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Coital positions and clitoral blood flow: A biomechanical and sonographic

analysis

Article in Sexologies · July 2022

DOI: 10.1016/j.sexol.2022.04.007

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Coital positions and clitoral blood flow: A

biomechanical and sonographic analysis
K. Lovie ∗, A. Marashi

Department of medical imaging and AI, New H Medical, PC, 176 Johnson Street #6H Brooklyn, 11201 New
York, United States

KEYWORDS Summary
Clitoris; Objective. — To create biomechanical models of five common coital positions, and evaluate the
Biomechanics; degree of contact and forces against the clitoris. To evaluate clitoral blood flow before and
Sexual positions; after engaging in these positions.
Sonography Methods. — Biomechanical models were rendered of a male and female pelvis in the follow-
ing coital positions: face-to-face/female above, sitting/face-to-face, face-to-face/male above
(with and without pillow), and kneeling/rear entry. The thrusting force and gravitational force
were estimated for the pelvis(es) providing the main forces. The areas of contact between
the pelvises were identified and highlighted. Sonography of the clitoris was performed before
and after a healthy volunteer couple engaged in each position, using a Philips LumifyTM ultra-
sound (Koninklijke Philips N.V., Amsterdam, Netherlands) with a L12-4 linear array transducer
(4—12 MHz).
Results. — The biomechanical models for each position, with the exception of kneeling/rear
entry, reveal a large amount of contact with the clitoris. Clitoral blood flow increased after
engaging in each position except for kneeling/rear entry. Positions in which the gravitational
force of the thrusting partner was in the same direction of (and thereby augmenting) the
thrusting force resulted in intense clitoral blood flow (face-to-face/female above, and face-to-
face/male above). Augmenting the face-to-face/male above position with a pillow generated
a component of the male pelvic gravitational force in the direction of the clitoris; this resulted
in more blood flow to all components of the cavernous body.
Conclusion. — From a biomechanical perspective, different coital positions vary in their poten-
tial to stimulate the clitoris. These positions lead to variable increases in clitoral blood flow,
concordant with our biomechanical models.
© 2022 Sexologies. Published by Elsevier Masson SAS. All rights reserved.

∗ Corresponding author at: 469 West 57 Street, #3C, 10019 New York, NY, United States.
E-mail address: kimberly.lovie@nycgyno.com (K. Lovie).

https://doi.org/10.1016/j.sexol.2022.04.007
1158-1360/© 2022 Sexologies. Published by Elsevier Masson SAS. All rights reserved.

Please cite this article as: K. Lovie and A. Marashi, Coital positions and clitoral blood flow: A biomechanical and sono-
graphic analysis, Sexologies, https://doi.org/10.1016/j.sexol.2022.04.007
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Introduction • parasympathetic stimulation of the clitoris resulting in

