Hormone-dependent sexual responses of female mice in response to manual genital stimulation.

Although copulatory behavior is thought to have a strong innate basis in mice, there is also clear evidence that sexual experience shapes its expression. Reinforcement of behavior through rewarding genital tactile stimulation is a primary candidate mechanism for this modification. In rats, manual tactile clitoral stimulation is rewarding only when it is temporally distributed, which is hypothesized to result from an innate preference for species-typical copulatory patterning. Here we test this hypothesis using mice, which have a temporal copulatory pattern which is distinctly less temporally distributed than that of rats. Female mice received manual clitoral stimulation which was either temporally continuous every second, or stimulation which was temporally distributed, occurring every 5 s, This pattern of stimulation was paired with environmental cues in a conditioned place preference apparatus to assess reward. Neural activation in response to this stimulation was evaluated by measuring FOS immunoreactivity. Results indicated that both temporal patterns of clitoral stimulation were rewarding, but that continuous stimulation better reproduced brain activation associated with sexual reward. Furthermore, continuous, but not distributed stimulation elicited a lordosis response in some females, and this response increased within and across days. Sexual reward, neural activation and lordosis resulting from tactile genital stimulation were eliminated by ovariectomy and restored with combined 17ß-estradiol and progesterone treatment but not 17ß-estradiol treatment alone. These observations are consistent with the hypothesis that sexual reward resulting from species-typical genital tactile stimulation has a permissive effect on copulatory behavior of female mice.

Probable drug-induced clitoral priapism due to potentiating effects of pregabalin and duloxetine.

PURPOSE: The following case report discusses probable clitoral priapism secondary to duloxetine and pregabalin. While this is a rare adverse effect, it is possible given the mechanism of action and potentiating effects of the combined therapy. This adverse drug reaction was reported to MedWatch and shows that additional research into the physiology of clitoral erection is warranted given the scarcity of information on how drugs influence this reaction. SUMMARY: A 53-year-old African American female with uncontrolled anxiety was started on duloxetine. Pregabalin was added 1 month later due to continued feelings of anxiety. Three weeks later, the patient reported symptoms of clitoral pain, as well as a swollen, tender, and erect clitoris. These adverse effects remained for 4 days, prompting the patient to present to the emergency department where a physical exam was completed with no significant finding except as noted above. Pregabalin was immediately discontinued by the attending physician based on the probability that the swelling was likely drug-induced clitoral priapism. During follow-up, the patient continued to note clitoral erection and pain. The psychiatric pharmacist tapered off duloxetine over 2 weeks with resolution of symptoms. In an examination of the mechanism of action of both drugs, pregabalin can amplify duloxetine's inhibitory effects on voltage-dependent calcium channels. It is likely this mechanism that causes smooth muscle relaxation and led to clitoral priapism. CONCLUSION: This case suggests that pharmacological agents affecting vasoconstriction through serotonergic receptors or calcium-dependent channels can also influence clitoral erection.

The complexity of female orgasm and ejaculation.

The anatomy and physiology of the female orgasm are often neglected. The female orgasm is a normal psychophysiological function to all women, and some even can achieve ejaculation as part of the normal physiological response at the height of sexual arousal. The complexity of female sexuality requires a deep understanding of genital anatomy. The clitoris is the principal organ for female pleasure. The vaginal stimulation of the anterior vaginal wall led women to orgasm due to the stimulation of the clitourethrovaginal complex and not due to stimulation of a particular organ called the G spot in the anterior distal vaginal wall. Female ejaculation follows orgasm. It consists of the orgasmic expulsion of a smaller quantity of whitish fluid produced by the female prostate. Squirting can be differentiated from female ejaculation because it is the orgasmic transurethral expulsion of a substantial amount of diluted urine during sexual activity, and it is not considered pathological. The female orgasm is influenced by many aspects such as communication, emotional intimacy, long-standing relationship, adequate body image and self-esteem, proper touching and knowledge of the female body, regular masturbation, male sexual performance, male and female fertility, chronic pain, and capacity to engage in new sexual acts. Stronger orgasms could be achieved when clitoral stimulation, anterior vaginal wall stimulation, and oral sex is involved in the same sexual act.

