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Validation of a Self-Report Questionnaire Assessing the Bodily and Physiological Sensations of Orgasm
PSYCHOMETRICS
Validation of a Self-Report Questionnaire Assessing the Bodily and Physiological Sensations of Orgasm Samantha Dubray, PhD,1 Marina Gérard, MA,1 Dominic Beaulieu-Prévost, PhD,2 and Frédérique Courtois, PhD2
ABSTRACT
Introduction: Despite a plethora of research on sexual functioning during the past decades, the field is still lacking standardized measurements specifically characterizing orgasm. Although several validated tools are available to assess sexual function in healthy and clinical populations, items on orgasm are limited to frequency or dichotomous responses. A neurophysiologic model of orgasm developed from previous research in able-bodied and spinally injured populations offers a promising framework for the construction of a new questionnaire. Aim: To develop and validate a brief self-report measurement of orgasm by the assessment of bodily and physiologic sensations perceived during climax by able-bodied individuals. Although the currently available tool focuses on the phenomenological sensations associated with climax, the goal of this questionnaire was to capture the more specific genital and extragenital sensations associated with orgasm. Main Outcome Measures: The current Bodily Sensations of Orgasm questionnaire and the Orgasm Rating Scale. Methods: Data from previous research conducted on individuals with spinal cord injury and the available empirical literature provided a pool of 45 items organized into four categories, which were reviewed by an expert panel. Upon review, a 28-item questionnaire was created and administered to a community sample of 227 participants, including men and women, 18 to 73 years old. Results: Exploratory factor analyses supported the four-factor model, in which orgasm is comprised of extragenital sensations, genital sensations and spasms, nociceptive sensations, and sweating responses. Overall, a high degree of internal consistency was found for the final 22-item questionnaire (Cronbach a ¼ 0.87), with individual reliability coefficients showing moderate to high internal consistency (r ¼ 0.65e0.79) for each dimension. Overall temporal stability of the measurement was acceptable (r ¼ 0.74). Using the Orgasm Rating Scale, satisfying convergent validity was confirmed, thereby indicating that the two measurements are complementary. Conclusion: The Bodily Sensations of Orgasm questionnaire allows for a brief evaluation of the physical and physiologic sensations associated with orgasm. Findings also suggest perceptual differences between men and women with regard to climax, with women reporting a larger repertoire of climactic sensations during orgasm. Dubray S, Gérard M, Beaulieu-Prévost D, Courtois F. Validation of a Self-Report Questionnaire Assessing the Bodily and Physiological Sensations of Orgasm. J Sex Med 2017;14:255e263. Copyright 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Orgasm; Spinal Cord Injury; Cardiovascular Responses; Autonomic Responses; Genital Sensations; Extragenital Sensations
INTRODUCTION
Received September 15, 2016. Accepted December 8, 2016. 1
Department of Psychology Université du Québec à Montréal, Montreal, Canada;
2
Department of Sexology, Université du Québec à Montréal, Montreal, Canada
Copyright ª 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsxm.2016.12.006
J Sex Med 2017;14:255e263
Despite much public interest and repeated attempts by the scientific community to characterize the human orgasmic experience, orgasm research is still marked by sex-specific definitions and an overall lack of unifying framework. This is particularly problematic in clinical practice for the assessment and treatment of orgasm difficulties in various populations, including those with spinal cord injury (SCI). The existence of multiple typologies also plays a key role in the lack of clear, agreed-upon characteristics of the human orgasm.1 Labels such as “mixed 255
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orgasms,”2,3 coital vs extra-coital orgasms,4 clitoral vs vaginal orgasms in women,5,6 and penile vs seminal orgasm in men7 contribute to the confusion. Despite recent attempts, the field has not reached a universally satisfying definition of orgasm. The pleasurable dimension of climax seems to be the only unifying theme thus far,6 albeit subject to considerable individual variability. Masters and Johnson8 examined such variability in their physiologic studies investigating the bodily and genito-pelvic changes occurring during climax. Since then, most studies have centered on the genital physiologic changes occurring during orgasm,1 focusing primarily on the muscle contractions (perineal and anal) recorded in men and women.9,10 Some researchers have attempted to broaden the definition of orgasm by highlighting the psychological state(s) associated with climax1 and by combining the psychological and physiologic dimensions that characterize the human orgasm.11,12 However, a major obstacle has been the emphasis put on dichotomous accounts of orgasm (vaginal vs clitoral orgasms, mind vs body sensations, occurrence vs nonoccurrence), rather than on the various physiologic sensations associated with the overall climactic experience. Two recent international consensuses on orgasm have been reached and they depart from the previous focus on the characteristic muscular contractions. In fact, these consensuses define women’s orgasmic experience as a “variable and transient peak sensation of intense pleasure creating an altered state of consciousness, usually accompanied with involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often uterine and anal contractions, in addition to myotonia that resolves the sexually induced vasocongestion, and usually accompanied with a sensation of well-being and contentment”13 and men’s as a “cerebral processing of pudendal nerve sensory stimuli resulting from increased pressure in the posterior urethra, sensory stimuli arising from the verumontanum and contraction of the urethral bulb and accessory sexual organs.”14 Although these definitions constitute a step toward the operationalization of orgasm as a concept, they are still associated with two major issues. First, they suggest that orgasm differs between men and women, despite physiologic and subjective evidence of similar orgasmic responses in men and women1,15,16; second, they fail to distinguish between intense sexual arousal and orgasm for women. This absence of a unifying description of orgasm translates to a lack of universally accepted assessment tools. In 1998, Warner17 designed and tested the Peak of Sexual Response Questionnaire to assess the psycho-affective dimensions of the female orgasm; however, this measurement failed to differentiate between orgasm and sexual arousal. Currently, the International Index of Erectile Function (IIEF)18 and the Female Sexual Function Index (FSFI),19 two widely used assessment tools in sex research, dedicate only one and three items to orgasm, respectively. Although these two well-validated measurements are useful for the assessment of overall sexual function, they do not address the physical sensations characterizing orgasm or pleasure, and they do not
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provide a unique tool to assess women and men. More recently, Mah and Binik20 developed the Orgasm Rating Scale (ORS) to assess the phenomenological sensations associated with orgasm in men and women. Their two-dimensional model conceptualizes orgasm as sensory and cognitive-affective characteristics, but the phenomenological adjectives do not particularly capture the specific bodily sensations that are associated with climax. Courtois et al21e24 developed a brief assessment tool organized by four categories of specific bodily sensations associated with the human orgasmic experience, as described in the literature on physiologic recordings in men and women during climax.8,22e24 Similar to the able-bodied population, findings from the SCI population describe climax as associated with different bodily responses, which also are observed during another phenomenon called “autonomic dysreflexia” (AD).25 AD is a clinical condition that is usually triggered by nociceptive stimulation, but also ejaculation, in individuals with lesions above T6 (ie, above the major sympathetic outflow from the spinal cord) and is associated with a sympathetic storm characterized by signs such as hypertension (systolic blood pressure > 20 mm Hg), tachycardia, hyperventilation, muscular contractions, and shivering.25 In ablebodied individuals, this autonomic storm triggered by climax is normally under supraspinal control24 and immediately tempered down to normal within 2 minutes after ejaculation.22e24 The similarities between the able-bodied and SCI populations led Courtois et al21e24 to postulate that orgasm is a nonpathologic equivalent of AD. Based on their data, Courtois et al23 developed a 33-item questionnaire to test the hypothesis that orgasm is related to mild AD symptoms. Their questionnaire assessed sensations, muscular contractions, autonomic arousal, and dysreflexic sensations. Preliminary data suggest that Courtois et al’s neurophysiologic model of orgasm is consistent with the many genital and extragenital events recorded during orgasm in men with and without SCI.8,22e24 Further research with able-bodied men and women is needed to establish the validity of their model. Therefore, the purpose of the present study was to validate the questionnaire in able-bodied men and women. Ultimately, the goal is to offer an assessment tool that could help patients identify the sensations of orgasm, for example, anorgasmic women identifying the specific bodily sensations that build up to and characterize orgasm. This study was designed to assess the validity of a tool measuring the specific bodily sensations characterizing orgasm, as experienced by men and women, and consistent with our four-factor model of climax as a non-pathologic equivalent of AD. The following hypotheses guided the research: (i) the validity of our four-factor model should be confirmed, (ii) the sensory dimension of our questionnaire should be mostly correlated to the ORS sensory dimension and the remaining dimensions should be moderately correlated to the ORS, and (iii) women should show a larger sensory repertoire than men during climax. J Sex Med 2017;14:255e263
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METHODS
Table 1. Demographic characteristics of sample
Participants
Variable
Men
Women
Two hundred twenty-seven healthy participants were recruited from a university campus, from surrounding areas, and by word of mouth. Sample size calculation was determined based on the number of items and variables under study, and recruitment was stopped once the adequate number of participants was reached. Eligibility criteria included being at least 18 years of age, having no history of sexual dysfunction, and having no current major physical or mental health condition. The final sample consisted of 227 participants 18 to 73 years old (115 women, mean age ¼ 34.9 years, SD ¼ 14.9; 112 men, mean age ¼ 38.2 years, SD ¼ 13.7). Detailed demographic data for the sample are presented in Table 1. Most were educated, heterosexual individuals who were single or in a committed relationship. All participants signed an informed consent form approved by the university ethics committee.
