happy,
well-adjusted, and stimulating marriage may progress through the
menopausal and postmenopausal years with little or no interrup­
tion in the frequency of, or interest in, sexual activity. Additionally,
social and economic security are major factors in many women’s
successful sexual adjustment to their declining years.
Needless to say, there is an increasingly large segment of the
female population that is diametrically opposite to the reasonably
adjusted individual described above. If a woman has been plagued
by seeming frigidity, or by lack of regularly recurrent or psycho-
sexually satisfactory coital activity during her active reproductive
years, there is reason to believe that the advent of the postmeno­
pausal years may serve to decrease sex drive and to make the
idea of any form of sexual expression increasingly repugnant. This
individual uses the excuse of her advancing years to avoid the
personal embarrassment of inadequate sexual performance or the
frustrations of unresolved sexual tensions.
There also remains the Victorian concept that older women
should have no innate interest in any form of sexual activity. The
idea that the postmenopausal woman normally should have little
or no sex drive probably has arisen from the same source. Even
dreams or fantasies with sexual content are rejected in the wide­
spread popular belief that sexual intercourse is an unsuitable
indulgence for any woman of or beyond middle age.
As emphasized by Newman and Nicols [240], the sexual activity
of the woman in the 70-plus age group unfortunately is influenced
by the factor of male attrition. When available, the male marital
partner is an average of four years older than the female partner.
Many of the older husbands in this age group are suffering from
the multiple physical disabilities of advancing senescence which
make sexual activity for these men either unattractive or impossible.
Thus, the wives who well might be interested in some regularity
of heterosexual expression are denied this opportunity due to their
partner’s physical infirmities. It also is obvious that extramarital
sexual partners essentially are unavailable to the women in this
age group.
246 CHAPTER FIFTEEN: PART TWO

The trend of our population toward an aging society of women

without men must be considered. Roughly 10 percent of women
never marry. In addition, the gift of longevity has not been divided
equally between the sexes. As a result, there is a steadily increasing
legion of women who are spending their last years without marital
partners [222]. Many members of this group demonstrate their
basic insecurity by casting themselves unreservedly into their
religion, the business world, volunteer social work, or overzealous
mothering of their maturing children or grandchildren. Deprived
of normal sexual outlets, they exhaust themselves physically in
conscious or unconscious effort to dissipate their accumulated and
frequently unrecognized sexual tensions.
Masturbation presents no significant problem for the older-age-
group women [205, 215]. The unmarried female who has employed
this method for relief of sexual tensions during her twenties and
thirties usually continues the same behavioral pattern during her
forties and through her sixties. When heterosexual contacts are
limited or unavailable the widowed or divorced woman also may
revert to the masturbatory practices of her teens and twenties when
sexual tensions become intolerable. As might be expected, there
is reduction in the frequency with which manipulative relief is
deemed necessary beyond 60 years of age.
There seems to be no physiologic reason why the frequency of
sexual expression found satisfactory for the younger woman should
not be carried over into the postmenopausal years. The frequency
of sexual intercourse or manipulative activity during the post­
menopausal years is of little import, as long as the individuals
concerned are healthy, active, well-adjusted members of society.
It would seem that the maladjustments and abnormalities of
sex drive shown by states of hyper- or hyposexuality which develop
during and after the menopause might best be treated by prophy­
laxis. If satisfactory counseling of sexual content were made more
available to sexually insecure, uneducated, or inadequate women in
the premenopausal years, there is reason to believe that the un­
resolved tensions of the later years might be reduced or, to a large
extent, avoided. There is no reason why the milestone of the
menopause should be expected to blunt the human female’s sexual
capacity, performance, or drive. The healthy aging woman normally
 THE AGING FEMALE 347

has sex drives that demand resolution. The depths of her sexual
capacity and the effectiveness of her sexual performance, as well
as her personal eroticism, are influenced indirectly by all of the
psycho- and sociophysiologic problems of her aging process. In
short, there is no time limit drawn by the advancing years to
female sexuality.
 i 6
THE AGING MALE

i. ANATOMY AND PHYSIOLOGY

Th e aging male’s anatomic and physiologic responses to effective

sexual stimulation have been investigated during the past decade.
This discussion of male sexual capacity and performance is based
on data obtained from 39 men whose ages ranged from 51 to
89 years at the time of their evaluation (Table 16-1).
As was true for their aging female counterparts, it was extremely
difficult to elicit active cooperation from even this small group
of men. The material to be presented must be accepted in the
light of an admittedly inadequate study-subject population. This
is particularly true for results reported from men over 70 years
of age. However, the returns from this limited number of aging
males provide opportunity for comparison with patterns of sexual
response firmly established for younger men and permit superficial
consideration of the effect of the aging process on male sexual
physiology. Men in the 51-60-year age group were included in
the discussion to provide a parallel to the menopausal women’s
response patterns. The four phases of the human cycle of sexual
response will serve as a means of descriptive comparison.
Sexual response patterns were described not only by the active
study subjects but also by the 212 men beyond 50 years of age
who cooperated with sociosexual interviews (see Part 2 of this
chapter).
As the male ages, the major differences in sexual response relate
to the duration of each of the phases of the sexual cycle. As
opposed to the younger man’s well-established reaction pattern
of immediate erection, early mounting, and rapid ejaculation, the
older man (particularly over 60 years old) is slower to erect, to
mount, and to ejaculate. The resolution-phase refractory period
also lengthens for the male past the age of 50 years.
248
 THE AGING MALE 249

TABLE 16-1

Age Distribution of 39 Geriatric Male Study Subjects

Age Distribution No. Active Participants

51-60 19
61-70 14
71-80 4
81-90 * 2
Total 39

* Oldest study subject was 89 years old.

If there has been a well-adjusted marital pattern of frequency

of coital exposure, it usually is maintained well into the fifties
by healthy males. As a rule, the urban male slows in tension
increment before his rural counterpart. Assuming equally good
health and coital opportunity, this may be more a reflection of
psychosocial distraction than of specific physiologic involution.
With rare exceptions the male over 60 years old usually will
be satisfied completely with one or, at the most, two ejaculations
a week regardless of the number of coital opportunities or the depth
of his female partner’s sexual demand. Many men in their middle
or late fifties and in their sixties find that they cannot redevelop
penile erection for a matter of 12 to 24 hours after ejaculation.
Those who achieve a relatively early return to erection may have
lost their ejaculatory urge and are perfectly content to serve their
female partners to the completion of the woman’s sexual demands
without recurrent ejaculatory interest.

EXTRAGENITAL REACTIONS

THÉ BREASTS

As is true for younger men, there is only one general anatomic

reaction of the male breast to effective sexual stimulation—nipple
erection during the plateau phase of sexual response. Few men
250 CHAPTER SIXTEEN: PART ONE

under 60 years of age ejaculate without an obvious turgidity, if not

full erection, of the nipples. As the male ages, however, the degree
of nipple turgidity is reduced. Four men in the 61-70 age group,
3 in the group between 71 and 80 years, and both men over 80
years of age showed no clinically discernible nipple erection.
Whether this lack of nipple sensitivity is evidence of loss of
elastic-tissue substrate in the nipples or reduction in the intensity
of the body’s physiologic responses to orgasm, or both, cannot
be determined at present.
Of interest is the fact that loss of nipple erection in the resolution
phase usually is delayed in the aging male. On occasion, men
60 years or older have been noted to maintain nipple erection
for hours after ejaculation, unless the opportunity to sleep has
intervened.

THE SEX FLUSH

Following the aging human female’s reaction pattern, the aging

male loses ability to develop the vasocongestive maculopapular
flush of sexual tension. Only 2 of the 39 males past the age
of 50 years were observed to develop the sex flush. One of these
men demonstrated a fleeting measles-like rash confined to the
epigastrium and anterior chest wall, whereas the other man de­
veloped a full-blown sex flush over the diaphragm, anterior chest,
neck, face, and forehead, but not on the back or extremities. In
younger males, the sex flush (plateau phase-oriented in its timing)
usually is evidence of severe levels of sexual tension. When an
older man developed the sex flush prior to ejaculation, clinical
observation and his subsequent vocalization created the impression
that the orgasmic experience was more severe than his average
intensity of response.

MYOTONIA

There is little incidence of involuntary muscle spasm such as

carpopedal spasm late in plateau or during ejaculation in the male
over 60 years old. Regularly recurring contractions of the mus­
culature of the target organs develop with obvious reduction in
 THE AGING MALE 251

intensity. Exceptions to this statement are created by men with

continued frequency of exposure to sexual episodes.

THE RECTUM

Rectal-sphincter contractions, which in younger men occur regu­

larly during orgasmic experience, decrease in frequency as the
male ages. Regularly recurrent contractions of the rectal sphincter
have been noted in only 4 males over 50 years of age: 2 were in
their fifties, 1 was in his sixties, and 1 man (a single observation)
was 74 years of age. This reduction in involuntary rectal-sphincter
tension may reflect a generalized reduction in physiologic intensity
of orgasmic experience as the human male ages, a suggestion not
too difficult to accept in light of further information to be pre­
sented.

THE EXTERNAL GENITALIA

THE PENIS

Excitement Phase. Penile erection normally develops with ex­

treme rapidity in young males. The penis may reach full erection
from an unstimulated flaccid state within 3 to 5 seconds of the
onset of any form of sexual stimulation (see Part 1 of Chapter 12).
This reaction time is at least doubled and frequently trebled as
the individual male passes through his fifties and into the 60-
and 70-year age status. Generally, the older the male is, the longer
it takes to achieve full penile erection, regardless of the effective­
ness of the stimulative techniques employed.
Once achieved, penile erection in the aging male may be and
frequently is maintained for extended periods of time without
ejaculation. This degree of ejaculatory control may be acquired
by the younger man with specific training or by avoiding great
intensity of or marked variation in stimulative techniques. For
the aged male such stimulative restraint or specific training usually
is not necessary. Regardless of the variety or effectiveness of
the sexually stimulative activity, the ability to maintain penile
252 CHAPTER SIXTEEN: PART ONE

erection over long periods of time without an ejaculatory sequence

is associated with the aging process. Whether this ejaculatory con­
trol is the result of wide coital experience or truly reflects a
reduction in the intensity of sexual response inherent in the aging
process has not been determined. The clinical impression persists
that both factors probably are involved in the aging male’s im­
proved ejaculatory control.
The younger man experiencing excitement-phase levels of sexual
tension over an extended period of time may attain a full erection,
partially lose it, and fully regain it several times during any
sexual cycle. When full penile erection has been attained by the
male over 60 years of age and subsequently lost without ejaculation,
increasing difficulty may be encountered in returning to full erec-
tive performance. Older males may react to loss of penile erection
without ejaculation with what might be termed a secondary re­
fractory period. Once erection has been attained and then lost
without an ejaculatory opportunity, many older men experience
difficulty in returning to excitement-phase levels of physiologic
response, regardless of continuation of the previously effective
stimulative techniques. This type of reverse refractory period—i.e.,
occurring during excitement rather than resolution phase of the
sexual cycle—rarely occurs in potent males under 50 years of age.
Plateau Phase. Full penile erection frequently is not attained
by the aging male (particularly by those over 60) until just before
the ejaculatory experience. The younger male may undergo an
involuntary congestive increase in the circumference of the glans
at the coronal ridge as the ejaculatory episode approaches (see
Part 1 of Chapter 12). The aging male not only experiences this
involuntary increase in glans circumference occurring late in the
plateau phase but also experiences increased length and diameter
of the entire penile shaft just prior to ejaculation. The rapid penile
erective pattern associated with the younger male’s excitement­
phase levels of sex tension is transformed by the slower reactive
qualities inherent in the aging process to a plateau-phase penile
erective potential for the man over 60 years of age. The color
change of the glans penis (particularly at the coronal ridge) that
occurs in men younger than 40 has not been observed in men after
the age of 60 years.
 THE AGING MALE 253

Orgasmic Phase. The aging male’s expulsive penile contrac­

tions are established by regularly recurring contractions of the
sphincter urethrae, the bulbospongiosus, the ischiocavernosus, and
the transverse perineal muscles, paralleling the younger man’s phys­
iologic response patterns (see Part 1 of Chapter 12). Contractions
of these muscles expand and extend the penile urethra, distend the
urethral bulb, and force the seminal fluid from the prostatic and
membranous portions of the urethra to and through the external
urethral meatus. The younger male can expel the seminal fluid
the full length of the penile urethra under such pressure as to
deposit initial portions of the seminal plasma 12 to 24 inches
from the unencumbered urethral meatus. The man over 50 years
of age exhibits markedly reduced ejaculatory prowess, 6 to 12
inches being the average distance that the seminal plasma can
be expelled. If penile erection has been maintained for an extended
period of time, the actual ejaculatory process may be one of
seminal-fluid seepage from the external urethral meatus rather
than the usual ejaculatory response with the seminal fluid under
obvious pressure.
The intercontractile intervals between the first few penile con­
tractions are similar in timing for both younger and older men.
These expulsive contractions occur at intervals of 0.8 second. The
older the male, the fewer the number of expulsive contractions
and, as mentioned previously, the less the severity of expulsive
force propelling the seminal fluid.
Although the male over 60 also starts the ejaculatory process
with an intercontractile interval of 0.8 second, the ejaculatory con­
tractions which produce significant expulsive force are reduced in
number to one or two at the most. The intercontractile interval
rapidly lengthens, particularly after the second expulsive contrac­
tion of the penile musculature.
Resolution Phase. There are two major differences between
the older and the younger man during the refractory period of the
resolution phase: (1) The refractory period lasts for extended
periods of time as the male ages, particularly after the age of
60; and (2) penile detumescence (immediately after ejaculation)
usually is so rapid in the aging male that first and secondary stages
 CHAPTER SIXTEEN: PART ONE
254

of detumescence, so characteristic of younger men (see Part 1 of

Chapter 12), cannot be established.
The late vasocongestive response of full penile erection that
for older men frequently is not accomplished until an advanced
plateau phase has been established is dissipated in such a rapid
fashion that the postejaculatory elderly male may have no recog­
nizable staging during penile involution. Seconds after a 60-year-
old man ejaculates the penis may have returned to an unstimulated
flaccid state.

THE SCROTUM

Excitement Phase. The older man’s scrotal integument (skin

and tunica dartos) in a sexually unstimulated state is quite thin
and characteristically demonstrates marked relaxation, with mul­
tiple folding and free movement over the subjacent scrotal content.
There is even more relaxation, folding, and sagging of scrotal
tissue as the male ages, since a significant degree of scrotal skin
elasticity is lost.
As sexual tensions mount in the younger male, the scrotal
folding patterns may be obliterated as the result of a notable
tensing and thickening of scrotal integument. These responses
to sexual tension are accomplished by localized vasocongestion
(see Chapter 13). In the man over 60 years of age, however, scrotal
vasocongestive response to sexual tensions is reduced markedly.
Frequently, there is no evidence of any localized scrotal vaso­
congestion. The integumental folding pattern usually persists
without tensing or flattening, and thickening of the skin and
dartos may not occur. This lack of superficial vasocongestive
response to sexual tension persists despite the fact that the aging
male obviously is responding successfully to sexual stimulation.
When the scrotal sac contracts in the younger male and thus
decreases the internal scrotal diameter, support is contributed
secondarily to the reaction of testicular elevation. In the older
male the reaction of testicular elevation, as it occurs, receives
relatively little support from the nonelastic, sagging, usually non­
congested scrotal integument. Occasionally a full scrotal vasocon-
 THE AGING MALE 255

gestive reaction develops, but there is no consistency to the per­

formance.
Plateau and Orgasmic Phases. There are no specific scrotal re­
actions to either plateau- or orgasmic-phase levels of sexual tension
in younger or older men.
Resolution Phase. The younger man resolves the engorged
scrotal integument in two different patterns. The more frequent
reaction is characterized by rapid loss of the congested, tense
appearance of the scrotum and early reappearance of the rugal
pattern. However, approximately 25 percent of all young men
undergo slow involution from the vasocongested orgasmic state.
Full loss of scrotal vasocongestion may be delayed as long as one
to two hours after the ejaculatory experience.
Since full vasocongestion of the scrotal integument is a relatively
rare occurrence for the 6o-year-old male, and, for that matter, for
many 50-year-old males no definitive resolution pattern has been
established. Suffice it to say that when scrotal vasocongestion in
clinically observable degree occurs in response to sexual stimula­
tion in older men, it usually follows a slow involutionary pattern.
As in the younger male, no specific color change of the scrotal
integument has been observed in any phase of the sexual response
cycle.

THE TESTES

Excitement and Plateau Phases. The reaction of testicular

elevation results from a shortening of the spermatic cords and is
established by contraction of the cremasteric musculature which
invests these cords (see Chapter 13). Testicular elevation occurs
in younger males in late excitement phase or early in plateau
phase of the sexual cycle. With few exceptions, males under 50
years cannot ejaculate until full testicular elevation has occurred.
In males beyond the midfifties, testicular elevation is reduced
in excursion. Frequently, older males have been observed to
ejaculate with the testes elevated only one-third or one-half way
to the perineum. The right testicle may elevate almost to full
perineal apposition, yet the left testicle will not elevate more than
a half or two-thirds of the way from the scrotal depths. There
256 CHAPTER SIXTEEN: PART ONE

is no real significance in older men’s plateau-phase as opposed

to younger men’s excitement-phase timing for the testicular-eleva­
tion reaction. This is another example of the older man’s delayed
reaction time in sexual response.
When testes elevate from the scrotal depths, they do so any
time from onset of sexual stimulation to shortly before ejaculation.
When early testicular elevation occurs, and an extended excite­
ment or plateau phase delays ejaculation, the contracted cremasteric
musculature loses tone and allows spermatic cord relaxation. The
cord lengthens and the testes descend toward the depths of the
scrotum. When the delayed ejaculation does take place, the testes
may be lower in the scrotal sac than they were during the ex­
tended excitement or plateau phase of the cycle. The aging male
loses contractile tone of the cremasteric musculature much more
rapidly than does the younger man and regains it at a much
slower pace.
During excitement-phase levels of sexual tension, the testes
of younger males frequently increase in size approximately 50
percent beyond the unstimulated baseline. This deep vasocon-
gestive reaction continues through plateau and achieves its greatest
severity as orgasm is experienced. Beyond the late fifties or early
sixties, the human male rarely develops obvious vasocongestive
increase in testicular size. In the present study, two males in
the 51-60-year and one in the 61-70-year age group demonstrated
occasional vasocongestive increase in testicular size.
Orgasmic Phase. There is no specific orgasmic-phase testicu­
lar reaction for the human male.
Resolution Phase. During the resolution phase, testicular de­
scent in the aged male is so rapid that occasionally it has passed
unobserved. Not infrequently, testicular descent starts during or­
gasmic experience. The testes may be returned to the scrotal
depths before the full ejaculatory experience has been completed.
Particularly is this true for men over 60 years of age.
Resolution-phase involution of the transitory increase in testicu­
lar size occurs almost as rapidly as the reaction of testicular descent
in older men. It is so fleeting, in fact, that unless the testes
are under direct observation, loss of the tension-inspired, localized,
deep testicular vasocongestion may not be noted.
 THE AGING MALE 257