Cardiometabolic Diseases and Female Sexual Dysfunction: Animal Studies.

BACKGROUND: The association between erectile dysfunction and cardiometabolic disease is well characterized; men are often diagnosed with cardiovascular disease 2-5 years following the incidence of erectile dysfunction. There is evidence that this relationship may also exist for cardiometabolic diseases and female sexual dysfunction (FSD) - particularly sexual arousal disorders. AIM: To provide a summary of the preclinical literature related to the evidence of FSD in animal models of cardiometabolic diseases and indicate where further research is needed. METHODS: A detailed Medline search of peer-reviewed publications was performed on the associations between animal models of cardiometabolic diseases, FSD and underlying mechanisms. OUTCOMES: A summary of the preclinical evidence of FSD in animal models of cardiometabolic diseases. RESULTS: Common methods for assessing female sexual arousal and physiology in animal models include: 1) behavioral assessments (apomorphine-induced genital vasocongestive arousal; hormone-dependent lordosis), 2) nerve-mediated vaginal and clitoral blood flow, 3) pudendal artery, vaginal and clitoral smooth muscle physiology (vasoreactivity and molecular biology), 4) morphology of genital tissues. Twenty-eight studies examined female animal models of atherosclerosis, hypertension, diabetes (type 1 and 2) and obesity. They showed functional alterations, including decreased lordosis, lubrication, or vaginal and clitoral blood flow, and structural impairments, such as increased clitoral and vaginal fibrosis. Several possible mechanisms have been described including increased TGF-ß, renin angiotensin system and endothelin/rho-kinase signaling, increased reactive oxygen species, and decreased nitric oxide/cGMP signaling. CLINICAL TRANSLATION: In line with existing clinical studies, preclinical evidence supports that cardiometabolic diseases alter female genital tissue's function and structure leading to impaired sexual arousal. STRENGTHS AND LIMITATIONS: This masterclass paper gives an overview of the preclinical research assessing FSD in cardiometabolic disease. Limitations include the small number of studies that have assessed sexual function and arousal in female cardiometabolic animal models. CONCLUSION: Preclinical evidence exists showing cardiometabolic diseases alter the structure and function of female genital tissues. However, similar to clinical studies, there are few studies to draw from, particularly in models of type 2 diabetes, obesity and metabolic syndrome. More studies are required using optimized animal models and methodology to confirm the mechanisms underlying cardiometabolic disease-induced FSD. Angulo J, Hannan JL. Cardiometabolic Diseases and Female Sexual Dysfunction: Animal Studies. J Sex Med 2022;19:408-420.

Mapping a Danger Zone of the Dorsal Nerve of the Clitoris: Implications in Female Cosmetic Genital Surgery.

BACKGROUND: The literature regarding the route of the dorsal nerve of the clitoris is sparse and lacks surgical focus. With an increasing number of procedures being performed on the labia, it is important to elucidate the route and note any variation from normal of the nerve. METHODS: Fifty-one cadavers were dissected to yield 97 dorsal nerve of the clitoris samples. Measurements were taken from (1) the dorsal nerve of the clitoris penetration point of the perineal membrane to the urethra, (2) the nerve's penetration point of the perineal membrane to the pubic bone, (3) the angle of the clitoris to the branch point of the dorsal nerve of the clitoris, and (4) the branch point of the nerve to the distalmost point of the glans clitoris. Any anomalous branching patterns of the dorsal nerve of the clitoris were recorded and classified. RESULTS: The means and standard deviations of each measurement were used to create a surgical danger zone. The mean of each measurement was (1) 34.63 mm, (2) 5.74 mm, (3) -3.07 mm, and (4) 30.40 mm, respectively. In addition, six distinct branching patterns were observed, organized, and classified based on the location and number of branches observed. CONCLUSIONS: The dorsal nerve of the clitoris has multiple branching patterns and typically travels along the same course in most women. Further investigation of the course and three-dimensional position of the dorsal nerve of the clitoris is warranted to preserve sexual sensation as the frequency of procedures involving the female pudendum increases.

