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1 Lawrence Erlbaum Associates (Taylor & Francis Group) Clitoral Foreskin Adhesions and Female Sexual Function Author(s): Benjamin Graber and Georgia Kline-Graber Source: The Journal of Sex Research, Vol. 15, No. 3 (Aug., 1979), pp Published by: Lawrence Erlbaum Associates (Taylor & Francis Group) Stable URL: Accessed: 09/11/ :59 Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at JSTOR's Terms and Conditions of Use provides, in part, that unless you have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you may use content in the JSTOR archive only for your personal, non-commercial use. Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printed page of such transmission. JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org. Lawrence Erlbaum Associates (Taylor & Francis Group) is collaborating with JSTOR to digitize, preserve and extend access to The Journal of Sex Research.

2 The Journal of Sex Research Vol. 15, No. 3, pp August, 1979 Clitoral Foreskin Adhesions and Female Sexual Function Abstract This article describes clitoral foreskin adhesions and reviews the past references to this condition. A retrospective analysis was done to determine the incidence and clinical significance of these adhesions in 271 women seen at a sexual dysfunction clinic. A high incidence, greater than 70%, was noted; however, no significant differences were found between groups divided on the basis of orgasmic status in coital and noncoital situations. The findings cast doubt on the clinical significance of this condition, and therefore also provide some contradictory evidence to the involvement of the clitoris in coital orgasm through a labial-preputial mechanism. In his Atlas of Human Sexual Anatomy, Dickinson (1939) illustrated a condition in which the foreskin of the clitoris is adhered to the glans. Although occasional reference (Masters & Johnson, 1970; Oliven, 1965) has been made to this condition, no extensive report is available on either its incidence or clinical significance. The clitoris, like its homologue, the penis, has a foreskin that covers the glans. The size, thickness, and configuration of this foreskin vary greatly from individual to individual (Sherfey, 1966). The foreskin in its unadhered state can be fully retracted and is freely moveable over the surface of the glans. With the development of an adhesion, the foreskin becomes fused to the glans, forming either a partial or complete covering of it. As in the male, smegma accumulates underneath the foreskin. It is not currently known if the adhesion is related to irritation produced by the smegma; however, removal of the adhesion often reveals entrapped particles of smegma. Clitoral adhesions have been referred to as clitoral Benjamin Graber, MD, is an Assistant Professor of Psychiatry at the Nebraska Psychiatric Institute, University of Nebraska Medical Center, Omaha, Nebraska. Georgia Kline- Graber, RN, BA, was formerly in private practice with Benjamin Graber in Marina Del Rey, California. The authors wish to thank Marjory Klein and Ben Peckham for their professional assistance and Amy Nelson and Chris Carey for their technical assistance. Requests for reprints should be sent to Benjamin Graber, MD, Nebraska Psychiatric Institute, University of Nebraska Medical Center, 602 S. 45th St., Omaha, Nebraska

3 206 phimosis (Rathman, 1959); clitoral adhesion (Hartman & Fithian, 1972); clitoral foreskin adhesion (Graber & Kline-Graber, Note 1); buried clitoris (Clark, 1968); and hooded clitoris (Clark, 1968). The present study was undertaken to determine the incidence of this condition in a sexually dysfunctional population. Method Subjects A retrospective analysis was done on the records of 271 women who were seen at the Sexual Therapy Medical Clinic. The women were classified by orgasmic capacity as follows: Group A (N = 150) was noncoitally and coitally anorgasmic; Group B (N = 103) was noncoitally orgasmic but coitally anorgasmic; Group C (N = 24) was noncoitally and coitally orgasmic. Group C was smaller because the study was conducted on a clinical population which was primarily dysfunctional. This functional population was available for comparison because the women had either accompanied a dysfunctional male partner or had appeared with a sexual or marital problem other than orgasmic dysfunction. Orgasmic capacity was assessed and determined in a clinical interview by a physician-nurse team. The patient's own opinion was asked and verification sought in the subject's report of actual physiological parameters known to be associated with orgasm (Kline-Graber & Graber, 1975; Masters & Johnson, 1966). Procedure The patients filled out a questionnaire that took approximately one hour and provided epidemiological data as well as specific sexual behavior data. They were then interviewed by a physician-nurse team which then performed a complete pelvic examination including additional attention to external genitalia. The clitoris was examined with the foreskin unretracted, and then an attempt was made to retract it. Figure 1 shows an attempt at retraction. The presence of an adhesion is indicated by the small pocket or "dimple" seen just superior to the clitoral glans. When an adhesion is lysed, this pocket is no longer visible (Figure 2) and a substantially larger portion of the glans is revealed. An estimate was made of the percentage of clitoral glans that was visible. The ability to estimate this percentage was refined and corroborated by experience