EJACULATION

The physiologic expulsion of seminal fluid by both the primary

and the secondary organs of reproduction is the biologic expression
of male orgasm. The act of ejaculation usually involves activity
of the highest cortical levels, but also it may be purely reflex
[110, 168, 207, 260, 285]. Following the established pattern of the
younger male, the ejaculatory process of the aging male may de­
velop in two stages: (1) the expulsion of seminal fluid from the
accessory organs of reproduction into the urethral pars prostatica
and (2) the progress of the seminal fluid through the urethra
from the pars prostatica through the pars membranacea and the
pars spongiosa to and through the urethral meatus.
Vocalization of subjective progression by young males has de­
scribed the two-stage ejaculatory process as follows: The first stage,
developed by accessory-organ contractions (prostate; questionably,
the seminal vesicles; etc.), elicits the sensation of ejaculatory in­
evitability and the “feeling that the ejaculation is coming.” In this
situation the young male no longer voluntarily can constrain or
control the ejaculatory process. There is a brief interval (2 to
3 seconds) when he feels the ejaculation coming, when he can no
longer control it, but before the actual emission of seminal fluid
occurs (see Chapter 14).
As the male ages, the entire ejaculatory process undergoes a
reduction in physiologic efficiency. Ejaculation is altered not only
in physiologic integrity but also in subjective progression.
In the older age group the first stage of ejaculation may be
either foreshortened to the extent that all sensation of ejaculatory
inevitability is lost or lengthened to such a degree as to stimulate
spasmodically recurrent sensations of ejaculatory imperativeness.
These marked variations in physiologic response will be explained
in context.
If the aging male’s penile erection has been maintained volun­
tarily during an extended excitement or plateau phase, the sen­
sation of ejaculatory inevitability usually does not develop in an
acute fashion. In this situation the male’s ejaculatory process is
one of sudden second-stage expulsion of seminal fluid through the
258 CHAPTER SIXTEEN: PART ONE

urethral meatus without separate first-stage warning contractions

of the accessory organs of reproduction. In other words, instead
of a two-stage, well-differentiated ejaculatory process, the elderly
male may have a single-stage expulsion of the seminal fluid, with
the secondary organs of reproduction contracting simultaneously
with the penile expulsive contractions rather than preceding them
by 2 or 3 seconds. Thus, the physiologic process of ejaculation
may be completed without a separate first-stage psychosexual warn­
ing of inevitability. Lowered ejaculatory pressure so frequently seen
as the male ages also may contribute to reduction of sensual
experience.
Rectal examinations made on one man in the 61-70 age group
and one man over 70 years of age during ejaculation did not
demonstrate clinically obvious contractions of the prostate during
the ejaculatory process. Similar rectal examinations in younger
men always have identified prostatic contractions which have
onset during the first stage of the ejaculatory process and which
continue into the second stage as well.
When the man over 60 retains first-stage contractions of the
accessory organs, this stage may be markedly extended and his
ejaculatory process altered significantly. The usual 2-3-second
duration of the first stage may stretch into a period of 5 to 6
seconds during which the man has the feeling of ejaculatory
imperativeness without the subsequent onset of second-stage penile
contractions.
It is possible that the efficiency of ejaculatory function of the
secondary organs of reproduction (prostate, seminal vesicles, etc.)
may be impaired by the aging process. These organs, under
stimulation, may develop a degree of spastic contraction rather
than regularly recurrent expulsive contractions. A severe sensation
of ejaculatory imperativeness develops, but the ultimate second-
stage seminal-fluid emission may not occur. This form of secondary
or acquired impotence usually is not a constant occurrence for
the aging male. This ejaculatory inadequacy has been observed
several times following long-continued penile erection and once
in a 67-year-old male who was under the influence of alcohol.
In brief, the aging male with the sensation of ejaculatory
imperativeness has the psychosexual demand to ejaculate, but
 THE AGING MALE 259

there may be loss or inefficiency of neurophysiologic control of

the process. It should be emphasized that this type of ejaculatory
inadequacy usually is transitory in character.
During the second stage of the ejaculatory process (penile
contractions) the young male can feel the actual emission of
the seminal fluid and is aware not only of the force of the
expulsive contractions but also of the localized sensation of fluid
emission as the seminal plasma is expelled under pressure along
the length of the penile urethra. The aging male, particularly if his
erection has been long-maintained, may have the experience of
seepage rather than of seminal-fluid expulsion. As the younger
male is terminating the second stage of the ejaculatory process,
a final drop or two of seminal fluid may seep from the urethral
meatus, obviously without expulsive force. This same feeling of
reduced or absent expulsive force may apply to the entire ejacula­
tory process of the man over 60 years of age. In this situation
there are no identifiable first-stage contractions of the accessory
organs of reproduction, and seminal fluid seeps from or escapes
the urethral meatus without significant ejaculatory pressure. The
expulsive penile contractions are reduced in intensity and duration.
Such a male usually does not have the sensation of ejaculatory
inevitability, nor is there the psychosexual satisfaction of expulsive
penile contractions. For these elderly men the ejaculatory process
is truly a one-stage rather than a two-stage affair.
As the male ages, the intensity and the duration of the localized
vasocongestive processes are diminished. There is marked reduction
in the frequency of the superficial sex flush and a slowing in
the development of full penile erection. This deep vasocongestive
phenomenon is delayed not only in rapidity but also in maturity
of development. Testicular elevation and scrotal-wall vasoconges-
tion are reduced in reactive quality, and congestive testicular size
increase does not occur frequently beyond 55 years of age. The
efficiency of ejaculatory physiology is reduced in reactive intensity
in both first and second stages. The psychosexual pleasure of the
ejaculatory process may be impaired. Finally, the two-stage ejacula­
tory pattern may be reduced to a single-stage, or other abnormal
ejaculatory patterns may develop.
2ÓO CHAPTER SIXTEEN: PART TWO

CLINICAL CONSIDERATIONS

Our aging population increasingly demands functional and func­

tioning roles not only within community structure but in private
life. Vocalization of these demands has stimulated renewed con­
sideration of the inevitable adjustments of the aging process. Not
the least of these adjustments are those related to physiologic
and psychologic capacity for sexual performance.
Investigative scrutiny rarely has been directed toward the func­
tional and functioning variations of the sexuality of the human
male during and beyond his climacteric years. Much in the aging
male’s life is affected by psychosocial adjustments occasioned by
sexual involution. Yet little scientific data has been established
as a baseline from which his psychosexual needs may be inter­
preted and solutions to related problems suggested. Although the
Kinsey group recorded data on over 5,000 white males, only 126
histories were obtained from men past 60 years of age [142]. Both
Finkle et al. [73] and Newman and Nicols [240] in independent
studies interviewed just over one hundred males beyond the age
of 55 years. Although Stokes [303] has assembled a massive
amount of pertinent information, his statistics and conclusions
have not been published to date [304].
In short, clinical material gathered to evaluate sexuality of
males in the geriatric population has been totally inadequate. This
statement should not be construed as reflecting adversely upon
prior investigations, but rather should serve to emphasize the
difficulties inherent in any attempt to evaluate the aging male’s
sexuality. In order to understand the rigid social resistance ex­
pressed toward any investigation of the aging male’s sexuality, it
may be helpful to recall that Victorian influence upon our society
has decreed for years that the aging male possesses little or no
socially acceptable sexuality.
When this culturally resistant facet of human sexual experience
was approached, the anticipated inadequacy of available clinical
material was encountered. In order to gather the 39 men (see
 THE AGING MALE 261

Part 1 of this chapter) who were able to cooperate unreservedly

with the program, 245 men over the age of 50 years were inter­
viewed. Of this total, 212 were sufficiently motivated to provide
detailed sociosexual histories which dated from earliest recall to
current state of sexual activity. Of the 212 aging men, 152 were
members of marital units in which both partners were past 50
years of age and were willing to provide histories of sexual be­
havior. Full advantage was taken of the opportunity to cross­
check the sociosexual histories of the 152 men by comparing
them insofar as possible with those obtained from their wives.
There was marked correlation in material on sexual capacity and
performance, including specifics of current frequency, techniques,
mounting success, and patterns of satisfactory response. When an
aging male or female cooperated to provide a history, the partner
was interviewed immediately to avoid suggested or jointly prepared
answers. It is from a review of this material, together with data
acquired from seven years of clinical therapy of male sexual in­
adequacy, that this chapter has been constituted.
The aging male’s obvious reluctance to impart material with
sexual orientation is evidenced by the fact that 245 men had to
be interviewed in order to accumulate the 212 histories granted
separately to both the male and female members of the interview
team. The age distribution, by decades, of these 212 cooperative
men and brief statistics relating to their formal education are pre­
sented in Table 16-2.

table 16-2
Age and Education of 212 Geriatric Male Study Subjects

Education

Age by No. Grade High Graduate

Decade Subjects School School College School

51-60 89 2 17 43 27
61-70 71 0 8 51 12
71-80 37 1 6 26 4
81-90 15 1 4 9 1
Totals 212 4 35 129 44
262 CHAPTER SIXTEEN: PA RT TWO

The bias toward higher levels of formal education than would

be expected for the general population is obvious. Only 4 men
failed to enter high school, and only a total of 39 (18 percent)
failed to enroll in college. Despite the exceptionally higher levels
of formal education apparent in the male study-subject population,
only 39 men had sufficient incentive and security of sexual per­
formance to cooperate actively with the study-subject group (see
Part 1 of this chapter).
There is no question of the fact that the human male’s sexual
responsiveness wanes as he ages. Particularly is this true if sexual
responsiveness arbitrarily is defined in such general, clinical terms
as (1) existing levels of sexual tension, (2) ability to establish coital
connection, (3) ability to terminate coition with ejaculation, and
(4) current history of masturbation and/or nocturnal emission. A
major difference exists between the response patterns of the middle-
aged male (41-60 years) and those of men past the 60-year land­
mark. This difference is reflected in the male over 60 years by loss
of maintained levels of sexual tension and reduced reactive intensity
during sexual expression. Not only does coital activity usually de­
crease but the incidence of masturbation and nocturnal emission
also is slowed with advancing years [26, 142].
The aging male's sexual capacity and performance vary from
individual to individual and from time to time in a particular
individual. Obviously, capacity and performance are influenced
directly by acute or chronic physical infirmity, or by the general
physiologic involution of the total body. Possibly the greatest
influence on geriatric sexual response may be inherent in the
sociosexual environment within which a male lives during his
sexually formative years. Kinsey et al. [142] suggested this possibil­
ity in 1948, and work with the present investigative population has
tended to support their thesis.
The most important factor in the maintenance of effective
sexuality for the aging male is consistency of active sexual ex­
pression. When the male is stimulated to high sexual output
during his formative years and a similar tenor of activity is
established for the 31-40-year age range, his middle-aged and
involutional years usually are marked by constantly recurring
physiologic evidence of maintained sexuality. Certainly it is true
 THE AGING MALE 263

for the male geriatric sample that those men currently interested
in relatively high levels of sexual expression report similar activity
levels from their formative years. It does not appear to matter
what manner of sexual expression has been employed, as long as
high levels of activity were maintained.
The incidence of sexual inadequacy in the human male takes
a sharp upturn after 50 years of age. As might be expected, second­
ary impotence increases markedly after this age and continues to
increase with each additional decade. During the last seven years
of experience in therapy for sexual inadequacy, 83 percent of
impotent males have been past the age of 40 years at onset
of treatment, and three of every four of these men were over
50 years of age. Of real interest is the fact that the male over
50 years old can be trained out of his secondarily acquired im­
potence in a high percentage of cases [39, 132, 133, 210, 216, 323].
Just as the secondarily impotent male over 50 years old can
be reconstituted, so can the potent aging male’s responsive ability,
dormant for physical or social reasons, be restimulated, if the
male wishes to return to active sexual practices and has a partner
interested in sexual performance. If he is in adequate health,
little is needed to support adequacy of sexual performance in a
70- or even 8o-year-old male other than some physiologic outlet
or psychologic reason for a reactivated sexual interest.
Briefly, if elevated levels of sexual activity are maintained from
earlier years and neither acute nor chronic physical incapacity inter­
venes, aging males usually are able to continue some form of
active sexual expression into the 70- and even 80-year age groups.
Even if coital activity has been avoided for long periods of time,
men in these age groups can be returned to effective sexual
function if adequate stimulation is instituted and interested part­
ners are available.

FACTORS IN MALE SEXUAL

INVOLUTION

Under what physical conditions or psychic influences does the

aging male progressively lose sexual responsiveness? Answers to
264 CHAPTER SIXTEEN: PART TWO

these questions comprise information of extreme importance in

both understanding and treating problems of geriatric sexuality.
Although the sample is small and obviously is not representative,
some suggestions worthy of consideration have emerged not only
from intensive team interrogation of the aging male but in many
instances from cross-interrogation of his spouse.
There are manifold physiologic and psychologic factors that
contribute to involution of the aging male’s sexual prowess. This
becomes particularly apparent when interrogation is carried out in
depth. Under detailed probing the individual basis for alteration
in male responsive ability usually falls within one or more of six
general categories: (1) monotony of a repetitious sexual relation­
ship (usually translated into boredom with partner); (2) pre­
occupation with career or economic pursuits; (3) mental or phys­
ical fatigue; (4) overindulgence in food or drink; (5) physical
and mental infirmities of either individual or his spouse; and (6)
fear of performance associated with or resulting from any of the
former categories. These six categories will be considered briefly
but in specific terms.

MONOTONY IN SEXUAL RELATIONSHIP

Loss of coital interest engendered by monotony in a sexual

relationship is probably the most constant factor in the loss of
an aging male’s interest in sexual performance with his partner.
This monotony may be the end-result of a sexual relationship
which did not develop beyond the stage of dutiful indulgence
and/or physical need for tension release. It also may develop from
a relationship in which the sexual component did not mature or
keep pace with other facets of marital progression.
Since the factor of overfamiliarity with the partner does in­
fluence sexual responsiveness, it should be considered in some
detail. For generations, the mores of a patriarchal society have
not confined the male to one sexual partner. When this attitude
exists in the male partner, it may provide a built-in reaction of
sexual restlessness after many years of partner restriction in a
monogamous state. The female partner may lose her stimulative
effect as her every wish, interest, and expression become too well
 THE AGING MALE 265

known in advance of sexual activity, especially if the subconscious

male focus has anticipated multiple-partner sexual variation. Al­
though the younger woman to whom such an aging male turns
may not in fact be as effective a sexual partner from a purely
physical point of view, the mere lack of familiarity with the
new personality creates an illusion of variation so attractive to
the sexual demands of many males. For the aging male, the
natural concomitant of this unconscious drive for variation is
the possible development of a need for a change of outlet in
order to create sexual tension or stimulate sexual capacity.
The complaint of sexual boredom frequently originates in the
fact that the female partner has lost sight of the necessity for
working at the marital relationship with the same interests in
stimulating and satisfying her male partner that she originally may
have demonstrated at the outset of marriage. The female partner
who incites boredom may have lost herself in the demands of
children, in social activities, in an individual career, or in any
combination of interests extraneous to the marital focus. By their
own admission many of the women interviewed no longer showed
either sexual interest in or sexual concern for their husbands. It
is the attitude of being taken for granted that the male apparently
rejects, at least at a subconscious level. The ego of the aging
male is especially vulnerable to rejection, either real or illusional.
The female partner in her forties may age, from the point
of view of physical appearance, more rapidly than the male partner.
Her overemphasis on or poor handling of the menopausal years
may impart an aura of being “unfemale,” with the result that
she ceases to have a sexually stimulative cathexis for the male
(see Part 1 of Chapter 15). Any loss of interest in personal
attractiveness joined with rapidity of menopausal disintegration
of her basic physical appearance may contribute to the male’s
feeling either of rejection or of overfamiliarity.

MALE CONCERN WITH ECONOMIC PURSUIT

Most men in the 40-60-year age group are reaching the competi­
tive heights of their occupations and are contending with the
greatest personal or family needs. They are engrossed with striving
266 CHAPTER SIXTEEN: PART ’TWO

for the preeminence in their particular interest deemed necessary

to provide that level of family financial security demanded by
their socioeconomic structure. The competitive male world can
be and frequently is allowed to become a demanding, all-con­
suming structure. This major diversion of male interest outside
the home progressively reduces time available to the marriage. The
male who is immersed in such an economic pursuit may make
little or no effort to vocalize his occupational concerns to his
female partner. Maintaining communication at any level permits
sexual interchange to remain a natural occurrence rather than to
become the result of a major effort of physical and mental
reorientation.
There are additional factors in the vagaries of the competitive
male world that should be considered. When the male has had
a bad day, when things have not gone well, usually there is less
interest in sexual activity than when he has experienced a most
successful day. While a small percentage of the men interviewed
reported finding comfort and reconstitution of ego within the realm
of sexual release, it is certainly true that preoccupation remains
a major deterrent to male as well as female sexuality.

MENTAL OR PHYSICAL FATIGUE

Fatigue is an important element in the involution of male

sexuality and exerts an ever-increasing influence during and beyond
middle age. Mental rather than physical fatigue is the greater
deterrent to male sexual responsiveness, although both are capable
of major influence in lowering or aborting sexual tension.
If the middle-aged male has the type of employment that
requires essentially a physical effort, he long since has conditioned
his body to these physical demands and there usually is relatively
little involution in sexual activity that results from such occupa­
tional efforts. The types of physical activity that have been re­
ported directly to inhibit male sexual interest are those of unusual
or excessive physical strain which are more often associated with
recreation than with job demands. Rarely does the middle-aged
male in our culture make any effort to maintain his physical
being in good condition. Therefore, the type of activity associated
 THE AGING MALE 267

with a weekend’s recreation frequently is more exhausting than

his routine job demands, particularly for the 50-plus age group.
An aging male in poor physical condition, exposed to occasions
of excessive physical activity, frequently complains of reduction
in or complete loss of sexual responsiveness during the 24 to 48
hours immediately following such unaccustomed physical effort.
As stated, mental as opposed to physical fatigue is the greater
deterrent to sexual tension during the male’s middle-aged years.
Reflected from the competitive male world, the loss of sexual
interest paralleling “the bad day at the office” initially results
from mental exhaustion which only later may be translated into a
physical counterpart. As the male ages, anything with which
he habitually is preoccupied necessitates the expenditure of sig­
nificant mental energy and subsequently reduces his sexual re­
sponsiveness. Occupational, financial, personal, and family emer­
gencies universally are reported by the male geriatric research
population to repress severely any existent sexual interest not
only during the immediacy of the emergency but also usually for
significant lengths of time thereafter. This sensitivity of male
sexuality to mental fatigue is one of the greatest differences be­
tween the responsiveness of the middle-aged and the younger
male.

OVERINDULGENCE IN FOOD AND DRINK

The aging male’s excessive consumption of either food or drink

has a tendency to repress his sexual tensions as it also lowers
his capacity to feel or achieve in other areas. Many males have
reported diminution of intensity in sensual focus, sometimes to
a degree of anesthesia, as a result of overeating. However, the
repression of sexuality is transient in nature unless the individual’s
eating patterns are grossly excessive and on a constant basis.
The syndrome of overindulgence has particular application to
alcohol. While under its influence, many a male of any age has
failed for the first time to achieve or maintain an erection of the
penis. Secondary impotence developing in the male in the late
forties or early fifties has a higher incidence of direct association
with excessive alcohol consumption than with any other single
z68 CHAPTER SIXTEEN: PART TWO

factor. When a man is traumatized by the inability to achieve

or to maintain an erection while under the influence of alcohol,
he frequently develops major concerns for sexual performance and
rarely associates his initial disability with its direct cause.
Not only does high alcohol ingestion directly reduce sexual
tension in the aging male but also it often places upon him the
additional indirect burden of concern for performance. He usually
faces this secondary psychologic problem, if it persists, either by
partial withdrawal from or by total avoidance of marital sexual
exposure. His frequent solution to his erective concerns is to seek
a sexual source unfamiliar with his personal concerns of sexual
inadequacy. If, coincidentally, he refrains from adding excessive
alcohol ingestion to the occasion of the first coital opportunity
with the new partner, his solution probably will work. Thus a
new problem within the marriage may arise. He is impotent with
his wife but has confidence in his sexual performance elsewhere.
The alternative to the alcohol-dependent male with an im­
potence pattern is the picture of the true alcoholic. As this male
progressively deteriorates physically and mentally, his sexual ten­
sions simply disappear. Since the chronic or even acute alcoholic
is in reality a mentally infirm individual, sexual involution under
these circumstances will be discussed under the next heading of
physical and mental infirmities.

PHYSICAL AND MENTAL INFIRMITIES

Physical infirmities that can reduce or eliminate sexual capacity

and performance obviously may develop at any age. However,
onset incidence rises precipitously beyond the 40-year age mark
and, of course, is particularly a factor after 60 years of age. Any
physical disability, acute or chronic, may and usually does lower
the sexual responsiveness of the involved male. If the physical
distress is acute, pneumonia for example, lack of sexual tension
usually is transient and is accepted without question by both
husband and wife. If physical infirmity develops as a chronic or
slowly progressive distress, emphysema for example, involution
of sexual capacity is among the early debilitating effects of progres­
sive reduction in physical efficiency. Longstanding chronic meta­
 THE AGING MALE 269

bolic diseases such as diabetes are known for the high incidence
of associated secondary impotence [104, 273].
Most forms of involutional psychopathology are associated with
evidence of reduced sexual activity. There are, however, notable
exceptions to the general rule of sexual regression for the male
experiencing mental senility. The entire problem has had little
definitive investigation.
In short, any acute or chronic distress, mental or physical in
character, that reacts to impair the male’s general physical condi­
tion or to reduce the efficiency of his body economy may be
associated with lowered or absent sexual tensions.
Androgens and estrogen-androgen combinations are being used
with increasing frequency in an effort to maintain the aging
male in a positive protein balance, just as these steroids have
been used in younger men with steroid imbalance [106]. There
has been some evidence of reawakened sexual interest subsequent
to effective steroid replacement in aging males. Clinical impression
suggests that the obvious elevation of eroticism is not a direct
effect of steroid replacement. Rather, it may be a secondary result
of the obvious improvement in total body economy and of a re­
newed sense of well-being [201 ].
Beyond the 60-year age level, the physical infirmity of the
female partner also is an ever-increasing factor. If the wife is
physically infirm, the aging male is restricted in sexual oppor­
tunity. As previously mentioned, regularity of sexual expression
is the key to sexual responsiveness for the aging male. With
loss of sexual outlet, many aging males report rapid loss of sexual
tension. It should be emphasized that this situation is not as
acute for the aging husband with a physically infirm wife as
it is for the aging wife with a physically infirm husband. In
our culture, the aging man has much more opportunity for sexual
outlet than does the aging woman.