The overlooked reproductive function of the human clitoris-News media responses to the published review.

A brief survey of how the news media reported and misreported on the publication of the review that revealed the overlooked empirical evidence for the reproductive function of the human clitoris.

The effect of clitoral stimulation post artificial insemination on pregnancy rates of multiparous Bos indicus beef cows submitted to estradiol/progesterone-based estrus synchronization protocol.

Clitoral stimulation after artificial insemination (AI) in beef cattle is a common practice utilized by AI technicians; however, the effect of clitoral stimulation during fixed-time AI (TAI) is still unknown. The objective of the present experiment was to evaluate the effect of clitoral stimulation on temperament responses and pregnancy rates to TAI in Bos indicus beef cows. A total of 1,186 multiparous Nellore cows across three different locations were assigned to an estradiol/progesterone-based estrus synchronization + TAI protocol (day -11 to 0). Cows were randomly assigned to receive either 3 s of clitoral stimulation (n = 602) or no clitoral stimulation (n = 584) immediately after TAI (day 0). Cow body condition score (BCS) was recorded on day -11. Estrus expression was evaluated based on estrus detection visual aid patch activation on day 0 (estrus, ≥50% activated; no estrus, <50% activated). Temperament was assessed by individual chute score based on a 5-point scale before TAI, and individual exit velocity was measured after clitoral stimulation. Pregnancy diagnosis was performed 30 d after TAI via transrectal ultrasonography. Pregnancy rate to TAI was positively affected by BCS (P < 0.01) and estrus expression (P = 0.03). Pregnancy rates of cows receiving clitoral stimulation did not differ (P = 0.39) from cows non-stimulated (47.5 ± 4.6% vs. 44.3 ± 4.6%, respectively). No interaction of clitoral stimulation and estrus expression was observed (P = 0.26). Chute score was positively correlated to exit velocity (P < 0.01; r = 0.29); however, clitoral stimulation did not affect exit velocity (P = 0.86). In summary, pregnancy rates to TAI are influenced by various factors and multiple strategies have the potential to increase the fertility of beef cows submitted to TAI; however, clitoral stimulation of Bos indicus beef cows did not improve TAI pregnancy rate.

A randomized, placebo-controlled laboratory study of the effects of D-cycloserine on sexual memory consolidation in women.

RATIONALE AND OBJECTIVE: The aim of this study was to investigate the possible facilitating effect of the partial NMDA receptor agonist D-cycloserine (DCS) on memory consolidation of conditioned sexual responses and to examine the capability of DCS to reduce context-specificity of learning. METHODS: In a randomized placebo-controlled double-blind trial, 50 healthy females were exposed to a differential conditioning procedure. Two pictures of a male abdomen were used as conditional stimuli (CSs), of which one (the CS+) was followed by the unconditional stimulus (US), a genital vibrotactile stimulus. After the conditioning session on day 1, participants received either 125 mg of DCS or a placebo. The effects of DCS on affect, sexual arousal and US expectancy in response to the CS+ and CS- were examined 24 h after the conditioning procedure. RESULTS: A main effect of DCS was found on affect at the first test trials (p = 0.04, ηp2 = 0.09), and a similar non-significant but trend level effect was found for sexual arousal (p = 0.06, ηp2 = 0.07), which appeared to persist over a longer time (p = 0.07, ηp2 = 0.08). Unexpectedly, ratings of positive affect and sexual arousal in response to both the CS+ and the CS- were higher in the DCS condition compared to the control condition, possibly indicating that DCS administration reduced stimulus specificity. Since the results did not show clear evidence for context learning, we were not able to test effects on context-specificity of learning. CONCLUSION: Although largely inconclusive, the results provide tentative support for a facilitating effect of DCS on affect and sexual arousal in response to stimuli that were presented in a sexual conditioning procedure, however, no conclusions can be drawn about effects of DCS on sexual reward learning, since the design and results do not lend themselves to unambiguous interpretation.

