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Wednesday, June 8, 2011

Self-Help for Sex

CAROL DOWNER

What would happen if groups of laypeople examined each other's bodies and talked about their health-related experiences? What if they were all women and the part of the body they were examining was their genitals? Shocking? Dangerous? Frivolous? Or a totally new approach to the understanding of female sexuality and reproduction?

In 1971 in Los Angeles, several women, in turn, removed their pants, lay down and inserted a plastic vaginal speculum, looked at themselves with a mirror, and then allowed others in the group to look at their vaginal walls and uterine cervices using a flashlight. Throughout the evening, they freely shared experiences with one another. This type of session, which we named the self-help clinic, has been repeated by many groups of women throughout the United States and abroad. Meetings like this continued and, in the next few years, became the basis for the Federation of Feminist Women's Health Centers, which includes centers in Los Angeles, Orange County, San Diego, and Chico, California, and in Atlanta, Georgia, and Tallahassee, Florida.

By breaking the societal taboo of letting our genitals be viewed outside a medical or sexual setting, we have been able to let the feelings of shame (Greek for the genital area is pudendum, meaning "shame") fall away and to learn directly about our own bodies.

Since 1971, through participating in self-help clinics, writing and distributing health pamphlets and books, and establishing feminist women's health centers and women's clinics, self-helpers have amassed a new body of knowledge about the healthy functioning of woman's body, including improved fertility-detection methods, new and safer birth-control methods, natural home remedies for common problems of well women, and healthy alternatives to estrogen-replacement therapy in menopause.

The women's health movement, for which the self-help clinic is the training ground, has exposed many medical myths perpetrated by male physicians whose only knowledge of women's bodies is derived from medical textbooks, their clinical practices, or personal sexual contact. But of all aspects of women's health, certainly women's sexuality has been the most neglected and misunderstood by the male dominated medical profession and the related fields of psychotherapy and psychology. Despite some substantial contributions made by William Masters and Virginia Johnson and by Mary Jane Sherfey, whose book, The Nature and Evolution of Female Sexuality (1972), is based largely upon Masters and Johnson's work, the first reliable glimpse of women's sexuality in today's society has come from Shere Hit. In the Hite Report (1976), which consists of over 1000 responses to a lengthy questionnaire, Hite argued persuasively that women are "sexual slaves," habitually satisfying men's needs during sex and ignoring their own:

The fact is that the role of women in sex, as in every aspect of life, has been to serve the needs of others-men and children. And just as women did not recognize their oppression in a general sense until recently, just so sexual slavery has been an almost unconscious way of life for most women-based on what was said to be an eternally unchanging biological impulse. . . . Women are sexual slaves insofar as they are (justifiably) afraid to "come out" with their own sexuality, and forced to satisfy others' needs and ignore their own . . . The truth is that almost everything in our society pushes women toward defining their sexuality only as intercourse with men, and toward not defining themselves as full persons in sex with men. Lack of sexual satisfaction is another sign of oppression of women.
At first, self-help clinics concentrated on the urgent topics of birth control, breast surgery, and alternatives to steroid hormones. But in 1976, in conjunction with writing a book on women's health care, a group of six women in Los Angeles were selected by the Federation of Feminist Women's Health Centers to spend several months studying the female sexual response and the structure and function of the sexual organ. Suzann Gage, an anatomical illustrator and member of the health center staff, brought in thick anatomy books in various languages for the group to consult. We sat on the floor and, using mirrors and flashlights, each carefully examined our genitals and compared them to the illustrations. First we found that although all of us had most of the structures pictured, the variation in size, proportion, coloration, texture, and shape of each component part gave each woman's genitals a markedly different appearance-different from one another, but especially different from the standard drawing. Among other differences, the drawings always show the opening that leads to the vagina as a gaping hole rather than the neatly closed opening that may or may not be visible, depending on the shape (or existence!) of the fourchette, a membranous fold of skin that stretches across the lower part of the opening. (See Figure 1, 2, and 3.)



As part of the study, some of the women masturbated to orgasm while being photographed so that the changes in the sexual organs during the sexual response cycle could be observed. These changes, while not as obvious as those that occur in the penis, are nevertheless pronounced and quite identifiable. Women at the Orange County FWHC also made motion pictures of sexual response. In some instances, the speculum was inserted and kept open throughout so that the changes in the vaginal walls and in the cervix could be seen during the phases of excitement, plateau, orgasm, and resolution.

