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Sexual and Relationship Therapy

ISSN: 1468-1994 (Print) 1468-1749 (Online) Journal homepage: https://www.tandfonline.com/loi/csmt20

An orgasm is… who defines what an orgasm is?

Roy J Levin

To cite this article: Roy J Levin (2004) An orgasm is… who defines what an orgasm is?, Sexual
and Relationship Therapy, 19:1, 101-107, DOI: 10.1080/14681990410001641663

To link to this article: https://doi.org/10.1080/14681990410001641663

Published online: 24 Jan 2007.

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Sexual and Relationship Therapy
Vol 19, No. 1, February 2004

PHYSIOLOGY UPDATE
An orgasm is. . . who defines what an
orgasm is?
ROY J. LEVIN
Department of Biomedical Science, University of Sheffield, Sheffield, Yorkshire, United
Kingdom

Introduction
One of the marked differences between men and women is the relative ease by which
most men can achieve an orgasm compared to the greater difficulty for a considerable
percentage of women. It is often said that men are goal-orientated to obtain an
orgasm during sex but that women are far less single-minded about the activity. A
national survey of British sexual behaviour using a statistically valid population
sample (Wellings et al., 1994) questioned both men and women to agree or disagree
with the statement: ‘‘Sex without orgasm cannot be really satisfying for a man/
woman’’. Approximately half of all men (48.7%) agreed or strongly agreed that it was
so for men while some 43.3% of all women also thought it was so for men. When the
question was posed for a woman, 37.4% of all men agreed while 28.6% of all women
agreed with the concept. However, in another survey of 100 women who sometimes
missed orgasm during coitus some 66% said that they were disappointed and
unsatisfied when this happened and they experienced considerable frustration and
were angered against their partners but the rest of the group were not that bothered
(Sigusch & Schmidt, 1971). A survey conducted in the United States (Lauman et al.,
1994) reported that orgasmic problems are the second most frequently reported
sexual problem in women. If women with orgasmic disorder are to be treated to attain
orgasm then it is clear that we should be able to characterize exactly what an orgasm is
so that when it occurs it will be easily recognized. There have been many attempts at
defining orgasm, Levin (1981) tabled some thirteen while 20 years later Mah & Binik
(2001) repeated the exercise and now listed twenty-six. Despite this increase
however, they were unhappy enough about the definitions not to have devised one of
their own. This should be relatively easy as the activity has been discussed if not
studied now for many years by a variety of specialities but in fact this is part of the
difficulty. The problem will become clear when we examine each specialty’s voice on
the matter. Who should define the criteria for accepting that the activity has definitely
occurred?

Correspondence to: R. J. Levin, Department of Biomedical Science, University of Sheffield, Western


Bank, Sheffield, S10 2TN, Yorkshire, United Kingdom. E-mail: [email protected]
Received 21 November 2003; Accepted 24 November 2003.

ISSN 1468–1994 print/ISSN 1468-1479 online/04/010101-07


# British Association for Sexual and Relationship Therapy
DOI: 10.1080/14681990410001641663
102 Roy J. Levin

The subject?
As orgasm is highly personal, truly one of the most wonderful subjective experiences
of life, surely it would make sense to ask the subject to self-report whether she has
experienced one for is not orgasm in the mind of the beholder? Unfortunately this
only works in those women suffering from secondary orgasmic dysfunction where
they have experienced an orgasm previously but now have become dysfunctional for
one reason or another. Some clinicians/therapists think that this is acceptable but
there are a number of reasons for caution. Firstly, it is well known that subjects under
treatment can want to please their therapist and thus be tempted to say that they have
had an orgasm, this is especially so if much effort and time has been expended on
them and they are still experiencing difficulty. Second, if the subject being treated has
never experienced an orgasm (primary orgasmic dysfunction) then how can she
distinguish between orgasm and a peak of very high sexual arousal? Ideally, some sort
of objective confirmation is necessary if we are to believe what the naı̈ve subject says.
This means that a physiological sign or signs of orgasm should have occurred and
been registered.

