Curr Sex Health Rep (2015) 7:59–62 DOI 10.1007/s11930-015-0041-2

CURRENT CONTROVERSIES (P KLEINPLATZ AND C MOSER, SECTION EDITORS)

Female Ejaculation, G Spot, A Spot, and Should We Be Looking for Spots? Beverly Whipple

Published online: 12 March 2015 # Springer Science+Business Media, LLC 2015

Abstract This review considers research concerning the phenomenon of female ejaculation, the G spot, and the A spot. These topics have been the object of controversy in recent decades. Female ejaculation has been written about for more than 2000 years. The area of the Grafenberg or G spot was named by Drs. John Perry and Beverly Whipple in the early 1980s in honor of Dr. Ernst Grafenberg, and the A spot was identified by Dr. Chua Chee Ann in 1997. The goal of this author’s research program has been to validate, in a laboratory setting, women’s reports of pleasurable sensual and sexual experiences, not to create new goals, new spots, or controversy. Keywords Female ejaculation . G spot . Grafenberg spot . A spot . Gushing . Squirting . Female prostate gland . Clitourethrovaginal complex . CUV

Introduction Female ejaculation refers to the expulsion of fluid from the urethra that is different from urine. The fluid is described as looking like watered-down fat-free milk, tasting sweet, and usually about a teaspoon (3–5 cc) in volume. The biological phenomenon of female ejaculation has been a normal and pleasurable experience of many women’s sexuality. Aristotle was probably the first to write about female ejaculation and Galen is said to have known about it in the second century C.E. In 1672 in his New Treatise Concerning the Generative This article is part of the Topical Collection on Current Controversies B. Whipple (*) Rutgers, The State University of New Jersey, 87 Matlack Drive, Voorhees, NJ 08043, USA e-mail: [email protected]

Organs of Women, De Graff described the female prostate and the fluid from the urethra in some detail. Female ejaculation was a tradition in ancient cultures of China, India, Japan, and other areas of Asia and Africa. The Romans called these fluids liquor vitae, and in ancient India, the fluids were known as a amrita (nectar of the gods). Many authors have described the history of female ejaculation, such as Grafenberg [1], Sevely and Bennett [2], Addiego et al. [3], Perry and Whipple [4], Ladas, Whipple, and Perry [5, 6], Belzer, Whipple, and Moger [7], Stifer [8], Zavaicic and Whipple [9], Cabello [10], Zavicac [11], Korda, Goldstein, and Sommer [12], and RubioCasillas and Jannini [13]. The area of the Grafenberg spot in women is located about halfway between the back of the pubic bone and the cervix, along the course of the urethra. It is a sensitive area that is felt through the anterior wall of the vagina, which swells when it is stimulated, although it is difficult to palpate in an unstimulated state. Drs. John Perry and Beverly Whipple named this area the Grafenberg spot to commemorate the research of Dr. Ernst Grafenberg, a German-born obstetrician and gynecologist, who developed the first IUD. In 1944, Grafenberg and Robert L. Dickinson described a zone of erogenous feeling located along the suburethral surface of the anterior vaginal wall [14]. In 1950, Dr. Grafenberg wrote about the sensitive area on the anterior wall of the vagina, which when stimulated seems to cause the female urethra to enlarge and swell. He also described a fluid from the urethra that is different from urine [1].

Female Ejaculation Perry and Whipple rediscovered the sensitive area they named the Gräfenberg spot while teaching women Kegel exercises using biofeedback for stress urinary incontinence. Some of the women who reported that they lost fluid from their urethra had

