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Journal of Sexual Medicine - 2010 - Brody - The Relative Health Benefits of Different Sexual Activities

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Journal of Sexual Medicine - 2010 - Brody - The Relative Health Benefits of Different Sexual Activities

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1336

REVIEW

The Relative Health Benefits of Different Sexual Activities jsm_1677 1336..1361

Stuart Brody, PhD

University of the West of Scotland, School of Social Sciences, Paisley, UK

DOI: 10.1111/j.1743-6109.2009.01677.x

ABSTRACT

Introduction. Although many studies examine purported risks associated with sexual activities, few examine poten-
tial physical and mental health benefits, and even fewer incorporate the scientifically essential differentiation of
specific sexual behaviors.
Aims. This review provides an overview of studies examining potential health benefits of various sexual activities,
with a focus on the effects of different sexual activities.
Methods. Review of peer-reviewed literature.
Main Outcome Measures. Findings on the associations between distinct sexual activities and various indices of
psychological and physical function.
Results. A wide range of better psychological and physiological health indices are associated specifically with
penile–vaginal intercourse. Other sexual activities have weaker, no, or (in the cases of masturbation and anal
intercourse) inverse associations with health indices. Condom use appears to impair some benefits of penile–vaginal
intercourse. Only a few of the research designs allow for causal inferences.
Conclusions. The health benefits associated with specifically penile–vaginal intercourse should inform a new
evidence-based approach to sexual medicine, sex education, and a broad range of medical and psychological
consultations. Brody S. The relative health benefits of different sexual activities. J Sex Med 2010;7:1336–1361.
Key Words. Sexual Intercourse; Health Behaviors; Masturbation

Introduction Aim
This review aims to provide an overview of studies
M any studies have examined purported health
risks associated with sexual activities, but few
studies have examined the potential physical and
examining potential psychological and physiologi-
cal health benefits or correlates of various sexual
activities, with a primary focus on studies differen-
mental health benefits of sexual activities. Even tiating the effects of distinct sexual activities. An
fewer studies have incorporated the scientifically additional aim is a discussion of implications for
essential differentiation of specific sexual behaviors. education, research, and clinical assessment and
Sexual medicine should be concerned not only with practice.
the treatment of ill sexual health, but the specific
evidence-based promotion of positive health.
An overview of the empirical evidence on psy-
Methods and Main Outcome Measures
chological and physiological differences between
sexual behaviors should inform the practice of Studies were identified from various sources,
sexual medicine, as well as other fields, including including those studies conducted in the laborato-
general medical practice, sex education, psycho- ries of the author and colleagues, previous briefer
therapy (both sexuality topics as well as sexuality as overview papers incorporating some aspects of
an aspect of character), and research in physiology health benefits associated with sexual behaviors
and psychology. [1–3], and searches in PubMed and PsycInfo. The

J Sex Med 2010;7:1336–1361 © 2010 International Society for Sexual Medicine

present review differs from those earlier reviews in virtuous circles) needs to be pondered in any cor-
its breadth and (with the exception of one [1]) relational or risk-factor epidemiological research
greater attention to differences between sexual design. Retrospective case-control studies might
behaviors. There is also more discussion of be subject to biased recall and/or insufficient
methodological issues, as well as a discussion of matching of cases and controls. Associations can
implications for education, research, and clinical also be a result of a shared unmeasured third factor
assessment and treatment. The presentation is (such as genetic influence) that affects both the
organized largely by the nature of the health topics, nominal outcome variable and the nominal predic-
which are found under the major headings of Psy- tor variable. These issues apply to risk-factor epi-
chological and Physiological factors (some topics, demiological studies in general, not only to studies
such as pain, could have arguably been placed under with potentially controversial findings.
either major heading). The topics range from “soft” Differences between health aspects of specific
variables such as relationship quality to “hard” vari- sexual behaviors (e.g., penile–vaginal intercourse
ables such as biochemical measures. The nature of [PVI], masturbation, sex with a partner other than
the research designs varies greatly. Although PVI) are highlighted. Some of the studies examine
experimental designs generally are viewed as offer- whether one has engaged at all in a sexual behavior
ing firmer evidence than correlational or risk-factor in a given time period, others examine frequency,
epidemiological designs, the reader is advised to others examine combinations of sexual repertoires,
look for convergent evidence using differing others examine manner of orgasm elicitation, and
samples and methods, optimally with examination others examine gross modification of the nominal
of some potential confounding variables. sexual behavior (e.g., condom use or clitoral mas-
A few studies noted in this review adjust for the turbation during PVI).
tendency of some people to underreport behaviors The discussion will address the compatibility
that they consider to be socially undesirable. of the observed results with both evolutionary
Although it might be conjectured that elevated and early psychoanalytic theories. These two
social desirability response scores might measure a approaches to understanding human behavior
propensity to actually behave in a socially desirable focus respectively on which characteristics have
manner, there is some evidence to the contrary: been most adaptive in the course of human evolu-
social desirability scores were higher than norma- tion (in the sense of increasing the likelihood of
tive values in large groups of men and women transmitting one’s genes), and the mental opera-
convicted of intimate partner abuse [4]. Social tions (many out of awareness) that motivate behav-
desirability response bias scores have been found ior and are rooted in problems of childhood
to mask the ability of greater life stress and poorer psychosexual development (with implications
psychological coping skills to predict athletic inju- for chronological adults). The discussion also
ries [5]. Social desirability response bias scores describes some physiological and other possible
predict discrepancies between (indirectly) mea- bases for the observed effects.
sured and self-reported caloric consumption [6–8].
However, social desirability responding varies Results
between individuals and situations, and as such, is
not always a confounding factor. Interestingly, Psychological Factors
social desirability responding might itself be asso- Satisfaction with One’s Mental Health
ciated with predictors of poorer physical health In a large representative sample of the Swedish
outcomes [9,10]. population, PVI frequency was a significant pre-
Most cross-sectional studies that focus on dictor of both men’s and women’s greater satisfac-
infirm populations have been excluded, because of tion with their mental health [11]. In contrast,
the risk of reverse causality (inability to engage in masturbation was inversely associated with mental
some sexual behavior because of the infirmity). In health satisfaction in the multivariate analyses that
contrast, the review includes studies that find controlled for other sexual behavior frequencies,
sexual behavior differences in healthy adults with and partnered sexual behaviors other than PVI
regard to subtle but important longitudinal predic- were uncorrelated with mental health satisfaction
tors of future morbidity or mortality (such as heart [11]. The same large Swedish survey also revealed
rate variability, and blood pressure stress reactiv- that women who had experienced vaginal orgasm
ity). However, the issue of causal direction (includ- (defined quite conservatively as having “had an
ing bi-directional causality, as in vicious or orgasm solely through the movement of the penis

J Sex Med 2010;7:1336–1361

in the vagina”) were more satisfied with their use of distraction as a coping mechanism [18].
mental health than the minority of women who Studies of Swiss and American patients found that
had only experienced orgasms through direct cli- alexithymia was associated with hypoactive sexual
toral manipulation [12]. The Swedish survey used desire [19], sexually dysfunctions, and paraphilias
in those studies was reported to not be affected by [20].
social desirability response bias [13,14]. FSI (but not frequency of either masturbation
or of partnered sexual activity excluding PVI), as
Intimate Relationship Quality
measured by both sexual behavior diaries and
In a small study of Portuguese women, frequency
recall, was associated with less alexithymia (hence,
of PVI (FSI) correlated positively with Perceived
more emotional integration) as measured by the
Relationship Quality Components (PRQC)
Toronto Alexithymia Scale (TAS-20) in a sample
Inventory dimensions of satisfaction, intimacy,
of healthy German women [21]. High social desir-
trust, passion, and love [15]. In contrast, frequency
ability scorers were excluded from the analysis.
of partnered sexual behaviors other than PVI was
In addition to the use of the validated psycho-
uncorrelated with the PRQC dimensions. Mastur-
metric measure of alexithymia, the association
bation frequency was inversely associated with
between habitual sexual behaviors and the labora-
love. PVI orgasmic frequency correlated positively
tory measured integration of vaginal responses
with the PRQC dimensions of satisfaction, inti-
into psychological arousal can inform the under-
macy, passion, and love. PVI orgasmic consistency
standing of emotional integration. Research has
(proportion of PVI occasions resulting in PVI
revealed that the awareness and integration of
orgasm) was inversely associated with masturba-
vaginal sensations into women’s subjective sense of
tion frequency. When PVI frequency was con-
sexual arousal varies as a function of their habitual
trolled in a partial correlation procedure,
orgasm sources.
noncoital sex frequency was associated with less
Several studies have concurrently examined
global relationship satisfaction, and noncoital
women’s subjective and vaginal response to erotica
partnered orgasm frequency was associated with
(videotape and/or fantasy), and in contrast to
less love. Social desirability scores did not con-
studies with men, most of the studies showed that
found the associations [15]. These results are fairly
overall, there was poor concordance between
consistent with an American study which found
women’s vaginal and subjective sexual arousal
that 100% of maritally and sexually satisfied
responses. Based on the inference that women who
wives—but only 68% of the maritally satisfied yet
have PVI orgasms were more likely than coitally
sexually dissatisfied wives—had PVI among their
anorgasmic women to successfully integrate their
sexual activities in the past week, that masturbating
physical and emotional feelings, it was hypothe-
the male to orgasm was reported by 4% of the
sized [22] that greater orgasmic consistency during
maritally and sexually satisfied but 30% of the
PVI (but not during other sexual behaviors) would
maritally and sexually dissatisfied women, and that
be associated with better concordance of vaginal
cunnilingus frequency was unrelated to satisfac-
and subjective sexual arousal.
tion [16]. Although not emphasized in Kinsey’s
Healthy menopausal Dutch women completed
writings, Kinsey researchers found that “marital
a questionnaire on their PVI, masturbation, and
happiness” was associated with female coital
noncoital partner sexual frequencies for a 1-month
orgasm [17]. In a large representative sample of
period, and noted for each occasion whether
the Swedish population, independent multivariate
orgasm occurred; orgasm consistency was the per-
predictors of men’s relationship satisfaction were
centage of each sexual event type resulting in
greater frequency of PVI, but lesser frequencies of
orgasm [22]. In the laboratory, they were exposed
masturbation, anal sex, and oral sex (for women,
to erotic videotapes, nonerotic (control) video-
the independent multivariate predictors were
tapes, and also asked to engage in epochs of sexual
simply greater frequency of PVI and lesser fre-
fantasy. They rated their sexual arousal, and their
quency of masturbation) [11].
vaginal response was measured with a vaginal pho-
Alexithymia toplethysmograph that assesses vaginal vaso-
Alexithymia is a relative inability to perceive, iden- congestion (the device allowed measurement of
tify, and express emotions. It is a personality trait vaginal pulse amplitude). The correlation
associated with some forms of psychopathology, (z-transformed) of subjective and vaginal response
associated with the use of immature psychological was the index of concordance. As hypothesized,
defense mechanisms and also associated with the concordance was significantly associated with PVI

