Self‐ratings of genital anatomy, sexual sensitivity and function in men using the ‘Self‐Assessment of Genital Anatomy and Sexual Function, Male’ questionnaire
Abstract
OBJECTIVE
To assess the perceptions of healthy men of their genital anatomy and sexual sensitivity, along with the re‐test reliability of these ratings, in a new self‐reported questionnaire, the Self‐Assessment of Genital Anatomy and Sexual Function, Male (SAGASF‐M).
SUBJECTS AND METHODS
Eighty‐one healthy, sexually active, men aged 22–57 years (median 33), with no history of genital surgery, completed the SAGASF‐M. This questionnaire comprises written text and images enabling men to rate details of their genital appearance, overall genital erotic and pain sensitivity, orgasm intensity, and effort required for achieving orgasm through stimulation of specified areas around the glans and shaft of the penis, scrotum and anus, along with the contribution of other sexually sensitive areas of the body. Anatomical locations were compared for the functional ratings by mixed‐model analysis of variance (anova). A second sample of 38 healthy men (median age 26 years, range 22–64) from the same source completed the SAGASF‐M twice with an interval of 2 weeks.
RESULTS
There was little variability in anatomy ratings. Ratings of overall penile sensitivity to sexual stimulation gave higher values of ‘sexual pleasure’ for penile stimulation by the partner than by self (P = 0.002) and marginally higher ratings of ‘orgasm intensity’ by partner stimulation (P = 0.077), but there were no corresponding differences on ratings of ‘effort needed to reach orgasm’ or of ‘discomfort/pain’. Overall discrimination between genital areas was highly significant (mixed‐model anova, P = 0.001) for ratings of ‘sexual pleasure’, ‘orgasm intensity’ and ‘orgasm effort’, but was not significant for ‘discomfort/pain’. Ranked by degree of ‘sexual pleasure’, the area ‘underside of the glans’ was highest, followed by ‘underside of the penile shaft’, ‘upper side of the glans’, ‘left and right sides of the glans’, ‘one or both sides of the penis’, ‘upper side of the penile shaft’, ‘foreskin’ (11 subjects), ‘skin between the scrotum and anus’, ‘back side of the scrotum’, ‘front side of the scrotum’, and ‘around anus’, but not all pair differences were significant. The rank order was similar for ‘orgasm intensity’, but less similar and with fewer significant pair differences for ‘orgasm effort’. Overall discrimination of other body parts that help orgasm when touched/stimulated was also highly significant (P = 0.001) and included (in order of degree) scrotum, ear, skin between scrotum and anus, neck, breast/nipples, buttocks, anus (exterior skin), anus (inside with penetration), wrist, and axilla, but many pair differences were not significant. In the reliability study, which was limited to the 45 function items with sufficient variability and sample size, the re‐test reliability values (Pearson r) were distributed as follows: seven were ≥0.80, 16 ≥0.70, 15 ≥0.60, four ≥0.50, two ≥0.40, and one ≥0.30.
CONCLUSION
The SAGASF‐M discriminates reasonably well between various genital and nongenital areas in terms of erotic sensitivity, when administered to genitally unoperated men varying widely in age and socio‐economic level.
Abbreviation
-
- SAGASF‐(M)(F)
-
- Self‐Assessment of Genital Anatomy and Sexual Function (Male) (Female) Version.
INTRODUCTION
Much is known about the sex‐differential anatomy of the genitalia, physiological changes in the body related to sexual arousal and orgasm, sexual behaviour and sexual dysfunction. For men, there are published standards of genital size from birth to maturity [1, 2], and detailed studies of the mechanisms of penile erection [3]. Information about differential genital sensation and its underlying innervation is less complete.
Genital sensory activation sites (the ‘genital sensory field’) are similar in all male vertebrates and include the foreskin, urethra, penis, scrotum, perineum, thigh and anus [4-10]. These sites are supplied by distinct nerves, including the pudendal nerve (foreskin and perineum); dorsal nerve of penis; cavernous nerve; nerves innervating the urethral sphincter; the pelvic nerve (rectal wall, rectum); and the genitofemoral nerve (thigh and perineum), rostral and complementary to the pudendal field [11-14]. Ascending sensory information via nerves from these genitosensory fields overlap and converge in stimulating male sexual arousal. Other nongenital sensory sites might also contribute.