Sexual orientation, n (%) Heterosexual Same-sex oriented Bisexual Relationship status, n (%) Single Common law Married Separated Divorced Widowed Annual income, n >$15,000, % $15,000e$25,000, % $26,000e$35,000, % $36,000e$45,000, % >$46,000, % Education, n High school, % College level, % Undergraduate, % Masters, % PhD, %
112 98 (87.5) 6 (5.4) 8 (7.1) 112 60 (53.6) 27 (24.1) 13 (11.6) 10 (8.9) 2 (1.8) 0 82 30.45 22.95 12.20 20.73 14.63 82 13.42 17.07 48.78 14.63 6.10
115 90 (78.3) 3 (2.6) 22 (19.1) 115 53 (46.1) 36 (31.3) 12 (10.4) 8 (7.0) 5 (4.3) 1 (0.9) 94 39.36 30.85 9.57 9.57 10.64 94 7.45 25.53 50 12.77 4.26
Questionnaire Development The questionnaire was constructed based on previous findings from able-bodied men and women6e11 and individuals with SCI.21e24 Based on a thorough literature review conducted by the research team using PubMed, PsychInfo, and PsychArticles, a list of sensations and reactions associated with orgasm and experienced by men and women was compiled, yielding a pool of 45 items. These items were sorted into the following four categories according to their physiologic bases and Courtois et al’s neurophysiologic model of orgasm: cardiovascular sensations, muscular sensations, autonomic sensations, and negative sensations associated with AD (eg, headache, sensation of tightness). To account for sex differences, two versions of the questionnaire were created, with three items differing according to sex-specific responses (eg, clitoral pulsation vs penile contraction). Using a five-point Likert scale of 0 to 4 (0 ¼ not at all, 1 ¼ somewhat, 2 ¼ moderately, 3 ¼ a lot, 4 ¼ extremely), participants were asked to rate the extent to which they experienced each of these sensations during ejaculation or orgasm. Construct validity was supported by a panel of four experts in sexual dysfunctions who were asked to rate each item on a dichotomous scale (adequate vs inadequate) and suggest individual comments. This initial review decreased the number of items from 45 to 28 and led to the rewording of some items. As part of a pre-assessment, the reformatted questionnaire was distributed to 50 participants to assess its internal consistency, face validity, and accuracy of its categories. Initial analyses computed on those 50 questionnaires yielded satisfying indices of internal consistency; therefore, it was distributed to the remaining participants (n ¼ 177) for a total of 227 completed questionnaires.
in French were translated into English using the method of Vallerand,26 consisting of a translation into English by an English-speaking translator and the English version being translated back into French by a French-speaking translator, and the inconsistencies were discussed to reach a consensus. A second measurement used for construct validity was the ORS,20 which assesses the phenomenological experience of orgasm using 28 items organized into two categories: a sensory dimension and a cognitive-affective dimension. A French adaptation of the ORS and a 0 (not at all) to 4 (extremely) Likert scale were used for our sample.
Procedure Participants were asked to complete the two questionnaires at home within 30 minutes of a sexual activity of their choosing resulting in orgasm. Each version of the question started with the question, “To what extent did you feel the following signs during ejaculation or orgasm?” To assess reliability, participants were asked to complete these two measurements at a second time point 2 to 3 weeks after the first completion. Hard copies and online versions of the forms were available.
Main Outcome Measures The final questionnaire included 28 bodily and physiologic sensations associated with orgasm and organized into four categories: cardiovascular, muscular, autonomic, and dysreflexic sensations. Each item was scored on a five-point Likert scale ranging from 0 (not at all) to 4 (extremely). The items developed J Sex Med 2017;14:255e263
RESULTS Descriptive Analyses All participants achieved orgasm (N ¼ 227), mostly after selfstimulation (41.4%) and penile-vaginal intercourse (19.8%).
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For the type of sexual activities leading to orgasm, data showed some similarities and differences between men and women in preferred activities. Overall, men and women relied mostly on self-stimulation (44.6% for men and 38.3% for women) and penile-vaginal penetration to reach orgasm (27.7% for men and 12.2% for women). Interestingly, women reported using a wider variety of sexual activities to reach orgasm compared with men. Most participants reported more cardiovascular (mean ¼ 12.81, SD ¼ 5.03), muscular (mean ¼ 12.80, SD ¼ 4.94), and autonomic (mean ¼ 14.58, SD ¼ 6.24) sensations, with few, if any, AD-related sensations (mean ¼ 1.08, SD ¼ 1.601; Table 2). Cardiovascular sensations after orgasm included tachycardia (“accelerated heartbeat,” “stronger heartbeat”) and hyperventilation (“accelerated breathing”) as the highest rated items. Items
pertaining to clitoral or penile contraction and “overall muscular tension” were scored the highest among the muscular sensations associated with orgasm. Autonomic sensations such as “clitoral or gland hypersensitivity,” “ejaculation,” and “hot flushes” also were largely reported. The most frequent item relating to the negative sensations of AD endorsed by participants was “feeling of tightness,” albeit to a minimal extent. Table 2 also presents significant sex differences, with women indicating feeling a significantly larger overall repertoire of sensations during orgasm than men (t224 ¼ 3,357, P < .001) based on the degree to which they endorsed each item. Moreover, women reported more cardiovascular (t224 ¼ 4,625, P < .001) and muscular (t224 ¼ 3.152, P < .0023) sensations compared with men. Data gathered from the ORS showed that within the sensory dimension, adjectives such as “throbbing,” “pulsating,” and
Table 2. Participants’ data on bodily and physiologic sensations during orgasm Participants (N ¼ 227)
Men (n ¼ 112)
Women (n ¼ 115)
Questionnaire items
Mean score
SD
Mean score
SD
Mean score
SD
Cardiovascular dimension 1. Increased blood pressure 2. Increased heart rate 3. Heart beating stronger 4. Irregular heart beating 5. Faster breathing 6. Choppy breathing (apnea) 7. Moaning Muscular dimension 8. Clitoral or penile pulsation 9. Vulvar or testicular pulsation 10. Anal contraction 11. Urethral contraction 12. Overall muscular tension 13. Lower limb spasms 14. Abdominal contractions Autonomic dimension 15. Hypersensitive clitoris 16. Ejaculation 17. Hardening nipples 18. Shivers or goosebumps 19. Hot flashes 20. Reddening of ears or skin rash 21. Perspiration 22. Hot and cold 23. Facial tingling 24. Skull tingling 25. Urge to urinate Autonomic dysreflexia dimension 26. Feeling of tightness 27. Intracranial pressure 28. Cranial pulsations or headache Total sensations
12.81 1.82 2.20 2.31 0.60 2.17 1.54 2.16 12.80 2.74 1.91 1.17 1.13 2.47 1.62 1.77 14.58 2.76 2.08 1.48 1.50 2.04 1.70 1.22 0.50 0.41 0.48 0.86 1.02 0.50 0.33 0.20 41.20
5.03 1.14 1.03 1.05 0.95 1.11 1.31 1.15 4.97 0.99 1.22 1.14 1.19 1.03 1.32 1.28 6.24 1.15 1.50 1.29 1.26 1.27 1.34 107 0.86 0.82 0.85 1.04 1.601 0.83 0.63 0.54 14.37
11.31 1.77 1.98 2.17 0.61 1.92 1.09 1.78 11.76 2.78 1.48 1.20 1.31 2.29 1.32 1.38 13.92 2.53 3.11 1.09 1.46 1.77 0.95 1.17 0.39 0.39 0.44 0.67 2.38 0.40 0.38 0.23 39.38
5.13 0.11 0.10 0.10 0.09 010 0.11 0.11 4.83 0.08 0.12 0.11 0.12 0.09 0.12 0.11 6.35 0.12 0.08 0.12 0.12 0.11 0.11 0.10 0.07 0.07 0.07 0.89 2.18 0.07 0.06 0.05 15.0
14.28 1.87 2.42 2.46 0.59 2.42 1.99 2.53 13.81 2.69 2.33 1.14 0.95 2.63 1.90 2.16 15.22 2.99 1.06 1.86 1.53 2.30 1.57 1.26 0.59 0.59 0.47 1.05 2.48 0.59 0.28 0.16 45.78
4.49 0.11 0.09 0.09 0.09 0.11 0.12 0.09 4.93 0.10 0.11 0.11 0.10 0.09 0.12 0.12 6.09 0.09 0.12 0.11 0.12 0.12 0.13 0.10 0.09 0.09 0.08 0.10 2.16 0.08 0.05 0.04 13.65
Sex differences (t224) 4.62*
3.15*
1.57
0.33
3.36*
*P < .001. J Sex Med 2017;14:255e263
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Table 3. Participants’ data on the Orgasm Rating Scale by Mah and Binik20 Participants (N ¼ 201)
Men (n ¼ 104)
Questionnaire items
Mean score
SD
Mean score
SD
Mean score
SD
Sensory dimension 22. Building 23. Swelling 24. Flowing 26. Flooding 19. Flushing 27. Spreading 25. Spurting 18. Shooting 14. Throbbing 15. Pulsating 16. Shuddering 20. Trembling 17. Quivering Affective dimension 31. Close 32. Loving 29. Passionate 30. Tender 21. Unifying 28. Ecstatic 11. Elated 12. Euphoric 13. Rapturous Cognitive dimension 3. Pleasurable 9. Satisfying 33. Fulfilling 1. Relaxing 2. Peaceful 8. Soothing Total sensations
21.03 2.31 1.66 1.49 1.13 0.50 1.85 1.91 0.89 2.18 2.55 1.99 1.00 1.56 19.42 1.82 2.16 2.19 1.81 2.17 2.44 2.40 2.24 2.18 16.88 3.54 3.18 2.89 2.42 2.65 2.21 57.32
9.20 1.30 1.32 1.24 1.29 0.89 1.33 1.42 1.16 1.24 1.14 1.31 1.17 1.35 8.73 1.43 1.39 1.29 1.30 1.39 1.23 1.20 1.27 1.28 4.183 0.66 0.79 1.10 1.29 1.13 1.28 19.079
21.22 2.06 1.50 1.68 1.34 0.48 1.80 2.61 0.86 2.05 2.45 1.94 0.83 1.63 18.75 1.75 2.11 2.14 1.77 2.00 2.33 2.46 2.13 2.07 16.73 3.53 3.10 2.81 2.56 2.68 2.05 56.70
9.96 1.31 1.26 1.30 1.25 0.96 1.22 1.15 1.18 1.32 1.17 1.34 1.05 1.36 9.02 1.41 1.35 1.39 1.33 1.38 1.20 1.15 1.28 1.31 3.96 0.65 0.78 1.14 1.18 1.06 1.29 20.07
20.82 2.57 1.84 1.28 0.90 0.53 1.90 1.17 0.93 2.31 2.66 2.04 1.19 1.49 20.13 1.90 2.22 2.24 1.85 2.35 2.56 2.34 2.37 2.30 17.04 3.54 3.27 2.99 2.27 2.61 2.38 57.99
8.36 1.24 1.36 1.15 1.30 0.80 1.44 1.30 1.14 1.15 1.11 1.28 1.26 1.34 8.39 1.47 1.43 1.16 1.27 1.38 1.25 1.26 1.26 1.24 4.43 0.66 0.80 1.06 1.40 1.20 1.25 18.04
“building” received the highest ratings (Table 3). All items related to the cognitive-affective dimension received a score higher than 2 (ie, ranging from “moderately” to “a lot”), with a noticeable emphasis on “pleasurable” and “satisfying.” There were no significant sex differences for the sensations felt during orgasm on this questionnaire (Table 3).