J Sex Med 2010;7:1336–1361

orgasm consistency, but not consistency of orgasm PVI in favor of other or no sexual behaviors, with
during other sexual activities: women who regu- noxious consequences for mental health and inti-
larly had PVI orgasms had excellent concordance mate relationships.
of vaginal and subjective arousal, but other women In a sample of healthy Portuguese women,
(even those who orgasmed reliably through means vaginal orgasm (triggered solely by PVI) was asso-
other than PVI) had a functional disconnection ciated with less use of immature defenses [24].
between their vaginal arousal and their mental Defenses were measured with the Defense Style
experience. The results were not confounded by Questionnaire, a well-validated (including associa-
social desirability responding. tion with various psychopathologies) measure of
Also of note were the findings that (i) orgasm immature, neurotic, and mature defenses [26,30].
consistency rates were similar for PVI and for non- Vaginal orgasm was associated with less overall use
coital sexual activities, and (ii) PVI and masturba- of immature defenses, as well as with less use of the
tion orgasm consistency were uncorrelated. This specific component immature defenses: somatiza-
latter finding implies that most of the coital tion, dissociation, displacement, autistic fantasy,
orgasms were most likely not masturbatory clitoral devaluation, and isolation of affect. Orgasm from
orgasms, but real vaginal orgasms (i.e., female clitoral stimulation or combined clitoral–
orgasm induced by penile–vaginal stimulation per intercourse stimulation was not associated with
se). The latter finding also has implications for sex less use of immature defenses, and was associated
therapy, as masturbation and intercourse orgasms with more use of some immature defenses (e.g.,
are substantially different. orgasm from noncoital partner activity in the past
The same pattern and magnitude of vaginal- month was associated with the defense of dissocia-
subjective arousal concordance results were found tion). In one multivariate analysis, both (i) any
in a replication study [23] involving young Dutch masturbation orgasm in the past month and (ii)
women (all of whom had current partners; in the less vaginal orgasm consistency, made independent
first study a few of the women did not have current contributions to the statistical prediction of imma-
partners). ture defenses. In another regression analysis, (i)
It is specifically PVI orgasm consistency that is any use of extrinsic clitoral stimulation for inter-
related to integration of vaginal response into the course orgasm and (ii) lack of any vaginal orgasm,
appraisal of arousal. An analogy might thus be made independent contributions to the statistical
made between these findings and the aforemen- prediction of immature defenses. Vaginally anor-
tioned ones on alexithymia: in both cases an gasmic women had immature defenses scores com-
index of specifically and exclusively PVI reward parable to those of established (depression, social
(frequency [21] or orgasm consistency) was anxiety disorder, panic disorder, and obsessive–
associated with an index of greater awareness compulsive disorder) outpatient psychiatric
of feeling (vaginal sensation or differentiated groups. Results were not confounded by social
emotions). desirability responding [24].
A study of predominantly Scottish women who
Immature Psychological Defense Mechanisms completed an anonymous Internet-based survey
Psychological defenses are processes, generally [31] provided a cross-cultural replication of the
operating outside awareness, that reduce distress results obtained in the Portuguese sample. Greater
caused by emotional conflict. Immature (maladap- use of immature psychological defense mechanisms
tive) defense mechanisms involve a distortion of was associated with lesser vaginal orgasm consis-
reality and/or impairment of awareness, and they tency, with any orgasm from clitoral masturbation
are associated with a variety of indices of poorer during PVI, and with greater frequency of mastur-
mental health and relatedness, including psycho- bation orgasm. Immature psychological defense
logical immaturity and lesser ability to relate inti- mechanisms were also associated with greater fre-
mately with the opposite sex [24,25]. Immature quency of masturbation during PVI, and with fre-
defense mechanisms are associated with a variety quency and orgasm frequency of both anal sex and
of psychiatric disorders [26–29]. According to vibrator use. Immature psychological defense
early psychoanalytic theories, psychological mechanisms were also associated with greater
immaturity (psychosexual immaturity, with its quantity of alcohol consumed before sex [31].
concomitant greater use of immature defense Condoms impair many aspects of PVI, includ-
mechanisms) could lead to inhibition of frequency ing intimacy and sensation [32]. Freud opined that
and appreciation (including vaginal orgasm) of condom use during PVI, like sexual activities other

J Sex Med 2010;7:1336–1361

than PVI, led to a detrimental effect on orgasm ship duration, and there were no differences in
that fueled the neuroses. More psychologically depression between those in and not currently in
immature people might prefer condoms for PVI as a relationship. The investigators suggested that
a means of reducing intimacy and/or such reduc- their results (the results were reportedly repli-
tion might hinder psychological growth. Indeed, cated, but the details of the replication have not yet
research indicates that condom users do have been published in detail [39]) might be a result of
poorer relationship quality with their partners intravaginal absorption of seminal prostaglandins
[25,33]. In a study of healthy Portuguese adults, (as well as possibly seminal testosterone, luteiniz-
frequency of PVI with condoms correlated directly ing hormone [LH], and oxytocin) improving the
with use of immature defenses. In contrast, fre- mood of women, but the researchers did not
quency of PVI without condoms correlated measure the relevant chemicals in the individual
inversely with use of both immature and neurotic research participants. Even among women who
defenses. Results were not confounded by rela- rarely or never used condoms, depressive symp-
tionship status, age, cohabitation, or social desir- toms were associated with urinating after inter-
ability responding. Regression analyses revealed course [39], which the investigators noted would
that immature defenses were independently pre- decrease the quantity of seminal components that
dicted by condom use for PVI and by masturba- could be absorbed. Compared with women who
tion orgasms (for both sexes). For women, did not use condoms at all, consistent condom
additional predictors were orgasm from clitoral users were both more depressed at baseline and
masturbation during PVI, and lack of vaginal also evidenced a worsening of their mood during a
orgasm. The results are consistent with condom longitudinal study in the United States [33].
use during PVI being associated with psychologi- Although there might be a direct chemical antide-
cal immaturity and predisposition to poorer pressant effect of semen absorbed from the vagina,
mental health [25]. the large difference in mood and suicidality might
also be a result of intercourse with condoms not
Depression really being intercourse, but something akin to
Higher masturbation frequency (and even the mutual masturbation with the same latex device.
desire for more masturbation) is associated with One group that has both elevated rates of mas-
depression [34–36], and masturbation is associated turbation [40] and of partnered sexual activities
with less happiness [37]. The association of mas- other than PVI is homosexuals. Large representa-
turbation with depression is unlikely to be a result tive surveys have found much higher rates of sui-
of simply a lack of PVI, because more masturba- cidal ideation, mood disorders, substance use
tion and less PVI make independent contributions disorders, and other psychiatric disorders in homo-
to less satisfaction with relationships, sex life, life sexual men and homosexual women than
in general, and one’s mental health (the multivari- in their heterosexual counterparts (including in
ate analyses also examined some partnered sexual studies conducted in what is probably one of the
activities other than PVI, and revealed that anal most pro-homosexual countries: The Netherlands)
and oral sex frequency also have independent [41–43]. Although it was noted that among homo-
inverse associations with some of the satisfaction sexual men, perceived discrimination was associ-
indices) [11]. ated with suicidality [43], it was not made clear that
It is likely that only unfettered, real PVI has the defensive process of attributing one’s bad feel-
important mood-enhancing beneﬁts. A study of ings to other people is itself part of the process of
young women in the United States found that not depression for some people [44]. In a large
only did Beck Depression Inventory scores worsen UK-based survey, 61.7% of homosexual men who
with increasing time since last PVI (i.e., lower FSI had sex with a man in the past year reported receiv-
is associated with more depression), but the use of ing ejaculate in their mouth (although 97.2%
condoms obliterated the apparent antidepressant reported performing fellatio at all) and 42.2%
effects of PVI [38]. Depressive symptoms and reported receptive anal intercourse without a
suicide attempts among women who used condom in the past year [45] (unfortunately there
condoms were proportional to the consistency of was not more precise quantiﬁcation of frequency of
condom use: more condom use means more the behaviors, except that in the updated version of
depression and more suicide attempts. The the survey, 24% reported receptive anal intercourse
depression and suicide association with condom without a condom in the past month, and an addi-
use was not because of confounding by relation- tional 18.5% reported it over a month but less than