dilation of the of the clitoral arteries;
The purported benefits of various coital positions are • erectile tissue of the clitoris becoming engorged with
described in numerous magazines, books, and public forums. blood (increased inflow and decreased outflow of blood);
However, there is little scientific research that evaluates the • secretions from the Bartholin and/or Skene glands and
association between different coital positions and their abil- urethra;
ity to produce female orgasm. A survey of Swedish women • sympathetic stimulation of the urovaginal plexus (through
evaluated the tendency of various sexual techniques (but the hypogastric nerves and inferior hypogastric plexus);
not positions) to cause climax. In this study, 51—57% of • skeletal muscle contraction of the vagina, anus, and ure-
women achieved orgasm though penile penetration alone, thra (through the pudendal nerve).
and 50% through clitoral stimulation alone (Fugl-Meyer
et al., 2006). Swieczkowski and Walker evaluated the ability From a biomechanical perspective, pelvic floor mus-
of different coital positions to produce orgasm by adminis- cles are also crucial to orgasm, with stronger pelvic floor
tering a questionnaire with a 40-point Likert scale (ranging muscles associated with improved sexual function (Kanter
from 0/‘‘not at all’’ to 40/‘‘exclusively’’). The average et al., 2015; Kegel, 1952; Graber and Kline-Graber, 1979;
ratings, in order of decreasing orgasm potential, were: Lowenstein et al., 2010; Martinez et al., 2014). Although
face-to-face/male above (28), face-to-face/female above other biomechanical factors (i.e. forces against the cli-
(26.36), manipulation of female genitals by partner (23.47), toris) likely play a major role in this process, female
cunnilingus (17.94), face-to-face/side position (16.73), orgasm has yet to be formally studied from this perspec-
stimulation of breasts and other non-genital areas (11.69), tive. Researchers generally agree that there is a distinction
sitting/face-to-face (10.78), prone/rear entry (8.23), kneel- between orgasms resulting from clitoral stimulation, or
ing/rear entry (5.85), sitting/rear entry (3.81), stimulation ‘‘clitoral orgasm’’ (CO), and those resulting from vaginal
by vibrator (2.26), and anal intercourse (0.89) (Swieczkowski penetration without clitoral stimulation, or ‘‘vaginally acti-
and Walker, 1978). vated orgasm’’ (VAO) (Jannini et al., 2012; Buisson and
In 2018, Krejcová et al. investigated coital positions Jannini, 2013). A VAO is hypothesized to involve stimula-
in a group of Czech volunteers. Participants were shown tion of the clitorourethrovaginal (CUV) complex (Jannini
a series of black and white drawings of 13 sexual posi- et al., 2012; Buisson and Jannini, 2013). Buisson and Jannini
tions and were asked to estimate what percentage of the performed a sonographic study to evaluate clitoral blood
time they led to orgasm; 9 positions were coital: face to flow after external and internal stimulation (Buisson and
face/male above, prone/rear entry, standing/face-to-face, Jannini, 2013). Additional sonographic studies have evalu-
standing, face-to-face/female above, supine/female above, ated the CUV complex (Buisson et al., 2008; Gravina et al.,
kneeling/rear entry, sitting/face-to-face, and standing/rear 2008; Foldes and Buisson, 2009; Battaglia et al., 2009;
entry. The most common positions (over participants’ life- Battaglia et al., 2010a; Battaglia et al., 2010b). However,
times, and within the past 5 years) were: face to face/male no sonographic studies have been performed to evaluate the
above (median 80% for females), face-to-face/female above efficacy of different coital positions.
(median 40% for females), and kneeling/rear entry (median
42% for women). The face to face/female above and
sitting/face-to-face positions were most likely to result in
Materials/Patients
orgasm, while the kneeling/rear entry position was least
likely (Krejcová et al., 2020). We evaluated different common coital positions and their
Krejcová et al. attribute the success of face-to-face ability to stimulate areas in the female pelvis that are
positions to their ability to facilitate communication, both involved in orgasm, with attention to the clitoris. The fol-
verbal and physical (Krejcová et al., 2020). Although these lowing five positions were assessed: face-to-face/female
psychological factors are involved in orgasm (Meston et al., above, sitting/face-to-face, face-to-face/male above (with
2004; Brody, 2010; Brody and Costa, 2017; Adam et al., and without pillow), and kneeling/rear entry. These five
2020), physical stimulation of the clitoris, which has been positions were chosen because they were among the most
recognized as ‘‘possibly the most critical organ for female or least likely to cause orgasm, or were the most com-
sexual health,’’ likely plays a dominant role (Mazloomdoost mon based on the results of Krejcová et al. (Krejcová
and Pauls, 2015). Female orgasm is hypothesized to be regu- et al., 2020) In their study, the face-to-face/female above
lated by both autonomic and somatic nerves, and involves a and sitting/face-to-face positions were most likely to cause
complex reflex arc. According to O’Connell et al. (O’Connell orgasm. The kneeling/rear entry position was least likely
et al., 2005) this process probably involves: to cause orgasm. The face-to-face/male above position was
evaluated because it was the most common (Krejcová et al.,
2020). We also evaluated the face-to-face/male above posi-
tion with a pillow because it is a common coital practice.
• Receptors within the clitoris and vulva detecting stimulus The five positions were performed by a healthy medi-
(i.e. touch); cal doctor couple, both 32-years-old, at home. Given the
• somatic afferents of the pudendal nerve (dorsal clitoral sensitive nature of the research, the participants were cho-
and perineal branches); sen because they were well-known to the researchers, and
• S2-4 spinal cord levels transmitting information to the willingly volunteered for the study. The participants were
brain; in a monogamous relationship with each other. Both partici-
• visceral efferents of the pelvic splanchnic nerves; pants were healthy and had no sexually transmitted illnesses