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very strong pelvic floor muscles, while women with stress urinary incontinence usually have weak pelvic floor muscles. The women with strong pelvic floor muscles also reported that they only lost fluid from their urethra during sexual stimulation and some during orgasm. This led Perry and Whipple to conduct a study comparing the pelvic muscle strength of women who they called Bfemale ejaculators^ to women who did not experience female ejaculation [4]. The results of this study demonstrated that the pelvic muscle strength of women who experience female ejaculation was significantly stronger than the women who did not have this experience. These women described the fluid as looking like watered-down fatfree milk, tasting sweet, not smelling like urine, and about a teaspoon (3–5 cc) in volume. The woman who experienced female ejaculation also reported that there seemed to be a sensitive area felt through the anterior wall of their vagina and stimulation of this area caused the expulsion of fluid from their urethra and in some cases an orgasm that felt different from their orgasm from clitoral stimulation. They reported that the orgasm felt deeper inside their body and produced a bearing down sensation, with the uterus pushing down into the vagina, rather than the tenting effect of the vagina (where the end of the vagina balloons out and the uterus pulls up), as reported at orgasm by Masters and Johnson in 1966, in response to clitoral stimulation [15]. Perry and Whipple’s team of medical doctors and nurse practitioners examined over 400 women and found this sensitive area, which swells when it is stimulated with a Bcome here^ motion, in all women tested [5, 6]. The women were lying on their back and the stimulation of the area felt through the anterior vaginal wall was done with two fingers, with the palm of the hand up, of the person doing the stimulation. They then named this area the Gräfenberg spot after Dr. Ernst Gräfenberg, who wrote about the sensitive area that surrounds the urethra and the expulsion of a fluid from the urethra that is different from urine [3, 4]. Dr. Milan Zaviacic and Dr. Beverly Whipple started an email correspondence after Perry and Whipple first published their findings in 1981. They met personally when Whipple visited Zaviacic in Bratislava in 1986 and again in 2005. They had mutual interests in female expulsion of fluid from the urethra and thus began an almost 30-year history of collaboration and consultation. Unfortunately, Dr. Milan Zaviacic, passed away on January 9, 2010. (unpublished data). Dr. Milan Zaviacic, after conducting hundreds of studies, concluded that the fluid expelled through the urethra comes from the female prostate gland. His book, The Human Female Prostate [11], cites most of his anatomical studies as well as chemical analysis of the fluid [16]. This fluid has been analyzed chemically by others, such as Addiego and colleagues [3], Belzer, Whipple, and Moger [7], and Rubio-Casillas and Jannini [13], all of whom found that the chemical components of the ejaculated fluid were significantly different from urine

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from the same subjects. Specifically, the ejaculate contains high levels of prostatic acid phosphatase, prostatic specific antigen, glucose, and fructose, but low levels of urea and creatinine. The chemical composition of healthy urine is the opposite of female ejaculate, so they are easily differentiated from each other. That is, healthy urine contains high levels of urea and creatinine and no prostatic acid phosphatase, prostatic specific antigen, or glucose (of course, the urine of persons with diabetes may contain glucose). Other researchers have described the occurrence of female ejaculation without performing any chemical analysis. There are many films and books claiming to teach women to ejaculate, but these films and books do not report an analysis of the fluid, and the amounts shown to be expelled in these films are much larger than those collected and analyzed in laboratory settings. Rubio-Casillas and Jannini [13] have reported on the chemical composition of three fluids expelled from the urethra: urine, large amounts of a clear fluid that has been called squirting or Bgushing,^ and what Perry, Whipple, and Zaviacic have all called female ejaculation. Their biochemical evidence demonstrates that the clear and abundant fluid that is ejected in gushers is different from the real female ejaculation, and all are different from urine from the same subject. Consequently, it is questionable as to whether in those cases the large amounts of fluid are female ejaculate or, more likely, as Rubio-Casillas and Jannini demonstrated, dilute urine [17]. From these studies, it is evident that some women expel a fluid that is different from urine during sexual activities and orgasm and some women may also expel urine. In a review of the literature in 1991, Whipple and Komisaruk [18] reported that in some women, G spot stimulation, orgasm, and female ejaculation are related, while in others they are not. There are reports that some women have experienced female ejaculation with orgasm from clitoral stimulation and some women have reported experiencing ejaculation without orgasm [3, 5, 6].

The A Spot The A spot, the anterior fornix erogenous zone or AFE zone, was described by Chua Chee Ann, a Malaysian physician, as a possible sexual stimulatory region in women. It is a region of sensitive tissue on the anterior vaginal wall, proximal to the area of the vaginal wall through which the area of the G spot is stimulated, and just before the cervix [19]. Dr Chua suggests that not all women will find this area spontaneously sensitive. He says that some women need a fair amount of practice with the A spot stimulation technique before the area becomes erotically sensitized. He has a website about this area (www. aspot-pioneer.com).