For humans, Kinsey et al.[15] and Masters and Johnson [16] had suggested genital sensory sites related to sexual stimulation. Yucel and Baskin [14, 17, 18] recently expanded the information about innervation of the penis, but little is known about the dermatome that this innervation creates. Innervation of the male genitalia has been elucidated in fetal penile studies, which showed the greatest nerve density superior to and fanning out above the penis [14]. Psychophysical studies of genital sensitivity (by applying somatosensory stimuli to male genital skin) have been conducted for fine touch, thermal dimensions, vibratory sensitivity, and electrostimulation for sensory thresholds [19-24]. Differential sensitivity comparing the penile areas to other genital areas has not been studied. Sensitivity specifically related to sexual stimulation, for mapping of genital erotic sensitivity to tactile stimulation, has yet to be done in the healthy male.
Sexual arousal in humans depends on neural, hormonal and genetic factors, and on influences of culture and context. Because of the contribution of cognition and cultural factors in humans, we might expect greater variability than in other vertebrates in the arousal response, and even in site‐specific genitosensory field activation, when assessed by subjects’ ratings. Because of the multifactorial nature of human sexual response, sexual stimulation and its resultant response might be very specific to each person.
Observational studies of the human sexual response are not impossible, as has been documented by Kinsey et al.[15] and Masters and Johnson [16]. However, a natural sexual response generally requires a degree of privacy during stimulation, and many individuals and couples are likely to refuse functional evaluation by direct observation. Moreover, even if accepted, natural observation requires incorporation of the patient’s subjective reports of sensory experiences and feelings.
Surgical modification or removal of genital tissue, as it occurs in genital reconstruction surgery or circumcision, increases the potential for (objective) variations in sensory thresholds and might also alter structural integrity, meatal position, straightness during erection, erectile capacity, and personal and partner views of cosmesis [25-27]. In recent years, genital surgery, especially when done without the patient’s consent as is common in intersex children, has come under harsh criticism by patients, because of recurrent reports of the experience after surgery of poor cosmetic quality and/or impaired sexual functioning in adulthood [28]. Some intersex activists have even called for a moratorium on genital surgery, until more adequate follow‐up data are provided [29]. Thus, tools are urgently needed for the systematic assessment of surgical outcome.
A comprehensive evaluation of the outcome of genital surgery requires a consideration of many aspects of anatomy and function [30]. Traditional indicators of the success of masculinizing genitoplasty have been cosmesis, structural integrity and coital capacity of the penis, as judged by the surgeon [31]. Tools for objective assessment scoring have emerged for evaluating cosmesis and have played a role in evaluating the comparative success of different methods of repair [32]. However, several studies have shown that surgeons’ evaluations of cosmesis tend to be more positive than the patients’ views [33, 34]. More recently, overall psychosexual development and adjustment after genitoplasty have become a topic of study [35-37]. By contrast, specific cutaneous sensitivity of the genital region, its erotic sensitivity and contribution to orgasmic capacity, as experienced by the patient, have often been neglected, although these aspects have important implications for men’s quality of sexual life.
Ideally there would be a comprehensive standard battery of systematic assessment tools to characterize the genitalia before and after surgery in terms of observable anatomy and its perception by the patient, of nervous and vascular supply, nerve conduction, sensory response to systematic tactile and erotic stimulation, and the patient’s sexual experience in real‐life erotic situations. Within such a battery, tools for systematic self‐reporting will be an essential component. Self‐report tools are also more easily accepted by patients and pose less of a logistical problem than direct observation or direct‐testing procedures with the associated concerns about privacy. Several standardized self‐report questionnaires are currently in use for assessing sexual function in anatomically normal men [38-40]. No standard questionnaires are available that are specifically designed for assessing the patient‐perceived outcome of masculinizing genitoplasty in terms of appearance, sensitivity and sexual function, and that include all of the possibilities of genital atypicality and surgery.