The Clitoris-An Appraisal of its Reproductive Function During the Fertile Years: Why Was It, and Still Is, Overlooked in Accounts of Female Sexual Arousal.

Stimulating the clitoris activates the brain to instigate changes in the female genital tract, namely, the enhancement of vaginal blood flow that increases vaginal luminal pO2 , vaginal transudate (lubrication) facilitating painless penile penetration and partial neutralization of the basal luminal acidic pH, vaginal tenting, and ballooning delaying sperm transport and allowing semen de-coagulation and capacitation (sperm activation) factors to act until arousal ends (often by orgasm induction). All these genital changes taken together are of major importance in facilitating the possibility of reproductive success (and thus gene propagation) no matter how or when the clitoris is stimulated-they reveal its overlooked reproductive function. Of course, also commensurate with these changes, is its activation of sexual pleasure. The clitoris thus has both procreative (reproductive) and recreative (pleasure) functions of equal importance. Clitoridectomy creates not only sexual disability but also a reproductive disability. Clin. Anat. 32:136-145, 2019. © 2019 Wiley Periodicals, Inc.

Urethral regions with differential tissular composition may underlie urinary continence and voiding function in female rats.

AIMS: To analyze, in female rats, the anatomical and histological features of the urethra and its relationship with the vagina and clitoris, and its innervation. METHODS: Seventeen adult female Wistar rats were used. Gross anatomy and acetylcholinesterase (AchE) histochemistry were performed to describe the urethral features, adjacent structures, and innervation. The histomorphometric characteristics of the urethra were determined in transversal, longitudinal, or coronal sections stained with Masson's Trichrome. RESULTS: The female rat urethra is not a homogeneous tubular organ. The pre-pelvic and pelvic regions are firmly attached to the vagina with belt-like striated fibers forming a urethra-vaginal complex. The bulbar regions have curved segments and a narrow lumen. The clitoral region is characterized by a urethra-clitoral complex surrounded by a vascular plexus. The lumen area and thickness of the urethral layers significantly varied between regions (P < 0.05). Innervation of the urethra arrives from the major pelvic ganglion, the dorsal nerve of the clitoris (DNC), and the motor branch of the sacral plexus (MBSP). CONCLUSIONS: Differential tissular composition of the urethra may underlie urinary continence and voiding dysfunction through different physiological mechanisms. The urethra-vagina complex seems to be the main site controlling urinary continence through active muscular mechanisms, while the bulbar urethra provides passive mechanisms and the urethra-clitoris complex seems to be crucial for distal urethral closure by means of a periurethral vascular network.

Effects of ovarian hormones on the emission of 50-kHz ultrasonic vocalizations during distributed clitoral stimulation in the rat.

Fifty-kHz ultrasonic vocalizations (USVs) are emitted by adult rats during appetitive phases of behavior in response to stimuli thought to be associated with a positive affective state. In particular, 50-kHz USVs with rapid frequency oscillations, known as trills and flat-trills, in which these oscillations are flanked by a monotonic portion, are together positively correlated with appetitive behaviors such as rough and tumble play, drug and natural reward, and mating. Female rats produce 50-kHz USVs during a variety of sexual contexts, yet data are still vague as female sexual behavior is seldom studied on its own. Distributed clitoral stimulation (CLS) offers a unique approach to investigating female 50-kHz USVs as it mimics stimulation received during mating. Although CLS induces a sexual reward state, it is unknown whether CLS elicits trills and flat-trills. We addressed this question using eight ovariectomized rats, we investigated whether ovarian hormones augmented these call subtypes in response to CLS. The combined and separate effects of estradiol benzoate (EB) and progesterone (P), and oil vehicle were assessed through comparison of these call subtypes between CLS and inter-CLS interval. We found that CLS with EB + P significantly increased call duration and rate, lowered peak frequency, and widened the bandwidth of trills. Flat-trills showed a similar pattern except for call duration. Call distribution during the CLS and inter-CLS interval suggest that trill and flat-trills may be indicative of both anticipatory and sexual reward.