Factor Analysis Exploratory factor analyses were achieved on the questionnaire using a Monte Carlo principal component analysis27 and an28,29 Only items with a saturation value of at least 0.30 were retained; items characterized by a complex structure (ie, saturation value of 0.30 on more than one factor) were discarded, except for those with very large saturation differences. The analyses showed a final solution retaining 22 of the initial 28 items, suppressing “irregular heartbeat,” “urethral contraction,” J Sex Med 2017;14:255e263
Women (n ¼ 97) Sex differences (t) 0.306
1.120
0.532
0.480
“skull tingling,” “urge to urinate,” “hot and cold,” and “ejaculation” (Table 4). Sampling adequacy increased from 0.82 to 0.84. Factor analyses showed four dimensions as originally developed, with some items slightly reorganized. The first factor accounts for 13.1% of the variance and includes seven items related to salient cardiovascular and muscular sensations; the second factor accounts for 11.2% of the variance and includes eight items related to involuntary contractions of skeletal and smooth muscles; the third factor accounts for 7.4% of the variance and includes four items related to negative sensations rarely occurring in non-SCI populations; and the fourth factor accounts for 7% of the variance and includes three items related to diffuse autonomic sensations. The four categories were renamed according to their respective proportion of variance and new item composition. The first category was renamed “extragenital sensations” because it
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Table 4. Final results of exploratory factorial analyses after varimax rotation Questionnaire items 1. Increased heartbeat 2. Heart beating stronger 3. Faster breathing 4. Overall muscular tension 5. Choppy breathing (apnea) 6. Increased blood pressure 7. Moaning 8. Hardening nipples 9. Vulvar or testicular pulsation 10. Shivers or goosebumps 11. Anal contraction 12. Hypersensitive clitoris or glans 13. Clitoral or penile pulsation 14. Lower limb spasms 15. Abdominal contraction 16. Intracranial pressure 17. Feeling of tightness 18. Cranial pulsations or headache 19. Facial tingling 20. Reddening of ears or skin rash 21. Perspiration 22. Hot flashes
Factor 1—primary sensations
Factor 2—secondary sensations
Factor 3—negative AD sensations
Factor 4—diffuse autonomic sensations
0.731 0.705 0.630 0.521 0.454 0.442 0.347 0.641 0.621 0.506 0.502 0.407 0.407 0.402 0.390 0.708 0.623 0.5617 0.339 0.752 0.635 0.406
AD ¼ autonomic dysreflexia.
referred to items such as heart beating, breathing, blood pressure, and moaning during orgasm; the second category was renamed “genital sensations and spasms” because it referred to items such as genital pulsation, hypersensitive clitoris or glans, hardening nipples, and anal and abdominal contractions during orgasm; the third category was renamed “nociceptive sensations” because it referred to items such as headaches, intracranial pressure, and facial tingling during orgasm; the fourth category was renamed “sweating responses” because it referred to items such as perspiration, hot flashes, and reddening of the skin.
evaluative dimensions showed moderate (a ¼ 0.82 and a ¼ 0.73, respectively) internal consistency. Test-retest reliability was assessed by Pearson correlations between time 1 and 2 scores (2e3 weeks later) on the two completed questionnaires. Test-retest reliability for the overall score was acceptable (r ¼ 0.74), with individual correlations ranging from 0.76 for genital sensations and spasms associated with orgasm to 0.35 for nociceptive responses, which showed more variability over time.
Convergent Validity Internal Consistency and Test-Retest Reliability Internal consistency and test-retest reliability were assessed. Overall, a high degree of internal consistency was found for the 22 items of the questionnaire, as indicated by a Cronbach a value of 0.87 (Table 5). Further reliability analyses on the four categories showed appropriate levels of internal consistency, with the primary (a ¼ 0.79) and secondary (a ¼ 0.77) dimensions showing moderate internal consistency and the negative AD (a ¼ 0.65) and autonomic (a ¼ 0.69) dimensions presenting acceptable internal consistency. To confirm the psychometric properties of the construct and to assess the validity of our French adaptation, similar analyses were computed for the ORS using the Cronbach a statistic. Reliability tests yielded excellent internal consistency for the overall questionnaire (a ¼ 0.92) and for the affective dimension (a ¼ 0.90). The sensory and
Pearson correlations between the present questionnaire and the ORS indicated a significant correlation (r ¼ 0.54, P < .001, two-tailed) between the overall scores. For the individual dimensions, the dimension on genital sensations shared the strongest correlation with the ORS sensory dimension (r ¼ 0.55, P < .001), followed by the dimension extragenital sensations and the ORS sensory dimension (r ¼ 0.38, P < .001), the dimension nociceptive sensations and the ORS sensory dimension (r ¼ 0.36, P < .001), and the dimension sweating responses and the ORS sensory dimension (r ¼ 0.27, P < .001).