For assessing in that manner the anatomical and functional outcome of genital surgery in patients with disorders of sex development, we developed a written questionnaire with detailed pictorial material, the Self‐Assessment of Genital Anatomy, Sexual Sensitivity and Function, Male (SAGASF‐M) [41]. The SAGASF‐M is a self‐reported questionnaire designed to obtain a man’s perception of what his genitals look like, to map his experience of sexual pleasure, orgasm intensity, orgasm effort, and discomfort/pain across specific areas of his genital region, and to elicit reports of perceived changes in sexual function after surgery, if applicable. Detailed genital pictures and descriptive phrases are used to facilitate systematic self‐reporting.
In general, pictures included with text have been found to improve health communication by increasing attention, comprehension and recall [42-44]. The pictures used in the SAGASF‐M were based on the digitization of selected drawings of the foreskin, penis, scrotum, perineum and anus [45], which were modified to represent variations in size and location, and to identify specific areas of the genital region for sensation ratings.
Before administering the SAGASF‐M to men with a history of masculinizing genitoplasty, a pilot study was conducted on genitally normal men to determine the feasibility of this assessment approach, to test whether men can discriminate between various genital areas in terms of erotic function in this self‐report format, and to evaluate the retest reliability of such ratings.
SUBJECTS AND METHODS
For this methodological study we targeted English‐speaking men with no history of genital surgery and with a variable educational background. A broad age range, during which most men are sexually active, was represented. Male employees of a community hospital in a town in the North‐eastern USA were approached by the first author (a surgeon) during work hours and invited to complete an anonymous survey about sexual sensitivity. Inclusion criteria were adulthood and a sexually active status. Men with a history of genital masculinizing surgery or genital excision surgery were excluded. Circumcision status was documented, but this genital surgery was not an exclusion criterion. Each man was given a blank SAGASF‐M with no subject identifier, in an unmarked manila envelope. The men completed the survey at work or at home and returned it to a designated box at the hospital. A second smaller sample of healthy men from the same source completed the SAGASF‐M twice with an interval of 2 weeks. The study was approved by the institutional review boards of the respective institutions. All men were instructed in a cover sheet that they gave informed consent by completing and returning the questionnaire.
The SAGASF‐M begins with an introduction to the rating task, along with three graphs of the usual appearance of male genitals with verbal labels for the major parts. The self‐assessment starts with overall questions about the participant’s genital anatomy and several items requiring the selection of one of several options of appearance, size and position of his penis, urethral meatus, scrotum and testicles.
In a general section on overall penis sensitivity in terms of ‘sexual pleasure’, ‘discomfort/pain’, ‘orgasm intensity’, and ‘effort required to achieve orgasm’, all rated on 5‐point Likert scales, the participant provides separate ratings of the response to stimulation by self (i.e. masturbation) and by a partner. This is followed by several items on the experience of penile engorgement and unusual sensation.
Subsequently, the ratings of ‘sexual pleasure’, ‘pain/discomfort’, ‘orgasm intensity’, and ‘orgasm effort’ are repeated for each of 10 specific genital areas, which are graphically marked and labelled, based on the type of sexual touch/stimulation that ‘is best for you.’ An example typical of the standard item form is: ‘Sexual touch/stimulation of this area by a partner or yourself . . . , has produced (rate 1 through 5): – Orgasm’, followed by a response scale in Likert scale format with the points: 1/none, 2/mild, 3/moderate, 4/strong, 5/very strong. Additional ratings after these sections concern specific problems of penile intercourse, contributions to orgasm by stimulation of other parts of the body (e.g. neck, nipples). The final sections on the types and results of genital surgery experienced were not administered to these nonsurgical samples.