Body Movement Is Associated With Orgasm During Vaginal Intercourse in Women.

Very few studies have investigated the relationship between women's ability to experience an orgasm during vaginal intercourse and specific stimulation techniques. We examined two common techniques during vaginal intercourse both with and without simultaneous external clitoral stimulation: (1) body movement, in particular back-and-forth swinging movements of the pelvis and trunk; and (2) precise rubbing of the clitoris with an immobilized body. Structural equation modeling was used to compare the effects of the two stimulation techniques on women's orgasm frequency (N = 1,239). As hypothesized, the frequency of orgasm during vaginal intercourse with simultaneous clitoral stimulation was positively associated with a preference for body movement during arousal. Body movement, as opposed to body immobilization, was also associated with a higher frequency of orgasm during vaginal intercourse without simultaneous clitoral stimulation. We conclude that body movement is associated with more orgasms during vaginal intercourse, whereas precise rubbing of the clitoris with an immobilized body is not associated with more orgasms. Teaching women to move their pelvis and trunk in a swinging back-and-forth movement during vaginal intercourse might therefore facilitate reaching an orgasm, whereas encouraging them to self-stimulate the clitoris might be less helpful if done with an immobilized body.

The clitoral activation paradox - Claimed outcomes from different methods of its stimulation.

This article reviews clitoral structures, their functions and how they are activated during the stages of female life. The paradox that occurs is that different procedures of activation are claimed by some to favor 'noxious outcomes' to the physical and psychic health of women who use it to achieve sexual arousal/orgasm with or without penile vaginal intercourse. A number of the difficulties and inconsistencies in relation to these claims are explored. The proposed justification for the 'noxious outcomes' is that 'evolution' punishes sexual arousals other than by coitus because it is the only one that leads to gene propagation. In this context, however, the new, evolutionary interpretation of clitoral function in the fertile years as a fundamental proximate mechanism for facilitating female reproductive fitness makes such a justification improbable. The role of coital alignment technique (CAT) in the treatment of female orgasmic disorder is discussed in relation to its features of introital, clitoral and periurethral glans stimulation. Attempts to control female sexuality through various 'clitoridectomies' are examined, and unanswered questions about clitoral stimulation are listed. Clin. Anat. 31:650-660, 2018. © 2018 Wiley Periodicals, Inc.

Morphometric and Vascular Modifications of the Clitoris During Pregnancy: A Longitudinal, Pilot Study.

During pregnancy, women go through a series of physical and emotional changes that may have an impact on their sexuality. The aim of the study was to examine modifications in sexual function during pregnancy by means of translabial ultrasonography and administration of questionnaires on sexual activity. Eighteen healthy and adult (25-35 years) pregnant women without sexual dysfunction and with a stable heterosexual relationship were examined at 10-12, 18-20, and 30-32 weeks of gestation. Patients underwent ultrasonographic translabial clitoral volume and labia minora thickness measurements and color Doppler assessment of the dorsal clitoral and posterior labial arteries. On the same day, each patient completed the two-factor Italian McCoy Female Questionnaire (MFSQ) and the Female Sexual Function Index (FSFI). The mean clitoral body volume progressively increased during pregnancy, and color Doppler analysis of the dorsal clitoral artery showed a significant decrease in the pulsatility index from the first to the third trimester. Similarly, the labia minora thickness increased and the posterior labial artery pulsatility index progressively decreased throughout gestation. The MFSQ score for sexuality and partnership and the number of intercourses/week did not significantly change during the study period. However, the MFSQ score for partnership reached the lowest value in the third trimester of pregnancy. Analysis of the FSFI data showed no significant differences throughout pregnancy for the majority of the domains (sexual desire, arousal, orgasm, lubrication, and pain), with the exception of the satisfaction item, which decreased during the third trimester. A significant proportion of women are concerned that changes in their body during pregnancy may have a detrimental effect on sexuality. Despite significant changes in genital morphology and vascularity throughout gestation, these modifications do not seem to have an impact on sexual function in pregnancy.