FEAR OF FAILURE

There is no way to overemphasize the importance that the factor

“fear of failure” plays in the aging male’s withdrawal from sexual
performance. Obviously, any of the categories discussed briefly
270 CHAPTER SIXTEEN: PART' TWO

above would and do create in the aging male a fear of ineffective

sexual performance. Once impotent under any circumstance, many
males withdraw voluntarily from any coital activity rather than
face the ego-shattcring experience of repeated episodes of sexual
inadequacy. Not infrequently they vocalize, and eventually come
to believe, extraneous excuses for sexual withdrawal rather than
accepting the clinical fact of a normal involutionary process.
Expressions of anger or personal antipathy toward a partner
frequently are used aS an escape from a feared loss of ability
to perform adequately. Innumerable instances of the middle-aged
male’s turning to a younger female partner for sexual stimulation
provide everyday cases in point. This clinical picture has been
interpreted widely as the male’s subconscious attempt to rees­
tablish sexual potency in his own eyes, and to support his ego
by proving repeatedly his sexual prowess. The fallible element
in this solution is obvious when attempts to meet the increased
demands of the younger partner often have changed the aging
male’s passing concern for performance into an established physi­
ologic sexual inadequacy.
When aging males express a lack of interest in sexual perform­
ance or seek sexual stimulation extraneous to the marriage, their
wives are left without true insight into their husband’s fear of
performance and may feel personally rejected by his withdrawal
from marital sexual activity. If insight is present, the wives still
fear to push the reluctant aging male into the possibility of
recurrent episodes of erective failure. In any event, attempts at
sexual performance usually are reduced in intensity and frequency,
and the real factor of sexual stagnation takes over the marriage.
When the aging male is not stimulated over long periods of
time, his responsiveness may be lost.
There is every reason to believe that maintained regularity
of sexual expression coupled with adequate physical well-being
and healthy mental orientation to the aging process will combine
to provide a sexually stimulative climate within a marriage [131].
This climate will, in turn, improve sexual tension and provide a
capacity for sexual performance that frequently may extend to
and beyond the 80-year age level.
GENERALITIES IN
SEXUAL RESPONSE
 17
SIMILARITIES IN
PHYSIOLOGIC RESPONSE

lhe anatomy and physiology of human response to sexual stimuli

have been discussed in detail. In order to provide continuity, the
presentation of material has been oriented primarily to anatomic
structuring of reproductive viscera. While the technique of dis­
cussing physiologic capacity of the human male and female for
sexual performance in separate presentation does improve continu­
ity, it also tends to create a false impression. This technique
tends to emphasize the differences in sexual response between
the two sexes rather than the similarities.
Certainly there are reactions to sexual stimulation that are
confined by normal anatomic variation to a single sex. There
also are differences in established reactive patterns to sexual stimuli
—for example, duration and intensity of response—that usually
are sex-linked in character. However, parallels in reactive potential
between the two sexes must be underlined. Similarities rather
than differences of response have been emphasized by this in­
vestigation.
The similarities of male and female response to sexual stimuli
are highlighted in this skeletal review of body systems and in
the accompanying discussion of physiologic reaction presented
within the frame of reference of the cycle of sexual response.

THE BREASTS

The first response of the female breast to sexual stimulation

is erection of the nipple. However, the nipples frequently do not
achieve a state of full erection simultaneously. This is particularly
273
2?4 CHAPTER SEVENTEEN

true when there is an obvious difference between the breasts in

volume or when the nipples in unstimulated positioning are either
flat or in some degree of inversion. Usually the nipple of the
smaller breast or that least inverted will be first to become fully
erect. There has been no constancy of nipple erection established
for the male breasts. A minimum of 30 percent of sexually re­
sponding men provided positive evidence of an erective reaction
of the nipples in an earlier study [213]. A wider experience with
the sexually responding human male of all ages has resulted in
an upward revision of these figures. At present it is estimated that
50 percent to 60 percent of all sexually responding males demon­
strate some degree of nipple tumescence, resulting in a partial,
if not full, erective reaction.
As opposed to the excitement-phase timing for female nipple
erection, that of the male, although frequently developing during
the excitement phase, well may be delayed into the plateau phase
before a full erective reaction is established. There is also a
turgidity or tumescence of both the male and female nipple
developing after full erection is achieved, which has not been
mentioned previously. This increase in nipple diameter rather than
in nipple length develops late in excitement or early in plateau
phase for the human female, but not before plateau phase is well
advanced for the human male. This turgidity of the nipples be­
comes particularly evident if either excitement or plateau phase
of the sexual response cycle purposely is prolonged to an unusual
degree. This tumescence of the fully erect nipple in response
to long-maintained high levels of sexual tension is masked so
frequently in the female by advanced tumescence of the areolae
that no estimates of incidence can be presented with security.
Since turgidity of the erect male nipples occurs, as in the female,
only during long-maintained plateau levels of sexual tension, no
satisfactory estimate of frequency of occurrence can be provided.
The increase in breast size and tumescence of the areolae,
which are relatively constant clinical entities for the human female
(particularly for the nullipara), are not demonstrated by the male
breast.
As opposed to the relatively rapid resolution-phase involution
 SIMILARITIES IN PHYSIOLOGIC RESPONSE 275

of female nipple erection, male nipple erection, when established,

may persist for many minutes or even hours after ejaculation
before detumescence has been completed.

SEX FLUSH

Both male and female study subjects have demonstrated a

superficial vasocongestive flush that develops in response to sexual
stimulation. For the female the sex flush appears late in excite­
ment or early in the plateau phase, but for the male the flush
has been observed only late in the plateau phase of sexual response.
The sex flush achieves its widest distribution in both sexes in the
immediate preorgasmic sequence. It has been observed in approxi­
mately 75 percent of all female and 25 percent of all male study
subjects during individual sexual response cycles. Environment
contributes to the incidence of the sex flush. As might be expected,
it is more apt to develop in a warm rather than a cool atmosphere.
Despite acknowledged environmental influence, the appearance
of the sex flush always identifies severe levels of sexual tension.
For instance, a study subject may go through an entire orgasmic
experience without manifesting a flush, yet, in an immediately
subsequent sexual encounter during which more severe levels of
sexual tension develop, a widespread sex flush may be quite evident.
In both sexes, when the flush occurs it originates over the
epigastrium and spreads to the anterior chest wall. The neck,
face, and forehead are involved progressively. In the female the
flush frequently spreads over the lower abdomen, the thighs, the
arms, and even the low back and the buttocks in the more
extensive reactions. With the exception of the forearms and shoul­
ders, the flush rarely is seen in the male other than in the primary
sites of epigastrium, chest, neck, face, and forehead.
Involution of the sex flush during the resolution phase follows
a well-established pattern of inverse order of occurrence, regardless
of the sex of the individual involved. The flush first disappears
from the epigastrium, chest, shoulders, extremities, and back, and
finally from the neck, face, and forehead.
276 CHAPTER SEVENTEEN*

MYOTONIA

Since elevated muscle tension is second only to vasocongestion

as physiologic evidence of eroticism, the numerous voluntary and
involuntary reactions of skeletal muscles to progressive degrees of
sexual tension are understandable. During the excitement phase
of sexual response muscle tension is primarily voluntary in char­
acter. Some evidence of involuntary-muscle activity, such as ex­
pansion of the vagina in length and transcervical diameter (see
Part 1 of Chapter 6) and partial testicular elevation (see Chapter
13) does occur. However, evidence of muscle tension increment
is slow to develop in either sex when compared to the excitement­
phase evidence of vasocongestive reactions.
In general, specific examples of both voluntary and involuntary
muscle tension first develop in the plateau phase of the sexual
response cycle. The musculature of the legs, arms, and abdomen,
as well as the neck and face, contract or contort spasmodically
as late plateau and orgasmic phases of sexual tension are ex­
perienced. One of the most prominent of the involuntary muscle
tension reactions is that of carpopedal spasm, which develops late
in excitement or early in plateau-phase response. Carpopedal
spasm has been observed in both male and female study subjects
in the supine position during coition. However, male and female
subjects develop severe carpopedal spasm more frequently when
the sexually stimulative techniques are manipulative rather than
coital.
The physical activity of coition, with normal employment of
the voluntary musculature of the trunk, pelvis, and extremities,
precludes frequent development of uncoordinated striated-muscle
spasm for the superior-positioned coital partner. However, many
male partners have demonstrated involuntary contractile spasm
of the gluteal musculature immediately prior to ejaculation when
in a superior position. They also use voluntary gluteal contraction
extensively during masturbation or when trying to avoid premature
ejaculation. Preorgasmic contractions of the gluteal musculature
also have been observed frequently in female study subjects. The
 SIMILARITIES IN PHYSIOLOGIC RESPONSE V]']

female, even more than the male, uses voluntary gluteal con­
tractions to elevate sexual tensions. This technique is prevalent
in female superior or knee-chest coital positioning or during auto-
manipulative episodes.
During the orgasmic phase both sexes regularly demonstrate in­
voluntary spastic contraction of general muscle groups such as the
rectus abdominis and sternocleidomastoid muscles and the facial
musculature. The orgasmic spasticity of these muscle groupings
extraneous to the pelvic musculature has been discussed in the
literature for many years [8, 21, 76, 88,141-143,155, 228].
During resolution, muscle tension is lost rapidly for both sexes
if orgasmic release is experienced. As a rule voluntary-muscle con­
traction is released more rapidly than involuntary-muscle spasm.
If orgasm does not develop, muscle tension is lost with a rapidity
that parallels the degree of sexual tension achieved. For instance,
there is little muscle tension either voluntary or involuntary de­
veloped during the excitement phase, but significant tension of
both types is accumulated during the plateau phase. No difference
has been observed between the sexes in rapidity of muscle tension
release.

HYPERVENTILATION

Hyperventilation is a constant late-plateau-phase reaction for

both sexes, regardless of the type of sexual stimulation or activity
[119, 239, 268, 308]. The physiologic intensity and duration of
the reaction are indicative of the degree of sexual tension that
has developed. Respiratory rates have been recorded at peaks as
high as 40 per minute for both sexes.
When this physiologic evidence of sexual tension develops late
in male plateau phase, it usually continues through orgasm and
terminates during the refractory period of the resolution phase.
The female has been observed occasionally to return to a second
orgasmic experience before the primary state of hyperventilation
has resolved. In other words, once the male, even a young man,
ejaculates, he is refractory to reinstituted sexual stimulation until
278 CHAPTER SEVENTEEN

the hyperventilative reaction has subsided, but the female may

move from first to second orgasm while still hyperventilating from
the first orgasmic experience.

TACHYCARDIA

Both the sexually responding human male and female achieve

equal degrees of tachycardia while experiencing the various levels
of sexual stimulation. Recordable cardiac rates range from 100
to 175 beats per minute during plateau phases of sexual tension.
During orgasmic experience cardiac rates have been recorded
from 110 to 180+ beats per minute. Tachycardia developing during
advanced degrees of sexual tension has been described frequently
in the past [6, 22, 30,93,136,151,152, 258, 305].

BLOOD PRESSURE

Blood pressure elevation in response to sex tension increment

has been roughly parallel for both sexes. The male systolic eleva­
tions have increased by 40-100 mm. Hg and diastolic elevations
by 20-50 mm. Hg. The female elevations have ranged slightly
lower, with increases of 30-80 mm. Hg systolic and 20-40 mm.
Hg diastolic.
Specific investigative details of cardiorespiratory physiology in
sexually responding human males and females will be reported in
a separate monograph on sexual physiology.

PERSPIRATORY REACTION

Approximately one-third of both sexes develop an involuntary

sweating reaction during the immediate postorgasmic segment of
the resolution phase. This reaction may develop whether or not
there has been marked physical activity during the sexual encounter
and whether or not a sex flush has appeared. In male study
subjects this perspiratory reaction usually is confined to the soles of
 SIMILARITIES IN PHYSIOLOGIC RESPONSE 279

the feet and the palms of the hands, although appearing occasion­
ally on the trunk, head, and neck. In the female, perspiration is
distributed more frequently over the back, thighs, and chest wall,
with occasional spread to the forehead and upper lip. The appear­
ance of a postorgasmic perspiratory reaction has been described
previously in the literature [58,144, 234].

PELVIC VISCERA

EXCITEMENT PHASE

The first responses of the pelvic viscera to the stimulation of

sexual tensions are the erection of the penis and the production
of vaginal lubrication. Both reactions primarily are vasocongestive
in character. Penile erection usually is accomplished in 3-8 seconds
in the sexually responding male under 40 years of age. Generally,
younger males (21-30-year age group) achieve penile erection
faster than males over the age of 30 years. The comparable
female response to the onset of sexual stimulation is vaginal
lubrication. This transudate-like material appears on the walls of
the vagina in the woman under 40 years old in 10-30 seconds from
onset of stimulation. Beyond the age of 40, the speed of attain­
ment of full penile erection or vaginal lubrication generally is
slowed, but under effective stimulation these reactions may con­
tinue into the 80-year age group.
Both erection and lubrication vary in reactive intensity if
excitement-phase levels of sexual tension are prolonged. The male
may lose full penile erection during long-maintained excitement­
phase levels of sexual stimulation. Under similar circumstances
the female may reduce or even stop production of vaginal lubrica­
tion. In both sexes these reactions are reversible, particularly when
sex tension levels are stimulated and/or maintained by manipulative
rather than coital techniques.
There is a second vasocongestive response to excitement-phase
levels of sexual tension that is identical for both sexes. It is
demonstrated in the male by thickening of the scrotal integument,
with resultant flattening, constriction, and elevation of the scrotal
a8o CHAPTER SEVENTEEN1

sac. In the nulliparous female the major labia elevate and flatten
against the perineum; in the multipara the labia separate from
the midline and thicken from venous congestion. The minor labia
simultaneously develop a two- to threefold vasoeongestive increase
in size. This results in an extension of the vaginal barrel except
at the fourchette.
As the excitement phase progresses toward plateau, the male
responds to increasing sexual tensions by moderate elevation of
the testes. Simultaneously the testes undergo a deep vasoeongestive
size increase. Correspondingly, the female expands the inner two-
thirds of the vagina, adding 2-3 cm. to the length of the vaginal
barrel, and develops a two- to threefold increase in vaginal width
at the transcervical diameter.
As is true for penile erection and vaginal lubrication, the
physiologic responses of enlargement and elevation of the testes
and expansion and extension of the vaginal barrel are reversible
reactions during electively prolonged excitement-phase levels of
sexual tension. Under such circumstances, the depths of a relaxing
scrotal sac and the normal scrotal folding patterns may reappear.
These reversible reactions of the testes and scrotum will occur
even if penile erection is maintained. Providing the female has
not been mounted, prolonged excitement-phase tension levels will
result in reduction of the transcervical expansion and a con­
comitant decrease in the vaginal-barrel length. These reactions
will occur even though advanced degrees of vasocongestion of
the vaginal walls and the minor labia are maintained.

PLATEAU PHASE

If sexual tension is elevated to plateau-phase levels, the male

reflects these higher tension levels with further vasoeongestive
response. Although the penis may have appeared fully erect, an
obvious increase in penile circumference at the coronal ridge
develops before ejaculation.
The female’s physiologic response to plateau-phase levels of
sexual tension also provides further evidence of deep pelvic vaso­
congestion with the development of an orgasmic platform in
the outer third of the vagina. This vasoeongestive reaction usually
 SIMILARITIES IN PHYSIOLOGIC RESPONSE 181

progresses to such an extent that the outer third of the vaginal

barrel may be obtunded by at least a 50 percent reduction in
diameter.
Further parallels of physiologic response of the pelvic viscera
of both sexes to plateau-phase levels of sexual tension are evidenced
by superficial vasocongestive reactions. The male response is an
increased purple cast to the coronal area of the penis. This color
change is inconsistent, even if orgasm is to ensue. Many men
never demonstrate this color change, while others do so only oc­
casionally.
As opposed to this inconsistent male indication of preorgasmic
tension levels, the female develops such a marked discoloration
of the minor labia that it has resulted in the designation of
these tissues as “sex skin.” The nulliparous minor labia turn a
bright red, and those of the multipara may darken to a burgundy­
wine color as plateau-phase sexual tensions move the woman
toward orgasmic expression. Once the minor labia go through
this sex tension color change, orgasm is inevitable if effective
sexual stimulation is maintained without interruption. Many
women achieve plateau-phase sexual tension levels but do not
experience orgasmic-phase release. These women do not show
sex-skin discoloration of the minor labia.
Further clinical responses which develop in parallel manner for
both sexes during the plateau phase are mucoid secretory emissions.
The male has a preejaculatory emission from the urethral meatus
that has been identified with Cowper’s glands. This material
usually is restricted to two or three drops in volume. Occasionally,
during long-maintained plateau-phase levels of sexual tension, al­
most 1 cc. of the material has been secreted and collected.
The female mucoid emission is provided by Bartholin’s glands
during the plateau phase. The function of this material has
been identified previously with vaginal lubrication [30, 119, 228,
268, 305, 318, 319]. Bartholin’s glands do not contribute to the
lubrication of the vaginal barrel with the exception of the immedi­
ate area of the fourchette and then only subsequent to long-
maintained plateau-phase levels of sexual stimulation. With pro­
longed coital activity, the production of vaginal lubrication is
slowed, and continued fourchette protection is accomplished by
282 CHAPTER SEVENTEEN

the Bartholin’s glands. In view of the plateau-phase timing and

the mucoid consistency of both materials, biochemical definition
possibly may identify them as basically similar substances.

ORGASMIC PHASE

The ejaculatory phenomenon is unique in the entire cycle of

sexual response and is the essence of the male orgasmic experience.
Orgasm in the male is initiated by contraction of the accessory
organs of reproduction. The vas deferens, seminal vesicles, ejacula­
tory duct, and prostate contract with regularity to provide the
seminal plasma necessary for the ejaculate total. Contraction of
the secondary organs of reproduction is experienced by the male
as an impression of ejaculatory inevitability. The sensation develop­
ing over a 2-3-second interval has been described as a feeling that
the ejaculate is coming and can no longer be controlled. This
anticipatory sensation is experienced during the collection of
seminal plasma in the prostatic urethra.
When seminal plasma is compressed in the prostatic urethra,
the internal sphincter of the bladder contracts to avoid retrograde
flow into the urinary bladder. The external bladder sphincter
and the membranous portion of the urethra relax, and the entire
seminal pool is ejected along the penile urethra and through
the urethral meatus under significant ejaculatory pressure. These
ejaculatory contractions are established by the periurethral muscles
as well as by the ischiocavernosus and bulbospongiosus muscles.
The contractions have onset intervals of 0.8 second and continue
at this spacing for two to three expulsive efforts. Thereafter the
contractions are slowed not only in interval timing but in ex­
pulsive force. However, they have been observed to continue on an
irregular basis and with little expulsive force for two to four
more occasions. The male orgasmic phase is terminated with the
cessation of expulsive contractions of the penile urethra (see
Chapter 14).
Female orgasmic experience usually is expressed over a longer
time sequence. It has onset with contractions of the uterine
musculature and of the vaginal orgasmic platform. The uterine
contractions develop in the fundus and move toward the lower
 SIMILARITIES IN PHYSIOLOGIC RESPONSE

uterine segment. Concomitant with the onset of uterine contrac­

tions is the development of contractions of the orgasmic platform
in the outer third of the vagina. These two physiologic responses
to overwhelming sexual tension provide the sensations of total
pelvic contraction that the sexually oriented woman identifies with
orgasmic expression.
Both uterine and vaginal-orgasmic-platform contractions have
simultaneous onset in an overall pelvic response pattern. The
orgasmic-platform contractions have onset at 0.8 second and con­
tinue for four to eight contractions before there is recordable
slowing in the intercontractile interval. Two to four more con­
tractions may be observed thereafter at irregular intervals and
with diminishing contractile force. They correspond to the non-
expulsive slowed contractions of the penile urethra at the termina­
tion of the male’s ejaculatory response (see Part 1 of Chapter 6,
and Chapter 8).
Further parallels of pelvic visceral response during orgasmic
expression have been observed in both sexes. In the male the
rectal sphincter contracts two to four times, with onset intervals
of 0.8 second. These rectal contractions have been observed to
parallel in time sequence the expulsive contractions of the penile
urethra. For the female the external rectal sphincter also contracts
two to four times at o.8-second intervals, again parallel in time
sequence with contractions of the vaginal orgasmic platform. An
additional female response is the occasional (10-15 percent) de­
velopment of irregular contractions of the external urethra which
occur without recordable rhythmicity and recur two or three times
at the most.

RESOLUTION PHASE

The male has a unique refractory period which develops as the

last, irregular, nonexpulsive contractions of the penile urethra
occur and is maintained until sexual tension in the male has
been reduced to low excitement-phase levels of response. The
female has no such refractory reaction. She generally maintains
higher levels of stimulative susceptibility during the immediate
postorgasmic period. She usually is capable of return to repeated
284 CHAPTER SEVENTEEN

orgasmic experience without postorgasmic loss of sexual tension

below plateau-phase levels of response.
Due to the postorgasmic loss of stimulative susceptibility, the
male pelvic viscera tend to lose superficial and deep vasocongestion
more rapidly than do those of the human female. Loss of penile
erection in the male occurs in two stages. The first stage evidences
rapid loss of vasocongestion until the penis is perhaps one to
one-and-a-half times enlarged. Second-stage penile involution is
a slowed response, particularly if the excitement- and/or plateau­
phase levels of the specific sexual response cycle have been pro­
longed markedly. If penile erection has been maintained for long
intervals before ejaculation, the second-stage involution of penile
vasocongestion is usually an extended process.
Loss of testicular vasocongestion and return of the testicles
to the depth of the scrotum, together with loss of congestion
of the scrotal integument and the reappearance of the scrotal
folding pattern, occur parallel in time sequence with the rapid
primary involution of penile erection.
The female loses the deep vasocongestion of the orgasmic plat­
form and the superficial sex-skin discoloration of the minor labia
more rapidly than any other postorgasmic involutionary process.
Yet these resolution reactions do not occur as rapidly as primary
involution of penile erection. Thereafter, loss of minor-labia vaso­
congestion and the return of the walls of the vaginal barrel
to unstimulated width and length frequently are extended over
many minutes, despite a most satisfying orgasmic experience. The
loss of the vaginal barrel’s deep vasocongestion is slowed when
compared to the rapid loss of scrotal and testicular vasocongestion.
Parallels between the anatomic responses of the human male
and female to effective sexual stimulation have been established.
As an aid to comparison, Tables 17-1, -2, -3, and -4 have been
provided and are self-explanatory. It is obvious from the descrip­
tions and discussions that the primary physiologic reaction of
either male or female to effective sexual stimulation is super­
ficial and/or deep vasocongestion, and that the secondary reaction
is one of increased myotonia, both voluntary and involuntary in
character. Hyperventilation, tachycardia, muscle spasm, pelvic-mus­
culature contraction, etc., are of secondary import when compared
 SIMILARITIES IN PHYSIOLOGIC RESPONSE 285

to widespread general-body and organ-system vasocongestion. The

parallels in reaction to effective sexual stimulation emphasize the
physiologic similarities in male and female responses rather than
the differences. Aside from obvious anatomic variants, men and
women are homogeneous in their physiologic responses to sexual
stimuli.