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The G Spot The tissues that compose the area of the G spot have been reported by many. In 1982, Perry and Whipple wrote that BThe G spot is probably composed of a complex network of blood vessels, the parauretheal glands and ducts (female prostate), nerve endings, and the tissue surrounding the bladder neck^ [5]. In the Orgasm Answer Guide, Komisaruk, Whipple et al. [20] noted that the area Jannini and colleagues call the clitorisurethra-vaginal complex (also known as the area of the G spot) contains several different organs in this highly complex body region. BThese include 1) the anterior vaginal wall, 2) the urethra, 3) the Skene’s glands (also called the para-urethral glands or female prostate gland), 4) perhaps other glands in this region (vestibular glands, Bartholin’s glands), 5) the surrounding muscle and connection tissue, and 6) perhaps even portions of the clitoris.^ [20, p. 101]. In 2010, in the section of the Journal of Sexual Medicine called BControversies in Sexual Medicine,^ Jannini, Whipple et al. presented information about the area of the G spot. The conclusion was that although a huge amount of data have been accumulated in the last 60 years, more research is still needed [21]. In 2012 in the same journal, Kilchevsky et al. [22] reported that the female G spot is not a distinct anatomical entity found in the anterior vaginal wall. Perry and Whipple [4], Ladas, Whipple and Perry [5], Addiego et al., [3], Jannini et al. [21], and other researchers have not defined it as a distinct anatomical entity in the anterior vaginal wall. Again in 2012 in the BControversies in Sexual Medicine^, in the Journal of Sexual Medicine, research was reviewed in which it was demonstrated that women can experience orgasm from many forms of stimulation and that the assumption that women may experience only the clitoral, external orgasm is not based on the best available scientific evidence [23]. Using modern imagery techniques, Jannini et al. [24] provide data to support the anatomical relationships and dynamic interrelations between the clitoris, urethra, and anterior virginal wall, which led them to calling the region of the Grafenberg spot the clitourethrovaginal (CUV) complex.

Controversy Since at least 2006, Dr. Vincenzo Puppo has been publishing papers saying that the G spot does not exist. He states that BGrafenberg discovered no G-spot in 1950; the supposed Gspot must not be identified with Grafenberg’s name^ [25 p.7]. Drs. Perry and Whipple named this sensitive area to honor Dr. Grafenberg for his earlier findings and his findings published in 1950, Dr. Grafenberg did not name this area after himself. Puppo further states that Bthe claims by Frank Addiego, Beverly Whipple, Emmanuele Jannini, Odile Bussion, Helen O’Connell, Irwin Goldstein, Barry Komisaruk and others have no scientific basis^ [25 p.8]. As far as the literature

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shows, Dr. Puppo has not conducted any research studies himself. In addition, he states that Bthe correct anatomical term to describe the erectile tissues response for female orgasm is the female penis^ [26, p.134]. When Dr. Komisaruk published a letter to the editor about Dr. Puppo’s criticism of our research, Dr. Puppo asked why our subjects used self-stimulation. He stated BWe have challenged him to repeat his experiment on other women in our presence, and in the presence of colleagues and journalists, but the women must not be selfstimulated. Dr. Komisaruk rejected our proposal^ [27 p.1]. Dr. Komisaruk and I do not conduct research with journalists watching, and we would not request IRB approval for a study as proposed by Dr. Puppo.

Conclusion It is important for women and their male and female partners to know that the phenomenon of female ejaculation is a normal part of healthy sexuality. Many women reported that they had surgery to correct this fluid expulsion and others reported that they stopped experiencing orgasm [4]. It is also important for health care providers to be aware of this phenomenon and to help their patients to realize that this is a normal, healthy part of female sexual responses. When writing about my research findings, I have ended one article with the following, BI want to conclude by saying that orgasm in women is in the brain, it is felt in many body regions, and it can be stimulated from many body regions as well as from imagery alone. Orgasm is not a just a reflex, it is a total body experience. We need to continue to be open to documenting the various pleasurable sensual and sexual experiences reported by women. It is important to be aware of the variety of sexual responses that women report and that have been documented in the laboratory. It is also important not to put women into a model of only one or two ways to experience sensual and sexual pleasure, satisfaction, and orgasm. Women need to be encouraged to feel good about the variety of ways they experience sexual pleasure, without setting up specific goals (such as finding the G spot, experiencing female ejaculation, or experiencing an orgasm from vaginal stimulation). Healthy sexuality begins with acceptance of the self, in addition to an emphasis on the process, rather than the goals of sexual interactions^ [23, p.959]. We need scientific studies and then acceptance of the reports of women’s sensual and sexual pleasure, we do not need any more spots. Compliance with Ethics Guidelines Conflict of Interest Beverly Whipple declares no conflict of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by the author.