4 CLITORAL FORESKIN ADHESIONS 207 FIG. 1. Clitoral foreskin adhesion before surgical lysis. gained in lysing adhesions that were causing dyspareunia secondary to imbedded granules of smegma (Masters & Johnson, 1970) (Figure 3). The adhesion percentage was recorded by the amount of foreskin adhered so that, for example, if it was estimated that only 10% of the glans clitoris remained exposed, the adhesion was recorded as 90%. Results The incidence of adhesions for each group is reported in Table 1. A chi-square analysis of the three diagnostic groups compared to each other in terms of presence or absence of adhesion was performed. There was no difference among these groups, X2(2) =.04, p >.05. The incidence of

5 208 FIG. 2. Clitoral foreskin adhesion after surgical lysis before removing smegma. adhesions in each group was as follows: Group A = 72%, Group B = 70.8%, Group C = 70.8%. An analysis of variance between the three groups for degree of clitoral foreskin adhesions was performed. The means were as follows: Group A =27.3; Group B = 32.3; Group C = There was no significant difference between groups, F(2,274) =.79, p >.10. Table 2 illustrates other sexual variables between the three diagnostic groups. Analysis of variance showed no significant differences in age, intercourse duration, foreplay duration, deliveries, or abortions. Group C had more pregnancies than either Group A or B (p <.05). A chi-square analysis of marital status showed no significant difference, X2(2) = There was a significant difference in intercourse frequency, with the

6 CLITORAL FORESKIN ADHESIONS 209 FIG. 3. Clitoral foreskin adhesion closeup during surgical lysis showing smegma. nonorgasmic groups (B and A) having higher frequencies. Also, Group B, the noncoitally orgasmic group, had a statistically higher frequency of masturbation. Discussion Since the data presented show no relationship between clitoral foreskin adhesions and sexual functioning, it is not conclusive as to the role of clitoral foreskin adhesions in female sexual functioning. The data do demonstrate the relatively high incidence of these adhesions but suggest that their role in orgasmic dysfunction may not be as significant as has been suggested elsewhere (Sherfey, 1966; Hartman & Fithian, 1972; Clark, 1968).

7 210 TABLE 1 Incidence of Clitoral Foreskin Adhesions Among Women of Varying Orgasmic Status Adhesion Group Orgasmic Status A B C Noncoitally Noncoitally Noncoitally and Coitally Orgasmic Coitally and Coitally Anorgasmic Anorgasmic Orgasmic No adhesion Adhesion TABLE 2 Means for Backgrolnd and Sexual Functioning Variables Among Women of Varying Orgasmic Status Mean Orgasmic Status Variable A B F Noncoitally and Coitally Anorgasmic Noncoitally a Noncoitally Orgasmic c and d and Coitally Coitally. Orgasmic Anorgasmic N=153 N=114 N-24 Age (Years) Para Gravida * Abortions Intercourse frequency ** (times per week) Intercourse duration (min.) Foreplay duration (min.) Masturbation frequency *** (times per week) * p <.05. * p <.005. ***p <.001. As to the incidence of clitoral adhesions, the only previous data reported that 92 of 100 consecutively examined women had adhesions (Clark, 1968). These data do not reflect that high a figure, but demonstrate approximately a 70% incidence regardless of orgasmic functioning. At first examination, it would seem surprising that a condition that