Women's Experience of Orgasm During Intercourse: Question Semantics Affect Women's Reports and Men's Estimates of Orgasm Occurrence.

Most women report reliably experiencing orgasm from masturbation, but a smaller proportion of women report regularly experiencing orgasm from intercourse. Research suggests that concurrent clitoral stimulation during intercourse increases the likelihood of orgasm, yet most surveys of orgasm during intercourse leave unspecified whether vaginal intercourse does or does not include concurrent clitoral stimulation (assisted intercourse or unassisted intercourse, respectively). Using an online sample of 1569 men and 1478 women, we tested whether phrasing of questions about the occurrence of orgasm in intercourse modulates women's reported frequency and men's estimates of women's frequency of orgasm in intercourse. Participants provided estimates of orgasm when asked explicitly about intercourse with stimulation unspecified, assisted intercourse, and unassisted intercourse. Women's reports of orgasm occurrence were highest in response to assisted intercourse (51-60%), second highest in response to intercourse with clitoral stimulation unspecified (31-40%), and lowest in response to unassisted intercourse (21-30%). Men's estimates of women's orgasms were highest in response to assisted intercourse (61-70%), and lowest in response to unassisted intercourse (41-50%); in both conditions, men's estimates were significantly higher than women's reports. When clitoral stimulation was unspecified, women interpreted "orgasm in intercourse" in three ways: as from intercourse alone, as including concurrent clitoral stimulation though it was unspecified, or as an average of assisted and unassisted intercourse. Taken together, these results demonstrate that the phrasing of questions about women's orgasm produces markedly different orgasm estimates, and suggest that concurrent clitoral stimulation increases the likelihood of women experiencing orgasm in intercourse.

Brain Activity Unique to Orgasm in Women: An fMRI Analysis.

BACKGROUND: Although the literature on imaging of regional brain activity during sexual arousal in women and men is extensive and largely consistent, that on orgasm is relatively limited and variable, owing in part to the methodologic challenges posed by variability in latency to orgasm in participants and head movement. AIM: To compare brain activity at orgasm (self- and partner-induced) with that at the onset of genital stimulation, immediately before the onset of orgasm, and immediately after the cessation of orgasm and to upgrade the methodology for obtaining and analyzing functional magnetic resonance imaging (fMRI) findings. METHODS: Using fMRI, we sampled equivalent time points across female participants' variable durations of stimulation and orgasm in response to self- and partner-induced clitoral stimulation. The first 20-second epoch of orgasm was contrasted with the 20-second epochs at the beginning of stimulation and immediately before and after orgasm. Separate analyses were conducted for whole-brain and brainstem regions of interest. For a finer-grained analysis of the peri-orgasm phase, we conducted a time-course analysis on regions of interest. Head movement was minimized to a mean less than 1.3 mm using a custom-fitted thermoplastic whole-head and neck brace stabilizer. OUTCOMES: Ten women experienced orgasm elicited by self- and partner-induced genital stimulation in a Siemens 3-T Trio fMRI scanner. RESULTS: Brain activity gradually increased leading up to orgasm, peaked at orgasm, and then decreased. We found no evidence of deactivation of brain regions leading up to or during orgasm. The activated brain regions included sensory, motor, reward, frontal cortical, and brainstem regions (eg, nucleus accumbens, insula, anterior cingulate cortex, orbitofrontal cortex, operculum, right angular gyrus, paracentral lobule, cerebellum, hippocampus, amygdala, hypothalamus, ventral tegmental area, and dorsal raphe). CLINICAL TRANSLATION: Insight gained from the present findings could provide guidance toward a rational basis for treatment of orgasmic disorders, including anorgasmia. STRENGTHS AND LIMITATIONS: This is evidently the first fMRI study of orgasm elicited by self- and partner-induced genital stimulation in women. Methodologic solutions to the technical issues posed by excessive head movement and variable latencies to orgasm were successfully applied in the present study, enabling identification of brain regions involved in orgasm. Limitations include the small sample (N = 10), which combined self- and partner-induced stimulation datasets for analysis and which qualify the generalization of our conclusions. CONCLUSION: Extensive cortical, subcortical, and brainstem regions reach peak levels of activity at orgasm. Wise NJ, Frangos E, Komisaruk BR. Brain Activity Unique to Orgasm in Women: An fMRI Analysis. J Sex Med 2017;14:1380-1391.