DISCUSSION One of the goals of the present study was to develop a brief, valid, and reliable self-report measurement of orgasm that provides J Sex Med 2017;14:255e263
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Table 5. Internal consistency of final dimensions Participants (N ¼ 226)
Men (n ¼ 112)
Questionnaire items
Mean score
SD
a
Mean score
SD
a
Primary sensations 2. Increased heart rate 3. Heart beating stronger 5. Faster breathing 12. Overall muscular tension 6. Choppy breathing (apnea) 1. Increased blood pressure 7. Moaning Secondary sensations 17. Hardening nipples 9. Vulvar or testicular pulsation 18. Shivers or goosebumps 10. Anal contraction 15. Hypersensitive clitoris or glans 8. Clitoral or penile pulsation 13. Lower limb spasms 14. Abdominal contraction Negative autonomic dysreflexia sensations 27. Intracranial pressure 26. Feeling of tightness 28. Cranial pulsations or headache 23. Facial tingling Diffuse autonomic sensations 20. Reddening of ears or skin rash 21. Perspiration 19. Hot flashes Total sensations
14.67 2.20 2.31 2.17 2.47 1.54 1.82 2.16 14.94 1.48 1.91 1.50 1.17 2.76 2.74 1.62 1.77 1.43 0.33 0.50 0.20 0.41 4.52 1.70 1.22 2.04 35.56
5.22 1.03 1.05 1.11 1.03 1.31 1.14 1.15 5.96 1.29 1.22 1.26 1.14 1.15 0.99 1.32 1.28 1.99 0.63 0.83 0.54 0.82 2.91 1.34 107 1.27 12.47
0.79
13 1.98 2.17 1.92 2.29 1.09 1.77 1.78 13.24 1.09 1.48 1.46 1.20 2.53 2.78 1.32 1.38 1.36 0.38 0.40 0.23 0.39 3.89 0.95 1.17 1.77 31.50
5.14 0.10 0.10 010 0.09 0.11 0.11 0.11 5.90 0.12 0.12 0.12 0.11 0.12 0.08 0.12 0.11 1.97 0.06 0.07 0.05 0.07 2.68 0.11 0.10 0.11 12.37
0.79
a concrete picture of the genital and extragenital sensations associated with climax. From a clinical perspective, the aim of this research was to help identify a repertoire of sensations associated with orgasm. Descriptive analyses of the overall sample (N ¼ 227) showed that cardiovascular, muscular, and autonomic sensations are pertinent to the assessment of climax for women and men, with some sensations being less representative of participants’ orgasmic experience. Analyses also showed significant sex differences, with women reporting a significantly larger repertoire of climatic sensations compared with men despite relying on similar stimulation types to reach orgasm. These differences suggest that women are better able to describe their sensations during climax or that they are more in tune with their internal sensations. Interestingly, research looking at sexual concordance, that is, the agreement between subjective and genital sexual arousal, has shown a sex difference in the opposite direction, with women demonstrating lower concordance levels than men in most studies.30 However, sex differences characterizing awareness of sexual arousal might not hold true for orgasm. J Sex Med 2017;14:255e263
0.77
0.65
0.69
0.87
Women (n ¼ 114)
0.78
0.70
0.66
0.87
Mean score
SD
a
16.32 2.42 2.46 2.42 2.63 1.99 1.87 2.53 16.60 1.86 2.33 1.53 1.14 2.99 2.69 1.90 2.16 1.50 0.28 0.59 0.16 0.59 5.14 1.57 1.57 2.30 39.56
4.77 0.09 0.09 0.11 0.09 0.12 0.11 0.09 5.56 0.11 0.11 0.12 0.11 0.09 0.10 0.12 0.12 2.01 0.05 0.08 0.04 0.09 3.01 0.13 0.13 0.12 11.26
0.75
0.73
0.60
0.70
0.83
Exploratory factor analyses confirmed the validity of the sensations included in the questionnaire and, to some extent, the validity of our four-dimension model. However, item distribution and categorization differed slightly from the initial model. Although the initial theoretical framework based on the literature on orgasm in able-bodied and SCI populations and tested on individuals with SCI22 suggested four dimensions related to orgasmic sensations that were identified as cardiovascular, sensory, autonomic, and AD-related sensations, analyses showed a slightly different distribution among the four categories, which were renamed extragenital sensations, genital sensations and spasms, nociceptive sensations, and sweating responses. Although the new item distribution departs from our initial model, it remains consistent with previous findings from the orgasm literature, which has documented the existence of genital and extragenital sensations and muscular contractions during climax in able-bodied populations.8e10,13 This new pattern also is consistent with orgasm research in individuals with SCI, in whom this questionnaire was first tested, and who also report overall muscular tension during orgasm.21e23 For the secondary sensations category, analyses showed a new pattern of eight items
262
pertaining to involuntary contractions (abdominal and lower limbs), smooth muscle contractions leading to genital pulsations (penis, clitoris, vulva), and shivering, thus leading to a reshuffling of items that initially belonged to the muscular and autonomic dimensions. These results also are consistent with the literature on able-bodied individuals8e10,13 and those with SCI for whom genital sensations, muscular contractions, and muscular tension are reported as part of an orgasmic experience.12,20,22 Analyses performed on the negative AD sensations category identified three items related to unpleasant sensations (tightness, tension headaches, tingling), which initially belonged to the autonomic and AD-related dimensions. Although these orgasm-related sensations are less common in the general population, they are representative of the climactic experience of individuals living with SCI.21e23 Because they are indicative of high blood pressure and AD-related symptoms, it was deemed important to retain these items on our questionnaire. Analyses also showed a pattern of three items for the autonomic sensations category (hot flushes, perspiration, red spots), which initially pertained to the original autonomic dimension. Individual test-retest reliability analyses yielded better stability indices for the primary (r ¼ 0.63), secondary (r ¼ 0.76), and autonomic (r ¼ 0.74) sensations than for negative AD sensations (r ¼ 0.35). Although the limited experience of the general population with the negative AD sensations could account for its low stability, the type of stimulation used to achieve orgasm (ie, masturbation rather than intercourse) also might explain the relatively weak stability of the score for negative AD sensations. In fact, masturbation requires less physical effort than intercourse, thereby influencing the intensity of the body’s autonomic response. In addition, previous research has highlighted the extent to which the female sexual response cycle can be modulated by the stimulation type used to achieve orgasm.31 The duration and intensity of climax have been shown to vary significantly based on whether women reach orgasm by self-stimulation, intercourse, or stimulation of the vulva by their partner.31 Overall test-retest reliability was confirmed over a 2-week period. Results support the psychometric stability of the measurement and confirm its capacity to assess orgasm-related sensations over time, regardless of the stimulation type used to achieve climax. Considering that our assessment and the ORS questionnaire assess different dimensions of orgasm and that orgasm was achieved with various types of stimulation, convergent validity results were deemed satisfying. As mentioned in the Introduction, few instruments are currently available in the literature to assess orgasm, and although the ORS well describes the phenomenological experience of climax, as defined by a sensory dimension and a cognitive-affective dimension, the adjectives found to characterize climax do particularly not capture the specific bodily sensations that build up to or accompany climax. Therefore, the Bodily Sensations of Orgasm questionnaire provides a nice complement to the ORS to assess the overall phenomenon of orgasm.
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Despite offering a promising approach toward a much needed and clinically applicable assessment of orgasm in the able-bodied population, some methodologic limitations are inherent to our research. Although participants were instructed to complete the questionnaire within a 30-minute period after their climactic experience, possible variations in stimulation types and delays in completion time remain unaccounted for. Similarly, given the subjective design of the study, the research team was unable to verify that participants did in fact achieve orgasm, rather than intense sexual arousal, before completing their questionnaire at home. An in-laboratory follow-up study is required to objectively assess the presence of orgasm and to confirm the reliability of these preliminary data. The findings open the door to various follow-up studies, including comparative studies assessing the validity of the instrument in healthy and clinical populations. To refine the discriminant validity of the questionnaire, future research also could assess the effects of the emotional, rational, and subjective contexts surrounding orgasm and test the inclusion of some phenomenological items that were significant in the ORS.
CONCLUSION Despite an abundance of research on the climactic phase of the sexual response, very few assessment tools exist to measure orgasm. The two most widely used standardized instruments in the field—the IIEF18 and the FSFI19—only allow for the assessment of the frequency or the presence of orgasm but do not address the specific characteristics associated with climax. Thus, the present questionnaire provides a brief and psychometrically sound instrument to assess the bodily and physiologic sensations associated with orgasm. Used in conjunction with the ORS1 questionnaire on the phenomenological experience of orgasm, these two instruments allow for a comprehensive evaluation of the human climactic experience. Corresponding Author: Frédérique Courtois, PhD, Sexologie, Université du Québec à Montréal, Montreal, QC, Canada; E-mail: [email protected] Conflicts of Interest: The authors report no conflicts of interest. Funding: None.
STATEMENT OF AUTHORSHIP Category 1 (a) Conception and Design Samantha Dubray; Frédérique Courtois (b) Acquisition of Data Samantha Dubray; Dominic Beaulieu-Prévost; Frédérique Courtois (c) Analysis and Interpretation of Data Samantha Dubray; Marina Gérard; Dominic Beaulieu-Prévost; Frédérique Courtois
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Assessment of Orgasmic Sensations Category 2 (a) Drafting the Article Samantha Dubray; Frédérique Courtois (b) Revising It for Intellectual Content Samantha Dubray; Frédérique Courtois Category 3
263 Second international consultation on sexual dysfunctions. Paris: Editions 21; 2004. p. 409-468. 15. Kinsey AC, Pomeroy WD, Martin CE, et al. Sexual behavior in the human female. Philadelphia: WB Saunders; 1953. 16. Vance EB, Wagner NN. Written descriptions of orgasm: a study of sex differences. Arch Sex Behav 1976;5:87-98.
(a) Final Approval of the Completed Article Samantha Dubray; Marina Gérard; Dominic Beaulieu-Prévost; Frédérique Courtois
17. Warner JE. Peak of Sexual Response Questionnaire (PSRQ). In: Davis CM, Yarber WL, Bauserman R, et al, eds. Handbook of sexuality-related measures. Thousand Oaks, CA: Sage Publications; 1998. p. 256-257.
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18. Rosen R, Riley A, Wagner G, et al. The international index of scale for assessment of erectile dysfunction. Urology 1997; 49:822-830.
1. Mah K, Binik YM. The nature of human orgasm: a critical review of major trends. Clin Psychol Rev 2001;21:823-856. 2. Singer J, Singer I. Types of female orgasms. J Sex Res 1972; 8:255-267. 3. Sholty MJ, Ephross PH, Plaut SM, et al. Female orgasmic experience: a subjective study. Arch Sex Behav 1984; 13:155-164. 4. Crepault C. L’expérience orgastique. In: Crépault C, Levy JJ, Gratton H, eds. Sexologie contemporaine. Silley, Canada: Les Presses de l’Université du Québec; 1981. p. 271-281. 5. Clifford RE. Subjective sexual experience in college women. Arch Sex Behav 1978;7:183-197.
19. Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000;26:191-208. 20. Mah K, Binik YM. Do all orgasms feel alike? Evaluating a twodimensional model of the orgasm experience across gender and sexual context. J Sex Res 2002;39:104-113. 21. Courtois F, Charvier K, Leriche A, et al. Blood pressure changes during sexual stimulation, ejaculation and midodrine treatment in men with spinal cord injury. BJU 2008;101:331-337.
6. Fisher S. The female orgasm: psychology, physiology, fantasy. New York: Basic Books; 1973.
22. Courtois F, Charvier K, Leriche A, et al. Perceived physiological and orgasmic sensations at ejaculation in spinal cord injured men. J Sex Med 2008;5:2419-2430.
7. Tordjman G. Considérations physiologiques et cliniques des réponses sexuelles de l’homme et la femme. Cah Sexol Clin 1984;19:261-268.
23. Courtois F, Charvier K, Vézina JG, et al. Assessing and conceptualizing orgasm after spinal cord injury. BJU 2011; 108:1624-1633.