A mixed‐model anova was used for comparing anatomical locations across participants for function ratings. These were followed by all possible pair‐wise group comparisons by paired t‐test using Bonferroni corrections for multiple comparisons, with α set at P = 0.05. All statistical analyses were conducted using SPSS for Windows Release 13.01 (December 12, 2004). To facilitate the visualization of results for the penile glans and shaft, mean ratings for each specific genital area were transformed to a depth of colour, which yielded maps of colour shades concordant with the men’s responses. Shades of red (Fig. 1A) indicated sexual pleasure ratings from stimulation of the specific area; the deepest represented most pleasure and the lightest the least. Shades of blue (Fig. 1B) indicate levels of orgasm intensity; the deepest represented the strongest intensity and the lightest the least. Shades of green (Fig. 1C) represent the effort required, the deepest representing the least effort required (or greatest ease of obtaining orgasm), the lightest the most effort. Re‐test reliability was evaluated using Pearson r correlation coefficients.

Colour depth from response means for A,‘sexual pleasure’, B,‘orgasm intensity’ and C,‘orgasm’.
RESULTS
The 81 participating men in the first sample included mostly Caucasians and a few African‐Americans, Hispanics and Asians (mean age 33 years, range 22–57). The education level spanned high‐school diploma to doctorate (MD/PhD); about half of those questioned had a college degree. Thus, this pilot sample was of higher socio‐economic background than the general population. All 81 men were able to complete all applicable items, and none reported any problems with this task. The time needed to complete the nonsurgical portions of the SAGASF‐M was ≈25 min.
Given that this was a largely healthy sample with no history of genital surgery, the initial ratings of genital anatomy, which showed little variability, are not described here. In terms of overall ratings of penile sensitivity, ratings of ‘sexual pleasure’ (Fig. 2A) were significantly higher for penile stimulation by partner than by self (P = 0.002) and ratings of ‘orgasm intensity’ marginally so (P = 0.077), but there were no corresponding differences between penile stimulation by partner and by self on ratings of ‘discomfort/pain’ or ‘orgasm effort’.

A, Responsiveness to stimulation by self vs by partner; and rating by genital area for B,‘sexual pleasure’, C,‘orgasm intensity’; D,‘orgasm effort’; E,‘discomfort/pain’; and F, rating of body areas contributing to orgasm.
Ratings showed considerable interindividual variability. For the sample as a whole, overall discrimination between the 10 genital areas was highly significant (mixed‐model anovaP = 0.001) for ratings of ‘sexual pleasure’ (Figs 1A,2B; Table 1), ‘orgasm intensity’ (Figs 1B,2C; Table 1) and ‘orgasm effort’ (Figs 1C,2D; Table 1), but was not significant for ‘discomfort/pain’ (Fig. 2E; Table 1). Note that, because there were few (11) uncircumcised men in this sample, ‘area A/foreskin’ was excluded from statistical analysis, but for comparison purposes included in the Fig. 2B–E). Ranked by degree of ‘sexual pleasure’ (Table 1), the area ‘underside of the glans’ was highest, followed by ‘underside of the penile shaft’, ‘upper side of the glans’, ‘left and right sides of the glans’, ‘one or both sides of the penis’, ‘upper side of the penile shaft’‘(foreskin)’, ‘skin between the scrotum and anus’, ‘back side of the scrotum’, ‘front side of the scrotum’, and ‘around anus’, but not all pair differences were significant. The rank order was similar for ‘orgasm intensity’ (Table 1), but less similar and with fewer significant pair differences for ‘orgasm effort’ (Table 1). ‘Discomfort/pain’ showed no differences between areas, even on pair‐wise testing by t‐test (Table 1).