J Sex Med 2010;7:1336–1361

a year ago [46]). Thus, most homosexual men (who sexual activity, particularly for PVI, the most emo-
were active in the past year) appear to have the tionally intimate sexual activity, might be aversive
opportunity for absorption of seminal components to many schizophrenics. Failure to develop a stable
at some location within the alimentary canal. The integrated self might also impair appreciation of
combination of high rates of depression despite the PVI, particularly PVI orgasm. These aspects of the
opportunity for absorption of seminal components schizophrenic situation might be viewed on a con-
suggests explanations including some combination tinuum with the rest of the population, such that
of: site-specific or sex-specific effects of seminal there are many nonpsychotics who are would be
component absorption (i.e., vaginal absorption has overburdened by the emotional intimacy and over-
important antidepressant effects not afforded by whelming pleasure that PVI can provide.
alimentary absorption), variations in frequency of Czech female schizophrenics, manic-depressives,
seminal exposure, or overwhelming genetic or psy- neurotics, anorexics, and a control group of gyneco-
chosexual developmental effects linking homo- logical spa patients were interviewed regarding
sexuality and depression. A recent large twin study their sexual histories [50]. The manic-depressive
revealed that not only do nonheterosexual men and (bipolar) patients did not differ from the control
women have significantly higher neuroticism and group in their prevalence of PVI orgasmic
psychoticism scores than heterosexuals (implying response, but the schizophrenics, neurotics, and
elevated psychiatric risk), but also that there is a anorexics all had lower rates of coital orgasm. Thus,
significant genetic correlation between nonhetero- it was not only the schizophrenics, but women with
sexuality and both neuroticism and psychoticism, some quite different forms of psychological prob-
but no significant environmental correlation with lems that were impaired in their ability to orgasm
nonheterosexuality. This implies that any common from intercourse.
cause of both nonheterosexuality and psychiatric Similarly, women with neurotic disorders were
risk is likely to be genetic rather than environmen- less likely to have PVI orgasms than were a group
tal [47]. of women without neurotic disorders. However,
they were no less likely to have orgasms from
Other Psychiatric Disorders direct clitoral stimulation [51].
In a study [48] comparing Scottish schizophrenics A similar pattern was found in a Czechoslovak
with controls of the same age, sex, and postal code, study comparing prostitutes with nonprostitutes
it was found that the schizophrenic men were [52]. The prostitutes were less likely than the
several times more likely to report a zero FSI than control group to orgasm during PVI. Prostitutes
were controls, and less likely to report intercourse (especially street prostitutes) have a high preva-
of at least weekly. However, they were not more lence of various forms of psychopathology, includ-
likely to report abstaining from masturbation or ing antisocial personality disorder, borderline
masturbating at least once weekly. Similarly, personality disorder, dissociative disorder, depres-
schizophrenic Scotswomen in the study were more sion, schizophrenia, and other psychiatric and
likely to report a zero FSI than controls, but they personality disorders [53]. This psychopathology,
did not differ in their masturbation frequency which includes psychological processes dissociat-
from controls. ing the experience of PVI, might contribute to the
Although some antipsychotic medications high mortality rate of prostitutes [53,54].
might cause sexual dysfunction and low desire (for Successful nonhormonal treatment of erectile
some, at least in part through prolactinergic dysfunction led to an increase in FSI, a concomi-
mechanisms) [49], there is also evidence that tant decrease in masturbation frequency, and a
untreated schizophrenics have low desire for sex decrease in psychiatric symptoms [55].
with a partner, and other studies also indicate that
schizophrenics have low rates of partnered sexual Physiological Factors
activity but elevated rates of masturbation [49]. Analgesia and Pain
Besides the issue of social skills deficits, the low Prostatodynia is characterized by urinary symp-
PVI frequencies among schizophrenics might be toms and pelvic pain suggestive of prostatitis but
in part the result of wanting to avoid intimacy. with a nonpathological prostate examination and
Apparently the tendency toward anhedonia without signs of inflammation or infection in pro-
(inability to experience pleasure) among schizo- static secretions. In a report on prostatodynia [56]
phrenics does not limit masturbation, only PVI in United Nations peacekeeping forces, the occur-
pleasure. The presence of another person during rence of the disorder was associated with not

J Sex Med 2010;7:1336–1361

having PVI, and it resolved with recommence- vaginal orgasm history and vaginal orgasm rating.
ment of PVI. However, masturbation led to either The report also noted previous studies that differ-
no improvement or to an exacerbation of pain entiated homosexual and heterosexual men and
symptoms. women on the basis of other aspects of gait, and
Vaginal stimulation has been shown to have discussed functional musculoskeletal issues, the
substantial analgesic properties, far greater than effect of the musculature on sexual function, and
clitoral stimulation [57]. The effects are not attrib- implications for sexual therapy [61].
utable to distraction [58], and appear to not be a
result of an opiate-type process [59]. One risk for Metabolism and Nutrition
women with some sexual pain disorders is the A study of healthy German adults revealed that a
learned avoidance of the potentially most analgesic (physician-measured) slimmer waist (for men and
and psychologically fulfilling sexual behavior. the sexes combined) and slimmer hips (for men and
women) were each associated with greater PVI
Vaginal and Pelvic Muscle Function
frequency [62]. In contrast, slimmer waist and hips
A review of the literature on female genito–genital
were associated with lesser masturbation frequency
reflexes concluded that vaginal intercourse helps
(men and the sexes combined), and noncoital part-
to maintain vaginal and pelvic function, including
nered sexual activity had a less consistent associa-
through penile thrusting triggering reflex muscu-
tion with slimness. Waist and hip circumference
lar contractions that maintain and improve vaginal
were associated inversely with PVI importance for
function [60]. There were also indications that the
men. Cohabitation status was an independent pre-
presence of seminal component prostaglandin
dictor of PVI frequency, and did not confound the
PGE1 in the vagina after ejaculation might main-
association of slimness with sexual behavior. Of
tain vaginal oxygenation and blood flow. Improv-
note, the effects were obtained despite exclusion of
ing blood flow could be expected to support sexual
obese and medically unfit subjects from the study.
response and vaginal health (and perhaps general
Persons with high social desirability scores were
health). Using condoms deprives women of many
also excluded from the analyses.
benefits, including those blood flow and oxygen-
In addition to issues of attractiveness (likely
ation benefits.
rooted in evolutionary processes that favor
Functional Musculoskeletal Disturbance healthier partners), higher body fat levels are asso-
Some theories of personality and psychotherapy ciated with lower testosterone levels and with less
have proposed a link between chronic muscle brain dopamine activity, and overeating tends to
blocks and disturbances of both character and increase brain serotonergic tone. These factors
sexual function [61]. Regardless of whether the might impair sexual desire and/or function, espe-
sites of chronic muscle blocks (or chronic muscle cially the most complex and evolutionarily relevant
flaccidity) have metaphorical meaning, they might sexual behavior: PVI [62]. Similar differential
be both an indicator and mechanism for impaired sexual behavior associations with slimness have
function, including sexual function. A study exam- been observed in other species: when presented
ined the association of general everyday body with slim females, both slim and obese male rats
movement with history of vaginal orgasm by hold the females and lick the vaginal region, but
asking healthy young Belgian women with known obese males have a much lower PVI frequency
histories of either vaginal orgasm or vaginal anor- than the slimmer males [63]. Although in some
gasmia (50% from each group) to be videotaped human societies, there is a tendency for men to
walking on the street; their vaginal orgasmic status find heavier women more attractive, these societies
was judged by trained (in the Functional- tend to be characterized by food scarcity (or
Sexological school) sexologists blind to their limited food storage), making the issue of energy
history [61]. History of vaginal orgasm was diag- storage within the potential fetus bearer more evo-
nosable at far better than chance level (81.25% lutionarily salient than the issue of the various
correct). The gait of the vaginally orgasmic morbidities associated with overweight (factors
women was characterized by being physiologically that become more salient when food scarcity is not
normal, and manifested fluidity, energy, sensuality, a major issue) [64].
freedom, and absence of both flaccid and locked In societies in which food scarcity is not a
muscles (greater pelvic and vertebral rotation were problem, people who enjoy PVI might make
characteristic of the vaginally orgasmic women). efforts to remain sexually desirable to partners by
Clitoral orgasm history was unrelated to both staying slim. Studies have indicated that adults

J Sex Med 2010;7:1336–1361

who report having been physically or verbally greater HRV was associated with greater PVI fre-
abused in childhood or adolescence are more likely quency, but not frequency of either masturbation
than others to be overweight or obese [65]. More or of noncoital partnered sex [71]. HRV was also
importantly, a review of longitudinal studies associated with greater subjective importance of
reported that hostility, anger, and depression lon- PVI. These results were obtained after exclusion
gitudinally predict the development of higher of persons with high social desirability scores. The
levels of adiposity (and other aspects of the meta- results were replicated in a larger healthy German
bolic syndrome) [66]. It would not be surprising if sample [70] and also found to be unconfounded by
a history of dissatisfaction with intimate relation- the various candidate variables that were exam-
ships leads to self-destructive and intimacy avoid- ined. There were no sex differences in these sta-
ing behaviors (including specifically minimizing tistical relationships. Thus, specifically PVI but
PVI frequency). not other sexual behavior was associated with an
Ascorbic acid (vitamin C) has many functions important measure of better homeostasis, better
(including reduction of approach anxiety, modula- parasympathetic tone, lower mortality risk, and
tion of brain dopaminergic and noradrenergic better psychological function (including better
activity, cardiovascular support, oxytocin secre- relatedness). Of course, given the correlational
tion, and reduction of stress [67,68]), some of design, it is unclear to what extent better HRV
which might support sexual behavior and some of leads to more PVI and appreciation thereof, to
which might only be manifest at high doses. A what extent more PVI leads to better HRV, and to
double-blind randomized controlled trial of high- what extent some other factors (such as genetics)
dose (14 days of 3,000 mg/day sustained release) influence both HRV and PVI.
ascorbic acid in healthy young German adults led In the first of the two HRV studies [71], but not
to the finding that ascorbic acid caused an increase the second [70], greater PVI (but not other sexual
in PVI frequency, but not in frequency of mastur- behaviors) was also associated with lower resting
bation or of partnered sexual behaviors other than diastolic blood pressure. In an Italian study, newly
PVI [69]. The ascorbic acid also improved mood. diagnosed, never treated hypertensive married
The results were not confounded by social desir- men aged 40–49 had an FSI 25% lower than a
ability responding. Exploratory analyses revealed control group of men who had blood pressure in
that the effect was largely a result of the response the normotensive range [72].
of women in the study. However, the seeming sex Blood pressure reactivity to acute stress is a risk
difference might be attributed to young women factor for the development of hypertension and
perhaps being more likely than young men to left ventricular hypertrophy, as well as for myocar-
fulfill rapidly any increased desire (caused by more dial infarction or death in susceptible persons. It is
optimal nutrition) within the 14-day recording mediated by increased sympathetic and decreased
period. parasympathetic nervous system activity (the latter
being largely a withdrawal of vagus activity). In a
Cardiovascular Health study of healthy German adults, blood pressure
Resting heart rate variability (HRV, an index of was recorded at baseline, after being instructed to
autonomic cardiac regulation) reflects heart rate prepare a speech, after giving the speech to an
fluctuations in response to subtle homeostatic unsupportive audience for 5 minutes (plus 5
demands, including the differing autonomic minutes of time-pressured verbal arithmetic), and
effects of inspiration and exhalation. Resting HRV after a 10-minute recovery period, as per the pro-
is driven largely by the parasympathetic nervous tocol of the standardized Trier Social Stressor Test
system (particularly the vagus nerve), which also [73]. The blood pressure responses were analyzed
has a role in sexual arousal. HRV is longitudinally as a categorical function of whether participant
predictive of lower mortality rates among both diaries indicated that they engaged at all (in the
normals and persons with a history of heart disease past 14 days) in PVI, masturbation, or partnered
[70,71]. Psychophysiological studies found that sexual activity in the absence of PVI the same day
greater HRV is associated with indices of better [73]. Persons with high social desirability scores
mood, attention, self-regulation, and responsive- were excluded from the analyses. Persons who
ness to emotional experience. HRV is also associ- engaged in PVI but no other sexual behaviors
ated with fewer antisocial personality features, less (except partnered sexual activity the same day as
sexual dysfunction, and perhaps with pair-bonding PVI) during the fortnight had not only statistically
processes [70,71]. In healthy German adults, significantly less, but markedly less, blood pressure