Tables 17-1, -2, -3, and -4 follow on pages 286-293.

 TABLE 17-1
Sexual Response Cycle of the Human Female—Extragenital Reactions

I. Excitement Phase II. Plateau Phase III. Orgasmic Phase IV. Resolution Phase
Breasts Nipple erection; increased Turgidity of nipples; fur- No observed changes Rapid detumescence of
definition and extension of ther increase in breast size; areolae and involution of
venous patterning; in­ marked areolar engorge­ nipple erection; slower de­
crease in breast size; tu­ ment crease in breast volume
mescence of areolae and return to normal ve­
nous patterning

Sex Flush Appearance of maculopap­ Well-developed flush; may Degree of flush parallels Rapid disappearance of
ular rash late in phase, have widespread body dis­ intensity of orgasmic ex­ flush in reverse order of
u
00 first over epigastrium, tribution late in phase perience (est. 75% inci­ its appearance
spreading rapidly over dence)
breasts

Myotonia Voluntary-muscle tension; Further increase in volun­ Loss of voluntary control; Myotonia rarely carried
some evidence of involun­ tary and involuntary ten­ involuntary contractions more than 5 min. into,
tary activity (vaginal-wall sion; semispastic contrac­ and spasm of muscle phase but not lost as rap­
expansion, tensing of ab­ tions of facial, abdominal, groups idly as many evidences of
dominal and intercostal and intercostal muscula­ vasocongestion
musculature) ture

Rectum No observed reaction Voluntary contraction of Involuntary contractions No observed changes

rectal sphincter as stimula­ of rectal sphincter occur­
tive technique (inconsis­ ring simultaneously with
tent) contractions of orgasmic
platform
 Hyperven­ No observed reaction Appearance of reaction oc­ Respiratory rates as high Resolves early in phase
tilation curs late in phase as 40/min.; intensity and
duration indicative of de­
gree of sexual tension

Tachy­ Heart rate increases in Recorded rates average Recorded rates range from Return to normal
cardia direct parallel to rising from 100 to 175 beats per 110 to 180+ beats per
tension regardless of tech­ min. min.; higher heart rates re­
nique of stimulation flect more variation in or­
gasmic intensity for female
than for male

Blood Elevation occurs in direct Elevations in systolic pres­ Elevations in systolic pres­ Return to normal
Pressure parallel to rising tension sure of 20-60 mm. Hg, sure of 30-80 mm. Hg,
w regardless of technique of diastolic 10-20 mm. Hg diastolic 20-40 mm. Hg
Qo
stimulation

Perspir­ No observed reaction No observed reaction No observed reaction Appearance of widespread

atory film of perspiration, not
Reac­ related to degree of physi­
tion cal activity
 TABLE 17-2
Sexual Response Cycle of the Human Female—Genital Reactions

I. Excitement Phase II. Plateau Phase III. Orgasmic Phase IV. Resolution Phase
Clitoris Tumescent reaction of cli- Withdrawal of clitoral No observed changes Return to normal position­
toral glans; vasocongestive body (shaft and glans)
increase in diameter of ing within 5 to 10 sec.
from normal pudendal- after cessation of orgas­
clitoral shaft; shaft elonga­ overhang positioning and
tion mic-platform contractions;
retraction against anterior slower detumescence and
body of symphysis loss of vasocongestion
Vagina Appearance of vaginal lu­ Development of orgasmic Contractions of orgasmic Rapid detumescence of or­
brication within 10—30 platform at outer third of platform starting at 0.8-
W
sec. after initiation of any gasmic platform; relaxa­
OO
00
vagina; further increase in sec. intervals and recurring tion of vaginal walls; re­
form of sexual stimulation; width and depth of vagi­ 5-12 times; after first 3 to
expansion and distention turn to normal coloring
nal barrel 6 contractions, intercon­ (may take as long as 10-15
of vaginal barrel; vaginal- tractile intervals lengthen min.)
wall color alteration from and contractile intensity
normal purplish-red to diminishes
darker, purplish hue of
vasocongestion

Uterus Partial elevation of anteri­ Full uterine elevation into Corpus contractions begin­
orly placed uterus; devel­ Gaping of external cervical
false pelvis; cervical eleva­ ning in fundus, progressing os which continues 20-30
opment of corpus irrita­ tion produces tenting ef­ through midzone, and ex­
bility min.; return of elevated
fect in midvaginal plane; piring in lower uterine seg­ uterus to unstimulated
increasing corpus irritabil­ ment; contractile excursion resting position in true pel­
ity parallels intensity of orgas­ vis; cervical descent into
mic experience; multipara, seminal basin
est. 50% size increase
 Nullipara: no observed re­ Nullipara: return to nor­
Labia Nullipara: flattening, sepa­ Nullipara: labia may be­
action mal thickness and midline
Majora ration and anterolateral come severely engorged
with venous blood during positioning
elevation of labia away
from vaginal outlet prolonged phase
Multipara: no observed re­ Multipara: involution of
Multipara: vasocongestive Multipara: further vaso­
action labial vasocongestion
increase in diameter; slight congestive swelling de­
lateral movement away pending upon degree of
from midline varicosity involvement

Occurrence of vivid color No observed reaction Color change from deep

Labia Minor labial thickening or bright red to light pink
Minora and expansion extending change ranging from
bright red to deep wine within 10—15 sec.; loss of
■ vaginal barrel approxi­ vasocongestive size in­
mately 1 cm. color; this sex-skin reac­
tion pathognomonic of im­ crease
w pending orgasm
oo
sO
Secretion of drop or two of No observed changes No observed changes
Bartho­ No observed changes
lin’s mucoid material aiding in
Glands lubrication of vaginal out­
let during long-maintained
coital connection
 TABLE 17-3
Sexual Response Cycle of the Human Male—Extragenital Reactions

I. Excitement Phase II. Plateau Phase III. Orgasmic Phase IV. Resolution Phase

Breasts Nipple erection (inconsis­ Nipple erection and tur- No observed changes Involution of nipple erec­
tent and may be delayed gidity (inconsistent) tion (may be prolonged)
until plateau phase)

Sex Flush No observed reaction Appearance of maculopap­ Well-developed flush; de­ Rapid disappearance of
ular rash late in phase (in­ gree parallels intensity of flush in reverse order of its
consistent); originates over orgasm (est. 25% inci­ appearance
epigastrium and spreads to dence )
anterior chest wall, neck,
2ÇO

face, forehead, and occa­

sionally to shoulders and
forearms

Myotonia Voluntary-muscle tension; Further increase in volun­ Loss of voluntary control; Myotonia rarely carried
some evidence of involun­ tary and involuntary ten­ involuntary contractions more than 5 min. intQ
tary activity (partial tes­ sion; semispastic contrac­ and spasm of muscle phase but. not lost as rap­
ticular elevation, tensing tions of facial, abdominal, groups idly as many evidences of
of abdominal and inter­ and intercostal muscula­ vasocongestion
costal musculature) ture

Rectum No observed reaction Voluntary contraction of Involuntary contractions No observed changes

rectal sphincter as stimu­ of rectal sphincter at 0.fl­
lative technique (inconsis­ sec. intervals
tent)
Hyperven­ No observed reaction Appearance of reaction oc­ Respiratory rates as high Resolves during refractory
tilation curs late in phase as 40/min.; intensity and period
duration indicative of de­
gree of sexual tension

Tachy­ Heart rate increases in di­ Recorded rates average Recorded rates range from Return to normal
cardia rect parallel to rising ten­ from 100 to 175 beats per 110 to 180 beats per min.
sion regardless of tech­ min.
nique of stimulation

Blood Elevation occurs in direct Elevations in systolic pres­ Elevations in systolic pres­ Return to normal
Pres­ parallel to rising tension sure of 20-80 mm. Hg, sure of 40-100 mm. Hg,
sure regardless of technique of diastolic 10-40 mm. Hg diastolic 20-50 mm. Hg
stimulation

Perspir­ No observed reaction No observed reaction No observed reaction Involuntary sweating reac­
atory tion (inconsistent), usually
Reac­ confined to soles of feet
tion and palms of hands
 TABLE 1 7-4
Sexual Response Cycle of the Human Male—Genital Reactions

I. Excitement Phase II. Plateau Phase III. Orgasmic Phase IV. Resolution Phase
Penis Rapid occurrence of erec­ Increase in penile circum­ Expulsive contractions of Detumescence occurs in 2
tion which may be par­ ference at coronal ridge; entire length of penile
tially lost and subsequently stages: (1) rapid loss of
color change in coronal urethra; contractions start
regained during ■ pro­ vasocongestion until penis
area (inconsistent) at 0.8-sec. intervals and is from 1 to 1% times en­
longed phase, or may be after the first 3 or 4 are
easily impaired by the in­ larged; (2) slower involu­
reduced in frequency and tion to normal state, usu­
troduction of asexual stim­ in expulsive force; minor
uli ally extended process
contractions continue for
several seconds
292

Scrotum Tensing and thickening of No specific reactions No specific reactions Rapid loss of congested,
scrotal integument; flat­
tening and elevation of tense appearance of scro­
scrotal sac tum and early reappear­
ance of integumental fold­
ing; sometimes delayed
process
Testes Partial elevation of both Enlargement of testes to No recorded reaction Loss of vasocongestive in­
testes toward perineum ac­ a 50% increase over their
complished by shortening crease in testicular size and
unstimulated noncongest­ full descent of testes into
of spermatic cords ed state; elevation to ■
relaxed scrotum; may oc­
position of close apposi­ cur rapidly or slowly de­
tion to perineum; full tes­ pending upon length of
ticular elevation pathogno­ plateau phase
monic of impending ejacu­
lation
 Secondary No observed changes No observed changes Contractions of secondary No observed changes
Organs organs which develop sen­
sation of ejaculatory inevi­
tability and initiate ejacu­
latory process

Cowper’s No observed changes Have been suggested as No observed changes No observed changes
Glands source of preejaculatory
emission of 2 or 3 drops
of mucoid fluid; timing is
essentially same as that
of secretory activity of
Bartholin’s glands in fe­
u male; active spermatozoa
xO
V it have been observed in
this fluid
 i8
MYOTONIA IN
SEXUAL RESPONSE

Sex tension increment initiates two physiologic reactions that have

total-body distribution in both the human male and the human
female—vasocongestion and myotonia. These protean reactions
have multiform response to sexual stimuli. Vasocongestion de­
velops as both superficial and deep reactions of target organs and
appears in either form in many other areas and organ systems
of the body. Myotonia may be evidenced initially by muscular ir­
ritability and, in mature form, is expressed and then resolved
either by regularly recurring contractions or by severe spasm of
the involved musculature. Venous congestion develops and is
released as an involuntary reaction, while myotonia may be both
voluntary and involuntary in origin and resolution.
Muscle tensions develop in response to sexual stimuli irrespective
of the sex of the responding individual. Generally, the degree
of muscle tension increment is related to specific levels of sexual
tension. As a rule, clinically obvious myotonia is confined to
plateau-phase tension levels. Despite the generally superior muscu­
lar development of the average human male as compared to that
of the female, sex-linked relationships have not been established
for the general development of myotonic response to sexual stimuli.
There are exceptions to this statement. These sex-linked specific
myotonic responses are reflected in the target organs of the male
and female pelves, and they have been described with proper
identification throughout this text. The framework of the four
phases of the sexual response cycle will serve as a descriptive
mechanism for the patterns of both contractile and spastic muscu­
lar reaction to sexual stimuli.
Both coition and automanipulation must be considered in order
to present an adequate clinical picture of voluntary and involuntary
294
 MYOTONIA IN SEXUAL RESPONSE 295

myotonic response to sexual stimulation. If every possible sexual

positioning and resultant specific muscular response were con­
sidered, the discussion would be almost endless and the level of
confusion extreme. For the sake of descriptive clarity, coition will
be presumed conducted with the female in the supine position, and
automanipulation with the individual also in supine positioning.
Recording techniques have been confined to direct observation
and to cinematography. Accurate physiologic estimates of total
body movement and of contractile excursion of specific muscle
groupings of sexually excited men or women have been impractical.
Polygraphic recording of muscle action potentials [5, 91] has not
been attempted in the laboratory.

EXCITEMENT PHASE

Total-body response to sex tension increment is characterized

clinically by increasing restlessness, irritability, and rapidity of
voluntary and involuntary movement. In responding to excitement­
phase levels of sexual tension, physical movement primarily is
voluntary in character. As tensions elevate during the excitement
phase, the responding individual moves restlessly and with in­
creasing rapidity. Under the stimulation of sex tension increment,
there is a gradual transition from the slow stroking or gentle
holding mannerisms of an initial stimulative approach to a more
rapid, forceful, and purposeful muscular movement.
During excitement-phase progression, there is obvious clinical
evidence of increased myotonia in the long muscles of both the
legs and arms, some involuntary tensing of the abdominal muscula­
ture, and an increase in the involuntary contractile rate of the
intercostal musculature, with elevation of the respiratory rates of
the responding individuals.

PLATEAU PHASE

With plateau phase established, myotonic response is clinically

obvious from forehead to toes of the responding individual. In
296 CHAPTER EIGHTEEN

reacting to elevated sexual tension levels, the individual frowns,

scowls, or grimaces as facial muscles contract involuntarily in
semispasm. There may be a spastic contraction of the musculature
surrounding the mouth. Late in plateau phase the mouth may
be opened involuntarily in a gasping reaction to hyperventilative
demand. There is more of a tendency toward oral patency in
coition than during masturbation. During automanipulation the
jaws frequently are clenched spastically, restricting inhalation to
the nasal passages. In turn, the nares flare in hyperventilative
response.
The muscles of the neck (sternocleidomastoid group) contract
involuntarily in a spastic pattern. As the result, the neck usually
is held rigidly in midposition, but with orgasm imminent, minor
degrees of opisthotonos may develop during an automanipulative
sequence or for the supine coital partner. Usually there is an
involuntary increase in the rate of contraction of the intercostals
as respiratory rates rise to maximum.
The abdominal musculature (recti abdominis) tense involuntar­
ily in semispastic contractile reaction during automanipulative
episodes. The same abdominal musculature voluntarily contracts
rhythmically to amplify the forceful pelvic thrusting movements
of the coital partners at plateau-phase tension levels.
Clinical evidence of myotonia in the long muscles of the arms
at plateau-phase levels of sexual tension depends on positioning
in coition and on specific automanipulative techniques. The arms
of the supine coital partner may express sexual demand. As demand
elevates, the voluntary muscular response of holding the shoulders
or back or upper arms of the superior-positioned partner changes
to an involuntary clutching or grasping reaction. With orgasm
imminent, clutching or grasping by the supine coital partner
is a well-established response pattern.
The arms and hands of the superior-positioned coital partner
usually are devoted to body support. Spastic contraction of the
involved musculature is rare in performance of this voluntary
muscular function. However, late in plateau, with the individual
straining for orgasmic release, the biceps frequently have been
observed in involuntary spasm.
In response to plateau tension levels during automanipulation,
 MYOTONIA IN SEXUAL RESPONSE 297

there is a voluntary increase in rate of hand and arm movement

and an involuntary increase in pressure applied locally either on
the mons area or along the shaft of the penis, as described in
Part 2 of Chapters 5 and 12. The uninvolved hand may develop
a clutching, clawlike, spastic contraction of the musculature (car­
popedal spasm ). This reaction also has been observed in one or
both hands of the supine coital partner during the terminal stages
of active coition immediately prior to orgasm. Carpopedal spasm
of the hands develops during coition only if the individual has
not established or has released any grasping or clutching of the
superior-positioned partner. This reaction has been described in
Chapters 3 and 11 in detail.
In addition to the recti abdominis, the muscles most actively
concerned with pelvic thrusting during automanipulation and
active coition are those of the buttocks, the gluteal musculature.
Late in excitement or early in plateau the gluteus muscles may
be used in a purely voluntary manner to increase subjective re­
sponse to sexual stimulation. Many women contract the muscles
of their buttocks during automanipulation or coition to elevate
sexual tensions from excitement into plateau-phase levels of re­
sponse. The gripping and constricting sensations that voluntary
contractions of the gluteal muscles develop are a most effective
method of elevating sexual tensions. Voluntary gluteal contractions
also are used by males to elevate their tension levels. Some males
have been observed to carry themselves in masturbation from
late excitement through plateau and to ejaculation with regularly
recurrent voluntary contractions of the gluteal musculature, with­
out direct manipulation of the penile shaft [144].
The active thrusting and accommodation of male and female
pelves in coition are controlled fundamentally by coordinated
contractions of the gluteal, abdominal, deep pelvic, and thigh
musculature. Male pelvic thrust and female pelvic accommodation
initially are voluntary muscular attempts at sex tension increment.
Late in plateau phase, immediately prior to orgasmic expression,
the rapid forceful pelvic thrusting of either sex essentially is
involuntary in character. For the male partner pelvic thrusting
becomes so involuntary a reaction late in the plateau phase that
the penis rarely is withdrawn more than halfway from the depth
2ç8 CHAPTER EIGHTEEN'

of the vaginal barrel before again being thrust deeply into the
cul-de-sac. Female pelvic accommodation to this manner of penile
thrusting follows a similar involuntary reaction pattern. The volun­
tary, full-excursion, pelvic thrusting of each sex so characteristic of
the excitement-phase tension increment becomes involuntary, pla­
teau-phase tension demand and results in spastic reduction in
pelvic excursion. Marked reduction in the excursion of penile
thrust or vaginal accommodation as coition is continued is pathog­
nomonic of impending orgasmic tension release.
The thighs provide a major muscular contribution to effective
sexual stimulation and in the process voluntarily and involuntarily
evidence high levels of myotonia. With coital onset, the legs of
the supine female partner are abducted from the midline and may
be elevated. Each of these accommodative movements is initiated
by voluntary contractions of individual muscle bundles.
As sexual tensions increase there is a female tendency toward
adduction of the thighs toward the midline. There may be volun­
tary adduction of the legs primarily in an attempt to accommodate
male penile thrusting and secondarily to elevate the sexual tensions.
The voluntary leg placement of excitement-phase accommodation
becomes almost a mechanism of involuntary demand as tensions
elevate through plateau-phase response level. Some women ad­
ditionally use leg elevation or spastic constriction of the thigh
musculature for subjective tension elevation just as they employ
the gluteal or abdominal muscular constriction.
For the superior-positioned male in coition, the legs, knees, arms,
and elbows provide body support. A significant degree of voluntary
muscle tension is necessary to support the male partner above
the female. In addition the male occasionally may have to support
some portion of the female’s weight. Most of the male’s structural
musculature is in voluntary contraction to support both his, and,
if necessary, portions of his partner’s, weight during excitement­
phase tension levels. However, during the plateau phase the sup­
portive musculature frequently contracts in semispasm in an es­
sentially involuntary manner.
When the male or female is in plateau-phase response to auto-
manipulative activity, the long muscles of the legs usually are
in spastic extension and are partially adducted toward the mid­
 MYOTONIA IN SEXUAL RESPONSE 299

line. The thighs of the male responding to automanipulative

techniques usually evidence the .same adductive tendency that
has been described for the coitally active or manipulating female.
The myotonic total of these voluntary contractions added to those
of the gluteus and the rectus abdominis muscles aids many men
and women to achieve high levels of sexual response. With orgasm
imminent, the voluntary rhythmic contractions of the thigh mus­
cles and the glutei turn into involuntary spasm that may remain
through orgasm.
Carpopedal spasm also develops frequently as an involuntary
hyperextension of the arch of the foot and as clawlike contractions
of the toes. This reaction may occur for the supine partner in
coition and for either male or female responding to automanipula­
tive techniques. These reactions also have been discussed in
Chapters 3 and 11.

