A New Study about Clit Size and Orgasms!!!

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This time on An Article I Read, I'll be looking at an article that aims to "evaluate clitoral size and location with regard to female sexual function." The conclusion, from the authors was, "Women with anorgasmia possessed a smaller clitoral glans and clitoral components farther from the vaginal lumen than women with normal orgasmic function." (The vaginal lumen is basically the vaginal hole BTW)

Clitoral size and location in relation to sexual function using pelvic MRI. Oakley SH1, Vaccaro CM, Crisp CC, Estanol MV, Fellner AN, Kleeman SD, Pauls RN.J Sex Med. 2014 Apr;11(4):1013-22. doi: 10.1111/jsm.12450. Epub 2014 Feb 13.

The Quick and Dirty
Here's the basics. This study is comparing measurement of clitoral size and also distance from different areas of the clitoris to the vagina among 10 women grouped as "anorgasmic" and 20 grouped as "normally orgasmic." The measurements for each woman are gained through pictures from pelvic MRI. The women were grouped based on their answers to 4 specific questions on commonly used sexual functioning assessments. Those same assessments were used in their entirely to assess the women's overall sexual function, and assessments were also used to evaluate their overall health and level of body self-consciousness during sex. Personal data was taken, and also their blood was also taken at the same time in each of their menstrual cycles in order to test for 5 different hormone levels measurements. All the information received from the women were assessed to see if there was a statistically significant difference between the 2 groups and to see if any of the assessments showed significant correlations to another assessment.

This is a pretty new article - 2014, and I think it's the newest one on this topic. I reviewed an article from a few years back that re-evaluated very old data on this topic HERE. This new study is important because, well, it's a modern study with modern techniques, and this is a topic that people wonder about. Although the paper concludes that there is a connection between women with anorgasmia and having a smaller clit, farther from the vagina, I don't think that statement is reasonably supported in this study. There were a lot of measurements of the clit size and distance that didn't show any statistically significant differences between the two groups of women. They took around 23 different measurements of size and distance, and only 5 actually show significance. In fact, the clitoral glans area that the authors put forth as a significant difference between the two groups of women is only significant when they measured it from the coronal, but not the sagittal view.  Unfortunately, this study also failed at asking the participants the proper questions so that they could be grouped in a way that would creating meaning when compared to the clitoral measurements. Statistics are only as good as the understanding that exists of the population it is describing, and I don't think the understanding was good at all. So, this might be harsh,  but I think there is some picking and choosing and bad assumptions going on with this study that make it basically meaningless....but oh do let me go into more detail...

The Study's Introduction
The authors point out that orgasm difficulty is found to be common among women, and that it's possible that the size and position of the clitoral complex has something to do with that. (Clitoral complex is a phrase that is used with some variety of meaning. Here I believe they are including it to mean all the inner parts of the clitoris, the vestibular bulbs, and the area around the urethra and anterior part of the vagina - or what is now being called the CUC or clitoral urethral complex). It points to other related studies: one that compares ability to vaginally orgasm with the thickness of the urethro-vaginal space (I wrote about that one HERE), one that I previously wrote about HERE that reassesses historical data, one on reconstructive surgery after female genital mutilation ([16] below) and another MRI study that concluded smaller clits were actually related to better sexual function ([15] below - I'll get to reviewing this one soon). The authors end the intro with the following.

"However, very little has focused on the clitoral-vaginal distance or size of the organ relative to female response. The available data were biased by small sample size [15], retrospective evaluation [15], or nongeneralizable populations undergoing surgery [16] and bear conflicting results. As such, a clear understanding of these facets of clitoral anatomy impact orgasm is lacking."

The Studies Aims

"Thus, the purpose of this cross-sectional study was to determine if the size of the clitoris and its location relative to the vagina impact sexual stimulation and subsequent orgasmic function. We hypothesized that women with normal orgasmic function may possess a larger clitoral area or a CUC which is closer to the vaginal wall compared to women with anorgasmia."