Genital Sensory Detection Thresholds and Patient Satisfaction With Vaginoplasty in Male-to-Female Transgender Women.

INTRODUCTION: Gender-affirming surgery is common for the treatment of gender dysphoria, but its effect on genital sensitivity is not well known. AIMS: To investigate genital sensory detection thresholds in male-to-female transgender women postoperatively and their relation to psychological well-being and variables of satisfaction. METHODS: Prospective study on 28 transgender women at least 18 years old operated on at least 3 months before the study by a single surgeon (N.M.J.). MAIN OUTCOME MEASURES: Medical complications; sensory detection thresholds for light touch, pressure, and vibration; and questionnaires on general and sexual satisfaction, sexual function, depression, and psychological well-being. RESULTS: Sensory detection thresholds ranged from 0.07 to 2.82 g for light touch, with the neck being most sensitive; from 20.23 to 34.64 g for pressure, with similar results for the neck and clitoris; and from 0.0052 to 0.0111 V for vibration, with similar findings for all stimulation points. Satisfaction with the appearance of the labia, vulva, clitoris, and sexual function was good to very good. Frequency of sexual activities increased significantly postoperatively for orogenital stimulation and decreased significantly for frequency of fantasies (t = -4.81; P < .0001). Orgasmic function was reported by 80% of participants. Psychological adjustment was good to very good, with low depression scores. Sexual satisfaction was statistically and positively correlated with vaginal function and depth, clitoral sensation, appearance of the vulva and labia minora, and natural lubrication and negatively correlated with depression scores. CONCLUSION: Gender-affirming surgery yields good results for satisfaction with appearance and function. Genital sensitivity showed the best results with pressure and vibration.

The Impact of a Topical Sexual Enhancement Cream on the Female Sexual Response and Its Relationship to Clitoral Blood Flow.

OBJECTIVE: The aim of this investigation was to determine, through two Investigational Review Board (IRB)-approved studies, if a new topical vasodilating cream (NTVC; Life Science Enhancement Corporation, Pittsburgh PA) could improve female sexual response. Study I subjectively evaluated sexual female response as accessed by a modification of the Female Intervention Efficacy Index (FIEI). FIEI was developed at the University of California as an immediate outcome measure of medical intervention to treat female sexual dysfunction.1 In Study II, 10 randomly selected positive responders from Study I were subsequently analyzed objectively with clitoral plethysmography in order to determine the effect of the NTVC and placebo on blood flow.2 RESULTS: In the subjective Study I (81 patients ranging in age from 18 to 63), a positive response trend for the NTVC was demonstrated compared to the placebo. In the objective Study II, 10 randomly selected patients who responded positive in Study I were objectively evaluated for response of increased blood flow in the clitoris after application of both the NTVC and placebo. The clitoral blood flow was shown to have increased with statistical significance for the NTVC in all 10 patients compared to the placebo, with the NTVC exhibiting an average 69% increase in clitoral blood flow. CONCLUSIONS: The female sexual response is complex. In the subjective Study I, the NTVC demonstrated positive trends for enhanced lubrication, genital sensation, intercourse, and overall sexual experience. In the objective Study II, 10 of the positive subjective responders from Study I were randomly selected to evaluate their response to the NTVC compared to the placebo. This was done via Doppler plethysmography (DP). All 10 patients demonstrated a statistically significant response rate for increase in clitoral blood flow using the NTVC compared to the placebo, with an average blood flow increase of 69%. This portion of the investigation demonstrates a significant positive end organ response to the NTVC. The positive subjective trends combined with the significant and substantial increase in clitoral blood flow may result in enhanced female sexual satisfaction.