ORGASMIC PHASE

In orgasm, there are severe levels of muscle tension evident

throughout the body, and almost every clinical evidence of myo­
tonia is involuntary in character. Since there may be significant
subjective loss of conscious focus during an orgasmic experience,
muscle strain from severe spastic contraction frequently is not
identified at the moment it occurs. It is not at all unusual for
a forcefully responding or multiorgasmic coital partner to be
aware the next day of severe muscle aching of the arms, legs,
back, or lower abdomen. Usually such an individual while in­
voluntarily responding in orgasmic experience is unaware of the
expended physical effort that has occasioned the muscle strain.
In response to effective sexual stimulation individuals may ac­
complish feats of muscular coordination that would be unattainable
in sexually unstimulated states.
The specifics of target-organ contraction in the male and female
pelves during orgasm have been discussed separately in Chapters
6, 7, 8, 12, and 14 and mentioned briefly in other areas throughout
the text. Therefore, no attempt will be made to describe these
sex-linked examples of muscle tension out of context.
300 CHAPTER EIGHTEEN

RESOLUTION PHASE

Rarely is clinically obvious muscle tension carried into the resolu­

tion phase more than five minutes past the termination of orgasmic
experience, assuming that sexual stimulation does not recur. How­
ever, in other than the target organs, myotonia usually does not
resolve as rapidly as superficial or deep vasocongestion.
 19
STUDY-SUBJECT
SEXUALITY

Dexuality is a dimension and an expression of personality. Cultur­

ally, sexual aggression has been accepted as a mode of expression
for the human male, an integral part of the “plumage” of his
dominant role. Currently, eroticism has become so synonymous
with maleness that it has progressed beyond acceptability to
desirability. It is presumed that only physical defect or the deple­
tions of the aging process will interfere with the male’s innate
erotic interests and his ability to respond to sexual stimuli. Two
conceptual errors defeat these basic presumptions: First, any
fear of performance, displeasing sensation, or sense of rejection
affects male eroticism as much as it does the physiologic effective­
ness of his response; and second, age does not necessarily deplete
the male’s physiologic ability for or psychologic interest in sexual
performance (see Chapter 16).
The fact that these presumptions of unflagging male eroticism
have endured in our society is demanding of some reverence. The
perpetuation of these fallacies may be related to the encompassing
principles that male sexual performance is necessary for procreation
and that the human female inevitably supports any cultural de­
mand that places or maintains the male in that role so necessary
to her own ultimate biologic function.
The acceptance of eroticism in the human female is as variable
as are the cultures in our society [38, 137, 230]. To date, a sexual
role for the female in which she freely participates has not re­
ceived total acceptance in Western culture, despite the currently
nebulous status of the double standard. The incredible swing from
yesterday’s Victorian repression to today’s orgasmic preoccupation
301
302 CHAPTER NINETEEN

has taken the human female but a few decades, and the shock
of the transition has been imprinted deeply on our society.
What are the current norms of male and female sexuality? How
do they differ from the picture created by the Kinsey sampling
collected almost a quarter-century ago? How does the sexuality
of male and female study subjects differ from that of our general
population, and are there significant differences? These biologic and
behavioral questions are of major moment. Unfortunately, they
are questions for which there are no answers, because there are
no established norms for male and female sexuality in our society.
In fact, the strength with which individual cultures continue
to exist in this country precludes the emergence of any dominant
influence. The sociologic challenge of accumulating statistics re­
flecting current human sexual behavior comparable to the Kinsey-
Pomeroy data [142, 144] has not been accepted. There are no
unquestioned authorities or sources of reference for any area in
the total of human sexuality with the exception of Gebhard’s
recent contribution pertaining to sex offenders [89].
Without established norms of human sexuality, there is no
scale with which to measure or evaluate the sexuality of the
male and female study-subject population. Therefore, material col­
lected from this investigational experience is presented in discussion
format. Comparisons may be drawn electively between the reported
response patterns of this highly selected research population and
the reader’s personal experience or his concept of norms of human
eroticism in today’s society. From these prejudiced levels of com­
parison, there is no appeal at this time.
In eleven years, 382 female and 312 male study subjects have
cooperated actively with the research program. The ages have
ranged from 18 to 78 years for the women and 21 to 89 years
for the men. The many aspects of selection inherent in this re­
search population have been discussed in Chapter 2. However,
the histories of two women and two men arbitrarily have been
selected to exemplify sociosexual background frequently encount­
ered among members of the study-subject population. Age, parity,
and years of active cooperation will be reported as of July 1, 1965,
or the date of the subject’s separation from the program.
 STUDY-SUBJECT SEXUALITY 303

SUBJECT A

Subject A, a 26-year-old woman, has cooperated with the research

program for three years. Family history records high-school matricu­
lation for both parents and graduation for the father, who has
worked as an electrician. The mother has worked irregularly out­
side the home as a domestic. There is no evidence of mutual
regard or continuing marital participation between mother and
father. One sibling, an older sister, married and left home at 16
years of age. Discussion of sexual material within the family was
not permitted, and toilet and clothing privacy were demanded.
Subject A has a masturbatory history starting at age 10, with
a frequency of two or three times a week maintained during
puberty and voluntary reduction to about a once-a-month level
in the midteens. She began dating at 13 years. Heavy petting
began at once and continued until age 15, when she describes
the first coital occasion. During the remainder of her high-school
years coital exposure continued with regularity and with multiple
partners. Contraception was practiced irregularly and varied from
a vague attempt at “rhythm,” to withdrawal, condoms, and an
intravaginal sponge.
At 20 years she married a man eight years older, was separated
at 22, and divorced in her twenty-third year. Contraception (con­
dom or withdrawal) was practiced by male demand during the
marriage. Coital connection developed four or five times a week
as much at her instigation as from male interest. During the
separation year she worked as a file clerk. There was severe
limitation of heterosexual opportunity, and she returned to a
masturbatory frequency of a minimum of twice a week as she
reacted to the socially enforced isolation from sexual opportunity.
One homosexual overture was made to her, which she rejected.
After the divorce, Subject A volunteered to join the study­
subject population upon suggestion of her physician, and has
cooperated actively with the investigation for three years. She
entered the program for two stated reasons—first because of
financial need and second for the socially secure opportunity
for regular release from her sexual tensions. Aside from the usual
3°4 CHAPTER NINETEEN

anatomic and physiologic review, she has worked specifically with

intravaginal-contraceptive evaluation and uterine-contractility pro­
grams.
Her history of sexual responsiveness at the start of her project
cooperation is one of multiorgasmic return to automanipulation
and an estimated 50 percent orgasmic return during intercourse.
The estimated 50 percent orgasmic response to sexual-partner
stimulus was Subject A’s pattern in high school and during her
marriage. Within the research design she repeatedly has been
multiorgasmic during automanipulation, and her orgasmic response
to artificial coition has averaged 85 to 90 percent of opportunities.
There have been several occasions in the research environment
during which she was multiorgasmic during artificial coition. She
has reported consistent use of fantasy when exposed to this tech­
nique.
The actual orientation of this subject to demands of the program,
aside from the initial interrogation, involved three sessions devoted
to (1) environment and equipment accommodation, (2) a mastur-
batory sequence, and (3) artificial coital experience, during which
she was quite at ease and fully orgasmic.
In brief, Subject A has no history of family direction or protec­
tion. Onset of dating and heavy petting was reported to have
occurred immediately after the other sibling, an older sister, left
home. During her teenage years she developed and maintained
multiple sexual relationships. Although at most 50 percent orgas­
mic in coital opportunity, she preferred coition to masturbation
despite the fact that during automanipulative episodes she usually
was multiorgasmic. Automanipulative release was used in mar­
riage only during episodes of partner separation or subsequent to
repeated coital occasion without orgasmic tension release.
Since sexual activity had become a major factor in the girl’s
life, termination of the marriage placed her in a difficult socio-
sexual position. Although there were several sexual partners during
the separation year and an increased masturbatory frequency, Sub­
ject A was well aware that she could not return to her high-school
pattern of indiscriminate acceptance of multiple sexual partners
without the strong possibility of jeopardizing socially her chances
of a successful second marriage. Obviously, the research program
 STUDY-SUBJECT SEXUALITY 305

has provided the opportunity for some regularity of tension release

and, of extreme importance to Subject A, the social protection
of anonymity.
She has explored the possibility of remarriage on two occasions
during the past three years while cooperating with the program,
but has felt that neither of the two opportunities would satisfy
her primary interest in the potential security of a home and
family. On both occasions she has voluntarily emphasized her
relief that she did not have to evaluate the marital opportunities
in a prejudiced state of sexual need.
Subject A has been selected from the 106 unmarried women
who have cooperated with the research program. She represents
the two reasons for joining the program most frequently vocalized
by these subjects—financial demand and sexual tension. Her re­
ferral source (physician) ranks third in frequency as a method
of female study-subject recruitment.

SUBJECT ■

Subject B, a 31-year-old woman, is a college graduate and has

been married for seven years. She has had one full-term pregnancy
(three years ago) without complication. There was an abortion
during the year prior to the successful conception. Contraception
currently is practiced by means of oral medication.
Family background records the father as a college graduate and
an insurance broker, and the mother as a high-school graduate.
There are two older brothers, both of whom are college graduates,
married, and living outside the area. Sexual material was discussed
frankly within the family, although both toilet and clothing
privacy were maintained. She describes a warm relationship be­
tween her mother and father.
Subject B has a masturbatory history with onset at 15 years,
which continued intermittently through her teenage and college
years without a firmly established frequency level. She always has
been orgasmic, although rarely multiorgasmic, during these auto-
manipulative episodes. Her first coital experience was at 17 years.
She established a sexual connection during her last year in high
306 CHAPTER NINETEEN

school that developed into a once-a-week pattern of coital fre­

quency. She was not orgasmic, did not practice contraception, and
did not become pregnant.
While in college she had intercourse with three men, and there
were numerous occasions of heavy petting with individual or mu­
tual manipulation to orgasm. She was engaged to one of these
men during her last year-and-a-half at college, again developing
a coital frequency of approximately once a week and supplementing
this with episodes of mutual manipulation to orgasm. In addition
to a casual practice of “rhythm,” condoms were used for contracep­
tion.
After Subject B graduated from college, she taught locally at
grade-school level. There was occasional coital exposure and she
maintained an irregular pattern of automanipulative activity. She
married at 24 years of age, after nine months of courtship, during
the last five months of which there was regularly recurring coition,
mutual manipulation, and mouth-genital contact.
Her husband, a college graduate four years older than Subject B,
is a junior executive in an industrial firm. His sexual history
is one of multiple heterosexual experimentation (no homosexual
experience) during both high-school and college years. His only
active homosexual contact was in the service after college
graduation and was accepted because he “just wanted to see what
it was like.” He was engaged to another girl before he met Sub­
ject B. During this engagement, coition, mutual manipulation, and
mouth-genital contact were employed freely.
The Subject B family unit has cooperated with the program
for five-and-a-half years and contributed, in addition to the general
physiology program, to the pregnancy and sexual-response in­
vestigations. The unit also has offered cooperation in the cardio­
respiratory investigative program. Their contributions both in­
dividually and as a family unit have been invaluable.
This family unit was selected as representative of the most
frequent source of recruitment for the study-subject population.
They volunteered their services after learning of work in progress
by local report, expressing the hope that they could contribute
in some manner to knowledge of human sexual response. Formal
orientation was limited to two sessions subsequent to the individual
 STUDY-SUBJECT SEXUALITY 307

history-taking. During the first session the unit was exposed to the
atmosphere and equipment of the research laboratory. As demon­
strated during the second session, their coital response under
observation was excellent. The husband never has had erective
or ejaculatory difficulty. Over the five-and-a-half years of program
participation Subject B has been orgasmic in 85 percent of recorded
coital opportunities, occasionally developing multiorgasmic re­
sponse. She always has been orgasmic, although rarely multi­
orgasmic, during an automanipulative sequence.
Both members of the Subject B family unit were reviewed
in depth early in 1965 after five years of cooperation with the
program. Neither partner described any identifiable variation in
individual or mutual sexual responsiveness in the privacy of their
home as opposed to the research environment. There has been
no erective or ejaculatory difficulty regardless of the environment,
and Subject B’s orgasmic return has not been altered by research
equipment or personnel. This man and woman have stated cate­
gorically that they have found program cooperation of significant
importance in their marriage. They have volunteered to continue
in the research program so long as there is need for their contribu­
tion.

SUBJECT C

Subject C is an unmarried 27-year-old male who has completed

a graduate-school education. He joined the program in 1956 and
was separated in i960. His family history records a graduate­
school education for his father and college graduation for his
mother. There are one older and one younger brother and an
older sister, all of whom have at least a college degree. The
family background, as expected, is one of multiple intellectual
interests, varied avocations, and relative lack of parental restraint.
Sexual material always has been discussed openly. There has been
no more than token toilet or clothing restraint. Subject C describes
more rapport with his mother than his father, whom he states
has little real interest in other than academic pursuit.
Subject C recalled onset of automanipulative activity in the
308 CHAPTER NINETEEN

thirteenth to fourteenth year, continuing with a frequency of

once or twice a week during the teenage years. He has a history
of several homosexual experiences. The first, as a 15-year-old boy,
was a single occasion with an older male, and the second was
with a college roommate during his nineteenth year. This episode
lasted three months. Finally, during service connection, he took
advantage of two single opportunities. He always has assumed the
passive role.
His heterosexual experience had onset with routine dating at
15 years and with petting ultimately to ejaculation at 16 years.
Intercourse, first experienced at 17, was continued irregularly during
his last year in high school. During his college years (other than
during his three-month homosexual episode), coital regularity was
established at a frequency level of two to three times a month.
There were several different partners.
Subject C was asked to join the research population while
in postgraduate school and remained with the program for four
years. Orientation required five sessions after initial interrogation.
The first exposure to atmosphere and equipment in the laboratory
was followed by two successful automanipulative episodes, the
first slowly and the second rapidly accomplished. The first coital
episode resulted in failure of erective performance, but the second
was successful, although the erection was maintained with dif­
ficulty. Subsequently, Subject C had no trouble with automanipula­
tive activity, but there were four failures with coital partners
during program cooperation that entailed 22 opportunities over
the four-year period. His functional coital difficulty was not in
achieving but in maintaining penile erection under the stress of
recording opportunity.
Although interrogated in depth, Subject C described no concern
for these episodes of erective inadequacy, stating that he fully
understood the problem and that erective inadequacy only de­
veloped when he was fatigued mentally from long periods of con­
centration. Physical expenditure appeared to have little effect on
his sexual responsivity. He considered these occasions of erective
inadequacy and his homosexual episodes all part of life experience
and expressed interest in continuing cooperation with the research
program on an indefinite basis. His homosexual exposures will
 STUDY-SUBJECT SEXUALITY 3°9

not be discussed in this text (see Chapter 2). Subject C was

separated from the program when the investigation of target-organ
physiology of male sexual response was completed. There was
no immediate evidence that a residual concern for performance
might be a factor in future sexual activity.
As part of a long-range evaluation, Subject C was reinterviewed
in August, 1965, approximately five years after separation from
the program. He has married and is the father of two children.
He describes his experience with the program as an important
episode in his personal education and one which he feels has been
most valuable to his marriage. He has had no erective difficulties
during the marriage, nor does he describe any further homosexual
interest or experience. Subject C has vocalized a desire to return
to the program accompanied by his wife as a contributing family
unit, when there is need for their services.

SUBJECT D

Subject D is a 34-year-old male, married 6 years and the father

of two children. He dropped out of college at the end of his
second year for both academic and financial reasons and has
been working as a draftsman since college withdrawal. His family
history is that of an only child. The father, a minister, died
when the boy was 18 years of age. The mother, a high-school
and secretarial-school graduate, has worked as a receptionist in
a doctor’s office since the father’s death. There is a history of
strict parental control during the teenage years and an excessive
concern for social mores. There is no history of normal exposure
to heterosexual activity until Subject D was a junior in high
school. At that time dating not only was allowed but encouraged.
However, curfews were strict and social control was dominant.
There is no automanipulative history until the first year in
college, and this single experimental episode was followed for a
full year by a severe guilt residual. In the second year of college
there were several occasions of petting with one partner, once
to involuntary ejaculation, with the experience followed for several
months by residual guilt feelings. Overt sexual experience was
310 CHAPTER NINETEEN

essentially negligible until after Subject D left college and was

working.
His first complete coital experience was with a prostitute one
year after withdrawal from college. This episode developed into
irregular prostitute exposure during the next four years. Social
exposure was confined almost entirely to male acquaintances. The
first history of steady dating developed at 25 years of age and
lasted for six months. The connection was broken by the female
partner because “she didn’t think [he] was aggressive enough.”
During the next year there was a three-month casual social con­
nection with a 20-year-old girl that resulted in several episodes of
overt masturbatory behavior and two coital experiences. Shortly
thereafter he met and seven months later married his wife. The
premarital sexual history is one of heavy petting after three months
of courtship and four coital episodes before marriage. Contraception
was not used and pregnancy did not occur. Since marriage, con­
ception has been controlled, first by diaphragm and later with
oral medication.
Subject D’s wife is a 33-year-old high-school and business-school
graduate. She has a history of occasional automanipulative ex­
periences starting late in her teens and continuing until marriage.
During the first six years of her twenties she had coition with
three men. Two men provided only single opportunities, but the
relationship with the third man was maintained for three months.
Premaritally she was orgasmic with automanipulation but not
during coition. She met Subject D while working as a secretary
in the same office with him. They have two children, 4 and 2%
years of age. There is a coital-frequency pattern of once or twice
a week.
For orientation, five episodes were necessary after team interroga­
tion. The first exposure was to background and equipment; during
the second, coition was attempted without ejaculatory success.
The third episode developed as successful coition for Subject D,
but his wife was not orgasmic. During the fourth session both
husband and wife were successful in individual automanipulative
episodes, and in the fifth episode no difficulty was encountered
by either partner in response to coital or manipulative stimuli.
This pattern of freedom from restraint has been the rule in
 STUDY-SUBJECT SEXUALITY Jll

subsequent program exposure, much to the surprise of both hus­

band and wife. The family unit has cooperated with long-range
response-evaluation and male-physiology programs.
Subject D and his wife represent yet another important aspect
in the development of the study-subject population. This family
unit has, as have many others, volunteered their services, hoping
to acquire knowledge to enhance the sexual component of their
marriage in return for their cooperation with the program. Subject
D was concerned with his own overcontrolled background, lack
of sexual experience, and a considered degree of sexual repression.
When his wife first joined the program, her orgasmic incidence
was reported as rare with coital exposure but consistent with
manipulation. Subsequent to working in the program her orgasmic
achievement during coition has risen to the 80 percent frequency
level. She has not been multiorgasmic either during coition or
automanipulation.
Subject D’s wife has stated repeatedly that subsequent to pro­
gram participation her husband has been infinitely more effective
both in stimulating and in satisfying her sexual tensions. He in
turn finds her sexually responsive without reservation. Her freedom
and security of response are particularly pleasing to him. Together
they maintain that they have gotten a great deal more out of
cooperating with the program than they have contributed, and they
wish to continue on a long-term basis.