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References 17. 1. Grafenberg E. The role of the urethra in female orgasm. Int J Sexol. 1950;3:145–8. 2. Sevely JL, Bennett JW. Concerning female ejaculation and the female prostate. J Sex Res. 1978;14:1–20. 3. Addiego F, Belzer EG, Comolli W, Moger W, Perry JD, Whipple B. Female ejaculation: A case study. J Sex Res. 1981;17:13–21. 4. Perry JD, Whipple B. Pelvic muscle strength of female ejaculators. J Sex Res. 1981;17:22–39. 5. Ladas A, Whipple B, Perry JD. The G spot: and other recent discoveries about human sexuality. New York: Holt, Rinehart & Winston; 1982. 6. Ladas A, Whipple B, Perry JD. The G spot and other discoveries about human sexuality. New York: Holt, Owl Books; 2005. 7. Belzer EG, Whipple B, Moser W. On female ejaculation. J Sex Res. 1984;20:403–6. 8. Steifter KF. Die Dritte Dimension-der Lust. Das Geheimnis der weiblichen Ejakulataion. Frankfurt Main: Ullstein; 1988. 9. Zaviacic M, Whipple B. Update on the female prostate and the phenomenon of female ejaculation. J Sex Res. 1993;30:148–51. 10. Cabello F. Female ejaculation: myths and reality. In: Borras-Valls JJ, Perez-Conchillo M, editors. Sexuality and human rights. Valencia: Nau Llibres; 1997. 11. Zaviacic M. The human female prostate: from vestigial skene’s paraurethal glands and ducts to woman’s functional prostate. Bratislava: Slovak Academic Press; 1999. 12. Korda JB, Goldstein SW, Sommer F. History of female ejaculation. J Sex Med. 2010;7:1965–75. 13. Rubio-Casillas A, Jannini EA. New insights from one case of female ejaculation. J Sex Med. 2011;8:3500–4. 14. Grafenberg E, Dickinson RL. Conception control by plastic cervix cap. West J Surg Obstet Gynecol. 1944;52:335–40. 15. Masters WH, Johnson V. Human sexual response. Boston: Little, Brown; 1966. 16. Zaviacic MS, Dolezalova IK, Holoman A, Zaviacicova M, Mikulecky, Brazdil V. Concentrations of fructose in female ejaculate

18.

19.

20.

21. 22. 23.

24.

25.

26.

27.

and urine: a comparative biochemical study. J Sex Res. 1988;24: 319–25. Whipple B. G spot. In: Whelehan P, Bolin A, editors. The international encyclopedia of human sexuality. Australia: John Wiley & Sons, Ltd; 2015. Whipple B, Komisaruk BR. The G spot, orgasm, and female ejaculation: are they related? In: Kothari P, editor. The Proceedings of the First International Conference on Orgasm. Bombay: VRP Publishers; 1991. p. 227–37. Chua Chee A. A proposal for a radical new sex therapy technique for the management of vasocongestive and orgasmic dysfunction in women: the AFE zone stimulation technique. Br J Sex Marital Ther. 1997;124:357–70. Komisaruk BR, Whipple B, Nasserzadeh S, Beyer-Flores C. The orgasm answer guide. Baltimore: The Johns Hopkins University Press; 2010. Jannini EA, Whipple B, Kingsberg SA, Buisson O, Foldes P, Vardi Y. Who’s afraid of the G-spot? J Sex Med. 2010;7:25–34. Kilchevsky A, Vardi Y, Lowenstein L, Gruenwald I. Is the female Gspot truly a distinct anatomic entity? J Sex Med. 2011;9:719–26. Jannini EA, Rubio-Casillas A, Whipple B, Buisson O, Komisaruk BR, Brody S. Female orgasm(s): one, two, several. J Sex Med. 2012;9:956–65. Jannini EA, Buisson O, Rubio-Casillas A. Beyond the G-spot: clitourethrovaginal complex anatomy in female orgasm. Nat Rev Urol. 2014. 10: Advance Online Publication. Puppo V, Puppo G. Anatomy of sex: revision of the new anatomical terms used for the clitoris and the female orgasm by sexologists. Clin Anat. 2014. on line. Puppo V. Anatomy and physiology of the clitoris, vestibular bulbs, and labia minora with a review of the female orgasm and the prevention of female sexual dysfunction. Clin Anat. 2013;26:134–52. Puppo V, Puppo G. Letter to the editor. Response to the Letter to the Editor by Barry R. Komisaruk BRe: Puppo V, Puppo G. 2014. Anatomy of sex: revision of the new anatomical terms used for the clitoris and the female orgasm by sexologists^. Clin Anat. 2014. on line.