Careful comparison of living genitals to drawings largely based on dissections of dead tissues, combined with our observations of the sexual response cycle, enabled us to piece together a full description of the clitoris, the female organ. We learned that the clitoris is an intricate organ located in the crotch below the ischium bones (the bones we sit on), which flare out, forming a triangular space. It consists not only of the hooded glans, the shaft, and the crura, as generally believed, but also of the ligament that suspends these structures from the symphysis (or midline) of the pubic bone; the muscles that bound the triangle; the networks of nerves and blood vessels that branch into the clitoral structures; the spongy erectile bodies, such as the urethral sponge, the clitoral bulbs, and the perineal sponge; and the inner lips, which extend from the hood until they again join and form the fourchette just above the perineum between the clitoral opening to the vagina and the anus. (See Figures 4, 5, and 6.)



In self-examination, the clitoris can be distinguished from the surrounding vulva (the pubic mound and the outer lips) by the fact that it has no hair. The inner part of the clitoris extends to the depth of the hymen, which separates it from the vagina, except along the roof, where a pad of spongy erectile tissue, the urethral sponge, extends back into the vagina. By inserting the index finger and pressing against the ischium bones, the crura (or legs) and the clitoral muscles that extend from the shaft and the pubic bone can be felt as thick rubber bands. By inserting the finger a little deeper and pressing sideways, the soft clitoral bulbs can be felt.

During sexual excitement, the suspensory ligament shortens, pulling the glans and the shaft up under the hood and into the groove of the symphysis. The erectile tissue of the shaft and the crura (corpus cavernosum) fills with blood and becomes bone-hard. As stimulation continues, the muscles begin to tighten, and the soft erectile tissues (corpus spongiosum) of the urethral sponge, the perineal sponge, and the clitoral bulbs swell with blood, causing the vaginal opening to become smaller and to "sweat" and become very moist. (See Figure 7.)
During the plateau phase, erection and muscular tension increase and the inner lips often become bright red or wine-colored from vasocongestion. (See Figure 8.) At orgasm, the mucles (ischiocavernosus, bulbocavernosus, and transverse perineal) contract rhythmically four to eight times at four-fifths of a second. The whole clitoral pulsates as it muscles force the blood from its engorged tissues back into the body. (See Figure 9.) During resolution, the ligament stretches, the shaft returns to its usual position, and muscle tension gradually subsides. This sequence of events closely parallels those that occur in the penis, with its comparable but somewhat differently arranged structures.



In our study, we observed that Masters and Johnson's extremely important discovery, that the male and the female sexual responses are similar instead of complementary, applies to the structure and the function of the sex organs as well as to the generalized body responses of systemic changes, such as increasing heart rate, rise in blood pressure and respiration, nervous excitation, vasocongestion, and muscle tension. 1

Since the women participating in this project had no access to dissection rooms, they were forced to rely on Masters and Johnson, Sherfey, anatomy texts, the drawings of Robert Latou Dickinson (an artist-physician who interviewed and sketched thousands of his patients in the 1920s and 1930s), and the observation of their own bodies. Some people may quibble with the claim that the women discovered "something new" in this study, since all of the structures they identified as being part of the clitoris can be found described in one anatomy book or another, especially if one searches back over the last 75 years. In defense of Masters and Johnson, who failed to describe the clitoris fully and who instead designated most clitoral structures as being, somehow an extension of the vagina called the "orgasmic platform" and located in the "outer third of the vagina," the functional unity of the clitoris is totally obscured by the literally fragmented approach that anatomists use. (Feminists will be forever grateful, however, to Masters and Johnson's recognition of the vital role that the glans and the shaft play in orgasm.)

Anatomical artists, first of all, cut out and study sections of tissue and, unless they conceptualize structures as belonging to a unit, do not see them as a unit. Second, for purposes of illustrating certain parts, the artist omits others; therefore, anatomical drawings of cross sections of the body seldom show all of the structures. Certainly, no one illustration or set of illustrations we found included all of the clitoral structures. For example, the urethral sponge was missing from all illustrations and descriptions except in three texts: Testut (1931), Toldt (1928), and Netter (1970). The perineal sponge is never pictured; it is merely alluded to in Kinsey's Sexual Behavior in the Human Female (1965). (See Figure 10.)

In any inquiry, the best test of theory is how well it fits the facts. As we described our understanding of how the sex organs work in self-help clinics, woman after woman has commented matter-of-factly, "Yes, that's how it is with me," not realizing how ignorant the medical profession has been of this simple truth: that the clitoris is an organ as complex and active as the penis. Also, another test is usefulness. After demonstrating self-examination and showing the parts of the clitoris and how it functions, discussions of our sexual experiences become much more concrete and specific. We now have a vocabulary and a conceptual framework to communicate with.

One of the major accomplishments of this group self-study project is to put to rest forever the controversy over clitoral or vaginal orgasms. Now that it is understood that the clitoral structures surround and extend into the vagina, the fact that women report pleasurable feelings deep in the vagina in no way contradicts Masters and Johnson's correct if inadequately pursued finding that all orgasms are of clitoral origin. The vagina is involved passively in the orgasm, and the pleasure that women receive from the thrusting of the penis comes from the sensations of the penis rubbing against the erect clitoris.