J Sex Med 2010;7:1336–1361

increase to the stressor than did persons engaging Pre-Eclampsia

in other or no sexual activities. They also had Among the several studies reporting on the asso-
faster recovery from the stressor (which some ciation between pre-eclampsia and less (unfet-
researchers suggest might be even more important tered) PVI is the report concluding that “birth
for health than more moderate stress reactivity). control methods that prevent sperm exposure may
Persons who engaged in PVI but also engaged in play a role in the etiology of pre-eclampsia” (p.
either masturbation or exclusively noncoital part- 3143) [75] and those reporting an odds ratio of
nered sexual activity on other days had results 17.1 for pre-eclampsia associated with the combi-
intermediate between the PVI-only group and the nation of <4 vs. >12 months of “cohabitation” in
noncoital partnered sexual activity only or mastur- combination with barrier contraceptive use [76].
bation only groups (who did little or no better than Fellatio is also associated with decreased risk of
the no-sex group) [73]. Overall, masturbation fre- pre-eclampsia: 44% of pre-eclamptic women, but
quency was correlated with higher (worse) blood 82% of controls reported fellatio before the index
pressure reactivity. pregnancy [77]; however, that study did not assess
Results were not confounded by any of the frequency of PVI.
many demographic, physiological, psychological,
or behavioral (including exercise minutes per Hormonal and Neurohormonal Effects
week) candidate variables that were evaluated. The In addition to any effects of testosterone levels
blood pressure reactivity difference between dif- supporting PVI frequency, there is evidence of the
ferent sexual behavior groups was at least numeri- causal arrow pointing in the other direction [78].
cally greater than differences associated with the Successful restoration of erectile function, through
many psychological, physiological, social, and any of a variety of forms of nonhormonal treat-
behavioral variables that have been examined in ment (psychological, surgical, vacuum device,
the sizeable psychophysiological literature on yohimbine, prostaglandin E1) led to a return of
blood pressure stress reactivity in normals [73]. testosterone levels to the typical range for the
The pattern of results suggest not only that it population. Men who responded to treatment with
is specifically PVI (rather than other sexual an FSI of at least 8 per month showed greater
behaviors) that is associated with optimal cardio- testosterone increases than men who responded
vascular “protection” from stress, but also that the with an FSI of 1–7, who in turn showed greater
benefits are not simply due to having a partner. testosterone levels than nonresponders [78]. As the
The study indicated that engaging in masturba- authors noted: “Since the pre-therapy low test-
tion or even partnered sexual behavior that osterone levels were independent of the aetiology
excludes PVI on some days detracts from the ben- of impotence, we hypothesize that this hormonal
efits of PVI. There are several possible reasons pattern is related to the loss of sexual activity, as
for this effect, including: (i) partial (rather than demonstrated by its normalization with the
complete) avoidance of PVI in favor of other resumption of coital activity after different thera-
sexual activities, (ii) approaching PVI with a psy- pies. The corollary is that sexual activity may feed
chological set akin to the other sexual activities, itself throughout the increase in testosterone
and (iii) the beneficial effects of PVI being par- levels” (p. 385). The same research group found
tially offset by untoward effects of the other that the FSI response to sildenafil or tadalafil treat-
sexual activities. ment also led to a corresponding decrease in serum
A within-subjects laboratory study [74] com- LH [79]. These latter results need to be consid-
pared the exercise value (oxygen uptake, and blood ered in light of recent experimental evidence that
pressure and heart rate stimulation) of men chronic administration of sildenafil itself stimu-
engaged in: masturbation, masturbation by a lates testosterone secretion in mice [80].
partner, and two intercourse positions (man on top In a randomized trial of coitus (vs. no coitus) for
and woman on top). PVI produced greater dura- the treatment of Nigerian women’s menopausal
tion of heart rate elevation and substantially hot flashes, PVI was found to decrease hot flash
greater oxygen uptake at orgasm than the other symptoms, an effect perhaps mediated by the
activities [74]. Although the exercise value was observed changes in LH and follicle-stimulating
greatest for male on top (probably at least in part hormone (FSH) [81].
because of greater motor activity), the woman on German women reporting earlier age at first
top PVI was still superior to either of the manual intercourse (in all cases, postpubertal) had less
forms of penile stimulation. intense cortisol increases in response to a stan-

J Sex Med 2010;7:1336–1361

dardized laboratory stressor (a nonsignificant and might also underlie differences between the
trend in the same direction was observed for sexual satisfaction associated with various sexual
males), and faster recovery from the stressor [82]. activities [11,12,87].
In contrast, age at first intercourse was unrelated
to the cortisol response to low-dose adrenocorti- Biochemistry of Ejaculate
cotropic hormone (ACTH) stimulation. Although In a sample of men with erectile dysfunction,
shared genetic factors might influence both age at greater frequency of masturbation was associated
first intercourse and cortisol response to stress with greater prostate specific antigen levels (mas-
(with its many important untoward psychological turbation was also associated with prostate abnor-
and physiological sequelae), cortisol might impair malities, including a swollen or tender prostate)
dopaminergic function, thereby impairing initia- [88].
tion of and response to sexual activity [82]. A comparison of semen ejaculated by the same
PVI leads to increases in dopamine levels in the men from masturbation and from PVI revealed
nucleus accumbens (a region important in at least that the volume of seminal plasma, sperm count,
attention to reward-related stimuli) of female sperm motility, and percentage of morphologically
hamsters. The brain stimulation effect was absent healthy sperm were all greater in the PVI samples
in females who were mounted as often by males than in the masturbation samples [89]. In addition,
but did not manage to have intercourse because of markers of the secretory function of the prostate
a hamster chastity belt: tape placed over their were significantly better for the PVI samples,
vaginal openings [83]. The chastity belt still which led the authors to infer that PVI was asso-
allowed the females whatever benefits are afforded ciated with a better prostatic secretory function
by being held and having stimulation of their than masturbation. Similarly, other researchers
external genital region by the males mounting [90] also used a within-subjects design and found
them, but that was insufficient to trigger the brain that compared with masturbatory samples of
stimulation effect provided by PVI. Thus, being ejaculate, men’s PVI samples had a larger semen
vaginally stimulated by a penis provides substan- volume and increased concentrations and total
tially greater stimulation of the nucleus accumbens amounts of prostaglandin E and polyamines
than that provided by partner masturbation of the (putrescine, spermidine, and spermine). Thus, PVI
external genital region. involved better prostate function, larger semen
The postorgasmic prolactin surge is associated volume, better quality sperm, as well as elimina-
with reduction of sexual drive and with some tion of more waste products.
aspects of sexual satiety (whether directly through In another study [91] that found that PVI
inhibitory central dopaminergic and peripheral yielded far better sperm volume and sperm quality
processes, or as a process secondary to dopamin- than did masturbation (an effect which was most
ergic effects) [84,85]. Dopaminergic signals from dramatic in men with seminal deficiencies), the
the hypothalamus are a primary determinant of authors noted that although the greater sperm
prolactin release, and dopaminergic neurons volume in the intercourse samples could be
(including mesolimbic dopaminergic neurons) in explained by greater sexual stimulation leading to
turn can be modulated by prolactin; a lengthier “greater loading of the vas deferens prior to ejacu-
discussion of these issues and a broader review of lation” (p 192), they could not explain the basis for
studies of prolactin control of sexual drive is avail- the difference in sperm morphology (quality),
able elsewhere [84,85]. In an experimental exami- which is “determined prior to spermatozoa reach-
nation of different sexual activities in the ing the tail of the epididymis.” Thus, the organism
laboratory by healthy adults, PVI caused both appears to anticipate that there will be PVI rather
sexes to manifest a postorgasmic prolactin increase than merely masturbation, and creates a higher
400% greater than that following masturbation quality seminal product, among other physical
climax (adjusted for prolactin changes in a non- benefits.
sexual control condition) [86]. The results indicate The experimental finding of better prostate
that PVI is not only more physiologically satisfy- function being associated with PVI (rather than
ing than masturbation, but the greater homeo- masturbation) is consistent with epidemiological
static dopamine modulating effects might be studies linking PVI but not masturbation with
among the mechanisms involved in the psycho- fewer disorders of the prostate. It is also consistent
logical and physiological benefits associated with with psychoanalytic and similar perspectives that
PVI rather than with other sexual activities [86], intercourse is more “disburdening” than other