The physiologist?
The physiologist is certainly able to describe or characterize many of the body
changes that occur concomitantly with an orgasm. Most of these come from the
observations and descriptions of William Masters and Virginia Johnson (Masters &
Johnson, 1966) who over 12 years studied in the laboratory the orgasms of 382
women and 312 males. To be accurate, the training of Masters was as a
gynaecologist but he regarded himself as researching in medical physiology while
Johnson, his associate, although she studied music at a college and attended
Missouri University surprisingly had no formal academic training or degree
(Brecher, 1972; Oakes, 2002). It is feasible to regard them as ‘honorary
physiologists’ because their observations and descriptions in the laboratory were
essentially physiological. What then are the objective signs that indicate that an
orgasm has occurred? While there are a few changes that occur during the actual
orgasm itself it is better to bracket the orgasm and look at changes that occur just
before (prospective), during (current) and just after (retrospective) an orgasm, some
of these changes are more amenable to observation and measurement than others.
Those that occur just before its initiation include the highest heart rate, blood
pressure and respiratory rate. A more unusual prospective sign of (impending)
orgasm was to be found in the colour changes of the labia minora, from pink to
deep red and then back to pink after the orgasm. Currently, during the orgasm, a
variable number of pelvic striated muscle contractions associated with an ecstatic
burst of erotic pleasure are evident while uterine contractions are also claimed to
occur. After the orgasm dramatic falls in blood pressure, heart rate and respiration
occur usually with a general feeling of lassitude and contentment. It was claimed by
Masters and Johnson (1966) that the primary areolae (the usually large pigmented
area around the nipples of the breasts) that swell up during arousal lose this
Who defines what an orgasm is? 103

congestion so quickly that they become corrugated before they become flatter. This
change is not an easy one to observe or record.
Problems arise because depending on the definition of orgasm, briefly a peak
subjective phenomenon with attendant physical manifestations, one has to ask when
the orgasm actually starts, is it when the subject first mentally perceives it or when the
first physical manifestation appears. Kinsey et al. (1953) argued to limit the definition
of orgasm to the sudden and abrupt reduction of sexual tension, a not very helpful
definition for practical purposes especially if a subject experiences a stimulus that is
not appreciated! They regarded the ‘vaginal spasms’ as the after-effects of the orgasm.
Masters and Johnson (1966) described a 3-stage process for the female orgasm. The
first was a sensation of suspension or stoppage, the second was a suffusion of warmth
initially in the pelvis and then spreading upwards through the body and finally came
the feelings of vaginal and pelvic contractions and pulsations. Hite (1976) also
regarded orgasm as an intense brief feeling followed by contractions. There are still
very few good published records of the orgasmic contractile activity of the pelvic
striated muscles with the accurate occurrence of the beginning and the end of the
perceived (subjective) orgasm either in males (Gerstenberg et al., 1990) or in women
(Bohlen et al., 1982a,b). Many have taken the presence of pelvic contractions as the
sine qua non proof of orgasm but in fact a number of women claim to have orgasms
without experiencing any such contractions (Bohlen et al., 1982b; Kratochvil, 1994).
Unfortunately, whether this is because the contractions happen at a low level and they
are not perceived or whether they are really not present cannot be elucidated from the
answers to questionnaires or face-to-face interviews but only by laboratory
measurement.

The endocrinologist ?
What can the endocrinologist tell about the hormonal responses at orgasm? While a
variety of hormones and neurotransmitters viz -adrenaline, nor-adrenaline, vasoactive
intestinal peptide (VIP), oxytocin, antidiuretic hormone (ADH) and prolactin have
been measured in the blood before, during and after orgasm the results have not been
totally consistent probably due to different ways of collecting and analysing the blood
and different types of sexual stimulation used. Most recently the enhanced secretion
of prolactin has been proposed as a specific marker signalling that an orgasm has
taken place in both men and women. It is claimed that sexual arousal per se does not
cause any increase in prolactin but that only after orgasm is it significantly raised for at
least 30 minutes (Krüger et al., 2002). Unfortunately, the authors did not investigate
whether stimulation of the nipples could have been involved in this increase as it is
known that such stimulation does cause an increase in prolactin in both men and
women (see Levin (2003a) for references).