8. Masters WH, Johnson VE. Human sexual response. Boston: Little Brown; 1966.
24. Courtois F, Dubray S. The neurophysiology of orgasm. Curr Sex Health Rep 2014;6:201-210.
9. Bohlen JG, Held JP, Sanderson MO. The male orgasm: pelvic contractions measured by anal probe. Arch Sex Behav 1980; 9:503-521.
25. Thurmbikat P, Tophill PR. Autonomic dysreflexia. J R Soc Med 2003;96:618-619.
10. Exton M, Bondert A, Kruger T, et al. Cardiovascular and endocrine alterations after masturbation-induced orgasm in women. Psychosom Med 1999;61:280-289. 11. Alzate H. Vaginal eroticism: a replication study. Arch Sex Behav 1985;14:523-531. 12. Bentler PM, Peeler WH Jr. Models of female orgasm. Arch Sex Behav 1979;8:405-423. 13. Meston CM, Hull E, Levin RJ, et al. Women’s orgasm. In: Lue T, Basson R, Rosen R, et al, eds. Sexual medicine: sexual dysfunctions in men and women. Second international consultation on sexual dysfunctions. Paris: Editions 21; 2004. p. 783-850. 14. McMahon CG, Abdo C, Incrocci L, et al. Disorders of orgasm and ejaculation in men. In: Lue T, Basson R, Rosen R, et al, eds. Sexual medicine: sexual dysfunctions in men and women.
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26. Vallerand RJ, Halliwell WR. One method of trans-cultural validation of psychological questionnaires: implications for sports psychology. Can J Appl Sport Sci 1983;81:9-18. 27. Watkins MW. Monte Carlo PCA for parallel analysis [computer software]. State College, PA: ED & Psych Associates; 2002. 28. Beaulieu-Prévost D, Charneau-Simard C, Zadra A. Making sense of dream experiences: a multidimensional approach to beliefs about dreams. Dreaming 2009;19:119-134. 29. Tabachnick BG, Fidell LS. Using multivariate statistics. Boston: Allyn & Bacon; 2007. 30. Chivers ML, Seto MC, Lalumière ML, et al. Agreement of selfreported and genital measures of sexual arousal in men and women: a meta-analysis. Arch Sex Behav 2010;39:5-56. 31. Basson R. A model of women’s sexual arousal. J Sex Marital Ther 2002;28:1-10.
Validation of a Self-Report Questionnaire Assessing the Bodily and Physiological Sensations of Orgasm Samantha Dubray, PhD,1 Marina Gérard, MA,1 Dominic Beaulieu-Prévost, PhD,2 and Frédérique Courtois, PhD2
ABSTRACT
Introduction: Despite a plethora of research on sexual functioning during the past decades, the field is still lacking standardized measurements specifically characterizing orgasm. Although several validated tools are available to assess sexual function in healthy and clinical populations, items on orgasm are limited to frequency or dichotomous responses. A neurophysiologic model of orgasm developed from previous research in able-bodied and spinally injured populations offers a promising framework for the construction of a new questionnaire. Aim: To develop and validate a brief self-report measurement of orgasm by the assessment of bodily and physiologic sensations perceived during climax by able-bodied individuals. Although the currently available tool focuses on the phenomenological sensations associated with climax, the goal of this questionnaire was to capture the more specific genital and extragenital sensations associated with orgasm. Main Outcome Measures: The current Bodily Sensations of Orgasm questionnaire and the Orgasm Rating Scale. Methods: Data from previous research conducted on individuals with spinal cord injury and the available empirical literature provided a pool of 45 items organized into four categories, which were reviewed by an expert panel. Upon review, a 28-item questionnaire was created and administered to a community sample of 227 participants, including men and women, 18 to 73 years old. Results: Exploratory factor analyses supported the four-factor model, in which orgasm is comprised of extragenital sensations, genital sensations and spasms, nociceptive sensations, and sweating responses. Overall, a high degree of internal consistency was found for the final 22-item questionnaire (Cronbach a ¼ 0.87), with individual reliability coefficients showing moderate to high internal consistency (r ¼ 0.65e0.79) for each dimension. Overall temporal stability of the measurement was acceptable (r ¼ 0.74). Using the Orgasm Rating Scale, satisfying convergent validity was confirmed, thereby indicating that the two measurements are complementary. Conclusion: The Bodily Sensations of Orgasm questionnaire allows for a brief evaluation of the physical and physiologic sensations associated with orgasm. Findings also suggest perceptual differences between men and women with regard to climax, with women reporting a larger repertoire of climactic sensations during orgasm. Dubray S, Gérard M, Beaulieu-Prévost D, Courtois F. Validation of a Self-Report Questionnaire Assessing the Bodily and Physiological Sensations of Orgasm. J Sex Med 2017;14:255e263. Copyright 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Orgasm; Spinal Cord Injury; Cardiovascular Responses; Autonomic Responses; Genital Sensations; Extragenital Sensations
INTRODUCTION
Received September 15, 2016. Accepted December 8, 2016. 1
Department of Psychology Université du Québec à Montréal, Montreal, Canada;
2
Department of Sexology, Université du Québec à Montréal, Montreal, Canada
Copyright ª 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsxm.2016.12.006
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Despite much public interest and repeated attempts by the scientific community to characterize the human orgasmic experience, orgasm research is still marked by sex-specific definitions and an overall lack of unifying framework. This is particularly problematic in clinical practice for the assessment and treatment of orgasm difficulties in various populations, including those with spinal cord injury (SCI). The existence of multiple typologies also plays a key role in the lack of clear, agreed-upon characteristics of the human orgasm.1 Labels such as “mixed 255
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orgasms,”2,3 coital vs extra-coital orgasms,4 clitoral vs vaginal orgasms in women,5,6 and penile vs seminal orgasm in men7 contribute to the confusion. Despite recent attempts, the field has not reached a universally satisfying definition of orgasm. The pleasurable dimension of climax seems to be the only unifying theme thus far,6 albeit subject to considerable individual variability. Masters and Johnson8 examined such variability in their physiologic studies investigating the bodily and genito-pelvic changes occurring during climax. Since then, most studies have centered on the genital physiologic changes occurring during orgasm,1 focusing primarily on the muscle contractions (perineal and anal) recorded in men and women.9,10 Some researchers have attempted to broaden the definition of orgasm by highlighting the psychological state(s) associated with climax1 and by combining the psychological and physiologic dimensions that characterize the human orgasm.11,12 However, a major obstacle has been the emphasis put on dichotomous accounts of orgasm (vaginal vs clitoral orgasms, mind vs body sensations, occurrence vs nonoccurrence), rather than on the various physiologic sensations associated with the overall climactic experience. Two recent international consensuses on orgasm have been reached and they depart from the previous focus on the characteristic muscular contractions. In fact, these consensuses define women’s orgasmic experience as a “variable and transient peak sensation of intense pleasure creating an altered state of consciousness, usually accompanied with involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often uterine and anal contractions, in addition to myotonia that resolves the sexually induced vasocongestion, and usually accompanied with a sensation of well-being and contentment”13 and men’s as a “cerebral processing of pudendal nerve sensory stimuli resulting from increased pressure in the posterior urethra, sensory stimuli arising from the verumontanum and contraction of the urethral bulb and accessory sexual organs.”14 Although these definitions constitute a step toward the operationalization of orgasm as a concept, they are still associated with two major issues. First, they suggest that orgasm differs between men and women, despite physiologic and subjective evidence of similar orgasmic responses in men and women1,15,16; second, they fail to distinguish between intense sexual arousal and orgasm for women. This absence of a unifying description of orgasm translates to a lack of universally accepted assessment tools. In 1998, Warner17 designed and tested the Peak of Sexual Response Questionnaire to assess the psycho-affective dimensions of the female orgasm; however, this measurement failed to differentiate between orgasm and sexual arousal. Currently, the International Index of Erectile Function (IIEF)18 and the Female Sexual Function Index (FSFI),19 two widely used assessment tools in sex research, dedicate only one and three items to orgasm, respectively. Although these two well-validated measurements are useful for the assessment of overall sexual function, they do not address the physical sensations characterizing orgasm or pleasure, and they do not
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provide a unique tool to assess women and men. More recently, Mah and Binik20 developed the Orgasm Rating Scale (ORS) to assess the phenomenological sensations associated with orgasm in men and women. Their two-dimensional model conceptualizes orgasm as sensory and cognitive-affective characteristics, but the phenomenological adjectives do not particularly capture the specific bodily sensations that are associated with climax. Courtois et al21e24 developed a brief assessment tool organized by four categories of specific bodily sensations associated with the human orgasmic experience, as described in the literature on physiologic recordings in men and women during climax.8,22e24 Similar to the able-bodied population, findings from the SCI population describe climax as associated with different bodily responses, which also are observed during another phenomenon called “autonomic dysreflexia” (AD).25 AD is a clinical condition that is usually triggered by nociceptive stimulation, but also ejaculation, in individuals with lesions above T6 (ie, above the major sympathetic outflow from the spinal cord) and is associated with a sympathetic storm characterized by signs such as hypertension (systolic blood pressure > 20 mm Hg), tachycardia, hyperventilation, muscular contractions, and shivering.25 In ablebodied individuals, this autonomic storm triggered by climax is normally under supraspinal control24 and immediately tempered down to normal within 2 minutes after ejaculation.22e24 The similarities between the able-bodied and SCI populations led Courtois et al21e24 to postulate that orgasm is a nonpathologic equivalent of AD. Based on their data, Courtois et al23 developed a 33-item questionnaire to test the hypothesis that orgasm is related to mild AD symptoms. Their questionnaire assessed sensations, muscular contractions, autonomic arousal, and dysreflexic sensations. Preliminary data suggest that Courtois et al’s neurophysiologic model of orgasm is consistent with the many genital and extragenital events recorded during orgasm in men with and without SCI.8,22e24 Further research with able-bodied men and women is needed to establish the validity of their model. Therefore, the purpose of the present study was to validate the questionnaire in able-bodied men and women. Ultimately, the goal is to offer an assessment tool that could help patients identify the sensations of orgasm, for example, anorgasmic women identifying the specific bodily sensations that build up to and characterize orgasm. This study was designed to assess the validity of a tool measuring the specific bodily sensations characterizing orgasm, as experienced by men and women, and consistent with our four-factor model of climax as a non-pathologic equivalent of AD. The following hypotheses guided the research: (i) the validity of our four-factor model should be confirmed, (ii) the sensory dimension of our questionnaire should be mostly correlated to the ORS sensory dimension and the remaining dimensions should be moderately correlated to the ORS, and (iii) women should show a larger sensory repertoire than men during climax. J Sex Med 2017;14:255e263
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METHODS
Table 1. Demographic characteristics of sample
Participants
Variable
Men
Women
Two hundred twenty-seven healthy participants were recruited from a university campus, from surrounding areas, and by word of mouth. Sample size calculation was determined based on the number of items and variables under study, and recruitment was stopped once the adequate number of participants was reached. Eligibility criteria included being at least 18 years of age, having no history of sexual dysfunction, and having no current major physical or mental health condition. The final sample consisted of 227 participants 18 to 73 years old (115 women, mean age ¼ 34.9 years, SD ¼ 14.9; 112 men, mean age ¼ 38.2 years, SD ¼ 13.7). Detailed demographic data for the sample are presented in Table 1. Most were educated, heterosexual individuals who were single or in a committed relationship. All participants signed an informed consent form approved by the university ethics committee.