As part of our research, we gathered accounts of individual experiences. We were more interested in the actual sexual experiences than in feelings about sexuality. We found that some women experience the entire sexual response cycle from the time that they are toddlers. On the other hand, it became clear that many women do not experience orgasm until they are in their 20s or 30s or even later, or never. We found few women who experience orgasm regularly and dependably during coitus. Women agreed with the subjects of the Masters and Johnson study who reported that orgasm from masturbation is frequently stronger than from coitus. Of course, as feminists, we were not very concerned with whether or not the orgasm was obtained during coitus, or by manual or oral stimulation, or with a vibrator. Our aim was not to train ourselves to have orgasms in dull sexual sessions where the only clitoral stimulation is from the penis. We found that women usually strive to achieve orgasm during coitus to reassure the partner. In self-help clinics, one of my favorite questions to ask is 'Would everyone here who has never faked an orgasm, please raise your hand?" I have yet to see one hand raised.

Other feminists, many of whom participate in self-help, conduct therapy groups for women called preorgasmic groups. Rather than viewing women's sexuality solely in the context of heterosexual intercourse, they help women to learn to achieve orgasm through masturbation. These groups use a variety of approaches, but all include group discussion, instruction on the basic facts of the sexual response cycle, and practical tips on how to masturbate to orgasm. Women who participate in these groups have excellent results.

Women in self-help groups not only reexamined the emphasis on a woman's having an orgasm during coitus but reexamined the advice given to couples to aid the woman in achieving orgasm at that time in light of our improved understanding of the structure and function of the clitoris. A typical piece of therapists' advice is to have the woman sit astride the male, in order to bring her glans and shaft into closer proximity to his penis and public bone. While this advice is successful in many cases, especially if a couple work together conscientiously with the one goal being the woman's orgasm, it seems probable to us that the success comes more often from the woman's ability to maneuver freely and to control the amount of stimulation she receives and the man's sincere interest in helping her to achieve orgasm, rather than from direct stimulation of the glans and the shaft.

Of course, we talked to women who wanted-indeed, needed-very strong direct stimulation of the glans and shaft, but most seemed to prefer stimulation of the other parts of the clitoris instead. The penis is in good contact with the clitoris at all times in all positions. For example, when the male inserts the penis from behind, the penis is thrusting toward the urethral sponge, which is along the roof of the vagina. Also, many women have said that direct stimulation of the floor of the clitoris, the perineal sponge, gives maximum pleasure.

Misunderstanding the clitoris as merely the glans and the shaft, along with the patriarchal insistence that women rely only on penile stimulation for "normal" orgasms, has led to shocking consequences. Some therapists refer women for female circumcision (clitoridotomy) to have their clitoral hoods removed so that they can be more sensitive to the thrusts of the penis. One gynecologist, James Burt of Dayton, Ohio, has even developed a two-hour operation for surgically redesigning the vagina, referred to as the "reborn Burt vagina." In addition to moving the glans and the shaft closer to the clitoral opening, he narrows and tightens the vagina, cuts the pubococcygeal muscle (which forms the floor of the pelvis and through which the vagina runs), and removes the hood. Some of the women who have this surgery are very satisfied, but others have had problems, such as vaginismus, afterward.

These operations are reminiscent of surgeries and mutilations performed on women's clitorises in the 19th century-and even today in a few countries. As far as we could determine, most of these surgeries were limited to excising the glans and some or all of the shaft (although an operation called infibulation can include the inner lips also). Surely these mutilations had a devastating impact on women's ability to have sexual pleasure and to achieve orgasm, but, physiologically it would seem that since most of the clitoris was left intact, including extensive networks of nerves, blood vessels, erectile bodies, and muscles, orgasm would still have been possible. Masters and Johnson even cite a case where a woman had orgasm despite amputation of the shaft. As for men, those who have had the outer shaft amputated are still capable of having orgasm.

As part of our sex research, we reviewed current sex theraphy practices and discussed them in self-help groups. One criticism women have consistently made of therapeutic measures is that often the assumption is made that it is possible for a woman to have a carefree, uninhibited sex life despite the difficulties she faces in a sexist society: "Oh, sure, just casually lie down in the field of wildflowers and have sex! What about birth control? Or is everybody supposed to use the Pill or IUD?" Or, "Well, I'm forty, and frankly, most men my age or even older just want casual sex with me and they seek out younger women to have even semipermanent relationships with." We came up with a list of institutions, laws, and practices that reinforce women's oppression or sexual repression; our evaluation of this list amounted to a broad-scale condemnation of patriarchal society. Any therapist who tells a women "it is up to her" and implies that she is responsible for her "hang-ups" is merely rubbing salt in the wounds inflicted by her church, which preaches the evil of sexuality, especially women's; by schools, which withhold sex education from her, except for perhaps a lecture on menstruation in junior high and another lecture on birth control in high school; and the ubiquitous pornography that degrades her.