The brain imager?


When men and women write down descriptions of how their orgasms feel with
any gender referencing clues removed, experts cannot tell the difference between
104 Roy J. Levin

those written by men or those written by women (Vance & Wagner, 1976).
This suggests that the mental activity of an orgasm appears to be similar for
men and women although other less likely explanations could be invoked such
as the experts were poor at their job or that our common vocabulary is not up
to delineating subtle differences. Apart from such subjective descriptions we had
little further insight of the effect of orgasm on brain or mental mechanisms
although Levin and Wagner (1985) reported that the subjective estimate of
orgasm duration in a laboratory study was practically half that of the objectively
measured duration suggesting a change in consciousness (time passes quickly
when you are having fun!). The idea of seeing what parts of the brain are
involved in sexual arousal and orgasm would have been far fetched. With the
advent however of brain imaging by functional magnetic resonance imaging
(fMRI) and blood oxygenation level dependent (BOLD) positron emission
transmission (PET) it is now possible by examining the increases or decreases
in regional cerebral blood flow (rCBF) to see the areas of the brain that are
involved in specific functional/mental operations. However, while a growing
number of studies have looked at rCBF during sexual arousal only two studies
in men (Tiihonen et al., 1994; Holstege et al., 2003) and a briefly reported but
yet to be published study in women (Holstege, 2003) have examined rCBF
during orgasm. The early semi-quantitative study by Tiihonen et al. (1994)
described right prefrontal cortical increases in rCBF and decreases in all other
cortical areas but according to Holstege et al. (2003) in men, orgasm and
ejaculation cause the primary activation of a number of brain areas namely the
mesodiencephalic transition zone including especially the ventral tegmental area
(involved in rewarding behaviours), the midbrain lateral central tegmental field,
the zona incerta, the suparafascicular nucleus and the ventroposterior, midline
and intralaminar thalamic nuclei and the cerebellum. Increased activation was
also found in the lateral putamen and adjoining parts of the claustrum.
Neocortical activity was exclusively on the right side in some six specific areas.
A decrease in activation was seen in the amygdala and adjacent entrohinal
cortex.
With the female orgasm a basically similar pattern of brain activation was
observed (Holstege, 2003) but a major difference was that in the female activation
was seen in the periaqueductal gray. This area is known to control the coital
posture of female cats but women do not have a fixed coital posture so it is still a
mystery in female humans as to why this area is specifically activated and what it
does. Another difference between women and men during orgasm is that while the
amygdala becomes inhibited in the latter this does not occur in women. One
speculation is that the male inhibition may be related to the activation of the post
orgasmic refractory time (PERT) that occurs in men but not women: during this
time the male cannot have another erection or ejaculation or orgasm (see Levin,
2003a).
It is obvious that while the rCBF imaging data is fascinating we do not yet have
enough understanding of what the various brain areas do to effectively use imaging as
a diagnostic criterion of the human orgasm.
Who defines what an orgasm is? 105