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or significant past medical history. They completed the Ari- adjacent to the cavernous body. The vestibular bulbs are on
zona Sexual Experiences Scale (ASEX) and the short form a more medial plane than the cavernous bodies, and are not
of the Female Sexual Function Index (FSFI-6), two validated seen in the sagittal image (Fig. 1).
tools for evaluating for sexual dysfunction; neither volunteer The biomechanical models for each position, with the
had sexual dysfunction. Informed consent was obtained for exception of the kneeling/rear entry position, reveal a large
both participants. This study was carried out in accordance amount of contact between the female’s clitoris and her
with The Code of Ethics of the World Medical Association partner’s skin.
(Declaration of Helsinki). In the biomechanical model for the face-to-face/female
above position, the gravitational force at the female pelvis
Methods center of mass is in the same direction as the female thrust-
ing force (Fig. 2a). This resulted in intense, symmetric blood
flow to all three parts of the cavernous bodies: the medial
Biomechanical anatomical drawings of a generic male and
aspect of the body and raphe, and the proximal aspect of
female pelvis were rendered in the five positions using
the glans (Fig. 2).
Adobe PhotoshopTM software. The male pelvis and penis
For the sitting/face-to-face position, both partners pro-
were depicted with decreased opacification to better visu-
vide a thrusting force in opposite directions. The location
alize the clitoris and vagina. Areas of contact between the
of the center of gravity for the male and female pelvis are
female vulva, vagina, and her partner’s skin and penis were
approximately in the same location between the partners.
rendered in pink. The dominant forces involved in each
This gravitational force is perpendicular to both thrusting
coital position were depicted with vector arrows. Of note,
force vectors (Fig. 3a). This position led to a relatively small,
the magnitudes of the vectors were chosen arbitrarily, as
symmetric increase in blood flow, localized to the medial
they depend on participant mass and thrusting forces (which
aspect of the cavernous bodies (Fig. 3).
are partner-dependent). The gravitational forceat the pelvic
In the face-to-face/male above position, the gravita-
center of mass was depicted for the pelvis that provided the
tional force of the male pelvis is almost perpendicular to
thrusting force; this allowed us to evaluate whether grav-
his thrusting force (Fig. 4a). This led to an intense, diffuse
ity (or its resolved components) added to the overall force
increase in blood flow to all aspects of the cavernous bodies,
directed against the clitoris. The location of the center of
and to the surrounding pelvic tissues (Fig. 4). Modifying the
gravity was estimated based on data from the Human Per-
face-to-face/male above position with a pillow can be mod-
formance Lab (Cincinnati Children’s Hospital) (Body Center
eled with the male and female pelvises on an inclined plane.
of Mass, 2022).
The force of gravity from the male pelvis (Fg ) is resolved into
The five positions were evaluated in the volunteer cou-
two components: the gravitational force perpendicular to
ple. The duration of each position was 10 minutes. The
the inclined plane (F⊥ ), and the gravitational force parallel
objective was to compare clitoral blood flow before and
to the plane (F// ) (Fig. 5a). This led to an intense, symmet-
after coitus in each of the five positions, after a stan-
ric blood flow to the body and raphe of the cavernous body
dardized period of time. Although it was not necessary to
(Fig. 5).
achieve orgasm, it was recorded if it occurred. Clitoral
The biomechanical model for the kneeling/rear entry
ultrasound was performed, with grayscale and color Doppler
position reveals minimal contact between the female’s
ultrasound images obtained before and after coitus, in the
clitoris and her partner’s skin. The male thrusting force
coronal and sagittal planes. Ultrasound was chosen as the
is perpendicular to the gravitational force at the female
imaging modality, as it is an efficient, low-cost method to
pelvis’ center of gravity (Fig. 6a). This resulted in a neg-
evaluate the clitoris, and can be performed in any setting
ligible increase in blood flow (Fig. 6).
(i.e. at home). Greyscale ultrasound images (not evaluating
The male and female volunteers achieved orgasm during
blood flow) were acquired to assess clitoral anatomy. Color
all five sessions.
Doppler ultrasound images were obtained to evaluate blood
flow before and after clitoral stimulation. The ultrasound
images were obtained with a Philips LumifyTM ultrasound Discussion
machine and L12-4 linear array (4—12 MhHz) transducer. Cli-
toral blood flow was assessed qualitatively with a uniform
The biomechanical models of the face-to-face positions
gain setting for all Doppler acquisitions. A uniform light pres-
(including face-to-face/female above, face-to-face/male
sure was applied with the transducer, acknowledging that
above with and without pillow, and sitting/face-to-face)
heavier pressure could skew blood flow. Each coital position
demonstrate a considerable amount of contact between
was evaluated on a different day to allow the clitoral blood
the female pelvis and her partner’s skin. Although Krejcová
flow to return to baseline. This ensured that the order in
et al. attribute the success of the face-to-face positions
which the coital positions was evaluated did not influence
to their ability to facilitate verbal and physical commu-
the results.
nication (Krejcová et al., 2020), our models support our
hypothesis that face-to-face positions also maximize cli-
Results toral stimulation and increase blood flow. The kneeling/rear
entry position produces the least amount of direct clitoral
The ultrasound acquisitions in the transverse plane reveal contact, and resulted in a negligible increase in blood flow
paired, hypoechoic cavernous bodies on either side of the compared to the face-to-face positions.
urethra. In the sagittal image, the glans, raphe, and body of According to Krejcová et al., the face-to-face/female
the cavernous body are visualized. The ischiopubic ramus is above position was among the most likely to lead to

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Figure 1 Transverse (a) and sagittal (b) views of the clitoris depicting the paired cavernous bodies (CB) urethra (Ure), glans (GL),
raphe (RA), ischiopubic ramus (IR), and vagina (VA).