PROGRAM INFLUENCE ON STUDY­

SUBJECT SEXUALITY

There are so many variables of sexual response that no possibility

exists for establishing norms of sexual performance for the study­
subject population. This position must be taken despite the degree
of selection inherent in the requirement that there be a positive
history of masturbatory and coital orgasmic experience before any
study subject is accepted in the program. Many family units and
individual men and women have joined the program for reasons
which reflect basic concern with personal levels of sexuality. For
312 CHAPTER NINETEEN

example, one of Subject A’s major reasons for participating in

the program for the last three years has been the opportunity
provided for anonymous relief of sexual tension. On the opposite
side of the coin, Subject D and his wife joined the program
for the express purpose of elevating the levels of their sexual
responsiveness and resolving personal concerns created by in­
experience and inadequacy of sexual performance.
From the onset of the investigation, major importance has
been attached to the theoretical possibility that participation in
the program might exert an adverse influence in the future upon
the individual’s own innate personal eroticism. There always has
been the possibility that sexual activity conducted in the artificial
atmosphere of the laboratory might create a responsive concern
or fear of performance that could carry over into life experience.
It also has been suggested that successful participation in the
program might elevate sexual tensions to a degree incompatible
with the sociosexual background of the individual involved. After
eleven years there was no information available to suggest that
active cooperation with the investigation has done other than
maintain or improve the effectiveness of individual sexual expres­
sion.
Family units have been interrogated each year during their
cooperation with the program, and after separation from the pro­
gram are evaluated at five-year intervals. Since the investigation
has been in existence eleven years, significant study-subject follow­
up now is available. There has been no evidence of inadequacy in
any phase of sexual performance developing among members of
the study-subject population subsequent to exposure to the research
environment.
Certainly, during episodes of active cooperation with the pro­
gram there have been many observations of orgasmic failure or
performance inadequacy. When failure statistics of coital per­
formance were evaluated, it was interesting to note that the oc­
casions of male sexual inadequacy far outnumbered those in­
stances recorded for the female. When individual study subjects
were unable to achieve ejaculatory or orgasmic levels of sexual
tension in the research environment, the failure of performance
was in the male on 65.1 percent of the occasions. These statistics
 S T U D Y-S U B J E C T SEXUALITY 313

reflect the tensions that accrue to the male and not to the female
under the extremes of long-established cultural demand for effec­
tive sexual performance. Subject C, for example, failed to maintain
erective adequacy in 4 of 22 coital exposures, although there is
no history of automanipulative failure.
Beach [9, 13] has pointed to similar performance inadequacies
in male cats and dogs in a laboratory environment.
Since episodes of sexual failure may create concern for future
performance, some discussion of areas of failure is in order. Over
the past eleven years, in automanipulative, coital, and artificial-
coital activity, over 7,500 complete cycles of sexual response have
been developed by female study subjects and more than 2,500
ejaculatory experiences have been recorded. During this period
there were 338 failures of coital and automanipulative sexual per­
formance in the research laboratory. Of the total of 338, 17 failures
were with automanipulation (7 male and 10 female) and 321 re­
corded failures of orgasmic return were with coital activity (213
male and 108 female).
As expected, the highest concentration of failures of performance
was encountered during the orientation program. However, neither
the failures nor the successes of performance occurring during this
period have been included in the reported statistics. In addition,
there were many investigative episodes during which orgasmic
return from the study-subject participants was not required. Such
situations also have not been included in the performance statis­
tics.
Primarily, male failure in coital exposure has been concentrated
in the areas of erective inadequacy. Failures have developed either
in attaining or maintaining penile erection to a degree sufficient
for mounting effectiveness. As a secondary source of coital failure,
premature ejaculation occasionally has been a problem with new
members of the male population. Fortunately, this sexual in­
adequacy has been readily reversible. Premature ejaculation has
not been of continuing concern, once adequate technical and
clinical suggestions have been made, accepted, and practiced.
Female study subjects’ orgasmic inadequacy also has been pri­
marily coitally oriented. As stated in Chapter 9, female orgasmic
experience usually is developed more easily and is physiologically
3M CHAPTER NINETEEN

more intense (although subjectively not necessarily as satisfying),

when induced by automanipulation as opposed to coition.
The psychologic and sociologic variables that tend to affect
female more than male sexual performance have been discussed
in Chapter 9. In addition, the influence of the hormonal cycle
and the depressant effect of excessive physical or mental fatigue
always must be considered in relation to the effectiveness of
sexual performance. However, for the female with manipulative
and coital orgasmic experience fear of overt demand for orgasmic
performance is a minor factor. The woman’s fear of sexual per­
formance which has been developing so rapidly in our culture
in recent years certainly does not apply to the sexually experienced
female. This is the major difference in reaction to the pressures
of performance between male and female study subjects.
When female orgasmic or male ejaculatory failures develop in
the laboratory, the situation is discussed immediately. Once the
individual has been reassured, suggestions are made for improve­
ment of future performance. As previously stated, there has been
no evidence that occasional inadequacy of sexual performance
under the pressures of the research environment has been trans­
ferred into a pattern of sexual inadequacy in private response.
Exactly the opposite effect has developed. Many family units,
following physician referral, have joined the research population
in an effort to improve the effectiveness of their individual and
mutual sexual performances. That these units have elevated their
levels of sexuality is evidenced by their interest in and desire
to continue as active research participants. There has been no
evidence among the individuals and the family units separated
from the investigation that the suggestions and techniques made
available during program orientation have become other than an
integral part of their private patterns of response.
Any assumption that definitive sexual stimulation accrues directly
from exposure to research personnel or environment seems contra­
dicted by the fact that overt exhibitionism has not been a factor in
the laboratory. In fact, modesty, social control, and even an exces­
sive regard for social mores has been the general response pattern.
Sexuality has many facets and many levels within the indi­
vidual man or woman. The mercurial tendency to shift rapidly
 S T UD Y-S U B J E C T SEXUALITY 315

from peak to valley has been exemplified by female study subjects,

while levels of sexual expression that remain essentially constant
are observed most frequently in male study subjects. Through
the years of research exposure, the one factor in sexuality that
consistently has been present among members of the study-subject
population has been a basic interest in and desire for effectiveness
of sexual performance. This one factor may represent the major
area of difference between the research study subjects and the
general population.
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 GLOSSARY

abduct To draw extremities from the midline of the body by

means of muscular contractions.
ablate To remove by cutting.
abortion Expulsion of the products of conception by the twelfth
week of pregnancy.
adduct To draw extremities toward the midline of the body by
means of muscular contractions.
adhesion A fibrous band or structure by which tissues are abnor­
mally joined.
adrenal hyperplasia Abnormal growth of the adrenal gland
usually resulting in overproduction of the adrenal hormones.
aerobic Living or growing only in the presence of oxygen.
afferent Carrying to or toward a certain region.
amenorrhea Absence of the menses.
ampulla A flasklike dilatation at the end of a tubular structure.
androgen A steroid hormone producing masculine characteristics.
antecubital fossa The triangular hollow in front of the elbow
joint.
apposition Contact between adjacent parts or organs.
areola The ring of darkened tissue on the breast surrounding the
nipple.
atrophy A failure of nutrition resulting in a wasting away or
diminution in the size of an organ or part of the body.
axilla The armpit.

Bartholin’s glands Two small glands imbedded in the minor

labia at the vaginal orifice which produce a mucoid substance
that contributes to the lubrication of the fourchette during pro­
longed coital activity.
337
338 GLOSSARY

carpopedal spasm A spastic contraction of the striated muscula­

ture of the hands and feet.
cathexis The investment of an object or person with special
significance.
cc. Cubic centimeter. A fluid measure; 5 cc. are approximately
equal to one teaspoonful.
climacteric The physical and psychologic phenomena that char­
acterize the termination of menstrual function in the woman and
reduction in sex-steroid production in both sexes.
cm. Centimeter. A measure of distance; 2.5 cm. are approximately
equal to one inch.
colporrhaphy The operation of suturing the walls of the vagina.
colposcope An instrument for the visual examination of the
vagina and cervix.
corona glandis The rim surrounding the base of the glans penis.
corpus luteum A yellow mass in the ovary formed from the rup­
tured graafian follicle. It secretes progesterone, whose function is
to prepare the uterus for implantation of the fertilized ovum.
corpus uteri That part of the uterus above the cervix; area of
implantation for fertilized ova.
Cowper’s glands Two bulbourethral glands in the penis which
secrete a mucoid material as part of the seminal fluid. They may
be homologues of Bartholin’s glands in the female.
cremasteric The muscles which elevate the testes.
crus (pl., crura) The leg, stalk, or trunk of a structure, as the two
legs of the clitoris that separate and join to the pubic arch.
cul-de-sac (of Douglas) The rectouterine pouch, formed by a
fold of the peritoneum.
cystocele Protrusion of the urinary bladder through the fascia
of the anterior vaginal wall; a hernia.

dartos See tunica dados.

descensus In this usage, the descent of the testes into the scrotum,
or the descent of the uterus from the false into the true pelvis
after the cessation of effective sexual stimulation.
 GLOSSARY 339

detumescence The subsidence of swelling; in this usage, the loss

of localized vasocongestion.
Dicrysticin A commercial product now discontinued; contained
300,000 units of procaine penicillin G and 100,000 units buffered
potassium penicillin/2 cc.
distal Remote or away from the point of origin.
dyspareunia Coitus that is difficult or painful for a woman.
dysuria Painful urination.

edema Swelling due to accumulation of excess fluid in any tissue

or in the intercellular spaces.
efferent Conveying outward or away from a structure; the op­
posite of afferent.
ego The individual’s concept of self.
emphysema The swelling or inflammation produced by the pres­
ence of air in any body tissue, particularly the lungs. When
present, it magnifies hyperventilation of plateau phase and re­
duces sexual tension.
endometrium The mucous membrane lining the cavity of the
uterus.
epigastrium The region lying over the stomach; the upper part
of the abdomen just beneath the diaphragm.
episiotomy Incision in the perineum to facilitate the birth of a
child.
erogenous areas Those parts of the body that, when stimulated,
create subjective erotic arousal.
erythematous rash Redness of the skin due to vasocongestion;
see sex flush.
estrogen A steroid hormone producing female characteristics.

estrus A cyclical period of sexual receptivity in the female animal,

during which the sex drive is intense.
etiology Causation; the study or theory of the causation of a
disease or abnormal functioning of life processes.
exteroceptive Receiving stimulation from the external surface
field of the receptor organs.
340 GLOSSARY

extragenital Originating outside or lying outside the genital

organs.

false pelvis Roughly, the part of the pelvis above the hip joint
and the iliopectineal line, the lower part being the true pelvis.
fascia A band of tissue that forms an investment for muscles and
certain organs of the body.
fellatio Insertion of the penis into the mouth for purposes of
sexual gratification.
fornix The upper portion of the vagina.
fourchette The fold of mucous membrane connecting the labia
minora along the posterior wall at the vaginal outlet.
frenulum A small fold of skin retained on the ventral surface of
the penis after circumcision.
frigidity A loosely applied term used to express female sexual
inadequacy, ranging from the freudian concept (inability to
achieve orgasm through coition) to any level of sexual response
considered to be unsatisfactory by either the individual female
or her partner on any particular occasion.
fundus The base of the internal surface of a hollow organ, as the
fundus of the uterus.

gluteal Pertaining to the buttocks.

glycogen A carbohydrate form of food material stored in the
liver, muscles, and some other tissues.
gravida A pregnant woman; referred to as gravida I, or primi­
grávida, during the first pregnancy, gravida II during the second
pregnancy, etc.

herniorrhaphy The operation of suturing a hernia.

heterosexuality Sexual interest in or sexual activity between
members of the opposite sex.
Hg Chemical symbol for the element mercury.
homologous Having a corresponding position, structure, and
origin with another anatomical entity; as, an organ or part of
 GLOSSARY 341

one sex being comparable to a unit in the opposite sex. These

organs may or may not have the same function.
homosexuality Sexual interest in or sexual activity between
members of the same sex.
humoral Pertaining to any fluid of the body.
hypertrophy The excessive enlargement or overdevelopment of
an organ or part; the opposite of atrophy.
hyperventilation Excessively rapid and deep breathing.
hysterectomy Surgical removal of the uterus, either through the
abdominal wall or through the vagina.

impotence Disturbance of sexual function in the male that pre­

cludes satisfactory coitus. It varies from inability to attain or
maintain full erection to total loss of erective prowess. Primary
impotence: difficulty from the onset of sexual activities. Sec­
ondary impotence: difficulty which arises later in life, following
a history of effective sexual functioning.
inguinal Pertaining to the groin.
integument The outer covering, especially the skin.
intercostal Between the ribs.
intima The innermost of the three coats of an artery.
introitus The entrance to a cavity or space, e.g., the vagina.
intromission Insertion of the penis into the vagina.
in vitro Observable or occurring outside of the living organism.
in vivo Within a living organism.
involuntary Performed independently of the will.
involution Retrograde development; a decline of physical or
mental function.
ischium The inferior dorsal portion of the hip bone.

“lethal factor” A factor within the vaginal environment of

some women that immobilizes spermatozoa within seconds in
severe concentrations and within minutes in more dilute con­
centration.
342 GLOSSARY

libido Sexual drive or urge.

lumen The internal cavity or interior of a tube.

macroscopic Large enough to be observed by the naked eye, as

opposed to microscopic.
maculopapular Spotted and raised or elevated.
masturbation Self-stimulation of the sexual organs.
meatus An opening, such as the end of the urethral passage
through the penis.
menopause The period of cessation of menstruation in the
human female, occurring usually between the ages of 45 and 50.
mensuration The process of measuring.
micturition The act of urinating.
miscarriage Expulsion of a fetus from the onset of the fourth to
the end of the sixth month of pregnancy.
monogamous Pertaining to monogamy, or marriage to but one
person at a time.
mount To make the initial thrust of the penis into the vagina
with onset of coition.
mucoid Resembling mucus.
mucosa A mucous membrane; a thin tissue that has a moist
surface.
multipara (adj., multiparous) A woman who has given birth to
two or more children.
myoma A tumor consisting of fibrous and muscle tissue that grows
in the wall of the uterus: also called fibroid.
myometrium The muscular substance of the uterus.
myotonia Increased muscular tension; a secondary physiologic re­
sponse to sexual stimulation.

neonate A newborn infant.

nullipara (adj., nullipdrous) A woman who has never bome a
viable child.
 GLOSSARY 343

oophorectomy Surgical removal of an ovary.

opisthotonos A form of tetanic spasm in which the head is bent
backward and the body is bowed forward.
os Mouth or orifice, as the os of the cervix.
ovulation The release of an ovum from the graafian follicle of
the ovary.

parity The condition of having borne a child or children: Para 1,

one child; para 4, four children; etc.
pathognomonic Characteristic of a certain disease; used to de­
scribe signs or symptoms by which a diagnosis can be made.
patulous Open, expanded; spread widely apart.
perineum The area between the thighs, extending from the pos­
terior wall of the vagina to the anus in the female and from the
scrotum to the anus in the male.
peritoneum The strong, transparent membrane lining the ab­
dominal cavity.
pH The symbol used in expressing hydrogen ion concentration,
the measure of alkalinity and acidity. pH values run from o to 14,
7 indicating neutrality, numbers less than 7 increasing acidity,
and numbers greater than 7 increasing alkalinity.
phallus The penis.
phimosis Tightness of the foreskin of the penis so that it cannot
be drawn back over the glans.
postpartum Occurring after delivery.
primigrávida A woman who is pregnant for the first time; also
written Gravida I.
primípara (adj., primiparous) A woman who has borne but one
child.
progesterone See corpus luteum.
prophylaxis Preventive treatment.
proprioceptive Receiving stimulation within the tissues of the
body.
protean Variable; readily assuming different shapes or forms.
344 GLOSSARY

psyche The thinking and emotional faculty in man, including

both the conscious and unconscious processes.
psychogenic Of psychic origin.
pubis The anterior inferior part of the hip bone.
pudendum The mons pubis, labia majora, labia minora, and the
vestibule of the vagina.

receptor A sensory nerve terminal that responds to stimuli.

rectocele Protrusion of part of the rectum into the posterior
floor of the vagina; a hernia.
reflex arc A neural mechanism. Any action that takes place
through such a mechanism is a relatively simple, automatic re­
sponse to a stimulus which is independent of the higher nerve
centers of the brain.
refractory period A temporary state of psychophysiologic re­
sistance to sexual stimulation immediately following an orgasmic
experience.
retraction reaction The retraction, during plateau phase, of
the clitoral body from its normal pudendal-overhang positioning.
retrograde Directed backward; reverse.
rugal Wrinkled, corrugated.

salpingectomy Surgical removal of an oviduct (fallopian tube).

sex flush The superficial vasocongestive skin response to increas­
ing sexual tensions (plateau phase-oriented).
sex skin In this usage, the preorgasmic discoloration of the minor
labia of the human female (plateau phase-oriented).
sex steroids A group name for compounds including sex hor­
mones with estrogenic and androgenic properties.
sexual inadequacy Any degree of sexual response that is not suf­
ficient for the isolated demand of the moment; may be constant
or transitory inability of performance.
Sims-Huhner test Postcoital examination of ovulatory cervi­
cal mucus usually conducted within two to three hours after
coition.
 GLOSSARY 345

somatogenic Of bodily origin.

speculum (pl., specula) An instrument for the visual examination
of a passage or cavity of the body, e.g., the vagina.
sphincter A ringlike muscle that surrounds and is able to close a
natural opening.
subjective Perceived only by the person affected; not perceptible
by another.
substrate An underlying layer or support possessing special
qualities.
sweating phenomenon An early phase in the production of vagi­
nal lubrication before coalescence of the material occurs.
sweating reaction An involuntary perspiratory reaction that oc­
curs during the immediate postorgasmic portion of the resolution
phase in the sexual response cycle of both men and women.
syndrome A group of symptoms which characterize a particular
disorder.

tachycardia Excessively rapid heart action.

tenesmus Ineffectual and painful straining to defecate or urinate.
testosterone The male testicular hormone. Its function is to
produce and maintain male secondary sex characteristics. Is in­
volved in both protein and carbohydrate metabolism.
trabecula (pl., trabeculae) A band or cord of fibrous and smooth
muscle tissue.
transformer In this usage, an organ or a part of one functioning
to step up or to increase reactive energy or potential.
transudate Any substance that has passed, like sweat, through
the pores of tissues.
tumescence The process of swelling or enlarging.
tunica dartos A layer of smooth-muscle fibers in the superficial
fascia of the scrotum.

urethrocele Protrusion of the female urethra through the fascia

in the anterior vaginal wall; a hemia.
346 GLOSSARY

vaginal agenesis Congenital absence of the vagina.

vaginal axis An imaginary line running directly from the vaginal
outlet to the depth of the cul-de-sac.
vaginal barrel The vaginal cavity.
vaginal lubrication A transudation-like material appearing on
the walls of the vaginal barrel within a few seconds from the
onset of any form of effective sexual stimulation. The first physi­
ologic response to sexual stimulation in the female.
varicocele Enlargement of the veins surrounding the spermatic
cord in the male.
varicosity A condition or state in which a vein is irregularly
swollen.
vasocongestion Congestion of the blood vessels. The primary
physiologic response to sexual stimulation; primarily venous
blood.
vasodistention Distention and dilation of blood vessels leading
to increased blood supply to the part; opposite of vasoconstric­
tion.
vestibule Space or cavity at the opening to a canal, such as the
vaginal outlet.
visceral The internal organs.
viscosity The quality or state of being sticky or glutinous.
voluntary Accomplished under control of the will.
 INDEX

Abdominal musculature, contrac­ in females, 63-65, 66, 313-314

tion of, 296 in aging women, 246
Abortion, spontaneous, 154, 155, Bartholin’s glands secretions in,
165 44
Acidity case histories of, 303, 304, 305,
of seminal fluid, 99 307, 310
vaginal, 44, 89-90 and clitoral hypertrophy, 58
neutralization of, 94 clitoral response to, 54
seminal fluid affecting, 98 clitoris, 63-65, 66
Age range of study subjects, 12, 13, mons area, 64
302 and multiple orgasmic experi­
geriatric female subjects, 18-19, ences, 65
223-
224, 239 postpartum, 163
geriatric male subjects, 18—19, in pregnancy, 159, 165-166
248, 249, 261 premenstrual, 125
husbands of pregnant women, uterine contraction in, 118,
156, 164 126, 165
pregnant women, 142 and uterine elevation, 114
Aging. See Geriatrics gluteal contractions in, 277
Alcohol consumption, effects of, heart rate in, 3 5
267-
268 and intensity of orgasm, 118, 133
Androgen therapy, effects of, 269 in males, 197-200, 313
Areolar tumescence in females, 29, in aging males, 262
274, 286 carpopedal spasm in, 173
in aging women, 225 case histories of, 307-308, 309
detumescence, 130, 226 and foreskin retraction, 190-
in pregnancy, 143, 144
Arm movements, in plateau phase, 191, 198
and preejaculatory fluid emis­
296
Artificial coition sion, 211
equipment for, 21 in uncircumcised males, 198
orientation to, 21 myotonia in, 294-299
Artificial vagina studies, 12, 15, 18, rectal sphincter in, 34
101—110
See also Vagina, artificial Bartholin’s glands, 38, 42-44, 69,
Automanipulation 211, 281-282, 289
carpopedal spasm in, 128, 173, in aging women, 232
276 secretory activity of, 43-44, 232
excessive, effects of, 201-202 Behavioral material, conclusions
failures with, 313 from, 8, 18, 20
347
348 INDEX

Bladder compared with females, 273—

in females, 33 275
in aging women, 227-228 in excitement phase, 290
in males, in ejaculation, 213, 282 nipple erection, 171, 249-250,
Blood pressure 273-27'5
in females, 35-36,130, 287 in orgasmic phase, 290
in males, 174-176, 291 in plateau phase, 290
Breasts in resolution phase, 290
in aging females, 224-226 vasocongestion, 171, 274
areolar engorgement, 225
in excitement phase, 224-225 Cardiac patients, male, sexual activ­
mottling of, 226 ity of, 175-176
nipple erection, 224, 226 Cardiorespiratory reactions
in orgasmic phase, 226 female, 130, 278
in plateau phase, 225-226 male, 174-176, 278
in resolution phase, 226 Carpopedal spasm, 33, 128, 276,
vasocongestion in, 224 297, 299
venous pattern in, 225 in automanipulation, 128, 173,
in aging males, 249-250 276
in females, 28-31, 286 in females, 276
in aging women, 224—226 aging women, 227
areolae, 29,130, 225, 286 in males, 173, 276
compared with males, 273-275 aging males, 250
in excitement phase, 28—29, Castration, female, and vaginal lu­
224- 225, 286 brication, 71
increased size of, 29, 143, 286 Cervix uteri. See Uterus
manipulation of, orgasmic re­ Childhood sexual behavior, 140
sponse to, 54, 67 Circumcision
mottling of, 30, 31, 226 female, and sexual response, 64
nipples, 28, 30, 130, 224, 226, male, 189-191
273-275, 286 and automanipulative tech­
nursing breasts, 29-31, 144 niques, 198
in orgasmic phase, 30, 130, uncircumcised subjects, 17, 18
226, 286 Clinic population, subjects from, 11,
painful, 143 14-15
in plateau phase, 29-30, 143, Clitoral orgasm, compared with vag­
225- 226, 286 inal orgasm, 66-67
postpartum, 29—31, 144 Clitoridectomy, automanipulation
in pregnancy, 143-144 after, 64
in resolution phase, 30—31, 226, Clitoris, 45-67, 288
286 in aging women, 229-230
suckling affecting, 29—31 anatomic positioning of, and sex­
vasocongestion in, 29, 30, 122, ual response, 57
143, 224, 274 anatomy of, 45-47
venous pattern in, 29, 143, 225, automanipulation of, 63-65, 66
286 See also Automanipulation
in males, 171—172, 290 as center of sensual response, 60,
aging males, 249-250 63
 INDEX 349

coital position affecting response, in aging women, 231-232

59-60 with artificial vagina, 107, 109
detumescence of, 53 postpartum, 15, 152
direct stimulation of, 67 in pregnancy, 147
dual capacity of, 56 mottling of breasts, 30, 31, 226
elongation of shaft, 50-51, 54, in penis, 183-184, 281
57-58, 288 in aging males, 252
in aging women, 230 in vagina, 75, 79, 288
erection of, 49-50 in aging women, 233
in excitement phase, 48-51, 288 in artificial vagina, 108,110
in aging, 230 See also Sex-flush reaction
functional role of, 189, 196 Conception
hypertrophy of, 47, 50 and seminal fluid retention in va­
manipulative, 58 gina, 80-88
indirect stimulation of, 58-59, 67 vaginal functioning role in, 88-
measurements of, 46, 56 100
in aging women, 229 Continence, sexual
in orgasmic phase, 288 female, effects of, 195, 240-241
in aging women, 230 male, affecting orgasmic experi­
pacinian corpuscles in, 46, 61 ence, 216
penile traction affecting response during pregnancy, 159-160, 163,
of, 57, 59, 60 164, 166-167
physiology of, 47, 57 Contractions
in plateau phase, 51-52, 58, 288 of bladder, in male, 213, 282
in aging women, 230 gluteal, 276-277, 297
psychogenic stimulation of, 56, of male secondary organs, 282,
61, 62 293
in resolution phase, 52-53, 288 of penis, 129, 184-185, 258, 259,
in aging women, 230 282, 283, 292
response patterns of, 47, 48, 53- in aging male, 253
55 of prostate, 212, 258, 282
retraction of, 46, 51-52, 57, 58, rectal, 277
65-66, 288 in females, 34, 129-130, 137,
in aging women, 230 229, 283, 287
secondary stimulation of, 58-59 in males, 173-174, 251, 283,
size of, 46 290
in aging women, 229 urethral
and sexual response, 56-57 in females, 130, 283
somatogenic stimulation of, 56, in males, 213, 215, 217, 282,
61 283
transformer response in, 62-63 uterine. See Uterus, contractions
tumescent reactions of, 49-50, 54, of
288 of vaginal orgasmic platform, 34,
in aging women, 230 78, 107, 128-129, 137, 148,
and sexual response, 57-58 185, 282-283, 287, 288
Color changes in aging women, 235-236
in labia minora, 7, 41-42, 53, with artificial vagina, 107
184, 231, 281, 289 postpartum, 151, 152
35° INDEX