Sexual orientation, n (%) Heterosexual Same-sex oriented Bisexual Relationship status, n (%) Single Common law Married Separated Divorced Widowed Annual income, n >$15,000, % $15,000e$25,000, % $26,000e$35,000, % $36,000e$45,000, % >$46,000, % Education, n High school, % College level, % Undergraduate, % Masters, % PhD, %
112 98 (87.5) 6 (5.4) 8 (7.1) 112 60 (53.6) 27 (24.1) 13 (11.6) 10 (8.9) 2 (1.8) 0 82 30.45 22.95 12.20 20.73 14.63 82 13.42 17.07 48.78 14.63 6.10
115 90 (78.3) 3 (2.6) 22 (19.1) 115 53 (46.1) 36 (31.3) 12 (10.4) 8 (7.0) 5 (4.3) 1 (0.9) 94 39.36 30.85 9.57 9.57 10.64 94 7.45 25.53 50 12.77 4.26
Questionnaire Development The questionnaire was constructed based on previous findings from able-bodied men and women6e11 and individuals with SCI.21e24 Based on a thorough literature review conducted by the research team using PubMed, PsychInfo, and PsychArticles, a list of sensations and reactions associated with orgasm and experienced by men and women was compiled, yielding a pool of 45 items. These items were sorted into the following four categories according to their physiologic bases and Courtois et al’s neurophysiologic model of orgasm: cardiovascular sensations, muscular sensations, autonomic sensations, and negative sensations associated with AD (eg, headache, sensation of tightness). To account for sex differences, two versions of the questionnaire were created, with three items differing according to sex-specific responses (eg, clitoral pulsation vs penile contraction). Using a five-point Likert scale of 0 to 4 (0 ¼ not at all, 1 ¼ somewhat, 2 ¼ moderately, 3 ¼ a lot, 4 ¼ extremely), participants were asked to rate the extent to which they experienced each of these sensations during ejaculation or orgasm. Construct validity was supported by a panel of four experts in sexual dysfunctions who were asked to rate each item on a dichotomous scale (adequate vs inadequate) and suggest individual comments. This initial review decreased the number of items from 45 to 28 and led to the rewording of some items. As part of a pre-assessment, the reformatted questionnaire was distributed to 50 participants to assess its internal consistency, face validity, and accuracy of its categories. Initial analyses computed on those 50 questionnaires yielded satisfying indices of internal consistency; therefore, it was distributed to the remaining participants (n ¼ 177) for a total of 227 completed questionnaires.
in French were translated into English using the method of Vallerand,26 consisting of a translation into English by an English-speaking translator and the English version being translated back into French by a French-speaking translator, and the inconsistencies were discussed to reach a consensus. A second measurement used for construct validity was the ORS,20 which assesses the phenomenological experience of orgasm using 28 items organized into two categories: a sensory dimension and a cognitive-affective dimension. A French adaptation of the ORS and a 0 (not at all) to 4 (extremely) Likert scale were used for our sample.
Procedure Participants were asked to complete the two questionnaires at home within 30 minutes of a sexual activity of their choosing resulting in orgasm. Each version of the question started with the question, “To what extent did you feel the following signs during ejaculation or orgasm?” To assess reliability, participants were asked to complete these two measurements at a second time point 2 to 3 weeks after the first completion. Hard copies and online versions of the forms were available.
Main Outcome Measures The final questionnaire included 28 bodily and physiologic sensations associated with orgasm and organized into four categories: cardiovascular, muscular, autonomic, and dysreflexic sensations. Each item was scored on a five-point Likert scale ranging from 0 (not at all) to 4 (extremely). The items developed J Sex Med 2017;14:255e263
RESULTS Descriptive Analyses All participants achieved orgasm (N ¼ 227), mostly after selfstimulation (41.4%) and penile-vaginal intercourse (19.8%).
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For the type of sexual activities leading to orgasm, data showed some similarities and differences between men and women in preferred activities. Overall, men and women relied mostly on self-stimulation (44.6% for men and 38.3% for women) and penile-vaginal penetration to reach orgasm (27.7% for men and 12.2% for women). Interestingly, women reported using a wider variety of sexual activities to reach orgasm compared with men. Most participants reported more cardiovascular (mean ¼ 12.81, SD ¼ 5.03), muscular (mean ¼ 12.80, SD ¼ 4.94), and autonomic (mean ¼ 14.58, SD ¼ 6.24) sensations, with few, if any, AD-related sensations (mean ¼ 1.08, SD ¼ 1.601; Table 2). Cardiovascular sensations after orgasm included tachycardia (“accelerated heartbeat,” “stronger heartbeat”) and hyperventilation (“accelerated breathing”) as the highest rated items. Items
pertaining to clitoral or penile contraction and “overall muscular tension” were scored the highest among the muscular sensations associated with orgasm. Autonomic sensations such as “clitoral or gland hypersensitivity,” “ejaculation,” and “hot flushes” also were largely reported. The most frequent item relating to the negative sensations of AD endorsed by participants was “feeling of tightness,” albeit to a minimal extent. Table 2 also presents significant sex differences, with women indicating feeling a significantly larger overall repertoire of sensations during orgasm than men (t224 ¼ 3,357, P < .001) based on the degree to which they endorsed each item. Moreover, women reported more cardiovascular (t224 ¼ 4,625, P < .001) and muscular (t224 ¼ 3.152, P < .0023) sensations compared with men. Data gathered from the ORS showed that within the sensory dimension, adjectives such as “throbbing,” “pulsating,” and
Table 2. Participants’ data on bodily and physiologic sensations during orgasm Participants (N ¼ 227)
Men (n ¼ 112)
Women (n ¼ 115)
Questionnaire items
Mean score
SD
Mean score
SD
Mean score
SD
Cardiovascular dimension 1. Increased blood pressure 2. Increased heart rate 3. Heart beating stronger 4. Irregular heart beating 5. Faster breathing 6. Choppy breathing (apnea) 7. Moaning Muscular dimension 8. Clitoral or penile pulsation 9. Vulvar or testicular pulsation 10. Anal contraction 11. Urethral contraction 12. Overall muscular tension 13. Lower limb spasms 14. Abdominal contractions Autonomic dimension 15. Hypersensitive clitoris 16. Ejaculation 17. Hardening nipples 18. Shivers or goosebumps 19. Hot flashes 20. Reddening of ears or skin rash 21. Perspiration 22. Hot and cold 23. Facial tingling 24. Skull tingling 25. Urge to urinate Autonomic dysreflexia dimension 26. Feeling of tightness 27. Intracranial pressure 28. Cranial pulsations or headache Total sensations
12.81 1.82 2.20 2.31 0.60 2.17 1.54 2.16 12.80 2.74 1.91 1.17 1.13 2.47 1.62 1.77 14.58 2.76 2.08 1.48 1.50 2.04 1.70 1.22 0.50 0.41 0.48 0.86 1.02 0.50 0.33 0.20 41.20
5.03 1.14 1.03 1.05 0.95 1.11 1.31 1.15 4.97 0.99 1.22 1.14 1.19 1.03 1.32 1.28 6.24 1.15 1.50 1.29 1.26 1.27 1.34 107 0.86 0.82 0.85 1.04 1.601 0.83 0.63 0.54 14.37
11.31 1.77 1.98 2.17 0.61 1.92 1.09 1.78 11.76 2.78 1.48 1.20 1.31 2.29 1.32 1.38 13.92 2.53 3.11 1.09 1.46 1.77 0.95 1.17 0.39 0.39 0.44 0.67 2.38 0.40 0.38 0.23 39.38
5.13 0.11 0.10 0.10 0.09 010 0.11 0.11 4.83 0.08 0.12 0.11 0.12 0.09 0.12 0.11 6.35 0.12 0.08 0.12 0.12 0.11 0.11 0.10 0.07 0.07 0.07 0.89 2.18 0.07 0.06 0.05 15.0