8 CLITORAL FORESKIN ADHESIONS 211 appears in such a high percentage of women has been described so infrequently in the medical literature. Actually, it is less surprising when one notes that the average pelvic exam gives little or no attention to the clitoris unless there is a complaint. Clitoral foreskin adhesions evidently only surface as pathology when embedded smegma causes irritation (Masters & Johnson, 1970). Secondly, unless one has surgically lysed a number of adhesions, the landmarks of the adhesions are so obscure that it is difficult to discriminate the degree of adhesion in many instances. Finally, although data indicate that at least some degree of adhesions is normally found in this population, it does not reveal whether this is the natural state. An investigation of female infants and children as well as, a wider selection of adults would shed light on this question. In relation to clinical significance, no well controlled study has been done about the importance of this condition. In regard to sexual functioning, a number of poorly documented or undocumented claims have been made regarding its importance (Sherfey, 1966; Hartman & Fithian, 1972). Others have questioned its significance, but again have not supplied the requisite data (Masters & Johnson, 1970; Kline-Graber & Graber, 1975). Those theorists who have been supporting the importance of clitoral adhesions have generally emphasized the role of the clitoris in what has been referred to as the labial-preputial mechanism (Sherfey, 1966). This mechanism, which provides a model for indirect clitoral stimulation during coitus, has been theorized as a solution to the "vaginal versus clitoral" orgasm controversy. This issue raised by Freud (1953) separates these two afferent or sensory zones and gives a primary role to the vagina in coital orgasm. Krantz's (1958) non-statistical qualitative report on the relative paucity of sensory nerve endings in the actual vaginal mucosa supposedly casts some doubts on the Freudian theory, which has become increasingly unpopular and challenged. Masters and Johnson (1966) reported on the labial-preputial mechanism, which works as follows: As the penis thrusts in and out of the vagina, it puts traction on the labia minora, which are directly connected to the clitoral glans and prepuce, providing stimulation to the sensory nerves of the clitoris. Since a clitoral foreskin adhesion prevents the foreskin from sliding over the glans, Sherfey, who is one of the major proponents of the importance of the labial-preputial mechanism, has stated: "Obviously the adherent prepuce practically precludes the possibility of coital orgasm" (Sherfey, 1966, p. 131). Our data contradict this in that over 70% of the coitally orgasmic women have clitoral foreskin adhesions, a percentage that is no different

9 212 from the nonorgasmic group. Twenty-five percent of the orgasmic women studied had had severe adhesions in which 50% or more of the glans was covered, and in spite of these adhesions, the women were coitally orgasmic. It is important to add that coital orgasm was defined as orgasm occurring during coitus without concomitant manual clitoral stimulation. It is also important to note that the examiner was aware of the orgasmic state of the patient prior to examination. Although this introduces a bias, it would be likely to be in the direction of increasing the percentage of adhesion in dysfunctional women since the clinician was seeking a cause for the dysfunction. While these data cannot preclude a pathological role for clitoral foreskin adhesions in coital orgasmic functioning, they cast doubt on its importance and simultaneously render questionable the significance of the labial-preputial mechanism in coital orgasm. This study was not a random sample and consisted of primarily middle to upper middle class white females, and any generalizations must take this into account. However, the incidence figures shown in these data suggest that this area deserves further study. Reference Note 1. GRABER, B., & KLINE-GRABER, G. Clitoral foreskin adhesions: Description, incidence, and technique for surgical lysis. Paper presented at the meeting for the Society for the Scientific Study of Sex, San Diego, August, References CLARK, L. 101 Intimate sexual problems answered. New York: Signet, CLARK, L. Adhesions between clitoris and prepuce. In H. Biegel (Ed.), Advances in sex research. New York: Hoeber, DICKINSON, R. L. Atlas of human anatomy. Baltimore: Williams and Wilkins, FREUD, S. Three essays on the theory of sexuality. In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 7). London: Hogarth Press, HARTMAN, W., & FITHIAN, M. The treatment of sexual dysfunctions. Long Beach: Center for Marital and Sexual Studies, KLINE-GRABER, G., & GRABER, B. Woman's orgasm: A guide to sexual satisfaction. New York: Bobbs-Merrill, KRANTZ, K. Innervation of the human vulva and vagina. Obstetrics and Gynecology, 1958, 12:4. MASTERS, W., & JOHNSON, V. Human sexual inadequacy. Boston: Little, Brown, MASTERS, W., & JOHNSON, V. Human sexual response. Boston: Little, Brown, OLIVEN, J. Sexual hygiene in pathology. Philadelphia: Lippincott, RATHMAN, W. Female circumcision: Indications and a new technique. General Practitioner, 1959, 20, SHERFEY, M. The nature and evolution of female sexuality. New York: Random House, Accepted for publication April 16, 1979