Vaginal Orgasm in Woman With Unique Pelvic Anatomy? - A Journal Article I Read

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Sexual function in a woman with congenital bladder exstrophy and multiple pelvic reconstructive surgeries: a case report. Vaccaro CM1, Herfel C, Karram MM, Pauls RN. J Sex Med. 2011 Feb;8(2):617-21.

Today, on A Journal Article I Read, we'll be talking about a case study of a woman who was born with a condition that affected her outer genitals and bladder. She has had her bladder and urethra removed, had necessary plastic surgery on her vulva and vagina, and endured many other pelvic surgeries including the removal of her cervix. She claims to have vaginal orgasms 100% of the time she has sex. The authors wonder whether she orgasms this way so easily because of the particularly unique organ configuration down there. So, to investigate this, they had her note the sexually sensitive areas on her genitals and then used MRI to see if clitoral tissue is related to those areas. The authors felt that her inner clitoral tissue corresponded to her sexually erotic areas.

So, that's basically the whole paper,  All in all, I thought the investigation into this women's experience was pretty cool. I have one big problem with it though. The researchers did not investigate into what exactly the subject meant when she said she orgasmed, and frankly when it comes to claims of orgasming through vaginal stimulation alone, researchers should not simply be taking a subject's word on the matter. This type of orgasm has a lot of baggage, and it has never been documented before. It requires special treatment. This is the same gripe I have with so many female orgasm studies, but it really is an important one. There is a physically verifiable rhythmic release of arousal-induced muscle tension that is an orgasm, and scientific investigation should verify and not simply assume, this is what is happening when a woman claims to orgasm vaginally. If a study does not take time for this verification, as is the case for this study, it deeply weakens any conclusions that are made from it.

So on to the study description. (All quoted material is from this study btw.)

A Disclaimer
I am no medical expert, and honestly, this article was pretty confusing for me the first couple times I read it. However, I do these article overviews so that I can get a deeper understanding of them and also so that I can offer other people a more accessible yet still extensive version of what these studies have to say.  So, I looked up a lot of shit on WebMD and Wikipedia, and things did start making more sense, so I tried to write about the procedures and stuff without so many big incomprehensible words. I hope that I didn't completely misunderstand anything and that what I did write is somewhat more comprehensible.

Some Background

• She was born with bladder exstrophy which occurs in only 1 in 50,000 births (males and female equally). It is a failure of development of the lower abdominal wall, genital tubercules (the embryonic beginnings of what will become either the penis or clitoral glans), and pubic rami (a piece of the pubic bone).
• Pelvic Organ Prolapse (a situation in which pelvic organs begin to kinda drop and end up pressing against things they shouldn't like the vagina) is a fairly common female disorder (about 1 in 11 women develop this), but it's way more common among women with bladder exstrophy. This condition could require surgery or multiple surgeries for some women.
• In a previous study of 12 women with bladder exstrophy: 8 reported regular sexual activity, 6 reported regular orgasm, and 4 reported vaginal pain (other that the pain involved with having a shorter vagina as seems to often end up being the case for these women).

The Details On This Lady

• She's 42, physically fit, well-groomed (I'm not sure why that was added to this report), 1 pregnancy delivered cesarean
• At 2, she had her bladder removed. She also had an operation (that looks like it is no longer used for people with her condition) where the ureters that carry urine from the kidney were diverted to the lower colon (uretero-sigmoidostomy).
• At 15 she had pain and found that her upper vagina was filling with menstrual blood. She then had a distal vaginoplasty  to "open and reconstruct the lower 1/3 of the vagina."
• During her pregnancy, she began experiencing pelvic organ prolapse in the form of cervical prolapse and 2 years later her cervix was removed as part of the treatment (Manchester procedure), which helped for a while.
• In 2000 she had a hysterectomy with an anterior repair, and "an anterior repair involves a midline dissection of the anterior vaginal mucosa and removal of redundant mucosa." (Vaginal mucosa is basically the lubrication making layer of the vaginal tissue)
• In 2003 she was back with a Stage 4 vaginal prolapse, in which it seems her upper vagina was sagging down into her lower vagina, basically turning it sorta inside-out, and a ligament vaginal vault suspension was performed to correct it.
• 2 years later the vaginal vault suspension failed and she had Stage 2 anterior vaginal wall prolapse. Sacrocolpoexy, another procedure to repair organ prolapse, was used.
• Over the following 2 years she had 3 more surgeries for these types of problems.
• She completed several questionnaires: the PISQ-12 and got 10/48 indicating a small impact of her pelvic orgasm prolapse on her sexual function, the FSFI with a 29.4/36 indicating good sexual function, the SF-12 with scores of 36.6 and 57.9, indicating she was above average in mental health and below average in physical health (which makes sense given her condition).
• At the time of this study, a pelvic exam confirmed Stage 2 anterior vaginal wall prolapse and a shortened vagina length of 6 cm (okay - so that's about 2.3 inches and I've read stuff that says average is 3 to 4. I know the vagina expands during arousal, so that's not as tiny as it seems, but I just wanted to know how short 6cm really was in the grand scheme of things)

