Self-assessment of genital anatomy, sexual sensitivity and function in women: implications for genitoplasty
Justine M. Schober, Heino F.L. Meyer-Bahlburg, Philip G. Ransley
BJU Volume 94, Issue 4 September 2004 Pages 589–594
My Intro
So I wondered upon this article looking at references in another one, and thought it might be a good one to write about right quick. It's about something I am pretty interested in reading more about, and I think it is headed down a very necessary path - understanding the orgasmic and arousal capacity of different parts of the female genitals in an effort to preserve those qualities when feminizing surgeries are required.
So, in terms of 'feminizing surgery,' I think this article was mostly written with intersex people in mind. If you haven't heard the word intersex before, you should look into it. There are people born every day that don't fit neatly into the physical category of male or of female. It's a normal variation in the possibility of human bodies, but you may not know about it because it has traditionally been taken on by the medical community to correct these bodies to either male or female in a swift and secretive way - sometimes that included genital surgery at a very young age. However, intersex people are starting to advocate for themselves and the newborn intersex children that cannot speak up; telling the medical community that medical intervention is not always needed and that intersex people deserve to choose the level of gender-related medical intervention. I wrote a little about this in 2010. The activism of intersex people is something we should all educate ourselves on a bit.
Anyway, although advocacy on intersex issues has done a lot of questioning about when and if masculizing or feminizing surgery should take place, there are still times that surgery seems appropriate by an individual intersex person and their doctors. There are also gender confirmation surgeries, genital reconstruction surgery for patients who have undergone female genital mutilation, elective genital cosmetic surgery, and other medically necessary genital surgeries. All of these surgeries would do well to preserve areas of arousal and orgasmic capability.
All that to say that there needs to be good information about the sexual sensitivity and functioning down there in order for there to be good surgical decisions.
My Quick Summary And Opinions
This paper is a very small initial step towards better information about where people experience erotic sensitivity in their genitals so that surgery to them doesn't fuck up capabilities for arousal and orgasm in that area. The authors point out that the quality assessment of a feminizing surgery had, in the past, often been based on how the surgeon, instead of the patient, perceived the anatomy and function - which clearly is not ideal.
So, to ascertain good patient assessment, these researchers did this here pilot study. They utilized a new (in 2004 at least) questionnaire that used pictures and questions to help a group of genitally "normal" women identify different areas of their outer genitals and inner vagina on a scale of 1-5 for the area's 'orgasm intensity' and for the effort required to achieve orgasm. They also had to select pictures and descriptions that best described their genitals.
From the results, the researchers found that women had the most orgasmic intensity above and on the clitoral glans, although they also had some (in order of greater to lesser) on the labia, the sides of the clit, below the clitoris, and around the vag-hole. There was less orgasm intensity inside the vagina, but the deepest part was rated higher in intensity than the middle or the part nearest the outside. Also women tended to rate their clits size as normal even when they picked a drawing to describe it that experts would describe as abnormally large.
So, the researchers said even with the preliminary nature of this study, they gained some insight. For instance maybe clits can be larger than experts now think and still be deemed normal and feminine - which may mean less need for clitoris reducing surgeries in intersex people. They also noted that since the top of the clit was rated as sensitive as the clitoral glans itself, then they should be real careful about snipping the skin up there.
Those are both well and good insights. They seem sensible and aligned with the data that was received, but I have to say there seems to be a general problem with the questionnaire in this study. It seems like these questions were actually pretty confusing to the women. 16% of these women said their vagina was not big enough for a penis and another 4% said it's not even big enough for a tampon...yet ALL of these women said they had intercourse. So there's something amiss that should cause one to wonder if the answers these women gave are reliable for the types of questions the researchers thought they were asking.
And on the whole question subject...Let's just be honest that women get real squirrely when they start answering questions about their orgasms. You know I don't trust women's self reports on this, and researchers shouldn't either. First off, women are known to fake orgasms - and that mental game-playing that goes into women pretending to have pleasure that they aren't actually having during sexual interactions could twist its way into how women answer survey questions about orgasm. Also, there is so much BS out there in the world about what orgasms are supposed to be like. I mean well up into the 70's medical professionals were telling women that they were sick in the head if they didn't have vaginally induced orgasms - (which is a way of achieving physical orgasm not actually found in scientific literature and for all we know might literally be an impossible feat). So, in all reality, with all the confusing and incorrect info fed into women's heads about what their orgasms are supposed to be like, it's very possible women call things orgasms that aren't actually a physical orgasm (i.e. the rhythmic release of pelvic muscle tension caused by arousal). They also might be making room in the survey for different non-orgasmic experiences. For instance maybe they are rating actual physical orgasms "Strong" and high arousal moments or ejaculations or spiritual climaxes as "mild" orgasms - or maybe even the other way around.