Contractions, of vaginal orgasmic of nipples. See Nipple erection

platform—Continued of penis, 177, 178-179, 187, 218,
in pregnancy, 148 279, 292
in status orgasmus, 131 in aging males, 251-252, 259
See also Myotonia See also Penis, erection of
Coronary artery disease, and sexual Eroticism of study subjects, 301-315
activities, 175-176 females, 301, 302
Cowper’s glands, 211, 281, 293 aging women, 242-247
Cremasteric reflex, 207, 255 postpartum, 161-163
Cystitis, honeymoon, 33, 228 in pregnancy, 152, 156-160
males, 301, 302
Diseases, chronic, effects of, 175, aging males, 263-270
268-
269 program influence on, 311—315
Duration of responses reports on four subjects, 303-311
in excitement phase, 6 Estrogen therapy, effects of, 241,
in orgasmic phase, 6 242, 269
in plateau phase, 6 Examination of subjects, physical,
in resolution phase, 6 12, 22
variations in, 7, 8 Excitement phase, 4, 5-6
Dyspareunia, 240, 241 in aging females
Dysuria, postcoital, 33, 228, 240 breasts in, 224-225
clitoris in, 230
Education levels of study subjects, uterus in, 237
11, 13-14, 15 vagina in, 234-235
geriatric female subjects, 239 in aging males
geriatric male subjects, 261 penis in, 251-252
husbands of pregnant women, 156 scrotum in, 254
pregnant women, 142 testes in, 255-256
Ejaculation, 65, 210-220, 282 female
in aging males, 257-259 aging females, 224-225, 230,
premature, 202, 218, 220, 313 234-235. 237
sensation of inevitability of, 133, artificial vagina in, 102-106
293 Bartholin’s glands in, 43, 44,
Electrocardiogram 289
in females, 3 5 blood pressure in, 287
in status orgasmus, 132 breasts in, 28—29, 224, 274,
in males, 174, 175 286
Elevation clitoris in, 48-51, 230, 288
of labia majora, 39, 231, 289 compared with males, 279—280
of testes, 206-207, 254, 255-256, labia in, 39, 40, 280, 289
276, 280, 293 myotonia in, 32, 276, 286, 295
of uterus, 112-114, 124, 148, nipple erection in, 286
152, 237, 288 pelvis in, 72
Endocrine imbalance. See Steroid in pregnancy, 145-147
starvation, effects of prolonged, 280
Engorgement. See Vasocongestion rectum in, 34, 287
Erection sex flush in, 227, 275, 286
of clitoris, 49-50 tachycardia in, 287
 INDEX 351

uterus in, 73, 82, 112, 237, 288 Fatigue, effects of, 266-267, 314
vagina in, 44, 69-75, 82-84, Fear
234, 279, 280, 286, 288 of pregnancy, in aging women,
vasocongestion in, 119, 279- 243-244
280 of sexual failure, in aging males,
male 269-
270
aging males, 251-252, 254, Female sexual response, 5, 27-168
255-256 age range of subjects, 12, 13, 18-
blood pressure in, 291 19, 142, 223-224, 239
breasts in, 171, 274, 290 in aging, 18-19, 223-247
compared with females, 279- areolar engorgement in, 225
280 automanipulation in, 246
Cowper’s glands in, 293 Bartholin’s glands in, 232
myotonia in, 173, 276, 290, bladder in, 227-228
295 breasts in, 224-226
penis in, 182-183, 279, 292 carpopedal spasm in, 227
prolonged, 218—219, 251-252, clitoris in, 229-230
257, 258, 259, 280, 284 dyspareunia in, 240
rectum in, 173, 290 dysuria in, 228, 240
scrotum in, 204-205, 279, 280, external genitalia, 229-232
292 extragenital reactions, 224-232
secondary organs in, 293 frequency of exposure to sexual
sex flush in, 172 episodes, 234, 236, 240
tachycardia in, 291 labia majora in, 231
testes in, 206-207, 293 labia minora in, 231-232
urethra in, 187 and monotony in sexual rela­
vasocongestion in, 279-280 tionship, 264-265
Extragenital reactions myotonia in, 227
female, 27-37, 286-287 nipple erection in, 224, 226
in aging women, 224-232 postmenopausal orgasm, 137
male, 171—176, 290-291 rectum in, 229
in aging males, 249-251 sex drive in, 242-247
sex flush in, 226, 227
Facial muscles, in plateau phase, urethra in, 227-228
296 uterus in, 236-238
Failure, sexual, 308, 313-314 vagina in, 195, 228, 233-236
fear of, 269-270 areolar tumescence. See Areolar
Fallacies tumescence in females
phallic, 188, 189, 190, 191-193, artificial coition studies, 21
200-203 automanipulation, 63-65, 66,
vaginal, 193-195 313-314
Family units as study subjects, 12, See also Automanipulation
306-307, 309-311, 312, 314 Bartholin’s glands. See Bartholin’s
Fantasy processes, 21,134, 302 glands
alterations in, 138 bladder in, 33
and clitoral reactions, 48, 49, 52, in aging women, 227-228
55 blood pressure in, 35-36, 130, 287
in pregnancy, 158,159 breasts in. See Breasts, in females
352 INDEX

Female sexual response—Continued pathology of reproductive organs,

carpopedal spasm in. See Carpo­ 16
pedal spasm and pelvic anatomy, 72
clitoral and vaginal orgasms, 66- perspiratory reaction, 36-37, 287
67 compared with males, 278—279
clitoris, 45-67, 288 plateau phase. See Plateau phase,
in aging women, 229—230 female
See also Clitoris pregnancy, 18, 141-168
coital deprivation. See Conti­ See also Pregnancy
nence, sexual rectum in, 34, 287
education among study subjects, in aging women, 229
14, 142, 239 See also Rectal responses, in
and eroticism. See Eroticism of females
study subjects resolution phase. See Resolution
excitement phase. See Excitement phase, female
phase, female sensual focus of, 60, 63, 64, 66,
external genitalia in, 38-44, 45- 189, 194, 196, 200
sex flush in, 27, 30, 31-32, 130,
67 286
in aging women, 229-232
See also Sex-flush reaction
extragenital responses, 27-37, sexual failures in, 313-314
286-287 similarities to male responses,
in aging women, 224-232
fear of sexual performance, 314 273-293
steroid starvation, effects of, 233,
genital reactions, 288-289 237, 238, 239-240, 241,
hyperventilation in, 34, 130, 287 242-243
compared with males, 277-278 and surgical history of subjects, 18
labia majora, 38-40, 289 tachycardia in, 34-35, 130, 137,
in aging women, 231-232 287
See also Labia majora See also Tachycardia
labia minora, 40-42, 289 unmarried subject, 303—305
in aging women, 231 urethra in, 33
See also Labia minora in aging women, 227-228
married subject, 305-307 contractions of, 130, 283
multiple orgasmic expression. See uterus in, 111-126, 288
Multiorgasmic episodes in in aging women, 236-238
females See also Uterus
myotonia in, 32-33, 128, 286, vagina in, 43, 44, 68-100, 288
294-300 in aging women, 228, 233—236
in aging women, 227 artificial vagina, 101-110
compared with males, 276—277 See also Vagina
See also Myotonia vasocongestion in, 27, 294
nipple erection in. See Nipple See also Vasocongestion
erection Fertility, male, in vitro evaluation
number of responses studied, 10, of, 92
12, 13, 15 Flush reaction. See Sex-flush reaction
orgasmic phase. See Orgasmic Frequency of exposure to sexual epi­
phase, female sodes
 INDEX 353

affecting aging females, 234, 236, in males, 174, 291

240 compared with females, 277-
affecting aging males, 251, 262- 278
263, 269
Impotence in males
Genital reactions and aging, 203
female, 288-289 beliefs about, 200-201
male, 292-293 and circumcision, 190
Genitalia, external primary, 201, 218, 220
female, 38-44, 45-67, 119 secondary, 202-203, 218, 220,
in aging women, 229—232 258, 263, 267, 269
male, 177-209 Incontinence, urinary, in females,
in aging males, 251-256 228
Geriatrics, 18-19, 223-270 Infant sexual response, 140, 181
female studies, 223—247 Infertility
See also Female sexual re­ evaluation procedures, 92
sponse, in aging and lethal factor in vagina, 97-
male studies, 248—270 100
See also Male sexual response, Intensity of sexual response
in aging in automanipulation, 118, 133
Gluteal contractions, 276—277, 297 and blood pressure, 36
and color of labia minora, 42
Hand movements, in plateau phase, and heart rate, 34-35
296-297 and perspiratory reaction, 37
Heart rate and rectal reaction, 34
in females, 34-35, 130, 137, 287 and respiratory rate, 34
compared with males, 278 and sex-flush reaction, 31
in status orgasmus, 131, 132 variations in, 7, 8
in males, 174, 291 Interviews
compared with females, 278 behavioral content from, 8, 18, 20
History-taking, method of, 22 dual-sexed interview teams, 22
Homosexuality, 22, 200, 201, 219, postpartum, 153
306, 308, 309 of pregnant women, 153
Hormonal imbalance. See Steroid See also Subjective responses
starvation
Huhner test, 89, 92 Labia majora, 38-40, 289
Hydrogen-ion concentrations in aging women, 231
in seminal fluid, 99 elevation of, 39, 289
vaginal, 89—100 in aging women, 231
Hypertension engorgement of, 39, 40, 231, 289
in females, 35-36, 130, 287 in excitement phase, 280, 289
in males, 174, 291 in multípara, 40
Hypertrophy in nullipara, 38-40
of clitoris, 47, 50, 58 in orgasmic phase, 289
of prostate, 180 in plateau phase, 289
Hyperventilation in pregnancy, 146
in females, 34, 130, 287 in resolution phase, 289
compared with males, 277-278 varicosities of, 40
354 INDEX

Labia minora, 40-42, 289 penis in, 181, 251-254

in aging women, 231-232 and physical and mental infirm­
color changes in, 7, 41-42, 53, ities, 268-269
184, 231, 281, 289 psychic influences on sexual re­
in aging women, 231-232 sponses, 260, 263—267, 268-
with artificial vagina, 107, 109 270
postpartum, 151, 152 rectum in, 251
in pregnancy, 147 scrotum in, 254-255, 259
in excitement phase, 280, 289 sex flush in, 250, 259
expansion of, 40-41, 42, 50, 119, sexual inadequacy in, 203, 263,
122, 289 270
in orgasmic phase, 289 testes in, 255-256, 259
penile traction on, 59, 60 vasocongestion in, 259
in plateau phase, 289 automanipulation, 197-200, 262,
in pregnancy, 146, 147
in resolution phase, 284, 289 See also Automanipulation, in
tactile sensitivity of, 64 males
Lactation period blood pressure in, 174—176, 291
breasts in, 144,150,151 breasts in, 171-172, 249-250, 290
eroticism in, 161, 162 See also Breasts, in males
Leg muscles, in plateau phase, 298- cardiac patients, 175-176
299 cardiorespiratory reactions, 174-
Lethal factor, vaginal, 97-100 176
Lubrication, vaginal. See Vagina, carpopedal spasm in. See Carpo­
lubrication in pedal spasm
and circumcision, 17, 18, 189—
Male sexual response, 5, 171-220 191, 198
age range of subjects, 13, 248, Cowper’s glands, 211, 281, 293
249 education among study subjects,
in aging, 18—19, 248-270 M> 15, 156, 261
ages of subjects, 248, 249 ejaculation. See Ejaculation
automanipulation, 262 and eroticism, 263-270, 301, 302
breasts in, 249-250 excitement phase. See Excitement
and concern with economic phase, male
pursuits, 265-266 extragenital reactions, 171-176,
ejaculation, 257-259 249-251, 290—291
extragenital reactions, 249—251 fears of performance, 200-203,
fatigue affecting, 266—267 218, 269-270
fear of failure, 269-270 genital reactions, 292—293
frequency of exposure to sexual homosexuality, 22, 200, 201, 219,
episodes, 251, 262-263, 269 306, 308, 309
impotence, 203 husbands of pregnant women,
and monotony in sexual rela­ 141, 156, 160, 163-165
tionship, 264-265 hyperventilation in, 174, 291
myotonia in, 250-251 compared with females, 277-
noctural emission, 262 278
and overindulgence in food and impotence. See Impotence in
drink, 267-268 males
 INDEX 355

involution of sexual responses, similarities to female responses,

263-270 273-293
lag between sensation of and ac­ and surgical history of subjects,
tual ejaculation, 118, 133, 19
215, 293 tachycardia in, 174, 291
married subject, 306, 309-311 compared with females, 278
mucoid emissions in, 210-211, testes in, 206-209, 293
281, 293 in aging males, 255-256, 259
myotonia in. See Myotonia, in See also Testes
males uncircumcised subjects, 17, 18,
nipple erection in, 171, 249—250 198
compared with females, 273- unmarried subject, 307-309
275 urethra in, 187-188
number used in study, 10, 13, 15 contractions of, 213, 215, 217,
orgasmic phase. See Orgasmic 282, 283
phase, male vasocongestion in, 294
pathology of reproductive organs, See also Vasocongestion
.17 Manipulation
penis, 177-203, 292 of clitoris, 229
in aging males, 251-254 hypertrophy from, 58
See also Penis response to, 54, 61-62, 66
perspiratory reaction, 176, 291 of mons area, female, 54, 64, 66,
compared with females, 278- 229
279 See also Automanipulation
plateau phase. See Plateau phase, Marital status of study subjects, 12,
in males i5-!7, 306-307, 309-311,
premature ejaculation, 202, 218, 312, 314
220 Masturbation. See Automanipulation
prostatic contractions, 212, 258, Menopause
282 changes after. See Females, aging
rectum in. See Rectal responses, physical complaints in, 243
in males Menstruation, uterine response in,
refractory period, 7, 283-284 124-126
resolution phase. See Resolution Micturition. See Urination
phase, male Milk control, loss of, in orgasm, 144
restimulation, response to, 7 Monotony in sexual relationship,
scrotum in, 204-206, 292 effects of, 264-265
See also Scrotum Mons area, female, manipulation of,
secondary organs in, 282, 293 54, 64, 66, 229
sensation of ejaculatory inevitabil­ Mucoid emissions
ity, 215, 257, 282, 293 in females, 289
sensual focus in, 179, 189, 196, See also Bartholin’s glands
199-200, 217 in males, 210-211, 281, 293
sex flush in, 172-173, 290 Multiorgasmic episodes in females,
in aging males, 250, 259 7, 65, 131, 216, 219, 229,
compared with females, 275 278, 283-284, 304, 307
sexual failures, 308, 312, 313-314 in pregnancy, 145, 159, 166
356 INDEX

Myotonia. 6. 7, zt. 294-300 breasts in. 226

abdominal muscles. 296 clitoris in. 230
arm and hand movements, 296- rectum in. 229
29" urinary meatus in. 22-—22S
in automanipulation. 294-299 uterus in. 23--23S. 241
carpopedal spasm. See Carpope­ vagina in, 235-236
dal spasm in aging males
in excitement phase. 286. 290. penis in. 253
295 rectum in. 251
facial muscles. 296 scrotum in. 255
in females, 32-33, 128, 2S6 testes in. 2 56
in aging women, 227 duration of. 6
compared with males. 276-2-7 female. 6,12--140
uterine response. 116-119 in aging women. 13-, 226-230,
gluteal muscles, 276-277, 29- 255-238. 241
leg muscles. 298-299 artificial vagina in. 107—108
in males. 173, 290 from automanipulation, 118,
aging males. 250-251 12S. 133. 165
compared with females, 276- Bartholin’s glands in. 2S9
-i i blood pressure in. 36. 130. 2S-
scrotal response. 204-205 from breast stimulation. 54. 67
testicular response. 206-207 breasts in. 30. 130. 226. 2S6
neck muscles. 296 carpopedal spasm in. 33
in orgasmic phase. 128. 286. 290, clitoral and vaginal orgasms.
299 66-67
pehic thrusting reaction. 297— clitoris in, 52. 65. 230. 2SS
298 compared with males, 131.
in plateau phase, 286. 290, 294. 282-2S3
295-299 failures in. 313
in resolution phase, 286. 290. 300 and fantasy. 134
hyperventilation in. 34. 130,
Neck muscles, contraction of, 296 2S-
Negro families in study. 14-15 intensity of. 11S. 133, 13-
Nipple erection labia in. 2S9
in females. 28, 30, 2S6 lag between subjective appre­
in aging women. 224. 226 ciation and phs-siologic re­
compared with males, 273—275 lease. 11S. 133
false erection reaction, 130 and loss of milk control in
in pregnancy, 143, 144 breasts. 144
in males, 171, 249-250
compared with females, 273— menstruation affecting. 125-
126
275 and modes of stimulation, 54,
Nocturnal emission, in aging males.
262 67, 133-134
Nursing subjects, reactions in, 144, multiple. Sec Multiorgasmic
150, 151, 161, 162, 225 episodes in females
myotonia in. 2". 2S6. 299
Orgasmic phase, 6 pelvis in. 7-. 119. 121
in aging females physiologic factors of, 128-134
 INDEX 357

postpartum, 151, 152 preejaculatory fluid emission,

in pregnancy, 137, 145, 148- 210-211, 293
»49, 159, 166 premature ejaculation, 202,
psychologic factors in, 134-137 218, 220, 313
rectum in, 34, 129-130, 137, psychology of, 214-217
229, 283, 287 rectum in, 174, 251, 283, 290
and relief of pelvic vasoconges- repeated ejaculations, 213-
tion, 125, 149 214, 216
sensory acuity in, 135 scrotum in, 205, 255, 292
sex flush in, 130, 286 secondary organs in, 282, 293
sociologie factors in, 138-140 and seminal fluid volume, 214,
stage I, 135-136 216
stage II, 136 sex flush in, 172, 290
stage III, 136 and sexual adequacy, 218—220
status orgasmus, 78, 118, 131- sociologic factors in, 138, 217-
132 220
subjective response to, 134- stage I, 212-213, 257
»37, 139 stage II, 213-214, 257
tachycardia in, 34, 130, 137, tachycardia in, 174, 278, 291
278, 287 testes in, 209, 256, 293
urethra in, 33, 130, 227-228, urethral contractions in, 282,
283 283
uterus in, 112, 116-119, 122, myotonia in, 7
126, 129, 237-238, 241, and response to restimulation, 6-7
282—283, 288 vasocongestion in, 7
vagina in, 77-78, 86, 128-129, Orgasmic platform, vaginal, 76, 77-
235-236, 282-283, 288 78, 84-86, 118, 122, 128,
vaginal and clitoral orgasms, 280, 288
66-67 in aging women, 235
vasocongestion in, 119, 121 in artificial vagina, 106, 107, 109
male, 6, 129, 210-220 See also Vagina, orgasmic plat­
in aging males, 251, 253, 255, form in
256, 257-259 Orientation program for study sub­
bladder sphincter in, 282 jects, 21, 22-23, 306-307,
blood pressure in, 291 308, 310
breasts in, 290 Ovarian steroids. See Steroid starva­
compared with females, 131, tion, effects of
282-283 Overindulgence in food and drink,
Cowper’s glands in, 293 effects of, 267-268
ejaculation, 65, 210-220, 282
failure in, 313 Pacinian corpuscles, 46, 61
hyperventilation in, 174, 291 Pain in females
lag between subjective appre­ in breasts, in pregnancy, 143
ciation and physiologic re­ coital, in aging women, 240, 241
lease, 118, 133, 215, 293 cramping in pregnancy, 145
myotonia in, 277, 290, 299 dysuria, postcoital, 33, 228, 240
penis in, 184-185, 253, 292 uterine, 118-119
physiology of, 212-214 in aging women, 238, 241
358 INDEX

