Female sexual dysfunction is commonly considered a psychogenic condition and is commonly believed to be temporary and potentially treatable by psychodynamic therapy. However, Goldstien and Berman (1) have written about what they call clitoral erectile insufficiency, referring to a local vascular condition in some women that is potentially treatable through pharmacological intervention. “There is a growing body of evidence that women with sexual dysfunction will commonly have physiologic abnormalities, such as vasculogenic female sexual dysfunction, contributing to their overall sexual health problems.” In 2012 I proposed a neurological aspect of the absence of clitoral erection in some women that is probably permanent and untreatable. However, such neurological impairment may be easily preventable during early brain development, through adequate genital self-stimulation long before the massive neural pruning of puberty. I also proposed the label Clitoral Erectile Dysfunction as more specifically descriptive of the most obvious functional effect of that neurological impairment (2). In the present paper I clarify my hypothesis and confront some possible criticism.
In some cultures physical mutilation of the tip of the clitoris by cutting or burning have been widely practiced, and in view of the history of religious hostility against sexual desire and sexual pleasure in the West, we may say that mental castration of girls and women is also widespread here and now. It’s not surprising that many Western women report some form of sexual dysfunction. In various surveys in the U.S.A (3), a majority of women who were surveyed self-reported sexual dysfunction, e.g. they never or almost never experience orgasm during normal genital intercourse. Due to the unfortunate tendency to blame oneself and feel ashamed, equally unsurprising is that many women deny the existence of clitoral erection, or claim that clitoral erection is unnecessary or unimportant, or admit faking orgasm only for convenience rather than to hide any inability to reach orgasm without the aid of a medical device popularly called a “vibrator.”
Many parents know that normal little boys experience frequent genital erections, either spontaneously or due to manual self-stimulation. My own observations of children at naturist (nudist) resorts in several countries have revealed that genital erections are just as common in little girls as in little boys. Long before puberty the tip of the immature clitoris often protrudes erect up to 5cm (2in), with the hood suspended from it like a curtain. Even when fully clothed and not visible, if a little girl straddles my knee I can sometimes feel the erect tip of the clitoris protrude and press against my knee like a very firm fingertip.
But clitoral erections seem to disappear after puberty and are rare in adult women, at least nowadays in the West. Most women and men I speak to about clitoral erections seem baffled. Despite Masters and Johnson’s reports of clitoral erections they detected (4), many women and men today are unaware that clitoral erections exist or are possible. Although both boys and girls are subject to “inhibition” by parents, it’s possible that such shame-training is more severe for girls, or simply more effective due to the cultural double standard. My hypothesis is that in some cases healthy clitoral erectile function atrophies during the massive neural pruning around puberty due to parental prohibition of childhood masturbation and sex play, and this is not merely a psychogenic problem but a neurological injury. There is some evidence of brain differences that develop in boys and girls: Between age four and puberty the interstitial nuclei of the anterior hypothalamus become larger in males compared to females, probably due to apoptosis (neuronal cell death) in females (5). Although the cause and functional significance of that finding is unclear, it is consistent with my hypothesis that girls who suffer a lack of stimulation during development have in effect suffered brain injury.
Physiology of Clitoral Erectile Dysfunction
Neural atrophy due to lack of stimulation during development is a well-accepted mechanism in brain development. The classic case is vision: if an eye is covered during development the animal becomes blind in that eye. There is not much wrong with the eye itself, but the relative brain areas that process signals from that eye atrophy due to lack of stimulation. “The fine-tuning of circuits in sensory cortex requires sensory experience during an early critical period. Visual deprivation during the critical period has catastrophic effects on visual function, including loss of visual responsiveness to the deprived eye1,2,3 reduced visual acuity4, and loss of tuning to many stimulus characteristics2,5” (6).
That is why newborns are examined for cataracts: if cataracts in an eye aren’t diagnosed and removed early the baby won’t develop binocular vision. Removing the cataracts later will be too late for normal brain development. The same principle is recognized for hearing and language, and these functions are all processed by the same part of the brain responsible for genital erection: the cerebral cortex (7). Although experimental evidence for this mechanism is with laboratory animals, I know of no dispute over the assumption that such a mechanism probably also exists in humans. I doubt that any responsible adult would suggest it’s Ok to prevent a child from exercising her legs until puberty, because the child will probably become a good walker anyway if she begins exercising her legs only at age 12 or 13. This is not a question of developing muscle tone, but rather early development of the respective brain areas that control the functions of each organ of the body.
Even a federal government website acknowledges this mechanism, although not specifically regarding sexual function: “The more babies are exposed to people speaking, the stronger their related synapses become. If the appropriate exposure does not happen, the pathways developed in anticipation may be discarded. This is sometimes referred to as the concept of ‘use it or lose it.’ It is through these processes of creating, strengthening, and discarding synapses that our brains adapt to our unique environment… Researchers believe that there are sensitive periods for development of certain capabilities. These refer to windows of time in the developmental process when certain parts of the brain may be most susceptible to particular experiences. Animal studies have shed light on sensitive periods… It is more difficult to study human sensitive periods. But we know that, if certain synapses and neuronal pathways are not repeatedly activated, they may be discarded, and the capabilities they promised may be diminished.” (8).
It’s also possible that early neglect may result in some local tissue damage, such as reduced vascularization and blood flow to clitoral cells, local ischemia, and stunted growth of the clitoris. There are some reports of genital erection occurring even after the spinal cord is severed (9), but only in patients whose erectile function was previously normal. Neural plasticity offers hope for regaining organ function lost due to disease or sudden injury to the brain, but again only in patients whose organ function was previously intact. I know of no women whose erectile dysfunction early in life eventually developed in adulthood. For these reasons I suspect that in some cases clitoral erectile dysfunction is probably permanent and untreatable.