The Population, Experimental Design, and My Rant

Dividing the women into groups
The researchers divided the women into either the "anorgasmic" or "normally orgasmic" groups based on their answers to 4 questions from 2 different questionnaires. Both these questionnaires are used to rate a woman's sexual function, and one is specifically related to pelvic organ prolapse or incontinence.

A response of "rarely able" or "never able" to achieve orgasm on question #2 of the the Prolapse/Incontinence Sexual Questionnaire-12 (PISQ-12)  and/or a total unadjusted score of < 6 on the orgasm domain of the Female Sexual Function Index (FSFI) put women in the "Anorgasmic" group. Likewise, in the PISQ-12 a response of "most" or "all" on question #2  and/or a total unadjusted score of  > 12 on the orgasm domain of the FSFI put women in the "normally orgasmic" group. The authors say the following about these questionnaires: "Both of these validated questionnaires inquire about sexual function during sexual activity, which could include caressing, foreplay, masturbation, and vaginal intercourse."

The actual questions used 
However, I looked those questionnaires up (The FSFI is used all the time in these types of studies so I thought I should become familiar) and strangely that's just not true.

PSQI-12 Question #2 (to be answered considering sex life over the last 6 months):
Do you climax (have an orgasm) when having sexual intercourse with your partner? -Always -Usually -Sometime -Rarely -Never 

The underline is their emphasis not mine, and since this question is from the validation study for the PISQ-12 that was cited (I triple checked), I find it incredibly odd the authors would say what they said above...cause it is clearly about intercourse. Also, the authors quoted the terms "most" "all" "rarely able" and "never able" when speaking about the question, but those terms aren't used in the actual question, so I find all that curious. Now, the FSFI questions were more open.

Orgasm Domain Questions (11-13) from FSFI - with the scoring included. (Here's the Scoring Key for the FSFI too):

11. Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you reach orgasm (climax)?
0 = No sexual activity
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never 

12. Over the past 4 weeks, when you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm (climax)?
0 = No sexual activity
1 = Extremely difficult or impossible
2 = Very difficult
3 = Difficult
4 = Slightly difficult
5 = Not difficult 

13. Over the past 4 weeks, how satisfied were you with your ability to reach orgasm (climax) during sexual activity or intercourse?
0 = No sexual activity
5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied

Why I think they are terrible questions for this study
So this is my absolute biggest gripe with this study: The questions that the researchers used to categorize these women are not useful to an investigation about clitoral size/location and orgasm ability.  First off, it's not necessarily women who have never/rarely orgasmsed vs. women who orgasm all the time. Both groups could include women who orgasm sometimes. For instance, in the FSFI, a woman could say she orgasmed sometimes (3pts), that it's slightly difficult (4pts) and that she's very satisfied with that (5 points), and she's got a score of 12 and is in the "normally orgasmic" group. But another women could say she orgasms sometimes (3pts), that it's very difficult (2pts) and that she's very unsatisfied with it (1pt), and she's got a score of 6 and in the "anorgasmic group." Maybe the only difference between these two women is that one feels worse about what she has to do to get off and her partner is less into it. Granted, that's probably not commonly the case, but even if that happened once among these 30 women, then it's enough to worry about.

But folks, that's just a surface gripe. The problems with this study go way deeper. The authors believe this study can discern if size or location of the clit impacts sexual stimulation and subsequent orgasmic function. I disagree.

It's an irrelevant thing to investigate
Women can orgasm through stimulation of the clitoral glans. There's no indication that there are women with anatomy that makes this impossible, so with sufficient stimulation, any healthy, intact women could orgasm through stimulation of her external clitoral glans area. It doesn't matter where it is or how big it is. It just needs to be found and touched. It's the same way for a man and his penis. Even considering the female orgasm during intercourse, size and location do not necessarily have anything to do with a woman's ability. If a woman wants to orgasm while having intercourse but her clitoral glans is a millimeter further from her vagina than another woman, well, who cares? She can just tilt her hips a millimeter more or less than the other woman would or maybe have her partner adjust their body slightly and then just continue grinding the clit up against his body. Or simply make sure her or her partner's hand or the vibrator is in the right place. It's that easy. The only reason this question about whether size and location makes a difference to orgasm ability even exists is because women's sexual experiences too often don't specifically cater to her organ of sexual pleasure (the clitoral glans) the way that men's sexual experiences regularly cater to the male organ of sexual pleasure (the penis). Thus the clitoral glans is often ignored, yet there is little realization that the lack of orgasm may simply be due to lack of proper clitoral stimulation. So, when a woman says on a survey that she has not orgasmsed much during her latest sexual encounters, it doesn't mean she cannot or that she is innately less capable of orgasm than another woman. It just means that she didn't get proper stimulation and arousal. So discerning between women the way this study does says more about these women's sexual technique, relationships, and past experiences than it does about anything innate. Honestly, thinking that the clitoral size and distance from the vagina has any meaningful relationship to the differences between these women is unrealistic if you really think about it, and frankly it's not very thoughtful about our sexual culture and the actual experiences of women and their orgasms.