J Sex Med 2010;7:1336–1361

sexual behaviors. Although this latter concept was decreased pleasure by decreasing the contact of the
largely meant to refer to the relief of tension, it vagina with the penis, and decreased the woman’s
appears to apply to other physiological domains as vaginal contact with semen (women who used
well. Rather than being just abstractions, some of condoms or coitus interruptus), were at greater risk
the differences between PVI and other sexual for developing breast cancer than women who
behaviors can be measured in a test tube. used oral contraception or an intrauterine device
[98]. The interactive effect (PVI frequency and not
Prostate Cancer
disrupting PVI by choosing condoms or with-
Several studies have reported an association
drawal) was noteworthy: those women who had
between recalled frequency of ejaculation and
PVI (without the disruptive effects of condoms or
lower prostate cancer risk [92,93]. Unfortunately,
withdrawal before ejaculation) for at least 20 years
some of these studies vitiated the opportunity to
had one-tenth the breast cancer risk of women
differentiate between protective and nonprotective
who never had intercourse. Once again, condom
ejaculation conditions [94]. A British study found
use (or withdrawal) is associated with the promo-
no association of FSI with subsequent prostate
tion of a life-threatening condition.
cancer risk, but did find an increased prostate
In addition to that French study, an earlier study
cancer risk associated with higher masturbation
from the United States found a similar association
frequency in the 20s, 30s, and 40s, but the opposite
[99,100]. Women whose men used condoms or
effect in the 50s. The authors noted that the latter
withdrawal (which generally involves the male
effect could be a result of, at least in part, reverse
switching from intercourse to masturbation for
causation [95].
ejaculation), as well as women not engaging in
A review of the literature on sexual risk factors
intercourse at all, had a breast cancer rate five
for prostate cancer found that cases had a lower
times higher than users of contraceptives that do
FSI from age 50 than did age-matched healthy
not reduce vaginal exposure to semen.
controls [96]. The cases also had a higher lifetime
Greater lifetime number of sexual partners was
prevalence of sexually transmitted disease, more
associated with decreased breast cancer risk [101],
use of prostitutes, and a higher masturbation fre-
and nuns were found to have very high rates of
quency [96]. Similarly, another study found that
breast cancer [102]. As noted in the Introduction,
compared with controls, cases had a lower lifetime
a variety of methodological factors should be con-
FSI (men who had intercourse more than 3,000
sidered in evaluating risk-factor epidemiological
times in their lives had half the risk of those that
studies.
did not), more homosexual partners (thus, not
PVI), and more use of prostitutes [97]. The exami-
Immune Function and HIV
nation of prostitute contact as a separate category
Although space constraints severely limit the pre-
is important and commendable. It is not only
sentation of the breadth of important evidence
a proxy for possible exposure to sexually trans-
related to HIV transmission risks that are gener-
mitted disease (the usual interpretation), but a
ally ignored, a few key points and references to
potential indicator of dissociated sexuality by both
review papers will be noted here. Of greatest
participants.
importance for the present exposition is the
As noted in the section on biochemistry of
extremely low risk of HIV transmission through
ejaculate, there are important differences between
PVI for healthy persons of reproductive age, the
sexual behaviors in markers of prostate function
underestimation of the prevalence and risk associ-
and quantity of waste products, and these differ-
ated with anal intercourse, and the underestima-
ences could conceivably impact prostate cancer
tion of the prevalence and risk associated with
risk.
punctures, especially those in medical and quasi-
Breast Cancer medical settings in sub-Saharan Africa and some
In a retrospective case-control study, both low PVI other parts of the developing world [103–128].
frequency and greater condom (or withdrawal) use Few studies of HIV transmission risks con-
were identified as risk factors for the development ducted in sub-Saharan Africa have incorporated
of breast cancer [98]. Women with infrequent or adequate measures of unsafe punctures (and other
no PVI had thrice the breast cancer risk of the invasive procedures) in medical settings. Those
controls (women who had more frequent PVI) in that have done so concurrently with measures of
the study. In addition, those women who did have sexual behavior have found that invasive medical
PVI but used a contraceptive method that exposures were associated with greatly increased

J Sex Med 2010;7:1336–1361

HIV incidence or prevalence, but measures of rectal insemination (but not saline introduced into
sexual activity (nominally PVI, as well as lack of the rectum) of male rabbits led to immune suppres-
condom use) were not associated with increased sion, including the development of immune com-
HIV incidence or prevalence [103,114,129]. plexes, sperm antibodies, and antibodies to
Mathematical models purported to support the peripheral blood lymphocyte antigens; additional
concept of PVI transmission have been shown to immune effects including impaired humoral
be dependent on the use of assumptions grossly immune response to T lymphocyte-dependent
inconsistent with reality [130]. The largest study antigens, keyhole limpet hemocyanin, and sheep
on mortality in American prostitutes found that red blood cells [136]. The results provide further
AIDS deaths occurred exclusively in those shown evidence that receptive anal intercourse is immune
or inferred to be injecting drug users [54]. In a suppressive, even in the absence of pathogens.
large representative American sample [131], con- In contrast, PVI is associated with HIV-relevant
trolling for history of homosexual contact and immune benefits that were obliterated by condom
injection drug use revealed that for non-Hispanic use [137]. The authors concluded: “Unprotected
black men, prevalent HIV infection was not posi- sexual intercourse might result in alloimmuniza-
tively associated with lifetime number of sex part- tion stimulated by HLA antigens in seminal or
ners. The focus on black men is key not only cervicovaginal fluid. Mucosal alloimmunization
because they are the most severely affected may reduce infection by HIV-1” (p. 518).
demographic (sex by race) group in the United
States, but also because their base rate of HIV Life Expectancy
infection is high enough to obtain stable statistical Several longitudinal studies have found that a
associations. greater FSI predicts a longer life expectancy, but
Perhaps most importantly, when the vagaries unfortunately most of these studies have not
and potential confounds of risk-factor epidemiol- explicitly contrasted FSI with frequency of other
ogy are bypassed, laboratory challenge of tissue sexual behaviors.
under optimal conditions revealed that vaginal and In a 25-year follow-up study, it was found that
cervical tissue could not become infected by expo- greater FSI predicted a lower annual death rate in
sure to HIV [132–134], but rectal tissue was men, whereas enjoyment of intercourse predicted
readily infected under the same conditions lower mortality among women [138]. Similarly,
[132,133] (in the cited studies, tissues used greater FSI was associated with lower age-adjusted
approximated those in natural conditions—none death rates in a 10-year study of British men that
were chemically abraded to the point of inchoate examined and excluded several possible confound-
disintegration, and viral exposure was restricted to ing variables [139]. Compared with men reporting
surfaces relevant to normal organs, rather than an FSI of at least twice weekly, men reporting an
allowing leakage from the sliced edges of the biop- FSI of less than monthly (as well as men who
sies). As one research group noted: “Our data show declined to answer the question) had twice the
that urogenital epithelial cells cannot be infected death rate. The benefits associated with greater
with NSI or SI phenotypic isolates of HIV-1” (p. FSI were most apparent for reduced coronary
1208) [132]; this bench science observation was heart disease mortality, which is the major cause of
echoed by another research group: “HIV particles death in most countries of the First World. The
are not transmitted across the human vaginal researchers controlled for baseline coronary heart
mucosa and Langerhans cells do not increase HIV disease, as well as for social class, smoking, and
transmission” (p. 1263) [134]. blood pressure, thereby limiting to some degree
In a study that examined immune function in the influence of reverse causality.
both female prostitutes and male to female trans- International comparisons suggest that national
sexuals (all HIV negative, matched for age, dura- FSI estimates (as derived from surveys) are
tion of prostitution, number of clients, and previous strongly associated with measures of national
use of antibiotics), receptive anal intercourse was development, including life expectancy [140]. Of
found to be associated with significantly decreased course, such ecological-level comparisons are
delayed-type hypersensitivity and CD4/CD8 ratios subject not only to the usual epidemiological
[135]. The authors concluded that receptive anal caveats, but to the risk of aggregation bias as well.
intercourse results in immunological abnormali- According to U.S. government estimates [141]
ties, and posited that the process is a result of rectal men using sildenafil are considerably less likely to
exposure to seminal alloantigens [135]. Similarly, die of a myocardial infarction the day that they use

J Sex Med 2010;7:1336–1361

the medication than would be expected from the is specifically PVI, competently performed and
population base rate of men that age dying from sensitively experienced, that is associated with (as
that major cause of death. One might infer that indicated by the correlational research designs),
most of the men used the medication for inter- and produces (as indicated by the experimental
course rather than for masturbation, but this infor- research designs) aspects of better mental and
mation was not provided. The results are not physical health. This is not the case for other
adjusted for some potentially important factors sexual behaviors (masturbation and anal inter-
(including how healthy the men were the preced- course are associated with poorer health indices,
ing day), and both intercourse itself and perhaps a effects not attributable simply to lack of PVI). It is
direct cardioprotective effect of the medication also not the case when PVI is done poorly, psycho-
might have some life-sustaining benefit. In con- logically dissociated, or impaired.
trast, it has been noted that during general physical The multimethod evidence presented here that
exertion, men are 10 times more likely to have a specifically PVI and the orgasm it produces (rather
myocardial infarction as when at rest [142]. than other sexual behaviors and responses) is asso-
Female crickets that mated repeatedly lived ciated with indices of better psychological and
32% longer than crickets that mated only once. physiological health has several implications.
Because the experimenters controlled the lifestyle Before addressing those implications, methodo-
of their subjects, the males provided only copula- logical issues and possible mechanisms for the
tion (and sperm and seminal fluid) to the females, observed effects are discussed.
but not food or protection, thereby demonstrating
that either the mating process itself or chemical Experimental, Correlational, and Quasi-Experimental
components of the semen extended female life Research Designs
[143]. Higher on the phylogenetic scale, male rats There were a few experimental studies reviewed
who (for apparently genetic reasons) had a rela- herein, and the potentially higher standard of evi-
tively high FSI lived 13% longer than those with a dence that they can provide leads to some of the
low or zero FSI [144]. In the latter study, admin- experimental findings being noted here again.
istration of the Monoamine oxidase B (MAO-B) In the randomized trial of coitus (vs. no coitus)
inhibitor deprenyl (also known as selegiline, it for the treatment of menopausal hot flashes, PVI
slows the degradation of dopamine and may have decreased hot flash symptoms, an effect perhaps
neuroprotective effects) increased FSI and the life mediated by the observed changes in LH and FSH
span of the rats. [81]. In addition to the specific health outcome,
the findings offer support for PVI leading to better
Tabular Summaries hormonal regulation (and the secondary benefits
Tabular summaries of the main studies reviewed thereof).
herein are provided (Table 1 for psychological and The randomized controlled trial of high dose
psychophysiological, and Table 2 for physiological ascorbic acid [69] indicated that better health (in
health aspects of different sexual behaviors). the form of better nutrition) can lead to greater
However, the Tables are not a substitute for the frequency of specifically PVI but not other part-
narrative expositions in the manuscript. The nered or solitary sexual behaviors (ascorbic acid
health benefits in the Tables are all worded such also improved mood, so it is unclear if mood
that a “+” in the last column indicates more health enhancement was part of the causal pathway).
benefits (including decreased health risks); a “-” in Thus, in addition to effects of specifically PVI
the last column indicates less health benefits leading to better health, better health can lead to
(including increased health risks); a “0” in the last greater frequency of specifically PVI, and this can
column indicates nonsignificant effects; a combi- be the case even in nominally healthy persons
nation of “0” and “-” or “+” indicates mixed results (rather than only as a consequence of identified
(often in different analyses); and the inclusion of a morbidity). As noted in the Introduction, there can
“?” indicates some mixed ambiguous results. be bi-directional causality, as in vicious or virtuous
circles of health.
In the laboratory, PVI was shown to produce
Discussion
greater physiological exercise value than mastur-
The present overview indicates that there are bation or masturbation by a partner [74].
many psychological and physiological health ben- In the laboratory, PVI caused both sexes to
efits associated with one specific sexual activity. It manifest a postorgasmic prolactin increase 400%