The psychologist?
It is only recently that psychologists have begun to take more than a passing
involvement in the orgasmic experience. Earlier studies were generally only interested
in whether orgasm occurred or not but a small number were interested in the intensity
and variability of the orgasm but from a site-based approach creating a typology for the
female orgasm. In essence, was the feeling of the orgasm the same if it was brought
about by stimulation of different (genital) sites? According to Masters and Johnson
(1966) an orgasm in physiological terms was essentially identical wherever it was
activated from but others (Butler, 1976; Clifford, 1978; Fisher, 1973) reported that
different sites, especially in the female, created different orgasmic feelings. This was
especially so for the stimulation of the clitoris (intense, sharp, ‘electrical’ feelings)
compared to the anterior vaginal wall throbbing, deep, diffused feelings. Singer (1973)
proposed from a limited literature then available three types of female orgasm namely,
(i) vulval, (ii) uterine and (iii) blended—a mixture of both. More recently, since the
acknowledgement of the so-called G-spot, better known as the periurethral glandular
area of the urethra (Levin, 2003b), stimulation of this area via the anterior wall of the
vaginal brings about rapid induction of orgasm in sensitive women (Hoch, 1986).
Moreover, it appears that a different balance of genital smooth muscle to pelvic striated
muscle activity can be recorded during orgasms induced from G-spot stimulation
compared to those obtained from clitoral stimulation (see records in Levin (2001)).
Jayne (1981) pointed out that orgasm and satisfaction are not necessarily
synonymous in women (or for that matter in men) but studies on satisfaction after
orgasm hardly exist. In their review and studies on the nature of the human orgasm
Mah and Blinik (2001, 2002) again stressed the lack of studies on its mental effects.
Apparently, the only standardized questionnaire developed for such study was the
Peak of Sexual Response Questionnaire (PSRQ, Davis et al., 1998) but it is applicable
only for female orgasms. In order to rectify this lack of an instrument to study orgasm,
Mah and Blinik (2002) developed and evaluated a three dimensional model viz:- (i)
sensory (muscle tension and contractions, congestions etc), (ii) cognitive (intensity,
pleasure, pain, etc) and (iii) affective (elation , intimacy, love etc) aspects of the
orgasm core experience of both men and women using an adjective-rating scoring
scale, called the Orgasm Rating Scale (ORS). The adjectives were collected from the
published self-reports in the literature and each one was scored between 0 and 5
according to how well it described the subject’s orgasmic experience. The only
substantive gender difference observed was that men gave a higher rating to ‘shooting
sensations’ which was interpreted as an aspect of their ejaculation, presumably not a
highly developed feeling for most women.
Interestingly, although the occasional clinician expressed the possibility of a male
orgasm typology (Zilbergeld, 1979), there have been no controlled studies as it has
been tacitly assumed by most that in the male (as in the female) wherever it is generated
from, an orgasm is an orgasm. However, orgasms derived from penile stimulation and
those derived from stimulation of the prostate per rectum have not been studied
critically. Anecdotal reports have described those obtained by from prostatic massage
as being ‘deeper’, more widespread and intense and lasting longer than those from
106 Roy J. Levin

penile stimulation (Hite, 1981) but no one has actually studied in the laboratory
orgasms obtained from the two sites. Perry (1988) described orgasms obtained by
prostatic massage as ‘emission type reflexive orgasms’ with occasional oozing of semen
from the penis, such ‘orgasms’ he contends can be repeated several times in the same
subject. This suggests perhaps that only the contractions of the smooth muscles of the
capsules of the accessory organs and in the male ductal system are involved, the
seeping ejaculation-with-orgasm noted when the pelvic striated muscles are paralysed
(Newman et al., 1982). Subsequent to such orgasms, stimulation of the penis can give
the forceful, spurting ejaculation with striated muscle contractions that then induces
the PERT, inhibiting further arousal and ejaculation for some considerable time
(Levin, 2003a). Perry described some laboratory research he conducted on a single
subject, a male psychologist. The subject stated that when his prostate was touched
(per rectum) he was able to isolate sensations associated with familiar sexual
experience—that of ejaculation. He discovered that the prostate had been familiar to
him all along as ‘the base of my penis’ which ‘always throbbed during an ejaculatory
orgasm’. These so-called prostate-induced-orgasms raise numerous questions, (i) is
prolactin secreted during them, (ii) if not, can they be repeatedly induced like female
orgasms?, and (iii) is the same brain pattern of rCBF seen in prostate-induced orgasms
as in penile-induced orgasms?

Conclusion
To characterize the phenomenon of orgasm in both men and women obviously needs
the combined skills of the physiologist, psychologist, endocrinologist, brain imager
and the subject but even then we have some obvious difficulties. While it is clear that
we still have very much to learn about orgasm and its typologies at least we have now
started on the journey of scientific investigation.

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Contributor
ROY J. LEVIN, MSc, PhD, Reader in Physiology (Retired)

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