Unless it's investigated this way....but, it's not
Okay, so there are a minority of women who say that they can orgasm through inner vaginal stimulation alone - with no additional touching of the outer clitoral glans area. The most high-profile theory (although not necessarily the only or the most well-backed one) right now for how that might occur is that the penis stimulates the inner clitoral legs through the vaginal wall and through the tissue between the clitoral legs and the vaginal wall. So, I can see how an investigation into the distance between the vagina and the inner clitoris might be useful if researchers were studying the anatomical differences between women who say they can regularly orgasm through vaginal penetration alone and women who say they cannot and have never orgasmed this way.

*I would like to point out that unlike our scientific knowledge of clitoral stimulation leading to orgasm, there is simply not any information that tells us exactly what specific kind of inner vaginal stimulation leads a woman to have an orgasm. In fact, an orgasm caused by inner vaginal stimulation has never ever been recorded or verified in any way, and so there is always that wild-card possibility that must be considered in which this type of orgasm doesn't actually exist as a physically verifiable thing in the first place. So, even if women were split up this way, it might actually just be two groups of women that both don't orgasm through vaginal stimulation, yet one group happens to describe the physically non-orgasmic experience as orgasmic and the other doesn't.* However, let's give it the benefit of the doubt and assume there are some women who can orgasm this way. It still leaves the question of whether this study coul have anything useful to say about how clit size/location affects this possible type of orgasm. And, it doesn't. It doesn't because the two groups of women who would need to be tested against each other (women who specifically claim to regularly orgasm vaginally with no extra clitoral stimulation vs. women who never/rarely orgasm this way) are not the groups used for this study. Questions that would have discerned these women from each other were not asked, and so this study simply has nothing to say on this aspect of female orgasm either.

Or this way....which the authors also don't do
There is one more theory about female orgasm that might benefit from information on size and location of the clitoris. Master's and Johnson found that some women could get a Rube-Goldberg thing going during intercourse where the skin around the vaginal opening was stretched, which pulled on the inner labia, which pulled on the clitoral hood, which gave the ol' clit just enough stimulation to orgasm. Never mind that M&J only observed this using a mechanical dildo  machine that the woman controlled and that could go in and out at speeds faster than any man, and also never mind that these orgasms, given their very indirect stimulation route to the clit, were the weakest ones the women had (in the amount of muscle contraction and her subjective rating). Just know that if a woman did get off this way, I could see how the size and location of the clit could affect that. Women who could orgasm this way and woman who could not orgasm that way would be good groups to use in an investigation for this type of orgasm. However, they were not. As I said above, questions that would have discerned these women from each other were not asked, so there is nothing that can be learned about this aspect of female orgasm from this study either.

Which means...
So, my point is that this study is not set up well to investigate the affect clitoral size and location has on female's ability to orgasm. The truth is, simply asking the broad question of whether clit size and location affects women's ability to orgasm seems the same as asking whether dick size and location has an affect on a man's ability to orgasm. It's not a useful question to ask because it seems obvious that people just find a way to stimulate dicks no matter the size or location. It's not hard, actually. I assure you no researchers out there are worrying about whether a dick that is a few millimeters closer to a dude's asshole makes it easier for him to come. It's just absurd when looked at realistically. However, there are specific questions about a woman't ability to orgasm during intercourse (with no additional clitoral stimulation) that warrant investigation into clitoral size and location, but those questions were not specifically asked and a suitable experimental population was not created for those questions. In the end we are left with a study that simply doesn't tell us anything useful about the relationship between a woman's ability to orgasm and her clit size/location...even though it claims that it does.