J Sex Med 2010;7:1336–1361

Table 1 Psychological and psychophysiological health aspects of different sexual behaviors
Health aspect Reference Design Participants DV Results

Mental health satisfaction [11] Correlational M, W Satisfaction with one’s mental health PVI frequency: +
(multivariate) Masturbation frequency: -
Healthy Sex

Noncoital sex frequencies: 0

[12] Correlational W Satisfaction with one’s mental health Vaginal orgasm (vs. clitoral orgasm) ever: +
Relationship quality [15] Correlational W Perceived Relationship Quality Components (PRQC) PVI frequency: +
Inventory dimensions: Satisfaction, Intimacy, Trust, Noncoital sex frequencies: 0/-
Passion, and Love Masturbation frequency: - (Love)
PVI orgasmic frequency: +
[16] Correlational W Marital and sexual satisfaction PVI frequency: +
Cunnilingus frequency: 0
Masturbating male to orgasm: -
[17] Correlational W (Kinsey data) Marital happiness PVI orgasmic frequency: +
[11] Correlational M Relationship satisfaction PVI frequency: +
(multivariate) Masturbation frequency: -
Oral sex frequency: -
Anal sex frequency: -
[11] Correlational W Relationship satisfaction PVI frequency: +
(multivariate) Masturbation frequency: -
Emotional awareness and [21] Correlational W Less alexithymia (Toronto Alexithymia Scale-20) PVI frequency: +
integration Masturbation frequency: 0
Noncoital sex frequencies: 0
Less psychological immaturity [24] Correlational W Less use of immature psychological defense Vaginal orgasm: +
(less use of immature mechanisms (Defense Style Questionnaire-40) Clitoral orgasm: 0/-
psychological defense Clitoral orgasm during PVI: 0/-
mechanisms) [25] Correlational M+W Less use of immature psychological defense PVI frequency without condoms: +
mechanisms (Defense Style Questionnaire-40) PVI frequency with condoms: -
Masturbation orgasm: -
Clitoral orgasm during PVI (W): 0/-
Vaginal orgasm: +
[31] Correlational W Less use of immature psychological defense Clitoral orgasm during PVI: -
mechanisms (Defense Style Questionnaire-40) Vaginal orgasm: +
Masturbation orgasm: -
Anal sex: -
Vibrator use: -
Less depression and less [34] Correlational M Lower MMPI depression scores Masturbation ejaculations: -
suicide attempts Partnered sex ejaculations: 0
[35] Correlational W Lower Beck Depression Inventory scores Masturbation: -
Desire for masturbation: -
Desire for partnered sexual activity: 0
[36] Correlational W Less likelihood of lifetime major depressive disorder Masturbation frequency: -
(Structured Clinical Interview for the DSM-IV)
[38] Correlational W Lower Beck Depression Inventory scores and less PVI without condoms: +
suicide attempts PVI with condoms: -
[33] Correlational W Lower Hopkins Symptom Checklist depression Condom use: -
(cross-sectional scores
and longitudinal)
[43] Correlational M+W Less suicide contemplation Homosexual (vs. Heterosexual): -
Less deliberate self-harm Homosexual (vs. Heterosexual; M): -
[41] Correlational M+W Less mood disorders Homosexual (vs. Heterosexual): -
1349

J Sex Med 2010;7:1336–1361

Table 1 Continued
Health aspect Reference Design Participants DV Results

J Sex Med 2010;7:1336–1361

Happiness [37] Correlational M+W Self-rated happiness Masturbation: -
Less psychoticism and [47] Correlational M+W Lower Eysenck Personality Questionnaire (EPQ-R) Homosexual and bisexual (vs. Heterosexual): -
neuroticism (Twin study) Neuroticism and Psychoticism scores (Note: Effects were found to be associated with genetic
but not environmental influences)
Less schizophrenia [48] Correlational M+W Less likelihood of schizophrenia diagnosis PVI frequency: +
Masturbation frequency: 0
[49] Correlational M Less likelihood of schizophrenia diagnosis Masturbation frequency: -
[50] Correlational W Less likelihood of schizophrenia diagnosis PVI orgasm: +
Less anorexia nervosa [50] Correlational W Less likelihood of anorexia nervosa diagnosis PVI orgasm: +
Less neurotic disorders [50] Correlational W Less likelihood of neurotic disorder diagnosis PVI orgasm: +
[51] Correlational W Less likelihood of neurotic disorder diagnosis PVI orgasm: +
Clitoral orgasm: 0
Less prostitution (related to [52] Correlational W Less likelihood of prostitution PVI orgasm: +
various psychological
disorders; [53])
Improved erectile function [55] Clinical trial of M Effect of restoration of erectile function PVI frequency: +
intracavernosal Masturbation frequency: -
injection (not blind) General psychiatric symptomatology reduction: +
Awareness and integration of [22] Mixed correlational W Concordance of vaginal pulse amplitude and PVI orgasmic consistency: +
vaginal sensations and experimental subjective sexual arousal Masturbation orgasmic consistency: 0
Noncoital orgasmic consistency: 0
[23] Mixed correlational W Concordance of vaginal pulse amplitude and PVI orgasmic consistency: +
and experimental subjective sexual arousal Masturbation orgasmic consistency: 0
Noncoital orgasmic consistency: 0
Reduced pain: Prostatodynia [56] Correlational M Reduced pain and voiding symptoms PVI: +
Masturbation: -
Reduced pain: Experimental [57,58] Experimental W Pain levels Vaginal >> Clitoral

Note: These tables are a summary, but not a substitute for the narrative expositions in the manuscript. The health benefits are all worded such that a “+” in the last column indicates more health benefits (including decreased health risks), a “-”
in the last column indicates less health benefits (including increased health risks), a “0” in the last column indicates nonsignificant effects, a combination of “0” and “-” or “+” indicates mixed results (often in different analyses), and the inclusion
of a “?” indicates some mixed ambiguous results.
M = men; W = women; DV = dependent variable; PVI = penile-vaginal intercourse; MMPI = Minnesota Multiphasic Personality Inventory.
Brody

Life expectancy [138] Correlational: Longitudinal (25 years) M+W Lower annual death rate PVI frequency: + (M)
Enjoyment of PVI: + (W)
[139] Correlational: Longitudinal (10 years) M Lower annual death rate PVI frequency: +
[140] Correlational: International ecological M+W Life expectancy (national) PVI frequency: +
[143] Experimental Crickets (female) Life expectancy PVI frequency: +
[144] Mixed correlational and experimental Rats (male) Life expectancy PVI frequency: +
(deprenyl trial)
Vaginal function [60] Review W Vaginal tone, oxygenation, blood flow PVI: +
Condoms: - (oxygenation, blood flow effects?)
Less functional musculoskeletal [61] Correlational W Anatomically normal gait Vaginal orgasm history: +
disturbance Clitoral orgasm history: 0
Less body fatness [62] Correlational M+W Slimmer waist and/or hip circumference PVI frequency: +
Masturbation frequency: -
Noncoital sex frequency: 0/+
[63] Correlational Rats (Male) Nonobese vs. obese PVI frequency: +
Cunnilingus: 0
Nutritional enhancement effects [69] Experimental (RCT) M+W Effect of 14 days 3,000 mg/day ascorbic acid vs. PVI frequency: + (effect attributable to W)
placebo Masturbation frequency: 0
Noncoital sex frequency: 0
Better heart rate variability [71] Correlational M+W Heart rate variability (resting) PVI frequency: +
Masturbation frequency: 0
Noncoital sex frequency: 0
Subjective importance of PVI: +
[70] Correlational M+W Heart rate variability (resting) PVI frequency: +
Masturbation frequency: 0
Noncoital sex frequency: 0
Subjective importance of PVI: +
Lower resting blood pressure [71] Correlational M+W Lower diastolic blood pressure (resting) PVI frequency: +
Masturbation frequency: 0
Noncoital sex frequency: 0
Note: ns results for diastolic blood pressure in [70]
[72] Correlational M Less likelihood of hypertension (newly diagnosed PVI frequency: +
and untreated)
Less blood pressure reactivity to [73] Mixed (correlational with sexual behavior, M+W Less blood pressure increase before and during PVI (past 2 weeks): +
acute stress experimental stressor) stress, and faster recovery after stress Masturbation (frequency past 2 weeks): 0/-
Pattern: PVI only > PVI + days with only other sexual
activities ⱖ only other sexual activities
Better exercise value [74] Experimental M Better oxygen uptake, and blood pressure and heart PVI > masturbation
rate stimulation
Less pre-eclampsia risk (3 studies) [75-77] Correlational W Less pre-eclampsia risk Condoms: -
PVI frequency: +
Fellatio: +
Improved testosterone levels [78] Experimental/Clinical M Restoration of normal testosterone level with various PVI frequency: +
nonhormonal treatments of erectile dysfunction
Decreased menopausal hot flashes [81] Experimental (randomized nonblind trial of W Effect on menopausal hot flashes and LH and FSH PVI: +
coitus vs. no coitus) normalization
Less intense cortisol response to [82] Mixed (correlational with sexual behavior, M+W Less intense cortisol response to stressor Earlier age at first PVI: + (W, ns trend for M)
stress experimental stressor)
Increases in dopamine levels in the [83] Experimental Rats (Female) Increases in dopamine levels in the nucleus PVI: +
nucleus accumbens accumbens Mounting/cuddling/external stimulation without PVI: 0
Greater prolactin increase following [86] Experimental M+W Greater prolactin increase following orgasm PVI >> masturbation
orgasm
1351

J Sex Med 2010;7:1336–1361

Table 2 Continued
Health aspect Reference Design Participants DV Results

Better sperm quality [89] Experimental M Volume of seminal plasma, sperm count, sperm PVI > masturbation
motility, and percentage of morphologically
healthy sperm
[91] Experimental M Greater sperm volume and quality PVI > masturbation