Pain in females—Continued coronal engorgement of, 7, 292

from vasocongestion, 119—120 erection of, 177, 178-179, 187,
Pathology of reproductive organs, in 218, 251, 279, 292
study subjects, 11, 12, 16, in aging males, 181, 249, 251-
17-18 252, 259
Parity inadequacy in, 308, 313
and Bartholin’s gland activity, 43- in infancy, 181
44 prolonged, 218-219, 251-252,
and breast size, 143 257, 258, 259, 280, 284
and eroticism in pregnancy, 156, in sleep, 180
157, 158, 159 in excitement phase, 182-183,
and labial reactions, 38, 40, 289 279, 292
and postpartum eroticism, 161 in aging male, 251-252
and seminal fluid retention, 82-83 and fears of performance, 200-
and uterine responses, 114, 115, 203
119, 120-121, 122, 129, 149 foreskin retraction in, 190-191,
and vaginal responses, 73, 75, 85, 198
147 functional role of, 188-189, 196-
and vasocongestion relief, 149
Pelvic thrusting reaction, 297-298 197
involution of, 180-181
Pelvis
female
in aging males, 254
anatomy of, 72 in resolution phase, 185-187,
in excitement phase, 72 253, 284, 292
false, 73, 82,112, 288 measurements of, 191-193
in orgasmic phase, 77 in micturition, 187
in plateau phase, 76 in orgasmic phase, 184-185, 292
postpartum, 161 in aging males, 253
in resolution phase, 79 phallic fallacies, 188, 189, 190,
vasocongestion in, 114, 119—120 191-193, 200-203
male in plateau phase, 183-184, 292
anatomy of, 180 in aging males, 252
in excitement phase, 182 in resolution phase, 185-188,
in orgasmic phase, 184-185 199, 284, 292
in plateau phase, 183 in aging males, 253-254
in resolution phase, 186 sensitivity of, postorgasmic, 199
Penis, 177-203, 292 size of, 191-193
affecting clitoral response, 57, 59, erection affecting, 191-192
60 increased, 280, 292
in aging males, 251-254 and skeletal development, 193
anatomy of, 177-179 and vaginal size, 193-195
artificial, 21 transformer role of, 196-197
circumcision of, 189—191, 198 Perineum, female, tactile sensitivity
color change in, 183-184, 281 of, 64
in aging males, 252 Perspiratory reaction
contractions of, 129, 184-185, in females, 36-37, 287
258, 259, 282, 283, 292 compared with males, 278-279
in aging male, 253 in males, 176, 291
 INDEX 359

compared with females, 278— postpartum, 150, 151, 152

279 in pregnancy, 147-148
pH rectum in, 34, 287
of seminal fluid, 99 sex flush in, 32, 227, 275, 286
vaginal, 89-100 tachycardia in, 34, 278, 287
Phallic fallacies, 188, 189, 190, 191- uterus in, 112, 120, 237, 288
193, 200-203 vagina in, 75-77, 84-85, 235,
and clitoral response, 45, 57 280-
281, 288
Phimosis, 180, 190 vasocongestion in, 280—282
Physical examinations of subjects, in males
12, 22, 189 aging males, 252, 255-256
Physical infirmities, effects of, 268- blood pressure in, 291
269 breasts in, 171, 274, 290
Plateau phase, 4, 6 compared with females, 280-
in aging females 282
Bartholin’s glands in, 232 Cowper’s glands in, 293
breasts in, 225-226 hyperventilation in, 174, 277,
clitoris in, 230 291
uterus in, 237 mucoid emissions in, 281, 289
vagina in, 235 myotonia in, 173, 276, 290,
in aging males 2?4: 295-299
penis in, 252 penis in, 7, 183-184, 192, 252,
scrotum in, 255 280, 281, 292
testes in, 255-256 preejaculatory fluid emission
duration of, 6 in, 210—211
in females rectum in, 173, 290
aging females, 225-226, 230, scrotum in, 205, 255, 292
232, 235, 237 secondary organs in, 293
artificial vagina in, 106-107 sex flush in, 172, 250, 275, 290
Bartholin’s glands in, 43, 44, tachycardia in, 174, 278, 291
232, 289 testes in, 207-209, 255-256,
blood pressure in, 35, 287 293
breasts in, 29-30, 143, 225- urethra in, 187
226, 274, 286 vasocongestion in, 280-282
carpopedal spasm in, 33 myotonia in, 7
clitoris in, 51-52, 58, 65-66, vasocongestion in, 7
230, 288 Population for research studies, 9-
compared with males, 280—282 23
hyperventilation in, 34, 277, age of subjects, 12, 13
287 artificial vagina group, 12, 15, 18
labia majora in, 39, 40, 289 clinic sources, 11, 14-15
labia minora in, 7, 40, 41, 42, education levels of subjects, 11,
281 13-14, 15
mucoid emissions in, 281-282, family units, 12, 306-307, 309-
289 311, 312, 314
myotonia in, 32, 276, 286, 294, female subjects, 12, 13
295-299 geriatric group, 18-19
pelvis in, 76 females, 223-224
360 INDEX

Population for research studies, geri­ breasts in, 143

atric group—Continued eroticism in, 156-158
males, 261 nulliparous women, 156-157
history-taking of subjects, 22 orgasm in, 148
male subjects, 13 orgasmic cramping in, 145
marital status of subjects, 15-17 parous women, 157-158
married female subject, 305-307 sexual tension in, 145
married male subject, 306, 309- uterus in, 147
311 vaginal lubrication in, 146
Negro families, 14-15 vasocongestion in, 146
number of subjects studied, 10, genital organs in, 145-152
12, 13r 15 husbands cooperating with study,
orientation of subjects, 21, 22- 141, 156, 163-165
23, 304, 306-307, 308, 310 intercourse contradicted in, 159-
pathology of reproductive organs 160, 163, 164, 166-167
in subjects, 11, 12, 16, 17-18 labia in, 40, 146, 147, 149
physical examinations, 12, 22, 189 male reactions to, 160, 163-165
pregnant women, 18 orgasm in, 137, 148-149
prostitutes, 10-11 pelvic vasocongestion in, 145, 146
recruitment of subjects, 305, 306 plateau phase in, 147-148
selection of subjects, 10, 11 postpartum responses, 150-152,
sexuality of study subjects, 301-
161-163, 167
315 prostitution in, 156, 157, 159
surgical history of subjects, 18, 19
uncircumcised subjects, 17, 18 resolution phase in, 149-150
unmarried female subject, 303- second trimester responses, 158—
3°5 159
unmarried male subject, 307-309 breasts in, 143
Position, coital eroticism in, 145, 158-159
and carpopedal spasm in males, labia in, 146
173 orgasm in, 148
and clitoral response, 53-54, 59- resolution phase in, 149
60, 67 sexual tension in, 145, 149
and seminal pool creation, 86 vasocongestion in, 146
and vaginal angulation, 81 third trimester responses, 159-
Postpartum period, 150-152 160
coition in, 167 breasts in, 143
eroticism in, 161-163 coition in, 166, 167
Pregnancy, 18, 141—168 labia in, 146
attitude toward, in aging women, orgasm in, 148
243-244 sexual tension in, 145, 149
automanipulation in, effects of, vasocongestion in, 146, 149
159, 165-166 uterus in, 147
breasts in, 143-144 vaginal lubrication in, 146-147
eroticism in, 152, 156-160 wastage statistics, 154,155
excitement phase in, 145-147 and automanipulation, 165
first trimester responses, 156-158 Prejudice, in studies of sexual re­
automanipulation in, 165 sponse, 8, 9
 INDEX 361
Premature ejaculation, 202, 218, sexual response cycle, 3-8
220, 313 . Resolution phase, 6-7
Progesterone therapy, effects of, 241 in aging females
Prostate breasts in, 226
contractions of, 212, 258, 282 clitoris in, 230
hypertrophy of, 180 vagina in, 236
Prostitute population, 10-11 in aging males
Psychologic factors penis in, 253-254
in aging females, 238-247 scrotum in, 255
in aging males, 260, 263—267, testes in, 256
268—270 duration of, 6
in clitoral response, 52, 55, 56, female
61, 62 aging women, 226, 230, 236
in female orgasm, 134—137 artificial vagina in, 109-110
in male orgasm, 214-217 Bartholin’s glands in, 289
and male sex flush, 173 blood pressure in, 287
in menopausal complaints, 243 breasts in, 30-31, 286
in penile erection, 183 cervical os dilatation in, 115,
in sexual performance, 314 237, 288
clitoris in, 52-53, 288
Rash, maculopapular. See Sex-flush compared with males, 283-285
reaction labia in, 39, 40, 42, 284, 289
Recruitment of subjects, 305, 306 myotonia in, 277, 286, 300
Rectal responses, 277 pelvis in, 79
in females, 34, 287 perspiratory reaction in, 36,
in aging women, 229 278-279,287
contraction, 129-130, 137, in pregnancy, 149-150
277, 283, 287 rectum in, 287
sensitivity, 200 sex flush in, 275, 286
in males, 173-174, 290 uterus in, 78-79, 87, 112-113,
in aging males, 251 115, 288
contractions, 277, 283, 290 vagina in, 78-80, 86-88, 284,
sensitivity, 200 288
Rectocele, effects of, 83-84, 228 male
Refractory period, in males, 7, 283- aging males, 253-254, 255, 256
284 blood pressure in, 291
Reproduction, vagina in breasts in, 250, 290
functional role of, 80-88 compared with females, 283-
functioning role of, 88-100 285
Reproductive organ pathology in Cowper’s glands in, 293
subjects, 11, 12, 16, 17-18 myotonia in, 277, 290, 300
Research in sexual response, 3-23 nipple erection in, 250
behavioral content from inter­ penis in, 185-188, 284, 292
views, 8, 18, 20 perspiratory reaction in, 278-
population used in study, 9-23 279, 291
See also Population for research rectum in, 290
studies respiration in, 174
problems encountered, 9-10 scrotum in, 205-206, 284, 292
362 INDEX

Resolution phase, male—Continued vaginal lubrication affecting,

secondary organs in, 293 92. 94
sex flush in, 173, 275, 290 containment of, 82
testes in, 209, 284, 293 expulsion of, 212-213, 253, 257,
urethra in, 188 282
Respiration in aging male, 253, 258
in females, 34 in vitro and in vivo evaluation of,
compared with males, 277-278 92, 96
in males, 174, 291 pH of, 99
compared with females, 277- vagina as receptacle for, 80-88,
278 112, 193
Restimulation, response to, 6-7 viscosity of, 96, 98
Retraction volume of
of clitoral shaft, 46, 51-52, 57, in recurrent ejaculations, 214,
58, 65-66, 288 216
in aging women, 230 subjective appreciation of, 216
of penile foreskin, 190-191, 198 wastage of, 83
Sensory acuity, loss of, in orgasm,
Scrotum, 204-206, 292 135
in aging males, 254-255, 259 Sensual focus
in excitement phase, 204-205, in females, 189, 196, 200
279, 280, 292 clitoris as, 60, 63
in aging male, 254 mons area as, 64
in orgasmic phase, 205, 292 reduction of, 194
in aging male, 255 in males, 179, 189, 196, 199-200,
in plateau phase, 205, 292 217
in aging male, 255 Sex-flush reaction
in resolution phase, 205—206, in females, 27, 30, 31—32, 130,
284, 292 286
in aging male, 255 in aging women, 226, 227
stimulation affecting, 199-200, compared with male, 275
204 resolution of, 32, 36, 37, 286
vasocongestion in, 204 in males, 172-173, 290
in aging male, 254 in aging male, 250, 259
Secretory activity compared with female, 275
of Bartholin’s glands, 43-44, 232, Sex-skin color changes. See Labia
281-
282, 289 minora, color changes in
in aging women, 232 Sexual failure, 308, 313-314
of cervix uteri, 70-71, 114-115 fear of, 269—270
in aging women, 236 Sexual response cycle, 3-8
in pregnancy, 147 in childhood, 140
of Cowper’s glands, 281, 293 excitement phase, 4, 5-6
uterine, 111 female, 5, 27-168
vaginal, 69-71 male, 5,171-220
Seminal fluid orgasmic phase, 6
affecting vaginal acidity, 98 phases in, 4, 5—7
artificial, 123 plateau phase, 4, 6
buffering power of, 95, 98 resolution phase, 6-7
 INDEX 363

similarities in responses, 8, 273— scrotal response to, 199-200, 204

293 somatogenic, 61-62
variations in duration and inten­ uterine response to, 111
sity, 4, 7, 8 variations in techniques of, 10
Sexuality of study subjects. See Erot­ Subjective responses
icism of study subjects female, 118, 133, 134-137, 139
Similarities of male and female re­ postpartum, 151, 152
sponses, 8, 273-293 in pregnancy, 149-150, 153
Sims-Huhner test, 89, 92 male, 118, 133, 189, 214-217
Skin responses. See Perspiratory re­ in ejaculation process, 257
action; Sex-flush reaction Suckling, affecting breasts, 29-31,
Sociologie factors in sexual perform­ 225.
ance, 314 Surgical history of study subjects,
in female orgasm, 138-140 18, 19
in male orgasm, 217-220 Sweating phenomenon, vaginal, 69,
Spasm, carpopedal. See Carpopedal 7i
spasm Sweating reaction. See Perspiratory
Spastic uterine contractions, in preg­ reaction
nancy, 148
Spermatozoa Tachycardia
immobile, 98 in females, 34-35, 130, 137, 287
longevity in vagina, 95 compared with males, 278
and vaginal acidity, 44 in status orgasmus, 131, 132
migration of, and uterine re­ in males, 174, 291
sponse, 115-116, 122-124 compared with females, 278
motility in vagina, 95 Tension, sexual
acid media affecting, 90 affecting total body. See Extra­
in preejaculatory fluid emission, genital reactions
211 cardiorespiratory response to, 36
vaginal environment affecting, 44, clitoral response to, 48, 51
88-100 control of, 10
Status orgasmus, 78, 118, 131-132 elevation of, 10
Steroid replacement, in aging males, loss in resolution phase, 6
269 in orgasmic phase, 6
Steroid starvation, effects of, 233, physiologic evidences of, 8
237, 238, 239-240, 241, physiologic residuals of, 7
242-243 postpartum response to, 151
postpartum, 151, 162 in pregnancy, 145
Stimulation, sexual, 5-6 processes for increment of, 21
clitoral response to, 56, 61, 66, 67 prolonged, 119-120, 218-219,
female reactions to, 27 251-252, 257, 258, 259,
modes of, and intensity of or­ 280, 284
gasm, 133-134 psychogenic aspects of, 7
pelvic responses to, 48 uterine reactions to, 73
penile reactions to, 179, 181 vaginal response to, 68, 73
physiologic responses to, 7-8 variations in reactions to, 8
psychogenic, 62-63 Tenting effect, vaginal, 73, 78, 82,
restimulation, 6-7 112, 147, 288
364 INDEX

Tenting effect—Continued in aging women, 237-238, 241

in aging women, 237 from automanipulation, 118,
Testes, 206-209, 293 126, 165
in aging male, 255-256, 259 painful, 118-119
elevation of, 206-207, 25276, in pregnancy, 137, 148
280, 293 sensation of, after uterine re­
in aging males, 254, 255-256 moval, 118
enlargement of, 203, 293 corpus response, 116-122
in excitement phase, 206-207, dilatation of cervical os, 115, 288
255, 293 in aging women, 237
involution of, postorgasmic, 209 elevation reaction, 112-114, 124>
in aging males, 256 288
in orgasmic phase, 209, 256, 293 in aging women, 237
in plateau phase, 207-209, 255- postpartum, 152
256, 293 in pregnancy, 148
in resolution phase, 209, 256, in excitement phase, 73, 82, 112,
284, 293 288
vasocongestion in, 208, 293 increased size of, 119-122
in aging males, 256 involution of, in aging, 237
Transformer role in menstruation, 124-126
of clitoris, 62-63 myotonia of, 116-119
of penis, 196-197 in orgasmic phase, 112, 116-119,
Tumescence. See Vasocongestion. 122, 126, 288
parity affecting responses of, 115,
Urethra 119, 120—121, 122, 129
in females, 33 in plateau phase, 112, 120, 288
in aging women, 227-228 postcoital cervical mucus exami­
contractions of, 130, 283 nation, 89, 92
in males, 187-188 postpartum, 151, 152
contractions of, 213, 215, 217, in pregnancy, 147
282, 283 in resolution phase, 78-79, 87,
Urinary loss, in coition, 228
Urination 112-113, H5> 288
painful, in women, 33, 228, 240 response to sexual stimuli, 111,
penis in, 187 114-116
postcoital urge for, 33 and sperm migration, 115-116,
Uterus, 111-126, 288 122-124
as abdominal organ, in pregnancy, retroversion of, 73, 86
167 and lack of elevation, 114
in aging women, 236-238 in pregnancy, 147
cervical response, 114-116 secretory activity of, 111
in aging women, 236-237 sucking concept of, 122-124
cervical secretory activity, 69, 70- vasocongestion in, 119-122
71, 114-115 in aging women, 237
in aging women, 236
in pregnancy, 147 Vagina, 68-100, 288
contractions of, 115, 116-119, acidity of, 44, 89-90
122, 126, 129, 133, 141, neutralization of, 94
282-
283, 288 seminal fluid affecting, 98
 INDEX 365

in aging women, 228, 233-236 measurements of, 73

angulation of, 81 in aging women, 233
artificial, 12, 15, 18, 101-110 artificial vagina, 104—105
color change in, 108, 110 in excitement phase, 73-75
contractions of, 107 in plateau phase, 76
distention of, 103 in orgasmic phase, 77-78, 86,
in excitement phase, 102-106 235-236, 288
and labia minora color changes, artificial vagina, 107-108
107, 109 orgasmic platform in, 76, 77-78,
lubrication in, 71, 102, 106- 84-86, 118, 122, 128, 280,
107 288
measurements of, 104-105 in aging women, 235
in orgasmic phase, 107-108 in artificial vagina, 106, 107,
orgasmic platform in, 106, 107, 109
109 contractions of, 34, 78, 107,
in plateau phase, 106-107 128-129, 137, 148, 185,
in resolution phase, 109-110 282-283, 287, 288
vasocongestion in, 106, 108 postpartum, 151, 152
color of, 75, 79, 288 in pregnancy, 147, 148, 149,
in aging women, 233 151
in artificial vagina, 108, 110 in status orgasmus, 131
postpartum, 151 physiologic reactions of, 80-88
conceptive function of, 80-88 in plateau phase, 75-77, 84-85,
distention and expansion of, 71, 235, 288
74, 276, 280, 288 artificial vagina, 106-107
in aging women, 233-234 in resolution phase, 78-80, 86-
in artificial vagina, 103 88, 236, 284, 288
postpartum, 150, 152 artificial vagina, 109-110
in excitement phase, 69—75, 82— as seminal receptacle, 80-88, 112,
84, 234-235, 286, 288 193
artificial vagina, 102-106 as sexual organ, 68-80
fallacies concerning, 193-195 size of, and penile size, 193-195
functioning role in conception, spermatozoa in, 88-100
88-100 sweating phenomenon in, 69, 71
involution of, 195, 233 tenting effect in, 73, 78, 82, 112,
lethal factor in, 97-100 147, 288
lubrication in, 43, 44, 48, 69-71, in aging women, 237
77, 79, 279, 281, 288 vasocongestion of, 70, 75, 76, 78,
affecting seminal fluid, 92, 94 288
affecting vaginal acidity, 91-92 in aging women, 235
in aging women, 228, 234, 240 artificial vagina, 106, 108
in artificial vagina, 71, 102, in pregnancy, 147-148
106-107 Vaginal orgasm, compared with cli-
and cervical secretory activity, toral orgasm, 66-67
114 Variations in duration and intensity
postpartum, 150, 152 of responses, 7, 8
in pregnancy, 146-147 Varicosities, labial, 40
366 INDEX

Vasocongestion, 6, 7, 294 penile, 196, 279, 292

in aging females, 224, 230, 231, in plateau phase, 280-282
235, 237 postpartum, 150, 151
in aging males, 254, 256, 259 of scrotum, .204
of breasts in aging male, 254
in females, 29, 30, 122, 143, and sex flush, 31
224, 274, 288 suckling affecting, 29
in males, 171, 274 in target organs, 122
of clitoris, 49, 50, 54, 288 of testes, 208, 293
in aging women, 230 in aging males, 256
and sexual response, 57-58 unresolved, affecting female, 119—
in excitement phase, 119, 279- 120
280 See dZso Tension, sexual, pro­
in female pelvis, i~/ longed
generalized, 114 uterine, 119—122
orgasm affecting, 119-120, 121, in aging women, 237
125, 149 vaginal, 70, 75, 76, 78, 279, 288
pain from, 119-120 in aging women, 235
in pregnancy, 145, 146, 149- in artificial vagina, 106, 108
150 in pregnancy, 147-148
labial, 40, 50, 119, 122, 280, 289 Venous pattern in breasts, 29, 143,
in aging women, 231 225, 286