14.28 1.87 2.42 2.46 0.59 2.42 1.99 2.53 13.81 2.69 2.33 1.14 0.95 2.63 1.90 2.16 15.22 2.99 1.06 1.86 1.53 2.30 1.57 1.26 0.59 0.59 0.47 1.05 2.48 0.59 0.28 0.16 45.78
4.49 0.11 0.09 0.09 0.09 0.11 0.12 0.09 4.93 0.10 0.11 0.11 0.10 0.09 0.12 0.12 6.09 0.09 0.12 0.11 0.12 0.12 0.13 0.10 0.09 0.09 0.08 0.10 2.16 0.08 0.05 0.04 13.65
Sex differences (t224) 4.62*
3.15*
1.57
0.33
3.36*
*P < .001. J Sex Med 2017;14:255e263
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Table 3. Participants’ data on the Orgasm Rating Scale by Mah and Binik20 Participants (N ¼ 201)
Men (n ¼ 104)
Questionnaire items
Mean score
SD
Mean score
SD
Mean score
SD
Sensory dimension 22. Building 23. Swelling 24. Flowing 26. Flooding 19. Flushing 27. Spreading 25. Spurting 18. Shooting 14. Throbbing 15. Pulsating 16. Shuddering 20. Trembling 17. Quivering Affective dimension 31. Close 32. Loving 29. Passionate 30. Tender 21. Unifying 28. Ecstatic 11. Elated 12. Euphoric 13. Rapturous Cognitive dimension 3. Pleasurable 9. Satisfying 33. Fulfilling 1. Relaxing 2. Peaceful 8. Soothing Total sensations
21.03 2.31 1.66 1.49 1.13 0.50 1.85 1.91 0.89 2.18 2.55 1.99 1.00 1.56 19.42 1.82 2.16 2.19 1.81 2.17 2.44 2.40 2.24 2.18 16.88 3.54 3.18 2.89 2.42 2.65 2.21 57.32
9.20 1.30 1.32 1.24 1.29 0.89 1.33 1.42 1.16 1.24 1.14 1.31 1.17 1.35 8.73 1.43 1.39 1.29 1.30 1.39 1.23 1.20 1.27 1.28 4.183 0.66 0.79 1.10 1.29 1.13 1.28 19.079
21.22 2.06 1.50 1.68 1.34 0.48 1.80 2.61 0.86 2.05 2.45 1.94 0.83 1.63 18.75 1.75 2.11 2.14 1.77 2.00 2.33 2.46 2.13 2.07 16.73 3.53 3.10 2.81 2.56 2.68 2.05 56.70
9.96 1.31 1.26 1.30 1.25 0.96 1.22 1.15 1.18 1.32 1.17 1.34 1.05 1.36 9.02 1.41 1.35 1.39 1.33 1.38 1.20 1.15 1.28 1.31 3.96 0.65 0.78 1.14 1.18 1.06 1.29 20.07
20.82 2.57 1.84 1.28 0.90 0.53 1.90 1.17 0.93 2.31 2.66 2.04 1.19 1.49 20.13 1.90 2.22 2.24 1.85 2.35 2.56 2.34 2.37 2.30 17.04 3.54 3.27 2.99 2.27 2.61 2.38 57.99
8.36 1.24 1.36 1.15 1.30 0.80 1.44 1.30 1.14 1.15 1.11 1.28 1.26 1.34 8.39 1.47 1.43 1.16 1.27 1.38 1.25 1.26 1.26 1.24 4.43 0.66 0.80 1.06 1.40 1.20 1.25 18.04
“building” received the highest ratings (Table 3). All items related to the cognitive-affective dimension received a score higher than 2 (ie, ranging from “moderately” to “a lot”), with a noticeable emphasis on “pleasurable” and “satisfying.” There were no significant sex differences for the sensations felt during orgasm on this questionnaire (Table 3).
Factor Analysis Exploratory factor analyses were achieved on the questionnaire using a Monte Carlo principal component analysis27 and an28,29 Only items with a saturation value of at least 0.30 were retained; items characterized by a complex structure (ie, saturation value of 0.30 on more than one factor) were discarded, except for those with very large saturation differences. The analyses showed a final solution retaining 22 of the initial 28 items, suppressing “irregular heartbeat,” “urethral contraction,” J Sex Med 2017;14:255e263
Women (n ¼ 97) Sex differences (t) 0.306
1.120
0.532
0.480
“skull tingling,” “urge to urinate,” “hot and cold,” and “ejaculation” (Table 4). Sampling adequacy increased from 0.82 to 0.84. Factor analyses showed four dimensions as originally developed, with some items slightly reorganized. The first factor accounts for 13.1% of the variance and includes seven items related to salient cardiovascular and muscular sensations; the second factor accounts for 11.2% of the variance and includes eight items related to involuntary contractions of skeletal and smooth muscles; the third factor accounts for 7.4% of the variance and includes four items related to negative sensations rarely occurring in non-SCI populations; and the fourth factor accounts for 7% of the variance and includes three items related to diffuse autonomic sensations. The four categories were renamed according to their respective proportion of variance and new item composition. The first category was renamed “extragenital sensations” because it
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Table 4. Final results of exploratory factorial analyses after varimax rotation Questionnaire items 1. Increased heartbeat 2. Heart beating stronger 3. Faster breathing 4. Overall muscular tension 5. Choppy breathing (apnea) 6. Increased blood pressure 7. Moaning 8. Hardening nipples 9. Vulvar or testicular pulsation 10. Shivers or goosebumps 11. Anal contraction 12. Hypersensitive clitoris or glans 13. Clitoral or penile pulsation 14. Lower limb spasms 15. Abdominal contraction 16. Intracranial pressure 17. Feeling of tightness 18. Cranial pulsations or headache 19. Facial tingling 20. Reddening of ears or skin rash 21. Perspiration 22. Hot flashes
Factor 1—primary sensations
Factor 2—secondary sensations
Factor 3—negative AD sensations
Factor 4—diffuse autonomic sensations
0.731 0.705 0.630 0.521 0.454 0.442 0.347 0.641 0.621 0.506 0.502 0.407 0.407 0.402 0.390 0.708 0.623 0.5617 0.339 0.752 0.635 0.406
AD ¼ autonomic dysreflexia.
referred to items such as heart beating, breathing, blood pressure, and moaning during orgasm; the second category was renamed “genital sensations and spasms” because it referred to items such as genital pulsation, hypersensitive clitoris or glans, hardening nipples, and anal and abdominal contractions during orgasm; the third category was renamed “nociceptive sensations” because it referred to items such as headaches, intracranial pressure, and facial tingling during orgasm; the fourth category was renamed “sweating responses” because it referred to items such as perspiration, hot flashes, and reddening of the skin.
evaluative dimensions showed moderate (a ¼ 0.82 and a ¼ 0.73, respectively) internal consistency. Test-retest reliability was assessed by Pearson correlations between time 1 and 2 scores (2e3 weeks later) on the two completed questionnaires. Test-retest reliability for the overall score was acceptable (r ¼ 0.74), with individual correlations ranging from 0.76 for genital sensations and spasms associated with orgasm to 0.35 for nociceptive responses, which showed more variability over time.
Convergent Validity Internal Consistency and Test-Retest Reliability Internal consistency and test-retest reliability were assessed. Overall, a high degree of internal consistency was found for the 22 items of the questionnaire, as indicated by a Cronbach a value of 0.87 (Table 5). Further reliability analyses on the four categories showed appropriate levels of internal consistency, with the primary (a ¼ 0.79) and secondary (a ¼ 0.77) dimensions showing moderate internal consistency and the negative AD (a ¼ 0.65) and autonomic (a ¼ 0.69) dimensions presenting acceptable internal consistency. To confirm the psychometric properties of the construct and to assess the validity of our French adaptation, similar analyses were computed for the ORS using the Cronbach a statistic. Reliability tests yielded excellent internal consistency for the overall questionnaire (a ¼ 0.92) and for the affective dimension (a ¼ 0.90). The sensory and
Pearson correlations between the present questionnaire and the ORS indicated a significant correlation (r ¼ 0.54, P < .001, two-tailed) between the overall scores. For the individual dimensions, the dimension on genital sensations shared the strongest correlation with the ORS sensory dimension (r ¼ 0.55, P < .001), followed by the dimension extragenital sensations and the ORS sensory dimension (r ¼ 0.38, P < .001), the dimension nociceptive sensations and the ORS sensory dimension (r ¼ 0.36, P < .001), and the dimension sweating responses and the ORS sensory dimension (r ¼ 0.27, P < .001).