I experienced repeated genital stimulation during early childhood (10), and I’ve continued to experience frequent erections (spontaneous and not) beyond puberty and into adulthood and old age. Contrary to popular fears, my early genital stimulation did not interfere with my otherwise normal development in other respects (11). In my younger years I was able to throb my penis to erection voluntarily. Much of human behavior that is apparently reflexive or involuntary in infancy, such as sucking, becomes voluntary later. Why shouldn’t genital erection also become voluntary in healthy individuals? In individuals with less developed genital function, erection seems to require considerable arousal, and according to my hypothesis they were probably insufficiently stimulated during early brain development before puberty.
What does penile erection have to do with clitoral erection? Some critics may object that genital erection is necessary for reproductive success in males but not in females. However, erection facilitates orgasm, and the anticipation of orgasm certainly contributes to sexual motivation or “desire,” as well as facilitating conception and contributing to a female’s quality of life. Researchers have found that females experience orgasm in other species of primates, so there is apparently evolutionary value to female orgasm.
Obstacles to Research
The cultural taboo against questioning the traditional sexual “inhibition” of children, especially any suggestion that childhood masturbation and sex play should be allowed or encouraged for any reason, leads to some alternative and bizarre attempts to explain female sexual dysfunction. One author has claimed that the reason many women have difficulty achieving orgasm during normal intercourse is because the clitoris is in the “wrong place” (12). Another author has claimed that since women don’t always have orgasm during intercourse, this “…must be seen as a design flaw” (13). I’m afraid the latter author is claiming a design flaw in anatomy or physiology, not a flaw in culture or education that leads to neural atrophy. There has also been well-intentioned criticism of attempts to medicalize all sexual problems in women (14), but in the case of clitoral erectile dysfunction I’m afraid such criticism would be misplaced. If my hypothesis is correct, we certainly don’t want to condone the continuing mental castration of millions of girls generation after generation.
In the past it was believed that “overstimulation” is a danger in early life, so children have been overprotected from self-masturbation and sex play with other children. Even premature babies used to be isolated to protect them from “stress,” but research has now demonstrated the contrary: the intense stimulation of touch and massage or “kangaroo care” of premature infants results in earlier discharge from intensive care. There are many things about the development of the child’s brain that we don’t understand. For example, although very young children usually love a gentle massage, they seem to go through a stage when they prefer to have their skin gently tickled. They are fascinated by the sensation of gentle tickling and like to feel it over and over again. It’s reasonable to guess that such stimulation serves some purpose in the development of the relative brain areas that control skin sensation. I certainly don’t like that sensation when anybody does it to me, but my relative brain areas that control skin sensation stopped developing a long time ago. The very concept of genital “overstimulation” of children lacks clarity and should require experimental validation rather than taking that supposed danger for granted (15).
An earlier version of this paper was published on my blog in 2012, and despite about 4,500 views so far it is interesting that the reaction of male and female readers up to now has been virtually complete silence. Although nobody wants to publicly acknowledge that my hypothesis is plausible, nor is anybody criticizing it. That should make us all wonder.
Testing the Hypothesis
This hypothesis could be disconfirmed by surveying women who report the presence or absence of clitoral erection in adulthood, and inquiring how permissive their parents were about childhood masturbation and sex play before puberty, to look for a correlation. Recognizing the limitations of retrospective self-report and correlation, preliminary studies should serve to at least draw attention to the question. It’s also possible that future researchers may detect differences in measurable genital vibratory perception thresholds in women who experienced more or less inhibition during their early development.
1. Goldstien, I, and Berman, JR. Vasculogenic female sexual dysfunction: vaginal engorgement and clitoral erectile insufficiency syndromes. Int J Impot Res. 1998 May;10 Suppl 2:S84-90; discussion S98-101. http://www.ncbi.nlm.nih.gov/pubmed/9647967
Sammy Elsamra, Michael Nazmy, David Shin, Harry Fisch, Ihor Sawczuk, Debra Fromer. Female sexual dysfunction in urological patients: findings from a major metropolitan area in the USA. BJU International, 2010; DOI: 10.1111/j.1464-410X.2009.09091.x. Another survey: 60% of women never or almost never experience orgasm during intercourse. Cited in: Kamisaruk, Barry R. et al. 2006. The Science of Orgasm. Baltimore, MD: Johns Hopkins University Press, p. 17. See also: Laumann E, Paik A, Rosen R . Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281: 537–544
Masters, WH and Johnson, VE. Human Sexual Response. ISHI, 2010.
Swaab, D.F., & Fliers, E. 1985. A sexually dimorphic nucleus in the human brain. Science228:1112-1115.
Arianna Maffei1, Kiran Nataraj1, Sacha B. Nelson1 & Gina G. Turrigiano1. Potentiation of cortical inhibition by visual deprivation. Nature 443, 81-84 (7 September 2006).
Jack Ende. Organic Impotence. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Walker HK, Hall WD, Hurst JW, editors. Boston: Butterworths; Chapter 187. 1990. See also: Yasin Temel1,*, Sepehr Hafizi2, Sonny Tan1, Veerle Visser-Vandewalle1 2006. Asian Journal of Andrology. “Evidence suggests that the most important structures [in penile erection] are the frontal lobe [of the cerebral cortex] , cingulate gyrus, amygdala, thalamus and hypothalamus.” Another author has written that sacral (pelvic) parasympathetic (involuntary) nerves that produce erection “originate in the brain – in the paraventricular nucleus of the hypothalamus…” Komisaruk, et al. op cit. p. 36