J Sex Med 2010;7:1336–1361

Better prostatic secretory function [89] Experimental M Better prostatic secretory function PVI > masturbation
Lower prostate specific antigen [88] Correlational M (with erectile Lower prostate specific antigen levels and fewer Masturbation: -
levels and fewer prostate dysfunction) prostate abnormalities
abnormalities
Better elimination of waste [90] Experimental M Increased concentrations and total amounts of PVI > masturbation
products prostaglandin E and polyamines (putrescine,
spermidine and spermine)
Less prostate cancer risk [95] Correlational M Less prostate cancer risk PVI frequency: 0
Masturbation frequency: ?
[96] Correlational M Less prostate cancer risk PVI frequency: +
Masturbation frequency: -
Prostitute use: -
[97] Correlational M Less prostate cancer risk PVI frequency: +
Homosexual partners: -
Prostitute use: -
Less breast cancer risk [98] Correlational W Less breast cancer risk PVI frequency: +
Condoms: -
Coitus interruptus: -
[99,100] Correlational W Less breast cancer risk PVI frequency: +
Condoms: -
Coitus interruptus: -
[101] Correlational W Less breast cancer risk Lifetime number of sexual partners: +
Tissue could not become infected [132–134] Experimental (tissue challenge without W (biopsies) Tissue could not become infected by exposure to Vaginal: +
by exposure to HIV (3 studies) excess damage to the tissue) large quantities of HIV Cervical: +
Rectal: -
Note: See the relevant section for important
extensive references to other studies with similar
implications
Less impairment of immune [135] Correlational W + MTF Delayed-type hypersensitivity (DTH) and CD4/CD8 Receptive anal intercourse: -
function Transsexuals ratios
[136] Experimental Rabbits (Male) Less immune complexes, sperm antibodies, and Rectal insemination (vs. saline introduced into the
antibodies to peripheral blood lymphocyte rectum): -
antigens; additional immune effects including
impaired humoral immune response to T
lymphocyte-dependent antigens, keyhole limpet
hemocyanin, and sheep red blood cells
Immune benefits including possible [137] Correlational M+W resistance to HIV-1 infection by challenging PVI: +
resistance to HIV-1 infection activated CD4-positive T cells with CCR5-binding Condoms for PVI: -
and CXCR4-binding HIV-1 strains

Note: These tables are a summary, but not a substitute for the narrative expositions in the manuscript. The health benefits are all worded such that a “+” in the last column indicates more health benefits (including decreased health risks), a “-” in the last column indicates less health benefits
(including increased health risks), a “0” in the last column indicates nonsignificant effects, a combination of “0” and “-” or “+” indicates mixed results (often in different analyses), and the inclusion of a “?” indicates some mixed ambiguous results.
M = men; W = women; DV = dependent variable; PVI = penile-vaginal intercourse; FSH = follicle-stimulating hormone; LH = luteinizing hormone; RCT = randomized controlled trial; MTF = male-to-female; ns = nonsignificant.
Brody

17436109, 2010, 4pt1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1743-6109.2009.01677.x by CochraneItalia, Wiley Online Library on [25/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
17436109, 2010, 4pt1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1743-6109.2009.01677.x by CochraneItalia, Wiley Online Library on [25/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Healthy Sex 1353

greater than following masturbation climax tered by natural and sexual selection, but also
(adjusted for a control condition) [86]. The greater influenced by individual differences in the load of
homeostatic dopamine modulating effects might harmful mutations [145]) interacting with devel-
be among the mechanisms involved in the psycho- opmental influences (including those which
logical and physiological benefits associated with support or impair psychosexual development), and
PVI rather than with any other sexual activities would involve various neurophysiological pro-
[86]. cesses (which themselves are conditioned to some
In multiple within-subjects studies [89–91] degree by experience).
comparing semen samples produced by PVI and
Possible Mechanisms: Evolutionary Issues
by masturbation, PVI led to indicators of better
First, there is the distal evolutionary theoretical
prostate function, better quality sperm, better
level: out of the universe of possible sexual activi-
semen volume, and elimination of more waste
ties, there is only one that is directly relevant to
products. Although not a health outcome per se,
gene propagation. Evolutionary pressures strongly
this has implications not only for prostate health,
reward behaviors and mutations even slightly asso-
but quite possibly for other beneficial conse-
ciated with increased likelihood of gene propaga-
quences of more effective elimination of waste
tion. The difference between PVI and other sexual
products.
behaviors is not slight. The mechanisms by which
Female crickets that were allowed to mate
such evolutionarily mandated rewards might
repeatedly lived 32% longer than crickets that
operate range from direct physiological mecha-
mated only once. Experimental controls allowed
nisms (responding favorably to PVI but neutrally
the inference that either the mating process itself
or unfavorably to other sexual activities) to mecha-
or chemical components of semen extend female
nisms secondary to the evolutionary behavioral
life [143]. Although the research subjects are a
“success” of specifically PVI being rewarded by
different phylum than the readers of this review,
better physical and mental health (and perhaps the
the finding is consistent with the human life
evolutionary behavioral failure of other sexual
expectancy epidemiological results and with the
activities such as masturbation being punished by
human PVI seminal exposure findings (related to
poorer physical and mental health). In addition to
better immune function, better vaginal blood flow,
whatever skills and characteristics might be
and less depression) reviewed herein.
required to obtain a sexual partner, there might be
The majority of studies in this review used cor-
additional skills and characteristics required for
relational (or risk-factor epidemiological) research
PVI that exceed those required for other partnered
designs (this problem is difficult to overcome,
sexual activities. Evolution might also reward
given the nature of some of the variables to which
engaging in the one potentially reproductive
research subjects cannot be randomly assigned,
behavior with various psychological (including a
such as immature psychological defense mecha-
sense of accomplishment and/or intimacy, for
nisms). In such research designs, there is always
some) and physiological benefits, and provide
the possibility that unmeasured third variables
incremental rewards when there is no impediment
influence both the predictor variable and the
to ejaculating into the vagina (i.e., without
outcome of interest (e.g., see below for a discus-
condoms).
sion of possible heritable factors).
Possible Mechanisms: Neurophysiological Issues
Possible Mechanisms Second, at the neurophysiological level, there are
The present review implied some mechanisms that differences between various sexual activities
might, at various explanatory levels, clarify some of and/or areas of stimulation. As noted earlier, for
the bases for the health benefits associated with both sexes, the magnitude of prolactin release fol-
specifically PVI. In addition to those processes lowing PVI orgasm is 400% greater than follow-
noted in the text above, a few such mechanisms ing masturbation orgasm (adjusted for responses
will now be briefly described. Although these pos- to a control condition), and there are likely impor-
sible mechanisms are examined separately, it is rea- tant psychological and psychophysiological impli-
sonable to conjecture that various mechanisms cations of this dopaminergically relevant process
interact. For example, psychological outlook can [86].
modify some effects of physiological and pharma- Lesions to the medial preoptic hypothalamic
cological stimuli. The psychological outlook itself area of adult male rhesus monkeys led to an elimi-
would be significantly influenced by genes (as fil- nation of PVI, but no change in general social

J Sex Med 2010;7:1336–1361

behavior or frequency of masturbation [146], evant) pudendal nerve has been severed. However,
implying that PVI is a neurophysiologically more if the (vaginally relevant) pelvic nerve is cut, oxy-
complex phenomenon than masturbation. tocin no longer increases sexual receptivity [147].
The activation of peripheral afferents also Therefore, it is the nerve carrying sensation
differs between some sexual activities. The pelvic from PVI, and not the nerve carrying signals from
nerve conducts sensory information from the external clitoral stimulation, that is required
vagina and regions of the cervix to the spinal cord for the hormone oxytocin to manifest some of
for transmission to the brain, whereas the puden- its functions.
dal nerve carries sensory information from the cli- Although there are sexual behavior differences
toris and external perigenital skin to the spinal in postorgasmic prolactin effects (and resting heart
cord for transmission to the brain [147]. The rate variability and blood pressure reactivity, sug-
hypogastric nerve carries sensory information gesting Vagus nerve effects) for both sexes, the
from the uterus and some regions of the cervix to peripheral genital nerve structures differentiating
the spinal cord for transmission to the brain. intercourse from other sexual activities are not as
These nerves enter the spinal cord in different obvious for males as for females. However, besides
places, and have other important differences that differentiation at the level of specific nerves, for
might relate to the quality of the signal and other both sexes, there is also the issue of patterns of
secondary effects of information that the nerves interactive stimulation that can differentiate
carry [147]. Vaginal–cervical (not clitoral) stimula- various sexual behaviors. A few studies have pro-
tion results in sensory information being conveyed vided some technical details regarding genital pul-
by the vagus nerve to the brain, bypassing the satile communication. Penile thrusting in the
spinal cord (and allowing even women with com- vagina and against the cervix results in the vaginal
plete spinal cord transection to orgasm from muscles gripping the lower part of the penis
vaginal–cervical stimulation, albeit not clitoral [151,152], potentially leading to not only identifi-
stimulation [148]). This vagus connection is espe- cation of the process being PVI as distinguished
cially interesting in light of the aforementioned from other sexual behaviors (including stimulation
studies reporting that vagus-mediated greater with nongenital objects), but also a virtuous circle
resting heart rate variability and lesser blood pres- of genital-to-genital response.
sure stress reactivity (as well as some personality As suggested to varying degrees in various
processes that might be related to greater vagus studies above [25,38,60,137,143], there is also
activity) are associated with PVI but not other the possibility that the absorption of semen by the
sexual activity frequencies [70,71,73]. Among vagina and absorption of vaginal secretions by the
other possibilities, there may be a “tuning” of penis activate psychological and physiological
autonomic functioning by habitual behaviors health-supporting pathways.
[149], and such tuning might influence not only There are likely other physiological (and
resting autonomic tone, but also the response to perhaps implicit psychological) mechanisms by
subsequent sexual activity. which the organism differentiates PVI from other
Transection of the female rat pelvic nerve sexual behaviors (to induce better health). One
reduced vaginocervical-stimulation induced Fos need only pause to reflect on the evolutionary
immunoreactivity in the medial preoptic area, bed value of differentiating perhaps one million differ-
nucleus of the stria terminalis, ventromedial hypo- ent colors as compared with the evolutionary value
thalamus, and medial amygdala. In contrast, of mechanisms for differentiating between activi-
transection of the clitorally linked pudendal nerve ties that could or could not perpetuate the “selfish
had no such effect [150]. This and other studies gene” [153].
suggest that (vaginal) pelvic nerve but not (clitoral)
pudendal nerve activity leads to crucial brain Possible Mechanisms: Psychosexual Issues
effects from PVI (including possibly facilitation of Third, there are the psychosexual developmental
readiness for future PVI). issues. As conjectured by Freud, problems in psy-
The hormone oxytocin has several functions, chosexual development can produce chronological
and appears to have a role in promoting pair- adults with psychological (including psychophysi-
bonding. When oxytocin is injected into female ological) problems, and associated impairment of
laboratory animals, they become more sexually the ability to appreciate fully PVI. Several studies
receptive [147]. This is the case not only in intact described herein, including those on alexithymia
animals, but also in those whose (clitorally rel- and on immature psychological defense mecha-