Her Sexual History

• "Via recorded face-to-face interview with the subject and her husband, a full sexual history was outlined. She reported that typical sexual encounters result in one vaginal orgasm with manual stimulation, followed by one orgasm with vaginal penetration, thus being multi-orgasmic with each coital episode. Although she prefers the female dominant position, she reported the ability to orgasm from any position without additional manual stimulation of the clitoris." (I really don't know what exactly is meant by vaginal orgasm by manual stimulation)
• "She described her pelvis as 'naturally tilted forward'...and she feels this leads to better stimulation of her clitoral tissue while in the female dominant position." 
• She has some lack of lubrication and uses lubricants about 50% of the time. Due to her shortened vagina she has pain during deep thrusting, but it doesn't prevent orgasm. She desires sex about once a week now, but it was daily at her sexual peak.
• She reports daily use of fluoxetine for depression, and alprazolam and acetaminaphen/hydrocodone as needed for anxiety and musculoskeletal pain.

The Investigation

• "Together with her husband, her erotic tissues were marked and photographed. The markings include her sites of sexual stimulation and engorgement. This mapping identified the 12 and 1 o'clock positions of the vagina just inside the introitus to be sites of sexual sensation leading to orgasm. Additionally, her mons pubis was marked as another area of sensitivity." (introitus is the hole btw)
• The pelvic MRI images were taken, and the researchers "identified the marked erotic locations as being consistent with clitoral tissue. therefore, in this subject the clitoris lies superficially on the distal anterior vaginal wall just beneath the mons pubis, with the most superficial sites being on her left." Superficially here means just beneath the surface and distal anterior is the part of the vagina that is close to the hole and towards the front of your body.
• I was seriously confused about the picture below from this study. It doesn't give a lot of detail in the writing, and let's be honest, sometimes looking at the vulva area close up with nothing to orient yourself is hard to figure out. But, I'm pretty sure that is the vaginal hole with no urethra or visible clitoral glans above it.   

Conclusion
So, this woman does not have a bladder or a urethra, and the authors tell us it's unlikely a G-spot could exist on this women. (The G-spot being the female prostate that surrounds the urethra and can be felt through the distal anterior vaginal wall. Some say it could be the cause of vaginal orgasms but although it has been shown to stimulate ejaculation, it has never been shown to cause orgasm - this is true for both men and women). The researchers point this out to eliminate the g-spot as a possible cause for the "vaginal" orgasms this woman claims to have. Instead, they point to the inner clitoris.

"...we believe that this patient's vaginal eroticism is the clitoral complex that 'drapes' the anterior distal vagina. Given the findings reported here it is clear that further research is needed to investigate how position and location of the clitoris relates to female orgasm and sexual function."

My Thoughts
Connecting Clitoral Placement to Her Vaginal Orgasm Ability
Relating the inner clitoris to vaginal eroticism is nothing new. In fact I'd say, within research, it's currently the most hip way of reasoning how vaginally stimulated orgasms might happen.  The hypothesis goes vaguely like this; the penis jostles the vaginal wall, which jostles the tissue outside the vaginal wall, which jostles the clitoral legs, and that's how the orgasm is caused. So, I imagine for these researchers it seems sensible to connect clitoral legs to this woman's capacity to vaginally orgasm, but it's much more of a stretch than one might think. There is indication that a penis moving in a vagina does jostle and press down on stuff in there, including the clitoral legs, but like all other hypotheses for how a vaginal orgasm happens, there is absolutely no proof an orgasm can or has ever been caused this way.

Still, the woman in this study has a unique anatomy which could provide insight into how women might orgasm vaginally if vaginal orgasms are, in fact, a thing that can happen. I'm honestly a little confused about how exactly the clitoris exists in this woman and how it is different from what is normally expected. My best assumption from the reading is that the glans is hidden beneath the skin and the clitoral legs are closer to the surface of the skin than is normally expected. The paper does not specifically describe these things in detail, so I could be wrong.

How The Glans Fits In
Without a visible, external glans, the researchers tell us that this woman's genital anatomy "has been altered in such a way not unlike those who have had female circumcision." However, they rightly point out that many women who have gone through female circumcision do still report the ability to orgasm due to undamaged clitoral tissue beneath the skin - which she seems to have. So stimulation of the glans through her skin seems to be a possibility for how she reaches orgasm - but she specifically claims to reach orgasm during any intercourse position without additional stimulation of the glans.

The glans is an important factor here because stimulation of the glans area is an observed, recorded and verified way that seemingly all intact, healthy women can orgasm. Stimulation to that external clitoral glans area is, actually, the only way that scientist have observed woman orgasming.