DISCUSSION One of the goals of the present study was to develop a brief, valid, and reliable self-report measurement of orgasm that provides J Sex Med 2017;14:255e263
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Assessment of Orgasmic Sensations
Table 5. Internal consistency of final dimensions Participants (N ¼ 226)
Men (n ¼ 112)
Questionnaire items
Mean score
SD
a
Mean score
SD
a
Primary sensations 2. Increased heart rate 3. Heart beating stronger 5. Faster breathing 12. Overall muscular tension 6. Choppy breathing (apnea) 1. Increased blood pressure 7. Moaning Secondary sensations 17. Hardening nipples 9. Vulvar or testicular pulsation 18. Shivers or goosebumps 10. Anal contraction 15. Hypersensitive clitoris or glans 8. Clitoral or penile pulsation 13. Lower limb spasms 14. Abdominal contraction Negative autonomic dysreflexia sensations 27. Intracranial pressure 26. Feeling of tightness 28. Cranial pulsations or headache 23. Facial tingling Diffuse autonomic sensations 20. Reddening of ears or skin rash 21. Perspiration 19. Hot flashes Total sensations
14.67 2.20 2.31 2.17 2.47 1.54 1.82 2.16 14.94 1.48 1.91 1.50 1.17 2.76 2.74 1.62 1.77 1.43 0.33 0.50 0.20 0.41 4.52 1.70 1.22 2.04 35.56
5.22 1.03 1.05 1.11 1.03 1.31 1.14 1.15 5.96 1.29 1.22 1.26 1.14 1.15 0.99 1.32 1.28 1.99 0.63 0.83 0.54 0.82 2.91 1.34 107 1.27 12.47
0.79
13 1.98 2.17 1.92 2.29 1.09 1.77 1.78 13.24 1.09 1.48 1.46 1.20 2.53 2.78 1.32 1.38 1.36 0.38 0.40 0.23 0.39 3.89 0.95 1.17 1.77 31.50
5.14 0.10 0.10 010 0.09 0.11 0.11 0.11 5.90 0.12 0.12 0.12 0.11 0.12 0.08 0.12 0.11 1.97 0.06 0.07 0.05 0.07 2.68 0.11 0.10 0.11 12.37
0.79
a concrete picture of the genital and extragenital sensations associated with climax. From a clinical perspective, the aim of this research was to help identify a repertoire of sensations associated with orgasm. Descriptive analyses of the overall sample (N ¼ 227) showed that cardiovascular, muscular, and autonomic sensations are pertinent to the assessment of climax for women and men, with some sensations being less representative of participants’ orgasmic experience. Analyses also showed significant sex differences, with women reporting a significantly larger repertoire of climatic sensations compared with men despite relying on similar stimulation types to reach orgasm. These differences suggest that women are better able to describe their sensations during climax or that they are more in tune with their internal sensations. Interestingly, research looking at sexual concordance, that is, the agreement between subjective and genital sexual arousal, has shown a sex difference in the opposite direction, with women demonstrating lower concordance levels than men in most studies.30 However, sex differences characterizing awareness of sexual arousal might not hold true for orgasm. J Sex Med 2017;14:255e263
0.77
0.65
0.69
0.87
Women (n ¼ 114)
0.78
0.70
0.66
0.87
Mean score
SD
a
16.32 2.42 2.46 2.42 2.63 1.99 1.87 2.53 16.60 1.86 2.33 1.53 1.14 2.99 2.69 1.90 2.16 1.50 0.28 0.59 0.16 0.59 5.14 1.57 1.57 2.30 39.56
4.77 0.09 0.09 0.11 0.09 0.12 0.11 0.09 5.56 0.11 0.11 0.12 0.11 0.09 0.10 0.12 0.12 2.01 0.05 0.08 0.04 0.09 3.01 0.13 0.13 0.12 11.26
0.75
0.73
0.60
0.70
0.83
Exploratory factor analyses confirmed the validity of the sensations included in the questionnaire and, to some extent, the validity of our four-dimension model. However, item distribution and categorization differed slightly from the initial model. Although the initial theoretical framework based on the literature on orgasm in able-bodied and SCI populations and tested on individuals with SCI22 suggested four dimensions related to orgasmic sensations that were identified as cardiovascular, sensory, autonomic, and AD-related sensations, analyses showed a slightly different distribution among the four categories, which were renamed extragenital sensations, genital sensations and spasms, nociceptive sensations, and sweating responses. Although the new item distribution departs from our initial model, it remains consistent with previous findings from the orgasm literature, which has documented the existence of genital and extragenital sensations and muscular contractions during climax in able-bodied populations.8e10,13 This new pattern also is consistent with orgasm research in individuals with SCI, in whom this questionnaire was first tested, and who also report overall muscular tension during orgasm.21e23 For the secondary sensations category, analyses showed a new pattern of eight items
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pertaining to involuntary contractions (abdominal and lower limbs), smooth muscle contractions leading to genital pulsations (penis, clitoris, vulva), and shivering, thus leading to a reshuffling of items that initially belonged to the muscular and autonomic dimensions. These results also are consistent with the literature on able-bodied individuals8e10,13 and those with SCI for whom genital sensations, muscular contractions, and muscular tension are reported as part of an orgasmic experience.12,20,22 Analyses performed on the negative AD sensations category identified three items related to unpleasant sensations (tightness, tension headaches, tingling), which initially belonged to the autonomic and AD-related dimensions. Although these orgasm-related sensations are less common in the general population, they are representative of the climactic experience of individuals living with SCI.21e23 Because they are indicative of high blood pressure and AD-related symptoms, it was deemed important to retain these items on our questionnaire. Analyses also showed a pattern of three items for the autonomic sensations category (hot flushes, perspiration, red spots), which initially pertained to the original autonomic dimension. Individual test-retest reliability analyses yielded better stability indices for the primary (r ¼ 0.63), secondary (r ¼ 0.76), and autonomic (r ¼ 0.74) sensations than for negative AD sensations (r ¼ 0.35). Although the limited experience of the general population with the negative AD sensations could account for its low stability, the type of stimulation used to achieve orgasm (ie, masturbation rather than intercourse) also might explain the relatively weak stability of the score for negative AD sensations. In fact, masturbation requires less physical effort than intercourse, thereby influencing the intensity of the body’s autonomic response. In addition, previous research has highlighted the extent to which the female sexual response cycle can be modulated by the stimulation type used to achieve orgasm.31 The duration and intensity of climax have been shown to vary significantly based on whether women reach orgasm by self-stimulation, intercourse, or stimulation of the vulva by their partner.31 Overall test-retest reliability was confirmed over a 2-week period. Results support the psychometric stability of the measurement and confirm its capacity to assess orgasm-related sensations over time, regardless of the stimulation type used to achieve climax. Considering that our assessment and the ORS questionnaire assess different dimensions of orgasm and that orgasm was achieved with various types of stimulation, convergent validity results were deemed satisfying. As mentioned in the Introduction, few instruments are currently available in the literature to assess orgasm, and although the ORS well describes the phenomenological experience of climax, as defined by a sensory dimension and a cognitive-affective dimension, the adjectives found to characterize climax do particularly not capture the specific bodily sensations that build up to or accompany climax. Therefore, the Bodily Sensations of Orgasm questionnaire provides a nice complement to the ORS to assess the overall phenomenon of orgasm.
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Despite offering a promising approach toward a much needed and clinically applicable assessment of orgasm in the able-bodied population, some methodologic limitations are inherent to our research. Although participants were instructed to complete the questionnaire within a 30-minute period after their climactic experience, possible variations in stimulation types and delays in completion time remain unaccounted for. Similarly, given the subjective design of the study, the research team was unable to verify that participants did in fact achieve orgasm, rather than intense sexual arousal, before completing their questionnaire at home. An in-laboratory follow-up study is required to objectively assess the presence of orgasm and to confirm the reliability of these preliminary data. The findings open the door to various follow-up studies, including comparative studies assessing the validity of the instrument in healthy and clinical populations. To refine the discriminant validity of the questionnaire, future research also could assess the effects of the emotional, rational, and subjective contexts surrounding orgasm and test the inclusion of some phenomenological items that were significant in the ORS.
CONCLUSION Despite an abundance of research on the climactic phase of the sexual response, very few assessment tools exist to measure orgasm. The two most widely used standardized instruments in the field—the IIEF18 and the FSFI19—only allow for the assessment of the frequency or the presence of orgasm but do not address the specific characteristics associated with climax. Thus, the present questionnaire provides a brief and psychometrically sound instrument to assess the bodily and physiologic sensations associated with orgasm. Used in conjunction with the ORS1 questionnaire on the phenomenological experience of orgasm, these two instruments allow for a comprehensive evaluation of the human climactic experience. Corresponding Author: Frédérique Courtois, PhD, Sexologie, Université du Québec à Montréal, Montreal, QC, Canada; E-mail: [email protected] Conflicts of Interest: The authors report no conflicts of interest. Funding: None.
STATEMENT OF AUTHORSHIP Category 1 (a) Conception and Design Samantha Dubray; Frédérique Courtois (b) Acquisition of Data Samantha Dubray; Dominic Beaulieu-Prévost; Frédérique Courtois (c) Analysis and Interpretation of Data Samantha Dubray; Marina Gérard; Dominic Beaulieu-Prévost; Frédérique Courtois
J Sex Med 2017;14:255e263
Assessment of Orgasmic Sensations Category 2 (a) Drafting the Article Samantha Dubray; Frédérique Courtois (b) Revising It for Intellectual Content Samantha Dubray; Frédérique Courtois Category 3
263 Second international consultation on sexual dysfunctions. Paris: Editions 21; 2004. p. 409-468. 15. Kinsey AC, Pomeroy WD, Martin CE, et al. Sexual behavior in the human female. Philadelphia: WB Saunders; 1953. 16. Vance EB, Wagner NN. Written descriptions of orgasm: a study of sex differences. Arch Sex Behav 1976;5:87-98.
(a) Final Approval of the Completed Article Samantha Dubray; Marina Gérard; Dominic Beaulieu-Prévost; Frédérique Courtois
17. Warner JE. Peak of Sexual Response Questionnaire (PSRQ). In: Davis CM, Yarber WL, Bauserman R, et al, eds. Handbook of sexuality-related measures. Thousand Oaks, CA: Sage Publications; 1998. p. 256-257.
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