Clitorally Stimulated Orgasms Are Associated With Better Control of Sexual Desire, and Not Associated With Depression or Anxiety, Compared With Vaginally Stimulated Orgasms.

INTRODUCTION: Most women report that clitoral stimulation is an integral aspect of their orgasm experience. Thus, recent claims that vaginal stimulation and vaginally generated orgasms are superior to clitoral stimulation and clitorally generated orgasms pathologize most women and maintain a clitoral vs vaginal dichotomy that might not accurately reflect the complexity of women's sexual experience. AIM: To have women report on their experienced source of orgasm, including combinations of vaginal and clitoral stimulation, the solo or partnered context of the stimulation, and the intensity of the orgasms from different sources and to predict indicators of mental health and sexual health using the orgasm source. METHODS: Eighty-eight women 18 to 53 years old answered detailed questions about their usual and recent orgasm experiences, sexual history, depression, and anxiety. Then, they viewed a series of neutral and sexual films. They were instructed to increase or decrease their sexual arousal or respond "as usual" to the sexual films. They reported their sexual arousal after each film. MAIN OUTCOME MEASURES: Outcomes assessed included mental health (depression and anxiety) and sexual health (orgasm quality, ability to regulate sexual response to sex films). Reported sexual arousal was analyzed for the regulation task. RESULTS: Most women (64%) reported that clitoral and vaginal stimulation contributed to their usual method of reaching orgasm. Women who reported that clitoral stimulation was primarily responsible for their orgasm reported a higher desire to self-stimulate and demonstrated greater control over their self-reported sexual arousal. The primary stimulation site for orgasm was unrelated to measurements of depression or anxiety despite sufficient statistical power. CONCLUSION: Most women reported that clitoral and vaginal stimulation is important in orgasm. Women experience orgasms in many varied patterns, a complexity that is often ignored by current methods of assessing orgasm source. The reported source of orgasm was unrelated to orgasm intensity, overall sex-life satisfaction, sexual distress, depression, or anxiety. Women who reported primarily stimulating their clitoris to reach orgasm reported higher trait sexual drive and higher sexual arousal to visual sexual stimulation and were better able to increase their sexual arousal to visual sexual stimulation when instructed than women who reported orgasms primarily from vaginal sources.

The Evolutionary Origin of Female Orgasm.

The evolutionary explanation of female orgasm has been difficult to come by. The orgasm in women does not obviously contribute to the reproductive success, and surprisingly unreliably accompanies heterosexual intercourse. Two types of explanations have been proposed: one insisting on extant adaptive roles in reproduction, another explaining female orgasm as a byproduct of selection on male orgasm, which is crucial for sperm transfer. We emphasize that these explanations tend to focus on evidence from human biology and thus address the modification of a trait rather than its evolutionary origin. To trace the trait through evolution requires identifying its homologue in other species, which may have limited similarity with the human trait. Human female orgasm is associated with an endocrine surge similar to the copulatory surges in species with induced ovulation. We suggest that the homolog of human orgasm is the reflex that, ancestrally, induced ovulation. This reflex became superfluous with the evolution of spontaneous ovulation, potentially freeing female orgasm for other roles. This is supported by phylogenetic evidence showing that induced ovulation is ancestral, while spontaneous ovulation is derived within eutherians. In addition, the comparative anatomy of female reproductive tract shows that evolution of spontaneous ovulation is correlated with increasing distance of clitoris from the copulatory canal. In summary, we suggest that the female orgasm-like trait may have been adaptive, however for a different role, namely for inducing ovulation. With the evolution of spontaneous ovulation, orgasm was freed to gain secondary roles, which may explain its maintenance, but not its origin.