J Sex Med 2010;7:1336–1361

nisms [21,24,25,31], speak to those issues. The tency (unfortunately, not specifying vaginal
results of those studies could generally be under- orgasm in any of the three studies) reported a
stood as an example of poorer health leading to heritability of 31–34% for intercourse orgasm
avoidance of or impairment of specifically PVI consistency [155,156] (and 45–51% heritability
(including choosing to use condoms for PVI, lack estimates for masturbation orgasmic consistency),
of vaginal orgasm, or choosing other sexual activi- as well as significant associations with extraversion,
ties in lieu of PVI), but one cannot not rule out being open to new experience, and less neuroti-
that there might be a role for impairment or avoid- cism [157]. These dimensions of personality also
ance of PVI leading to increased use of immature have a significant heritability. The association of
defense mechanisms. coital orgasm consistency with less neuroticism
Although the concept of impaired psychosexual would be consistent [158] with the findings of
development leading to avoidance of specifically immature defense mechanisms being associated
PVI frequency or response might seem arcane for with lesser vaginal orgasm consistency [24,25,31].
some readers, some basic aspects of the process can When feasible, future research on sexual behav-
be operationalized in an obvious manner. For ior and sexual medicine might incorporate sophis-
example, in a laboratory study [154], adult male ticated quasi-experimental designs that consider
hamsters underwent a single-trial learned aversion the effect of heritable factors. When one such
to vaginal secretion. Subsequently, they had a behavior genetic quasi-experimental design was
lower PVI frequency than did the control group. used, it was revealed that earlier age at first inter-
Although the hamsters with the learned aversion course is associated with less (rather than as usually
to PVI also had a lower frequency of grooming assumed, more) subsequent conduct disorder in
their own genitals, they did not differ in the American samples [159].
amount of time they spent licking vaginas [154].
Thus, the unpleasant early experience did not even Implications for Clinical Assessment,Treatment,
lead to avoidance of vaginal secretions, but to Research, and Sex Education
avoidance of the deeper function of PVI. Clinicians and researchers need to be specific in
Engaging in masturbation or even partnered examining various sexual behaviors (including
sexual behavior in the absence of PVI on some details of how PVI might have been modified from
days appears to detract from the psychological [11] its pure form, such as condom use or clitoral mas-
and physiological [73] benefits associated with turbation during PVI; studies noted herein found
having PVI on other days. Among the possible these practices to be associated with poorer func-
mechanisms for this is a psychological variant on tioning than undisturbed PVI). Despite the scien-
the autonomic tuning process [149] described tific and clinical importance of being specific
above: PVI might be approached in essentially the regarding the differences between specific sexual
same spirit (including less relatedness, which is behaviors, some of the most commonly used
manifestly the case for masturbation) as the other research and clinical measures of sexual function
sexual activities, leading to less psychological and explicitly obscure the differences between various
physiological benefit from PVI. Another possibil- sexual behaviors, thereby limiting their utility and
ity [73] is that PVI is being avoided on some but ability to help patients and scientific inquiry. For
not all occasions (by substituting other sexual example, Female Sexual Function Index [160]
activities), which might be because of a subtler questions refer to “sexual activity or intercourse,”
psychosexual dysregulation than complete avoid- thereby losing the essential differentiation (the
ance of PVI. questions that specify “vaginal penetration” are
those dealing with pain). The International Index
Possible Mechanisms: Genetic Factors of Erectile Function [161] includes many ques-
Fourth, genetic factors could conceivably produce tions with the nonspecific “sexual activity includes
both greater FSI (but not greater frequency of intercourse, caressing, foreplay & masturbation,”
other sexual behaviors) and better physical and and some with “sexual intercourse is defined as
mental health. Suggestive, if weak, support for sexual penetration of your partner” (which could
this hypothesis might be gleaned from the finding involve anal intercourse, and perhaps even broader
that male rats who—for apparently genetic interpretations might be made by some people).
reasons—had a relatively high FSI lived 13% More specific questionnaires specifying more spe-
longer than those with a low or zero FSI [144]. cific sexual behaviors [24] would be far more infor-
Studies of women’s intercourse orgasm consis- mative, and allow sexual medicine to advance.

J Sex Med 2010;7:1336–1361

In addition, sex education should begin to be tion of the “risk factors.” For example, a global
honest regarding physiological and psychological measure of women’s sexual dysfunction found mul-
health differences between specific sexual behav- tivariate associations with lower high density lipo-
iors. In a recent large representative survey of protein cholesterol, and higher low density
Czech women, vaginally orgasmic women were lipoprotein cholesterol, triglycerides, body mass
significantly more likely than vaginally anorgasmic index, and age [171]. Given that more favorable
women to report having being told in childhood or lipid profiles may be associated with more mature
adolescence that the vagina was an important zone emotion expression [172,173], and that specifically
for inducing female orgasm [162]. PVI frequency and response is associated with both
Treatment (including primary prevention) slimness [62] and better emotional functioning
should be supportive of PVI and the orgasm it [11,12,21,24,25], future research might examine
produces, and not assume that behavioral treat- the possibility that unfavorable lipid profiles might
ment of sexual dysfunction must involve mastur- be secondary to sexual behavior factors. Various
bation as part of the process. There are effective studies have indicated associations between depres-
PVI-based treatments for premature ejaculation sion, cardiovascular disease or risk, and sexual dys-
[163] and for female orgasmic dysfunction [164]. It function (especially erectile dysfunction). In
has been noted that for some women, repeated addition to such obvious pathways as cardiovascular
orgasm from clitoral stimulation can interfere with disease leading to erectile dysfunction leading to
the development of pathways leading to vaginal depression, other pathways are also likely [174].
orgasm [165,166]. In a recent large representative
survey of Czech women, risk of female sexual
arousal disorder with distress (albeit not without Conclusion
distress) was much lower for women who had a Based upon a broad range of methods, samples,
history of vaginal orgasm [167]. The concept of and measures, the research findings are remark-
sexual dysfunction merits both broadening and ably consistent in demonstrating that one sexual
more specificity (e.g., lack of vaginal orgasm [31]) activity (PVI and the orgasmic response to it) is
in light of the research described herein. associated with, and in some cases, causes pro-
Among the factors shown to be associated with cesses associated with better psychological and
greater likelihood of women’s orgasm with a physical functioning. Other sexual behaviors
partner is duration of PVI, but not duration of (including when PVI is impaired, as with condoms
foreplay (in contrast to the assumptions of many or distraction away from the penile–vaginal sensa-
practitioners) [162,168]. Future studies might tions) are unassociated, or in some cases (such
examine in greater detail which physiological and as masturbation and anal intercourse) inversely
psychological factors lead to people avoiding (in associated with better psychological and physical
behavior or full feeling and response) the key evo- functioning.
lutionarily driven sexual behavior, including Sexual medicine, sex education, sex therapy, and
choosing to substitute something else for one set sex research should disseminate details of the
of genitals in lieu of genital–genital (penile– health benefits of specifically PVI, and also
vaginal) intercourse. become much more specific in their respective
There might also be implications for future assessment and intervention practices.
research involving pharmacotherapy. Women’s
positive response to phosphodiesterase inhibitor Corresponding Author: Stuart Brody, PhD, School of
treatment for sexual dysfunction was better in Social Sciences, University of the West of Scotland,
women with “stable and/or happy relationships” High Street, Paisley PA1 2BE, UK. Tel: 44 141 849
(p. 156), and nonresponse was more common in 4020; Fax: 44 141 8483891; E-mail: stuartbrody@
hotmail.com
the “presence of psychological co-morbidities” (p.
156) [169]. Studies might examine the degree to Conflict of Interest: None. However, Dr. Brody discloses
which phosphodiesterase inhibitor benefit is more that he was or is a consultant for Bayer Schering.
likely in women [170] who are more aware of their
vaginal response (especially those with a history of
Statement of Authorship
vaginal orgasm).
Some studies of risk factors for sexual dysfunc- Category 1
tion might suggest future studies on the possible (a) Conception and Design
influence of better sexual function on the preven- Stuart Brody

J Sex Med 2010;7:1336–1361

(b) Acquisition of Data 14 Langstrom N, Hanson RK. High rates of sexual behavior in
Stuart Brody the general population: Correlates and predictors. Arch Sex
Behav 2006;35:37–52.
(c) Analysis and Interpretation of Data
15 Costa RM, Brody S. Women’s relationship quality is associ-
Stuart Brody ated with specifically penile-vaginal intercourse orgasm and
frequency. J Sex Marital Ther 2007;33:319–27.
Category 2 16 Hurlbert DF, Apt C. Female sexual desire, response, and
behavior. Behav Modif 1994;18:488–504.
(a) Drafting the Article 17 Gebhard PH. Factors in marital orgasm. J Soc Issues 1966;
Stuart Brody 22:88–95.
(b) Revising It for Intellectual Content 18 Parker JD, Taylor GJ, Bagby RM. Alexithymia: Relationship
Stuart Brody with ego defense and coping styles. Compr Psychiatry
1998;39:91–8.
19 Madioni F, Mammana LA. Toronto alexithymia scale in out-
Category 3 patients with sexual disorders. Psychopathology 2001;34:
(a) Final Approval of the Completed Article 95–8.
Stuart Brody 20 Wise TN, Osborne C, Strand J, Fagan PJ, Schmidt CW.
Alexithymia in patients attending a sexual disorders clinic. J
Sex Marital Ther 2002;28:445–50.
21 Brody S. Alexithymia is inversely associated with women’s
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Journal of Sexual Medicine - 2010 - Brody - The Relative Health Benefits of Different Sexual Activities

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Journal of Sexual Medicine - 2010 - Brody - The Relative Health Benefits of Different Sexual Activities

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1336

The Relative Health Benefits of Different Sexual Activities jsm_1677 1336..1361

Stuart Brody, PhD

J Sex Med 2010;7:1336–1361 © 2010 International Society for Sexual Medicine

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

increase to the stressor than did persons engaging Pre-Eclampsia

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

Noncoital sex frequencies: 0

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

J Sex Med 2010;7:1336–1361

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