Figure 2 Biomechanical model of the face-to-face/female above position. The thrusting force (FT ) is provided by the female
pelvis, and is in the same direction as the gravitational force (Fg ) at the female pelvis center of mass (a). Transverse and sagittal
views of the clitoris before (b and c) and after (d and e) engaging in the face-to-face/female above position, with color Doppler
flow.

Figure 3 Biomechanical model of the sitting/face-to-face position (a). Both partners apply a thrusting force (FT ) in opposite
directions, which are both perpendicular to the female and male pelvis gravitational force (Fg ). Transverse and sagittal views of
the clitoris before (b and c) and after (d and e) engaging in the sitting/face-to-face position, with color Doppler flow.

orgasm (Krejcová et al., 2020). Based on the biomechanical Krejcová et al. found that the sitting/face-to-face posi-
model, with the female positioned above, the downward tion had a high likelihood of causing orgasm (Krejcová et al.,
force of gravity maximizes the pressure on the clitoris. 2020), which is supported by our model. This position allows
This gravitational force is also in the same direction as each partner equal opportunity to exert a thrusting force
the female thrusting force, which can help facilitate this against the other, which can increase the pressure against
motion. Additionally, compared to when she is below her the clitoris. Of note, the gravitational force is perpendicular
partner, she has more control over the pressure exerted to both partners’ thrusting forces, and does not contribute
against the clitoris. Although this position did not lead to to the total force (and therefore pressure) exerted against
the largest increase in blood flow, it was the only posi- the clitoris. These biomechanical factors might explain why
tion in which all aspects of the cavernous body were the sitting/face-to-face position has a high likelihood of
involved. causing climax, but is not the most likely. These findings are

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Figure 4 Biomechanical model of the face-to-face/male above position (a). The thrusting force (FT ) is provided by the male
pelvis, and is approximately perpendicular to the gravitational force of the male pelvis (Fg ). Transverse and sagittal views of the
clitoris before (b and c) and after (d and e) engaging in the face-to-face/male above position, with color Doppler flow.

Figure 5 Biomechanical model of the face-to-face/male above with a pillow (a). The thrusting force (FT ) is provided by the male
pelvis. The force of gravity from the male pelvis (Fg ) is resolved into two components: the gravitational force perpendicular to the
inclined plane (F⊥ ), and the gravitational force parallel to the plane (F// ). Transverse and sagittal views of the clitoris before (b
and c) and after (d and e) engaging in the face-to-face/male above position with pillow, with color Doppler flow.

Figure 6 Biomechanical model of the kneeling/rear entry position (a). The thrusting force (FT ) is provided by the male pelvis,
and is approximately perpendicular to the gravitational force of the male pelvis (Fg ). Transverse and sagittal views of the clitoris
before (b and c) and after (d and e) engaging in the kneeling/rear entry position.

corroborated by ultrasound: the sitting/face-to-face posi- blood flow to the clitoris and surrounding tissues, which
tion resulted in increased blood flow compared to baseline, was diffuse. A variation of this position involves the woman
but less than the positions in which pelvic gravitational force tilting her pelvis upwards, sometimes with the aid of a pil-
is exerted against the clitoris. low. Pillows marketed for this intention, often referred to
The face-to-face/male above position (without a pillow) as ‘‘sex pillows,’’ or ‘‘positioning pillows’’ are usually firm
was the most common position reported by Krejcová et al. and wedged shaped, providing more precise and consistent
(median 80% for females). However, it was not among the pelvic angulation than conventional bed pillows. Although
positions most likely to lead to orgasm (Krejcová et al., Krejcová et al. did not evaluate the frequency of orgasm
2020). This finding might be explained by the woman hav- when a pillow was used in this position, the biomechanical
ing less control over the pressure exerted against the vulva. models suggest that a pillow would increase the likelihood of
Interestingly, this position led to the largest increase in orgasm: a female can adjust herself on the pillow to increase

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the amount of contact between the clitoris and her partner’s Acknowledgements
skin. The F// component of gravity created by the ‘‘inclined
plane’’ of the pillow allows more force (and therefore pres- We thank Dr. Nima Nouri Naini for his support and help-
sure) to be directed from the male pelvis to the clitoris. In ful radiology discussions from the beginning of our research
addition to increasing the amount of contact and pressure endeavors. We thank Claire Chanu for assistance with French
on the clitoris, pillows can increase the depth of penetra- translation.
tion. Of note, the participants studied by Krejcová et al.
rated positions with deep vaginal penetration as more plea-
surable (Krejcová et al., 2020). In our volunteer couple, this
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