The Rest of the Study Stuff
So, I've said my main piece. In a lot of ways everything else about this study is irrelevant because the population and the questions they are asking aren't meaningful to the conclusions they made. However, I'll still give you more details, but in bullet form.

• 10 women were  categorized as "anorgasmic" and 20 were categorized and "normally orgasmic." The women were matched via age and BMI
• All were over 18, sexually active with at least 1 sexual encounter within the last 4 weeks, and pre-menopausal. Also, they had no pelvic bulge or urinary incontinence, no history of sexual abuse, no sexual dysfunction in the domain of pain, no pregnancy, no use of serotonin uptake inhibitors or testosterone supplements
• They were questioned about how many times they had sex in the past 4 weeks and the percentage of time to orgasm, and their favorite positions for ease of achieving orgasm were ranked (missionary, female dominant, woman on all fours, manual, and oral) See table below.

• The women were given a questionnaire to assess their mental and physical health and one to asses their level of body exposure self-consciousness during sexual activity. There was no significant score difference between the two groups of women on those questionnaires.
• There was a statistically significant difference between the total scores on both the FSFI and PSQI-12 between the 2 groups of women, with the "anorgasmic" group scoring toward higher sexual dysfunction and the "normally orgasmic" group scoring toward lack of sexual dysfunction. It has to be noted (and the authors do briefly note this at the end) that there are problems with using the total scores on the FSFI and the PSQI-12 as indications of different sexual function between the two groups of women given that some questions on each of those surveys were used as criteria for putting the women into those groups in the first place.
• Their blood was taken at the follicular phase of their menstrual cycle. Estradiol, Free testosterone, Total testosterone, Free androgen index, and Sex hormone binding globulin was measured. There was no statistical difference between levels for the two groups of women except in the Sex hormone binding globulin. The "normally orgasming" group had higher.
• All kinds of distances were measured from pictures taken through MRI from the Sagittal, Coronal, and Axial view. The table is below, with some, but not all, of the the measurements. The majority of the measurements were not significantly different between groups. The only measurements that were significantly different between the groups were as follows - the coronal view of the glans area (the sagittal view of the glans area was not), sagittal distance between the inferior aspect of the glans to the anterior vaginal wall, sagittal distance between the body and the anterior vaginal wall, lateral axial crura distance, and total vaginal length.

• All the different variables (the hormone levels, every single measurement taken, every test score, and all the personal information) were all compared to each other to see if any had correlations. Most didn't, but here's a couple that did. A larger distance between the clitoral body and the vagina in sagittal view correlated with poorer scores on the PISQ-12, FSFI, and the BESAQ. Also clitoral glans area from the sagittal view correlated positively to testosterone measurements. A larger clitoral body was also noted to correlate with a higher estradiol level.

Conclusion

The study concluded with the following:

"In conclusion, a smaller clitoral glans and greater distance of the clitoral body from the vaginal lumen were noted in women with anorgasmia. Although adequate sexual function is complex, we document that clitoral size and location may be paramount in impacting sexual function, specifically orgasm. Although these physical characteristics cannot be changed, understanding the physiology of the female sexual response advances knowledge. In addition, such awareness may highlight strategies for treatment of women distressed by sexual dysfunction."

My Thoughts
This study makes a lot of attempts to find some correlation between the size and location of the clitoris and the ability for women to orgasm, but it only found statistically significant differences between the 2 groups of women in just a couple of the clitoral measurements attained - one of which ceased being significant when measured from a different view. However, the bigger issue is that the information taken from the women in this study was not enough to group them in an appropriate way for gaining any useful meaning from the clitoral measurements. The clitoral measurements are maybe a useful things to have, but they certainly do not, contrary to what the study purports, show that women with a larger clit closer to the vagina are better able to orgasm...and it's unfortunate that pop-science studies like THIS and THIS claim it does too.