How The Clitoral Legs Fit In
The clitoral legs are the inner clitoral structures. They are 2 spongy erectile legs that straddle the vagina. The researchers kept using the term "superficial placement" of the clitoris when discussing it's uniqueness, which I kinda just took to mean not the 'real' place it's supposed to be, but I slowly realized that they are probably meaning that it is very close to the surface of the skin (see I can learn vocabulary!). So, I imagine her clitoral legs are a little closer to the surface of the skin and maybe closer to the vagina...but I'm not positive about that. I do know that there's no bladder in there, so they are probably placed at least somewhat differently than most women's clitoral legs. I am also not completely sure whether the researchers felt the "superficial nature" of the vagina was important because it could be stimulated more easily through her pelvic skin around her vulva, or whether they felt it was closer to her vaginal opening and could be stimulated to orgasm through the movement of things going in and out of the vagina. Either way, the researchers seem to be focusing on orgasm through stimulation of the clitoral legs, and that is is not something that has ever been observed.

The Researchers Are Looking For The Cause Of Something That Hasn't Been Proven to Exist

So the idea that women can orgasm by stimulating the clitoral legs during intercourse is merely an untested hypothesis for how vaginally stimulated orgasms might work. Furthermore, vaginally stimulated orgasms themselves are also merely an untested hypothesis. Yes, this woman and a minority of other women clearly say they do have them, but this is a scientific investigation after all, and investigators really should be quite hesitant to take women at their word about experiencing something that the researchers have never seen proof for. Here's a few reasons why:

• Even quite educated people may not know what an orgasm is physically (the rhythmic release of muscle tension that has built up during arousal), or that an ejaculation is different from an orgasm in both men and woman. We don't usually learn those things in school, and people may use the word incorrectly.
• Even though a 'vaginal' orgasm has never been documented ever in science, and even though it is undisputedly not something the majority of women say they experience, it is the #1 way we see women orgasming in books, TV, movies, and porn. It's not unreasonable to assume women may be influenced in the way they describe and experience their sexual functioning by this discrepancy between their actual experiences vs. media depictions of female orgasm. It's not crazy to wonder whether women's words might not match the physical things happening in their bodies.
• The inability to orgasm 'vaginally' was professionally deemed a mental illness in our country up into the 1970's. My mother and her generation, the people who raised me and the other 20-40 somethings walking around today, were already functioning, sexually active people by that time. Do researchers think that this kind of deeply personal stigma around the ability to orgasm vaginally just fell off the earth? Do they not think that this stigma might influence answers to questions about whether she can or cannot? Do they not think they should take special care when investigating this?

This all to point out that, well, the subject in this study says she orgasms twice every single time she has sex, but...maybe she doesn't. It might be that she's not really lying about it. It might be that she's authentically describing her experience, but maybe that experience is more of a climactic feeling rather than the rhythmic muscle release that is physically an orgasm. Maybe she is physically orgasming 100% of the time she has intercourse. But, the truth is, we just don't know, and the researchers simply didn't think it was important enough to verify or even discuss the lack of verification as a possible limitation to this study.

Can I just say too, that ESPECIALLY because she was giving her sexual history face-to-face with her husband sitting right next to her, the researchers should have considered the possibility that the situation may have put undue pressure on the subject and could have skewed her answers. I mean, researchers know some women lie to their partners about their ability to orgasm, so they must know that there is pressure out there in the world that encourages women to misrepresent their sexual functions to their partners. It seems to me that having a woman describe her sexual function while her husband sits next to her puts a possible barrier to honest answers. The researchers should have at least commented and acknowledged that the husband situation complicated the study a bit.

My Conclusion
This truly was an interesting paper. With the subject's unique physiology, this paper could be a starting point for further investigation into orgasm ability in women with more common pelvic anatomy (and these researchers clearly understood that - in fact they actually followed up with THIS study that I wrote about here last week. It looked at clitoral size and distance in relation to a woman's ability to orgasm).

However, even as just a starting point, there are problems. The lack of verification for the subject's ability to orgasm during intercourse without additional clitoral stimulation is an important limitation for this study. Looking at this rationally, the subject has claimed to orgasm in a way that has never been observed. As far as scientific knowledge goes, it may not even be possible. I mean, if she is actually physically orgasming this way, she, with her unique genital anatomy, might be the only person who can orgasm like that. Verifying her ability to orgasm this way would actually be pretty huge. Yet, the researchers didn't even seem to consider verification. They simply go forward assuming that this type of orgasm is possible. Furthermore, they take the subject at her word that this type of yet-undocumented orgasm happens to her. There is a lot of assuming going on here. Granted, researchers almost never verify claims of vaginal orgasm, so this study is not out of the norm. However, just because this lack of verification is common doesn't mean it's quality science. Maybe, just maybe, some researcher somewhere should verify that there are women who can attain an orgasm from stimulation inside the vagina (checking for the rhythmic muscular activity is quite possible). If researchers are able to do that, then it would make sense for researchers to start concerning themselves with the mechanisms for how these types of orgasms happens and what kinds of things make it easier or harder for women. Until that happens though, any study that assumes without verification that its subject(s) can orgasm vaginally will contain conclusions that simply cannot be taken too seriously.