So, what I'm saying here is that women could be claiming they've had orgasms from stimulation of areas that they have not - for a variety of reasons. Maybe the researchers think they are hearing what women are telling them about where they can be stimulated to orgasm. However, they are really hearing a chaotic mix of where women can be stimulated to orgasm, where their partner likes to stimulate them, where they think they should be stimulated to orgasm, where they can be stimulated to arousal, where they can be stimulated to ejaculation, and where they most often get stimulated.
So, I think there are a lot of worries with this questionnaire just like any questionnaire where women are asked to self-report about orgasm...but I will say, the purpose here was to learn more about how women feel about their genitals, and even if a woman doesn't get an actual physical orgasm from wherever she said she did on the questionnaire, there is still some value in knowing that she answered the question about herself the way she did...although I do so wish researchers who rely on questions like these would fully acknowledge the limitations of female orgasm self reports.
Article Summary
Alright, and now for the details of this article - If you have any questions, please just check out the
Full Article. It's available! (big thanks to the authors letting this out into the world - I love that)
As always: Any quotes are directly from the article unless otherwise stated, and assume everything written is at least a rough summary of what the authors have said unless I write my own opinion in the (Me: ...).
Also, check out all my summaries of SSL Journal Article HERE.
Intro
The researchers tell us that in the past the assessment of how good a feminizing surgery went was often based on how the surgeon perceived the anatomy and function instead of the patient, and that this kind of surgery has recently come under a lot of fire because there seems to be a lot of cases where the patient's sexual functioning was impaired. In fact, some intersex activists have called for a complete stop to this kind of surgery until more is known . So clearly research into how women perceive their genitals and orgasmic functioning before and after surgery is important and needed quickly.
The authors go on to say that there is some good info out there about anatomy, physiological changes during orgasm and sexual arousal, and some other aspects of male and female genital physiology,
"However, standards for measures of the visible aspects of the female genitalia are largely lacking. For instance, the average diameter of the glans in adult females and the length or protrusion of the clitoris in the relaxed and aroused state are not well documented."
The researchers tell us that "genital sensation and its underlying innervation is even less complete, especially for women." However, there's a lot of detail known about what kind of sensation and touch needed for lady rats to get into lordosis (which is their sexually receptive position). Obviously, rat stuff can't be directly compared to human-lady stuff, they tell us, but it may have some relation. One of the authors has done some rat clit research, so there's a lot of detail there I won't go into.
The researchers also point out that although there is some research about tactile sensitivity in female genitals (with vibration, heat and touch), that tactile response is not quite the same as sexual stimulation, and a complete mapping of that is yet to be done. They note Graffenberg (the G-spot guy) said there's sensitivity in the vagina close to where the urethra lays above the vagina (lower anterior of the vagina), and Kinsey decided from masturbation studies that the cit and labia were the most sensitive and Singer and Singer "indicated that there are many sites of sexual sensation which differ in the kinds of orgasm they produce." (Me: so there's a variety of claims among top sexual researchers about what areas in the female genitals are most important to orgasm and arousal)
There have been fetal nerve studies of female genitals and a recent study has expanded information on clitoral innervation. They show the greatest nerve density in female genitals is above and fanning out down to the clitoris.
The researchers then point out that although it is possible and important to actually watch and measure women as they touch and arouse their genitals for data sake, it is a hard thing to do for a variety of reasons. Also,even if one were able to get that kind of physical, observational data, one would also need a good questionnaire to get the subjective perspective of the woman's experience to pair with that objective anatomical data (me: true dat, true dat). So, either way, a good questionnaire is important for this type of work.
This pilot study was used to test the questionnaire out on genitally 'normal' women to better understand its feasibility before it was tried on women having genital surgery and to "test whether women can discriminate between various genital areas in terms of erotic function in this self-report format."
A new questionnaire was used, the Self-Assesment of Genital Anatomy and Sexual Function, Female version (SAGASF-F) (me: I really tried to find this full questionnaire online, but couldn't find it anywhere. It has been used in several studies since though.)
"The SAGASF-F was designed to obtain a woman's perception of what her genitals look like, to map her experience of cutaneous sensitivity, sexual pleasure, discomfort/pain and orgasm across specific areas of her genital region, and to elicit reports of perceived changes in sexual function after surgery, if applicable. Genital pictures and descriptive phrases are used to facilitate systematic self-reporting. The pictures were based on the digitization of selected drawings of the clitoris and vagina, which were digitally modified to represent variations in size and location, and to identify specific areas of the genital region for sensation ratings."
Subjects and Method
The participants were women employees of a hospital. They were recruited and given the survey that they could complete anywhere and drop off anonymously into a box at the hospital. The 1st 50 women to return the survey are the participants. Half had a college degree. Their education spanned HS diploma to doctorate. Mean age was 38.7, and 42 of the 50 were white. It took about 25 minutes to take the survey.