Current sex therapy that relies primarily on sex histories and taeching techniques to overcome problems such as vaginismus, inability to achieve orgasm, or inability to maintain an erection seems to be of most help to men and women. Although Masters and Johnson pioneered this type of therapy, their excellent works is tainted with sexism in their use of prostitutes for research and the use of women as surrogate partners.

Like the use of surrogate partners, other tools of the sex therapist are less acceptable to feminists-tools like permission giving, advising, role playing or setting examples by role modeling and desensitization. Permission giving is the reverse side of the authoritarian coin that has denied people the right to decide their own sexuality. Advising is only as good as the adviser, and our experience is that therapists are as much a part of our culture as anyone else and pass on their own biases and hang-ups; the same criticisms applies to role playing and role modeling. Desensitization involves bombarding the clients with films of tapes of explicit scenes or shocking words to numb them to any feelings of shock or embarrassment. Feminists see a problem with these methods if a woman, in the process of losing her upsetness, also loses her very necessary armor against hurtful influences. Sexist jokes and pornography are more than distasteful; they shame and humiliate women and support sexist practices that cause harm to women.

If sex therapists, male or female, are sincere in wanting to help their female clients, they would be wise to consult feminists, especially those in the women's health movement, to reduce to the minimum their inevitable sexism. Unless sex researchers, counselors, and therapists raise their consciousness about women's oppression, they will perpetuate the models of heterosexuality that suppress women's sexuality. For example, Multi Media Resource Center puts out a series of films showing people having sex. One film starts out with a couple riding their motorcycle on a country road (of course, the man is in the lead, but perhaps that is nit-picking). As they turn down the lane toward their house, they dismount and lie down together among the leaves. The man, Rich, playfully pulls at Judy's clothes. She resists, he persists, and he finally succeeds in disrobing her. Then, in a scene on the sundeck next to their pool, he first applies suntan lotion to her and incorporates it as foreplay, but then he starts teasing her, then chases her and wrestles her down to the mat. He mounts her and embarks on a vigorous (actually borderline violent) coital session. Then, after his orgasm, he picks her up and throws her into the pool! When I asked a representative of the organization who made the film, he sidestepped any responsibility for the mock rape format by saying that this was the way this couple had sex and that their aim was not to judge but to record.

As part of their well-woman health-care program, the Women's Choice Clinic of the Feminist Women's Health center in Los Angeles has initiated a special self-help program where women can learn in groups about the female organs and sexual response. During the group session, which lasts two to three hours, women do self-examination and identify the parts of the vulva, clitoris, vagina, uterus, egg tubes, and ovaries. The phases of the sexual response cycle are presented. Each woman prepares an extensive sexual "herstory" as the group share their experiences and problems. Specific techniques for enhancing sexual enjoyment are demonstrated. The difference between these groups offered at the clinic and at the self-help clinics is that although all self-help clinics talk about sexuality to a greater or lesser extent, and some self-help clinics have chosen to concentrate on sexuality, the clinic sessions offer women the opportunity to come together for the express purpose of learning more about sex.

So a century after Freud asked plaintively, "What do women really want?", women are coming together and overcoming patriarchally instilled and socially enforced taboos to find out what type of sexuality they really want, and of course, from there, it is a short step to demanding that institutions change so that both men and women will be free to express their sexuality to other human beings constructively, joyously, and for mutual satisfaction.

1 The vagina, uterus, uterine ligaments, egg tubes, and ovaries-as well as the breasts, indeed, the whole body-are involved in female sexual response. We are merely focusing on the clitoris. For a detailed description of the clitoris, compatible with the observations in our study, see Masters and Johnson (1966, pp. 56, 60-61).

REFERENCES
-Hite, The Hite report. New York: Dell Publishing, 1976, pp. 419-420.
-Kinsey, A.C., Pomeroy, W. B., Martine, C.E., and Gebhard, P.H. Sexual behavior in the human female. New York: Pocket Books, 1965, p. 577
-Masters, W., and Johnson, V. Human sexual response. Boston: Little, Brown, 1966, pp. 56, 60-61.
-Murry, L. Building a better vagina. Playgirl, 1977, 5, 40+.
-Netter, F. H. The CIBA collection of medical illustrations, Vol 2. Summit, N.J.: CIBA Pharmaceutical Company, 1970.
-Sherfey, M. J. The nature and evolution of female sexuality. New York: Random House, 1972.
-Testut, J. L. Traite d'anatomie humaine (ed. 8, revised and enlarged by A. Latarjet), Vol. 5: Appareil urogenital peritoine. Paris: Doin, 1931.
-Toldt, C. Anatomisher Atlas. Berlin and Wien: Urban and Schwarzenberg, 1928.