The Survey
There is an intro to help understand the rating tasks. Then that participant is asked to "select one of several options of appearance, size and position of her clitoris and vagina. In addition, she rates on a 5-point Likert scale her orgasm intensity and the effort required to achieve orgasm for several graphically and verbally demarcated areas at and around the clitoris and within the vagina."
The results were calculated and a visual depiction of orgasm intensity and orgasm effort were created over genital pictures.
(me: I'm a little confused about exactly how the questions and pictures were presented to the women in the questionnaire, but it says women were "presented with sets of response options in terms of graphs and phrases, and asked to select the best description of their anatomy..." I'll quote whenever they describe the survey because that's the only clue we have to how it was worded, etc.)
Results
For the clitoris:
46% 'moderate-sized and raised'
42% 'small and raised'
6% 'large and slightly long'
4% 'large, raised'
2% 'enlarged and long'
(me: there was an option of 'I cannot locate my clitoris' and no one must have chosen that)
For vaginal location:
92% 'vaginal opening in midposition'
8% 'near anus (far back)'
(me: 2 other options were available to choose, but the paper does not say what they were)
For vaginal opening size:
78% 'adequate for sexual penetration'
16% 'just large enough to insert finger or small object, but not large enough to insert average sized penis, regular tampon or speculum'
4% 'not large enough to even insert small dilator or finger or small tampon'
2% 'very large'
(me: no one chose 'cannot locate my vagina' 'I have no vaginal opening' 'other (describe)' or a 4th option that must be a size somewhere smaller than 'adequate for sexual penetration' but not the other ones listed above)
All women reported their vagina was 'deep enough for intercourse with and average penis'
 |
| Deeper blue indicates stimulation area creating the most intense orgasms and deeper red indicates area most easily stimulated to orgasm, from Schober et.al. 2004 |
"to rate orgasm intensity the women were presented an item of the following form for each of the anatomical areas (after a written introduction to facilitate the understanding of the ratings). 'sexual touch/stimulation of this area by a partner or yourself, ... , has produced (rate 1 through 5):' 'Orgasm' (followed by a line with the anchors: 1/none, 2/mild, 3/moderate, 4/strong, 5/intense)."
For orgasm intensity, these are the areas with the highest to lowest mean ratings: clitoris, above clitoris, labia, below clitoris, sides of the clitoris, around vaginal opening
"For orgasm effort the women were asked for each area: 'If orgasm was achieved, please describe the effort required.' (followed by a line with the anchors: 1/very strong, 2/strong, 3/moderate, 4/little, 5/very little)."
For orgasm effort, these are the areas that had easiest to hardest mean ratings: clitoris, above clitoris, labia, below clitoris, sides of clitoris, and around vaginal opening
"For relationship between vaginal depth and orgasm intensity and effort, the women were presented with highlighted pictures representing vaginal depth at 3 levels' the introitus (Area A), mid vagina (Area B) and deep vagina (Area C), along with the same questions as above about orgasm intensity and effort."
The most intense orgasms and least effort went from deep to mid to introitus.
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| From Schober et.al. 2004 |
Discussion
"Whereas only two-fifths of the women indicated a clitoral size that would typically be regarded as normal, a similar proportion selected a descriptor 'moderate sized and raised' and a picture showing a clitoris that experts judged as larger than normal" The researchers wonder if that means there is less need than thought for clitoral reductions, but they also point out that 16% of women said their vaginal opening couldn't fit a penis yet all the women in the study 'reported being sexually active and engaging in sexual intercourse.' So maybe more work is needed on how women understand genital size - and also some direct anatomical measurements from a professional would probably be good to add to this type of data as well.
The researchers found things they thought were surprising:.
1) Both the clit and above the clit show about equal ratings of orgasmic sensitivity - both rated much higher than other areas. This does correspond to where the largest bundle of nerves are though.
2) The areas inside the vagina rated most orgasmically sensitive is deep in the vagina. This seems odd because the lower part of the vagina towards the belly-button (lower anterior region) is where researchers often say women have more vaginal sensitivity and where the location of the G-spot is often discussed. The researchers wonder if this is because their research is self reported and other research has used data that includes response to touches in different areas.
"For vaginal sexual stimulation, the scores of orgasmic sensitivity of the vagina at any depth are less than the scores for external surfaces."
Although this is a preliminary study, the researcher thought it suggests 2 important things things about genital surgery:
1) Many healthy women perceived their clitoral size to be something an expert would say is too large. Maybe this means women will accept a larger clit size than is commonly believed. This could mean maybe less surgical intervention in clitoral size in the future.
2) Healthy women find the area above the clit as or more orgasmically sensitive than the clit itself. This, plus the fact that nerve placement is densest above and on the clit, "makes a strong case against surgical separation of the skin above the clitoris to prevent nerve disruption..."
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