| Domain and area | Mean pleasure rating | Areas significantly different† |
|---|---|---|
| Sexual pleasure | ||
| C underside of glans | 4.12 | B*, D*, G*, E*, J*, I*, H*, K* |
| F underside of penile shaft | 4.08 | B, D, G*, E*, J*, I*, H*, K* |
| B upper side of glans | 3.76 | C*, F, D, E*, J*, I*, H*, K* |
| D sides of glans | 3.61 | C*, F, B, E, J*, I*, H*, K* |
| G sides of penis | 3.60 | C*, F*, E, J*, I*, H*, K* |
| E upper side of penile shaft | 3.35 | C*, F*, B*, D, G, J, I*, H*, K* |
| J between scrotum & anus | 2.90 | C*, F*, B*, D*, G*, E, K* |
| I Back side of scrotum | 2.87 | C*, F*, B*, D*, G*, E*, K* |
| H front side of scrotum | 2.83 | C*, F*, B*, D*, G*, E*, K* |
| K around anus | 1.94 | C*, F*, B*, D*, G*, E*, J*, I*, H* |
| Orgasm intensity | ||
| C underside of glans | 3.97 | D*, B*, G*, E*, H*, I*, J*, K* |
| F underside of penile shaft | 3.83 | D, B, G*, E*, H*, I*, J*, K* |
| D sides of glans | 3.49 | C*, F, E, H*, I*, J*, K* |
| B upper side of glans | 3.42 | C*, F, H*, I*, J*, K* |
| G sides of penis | 3.37 | C*, F*, E, H*, I*, J*, K* |
| E upper side of penile shaft | 3.18 | C*, F*, D, G, H*, I*, J*, K* |
| H front side of scrotum | 2.31 | C*, F*, D*, B*, G*, E*, K* |
| I Back side of scrotum | 2.23 | C*, F*, D*, B*, G*, E*, K* |
| J between scrotum & anus | 2.14 | C*, F*, D*, B*, G*, E*, K* |
| K around anus | 1.43 | C*, F*, D*, B*, G*, E*, H*, I*, J* |
| Orgasm effort | ||
| C underside of glans | 3.49 | B, G, D, E*, I, H* |
| F underside of penile shaft | 3.49 | G, E*, I, H* |
| B upper side of glans | 3.30 | C |
| G sides of penis | 3.26 | C, F, E, H |
| D sides of glans | 3.24 | C, I, H |
| J between scrotum & anus | 3.18 | K |
| E upper side of penile shaft | 3.12 | C*, F*, G |
| I Back side of scrotum | 2.95 | C, F, D |
| H front side of scrotum | 2.87 | C*, F*, G, D |
| K around anus | 2.69 | J |
| Pain/discomfort | ||
| K around anus | 1.23 | E, D |
| C underside of glans | 1.18 | |
| J Between scrotum & anus | 1.16 | |
| I Back side of scrotum | 1.15 | |
| F underside of penile shaft | 1.15 | |
| H front side of scrotum | 1.14 | |
| G sides of penis | 1.12 | |
| B upper side of glans | 1.11 | |
| E upper side of penile shaft | 1.08 | K |
| D sides of glans | 1.06 | K |
| Body areas contributing to orgasm | ||
| 241. scrotum | 2.73 | 235, 238*, 239*, 240*, 237*, 236* |
| 233. ear | 2.53 | 238, 239*, 240*, 237*, 236* |
| 242. skin between scrotum & anus | 2.52 | 235, 238, 239*, 240*, 237*, 236* |
| 234. neck | 2.48 | 238, 239*, 240*, 237*, 236* |
| 235. breast/nipples | 2.11 | 241, 242, 239*, 240*, 237*, 236* |
| 238. buttocks | 1.84 | 241*, 233, 242, 234, 239, 240, 237*, 236* |
| 239. anus (exterior skin) | 1.53 | 241*, 233*, 242*, 234*, 235*, 238, 240, 236 |
| 240. anus (inside with penetration) | 1.31 | 241*, 233*, 242*, 234*, 235*, 238, 239 |
| 237. wrist | 1.22 | 241*, 233*, 242*, 234*, 235*, 238* |
| 236. axilla | 1.13 | 241*, 233*, 242*, 234*, 235*, 238*, 239 |
- † In paired t‐tests, P ≤ 0.05;
- * indicate that after Bonferroni adjustment (for 45 comparisons) the respective areas remain significantly different (P ≤ 0.05).
Overall discrimination between other body parts that help orgasm when touched/stimulated (Fig. 2F; Table 1) was highly significant (P = 0.001) and included (in order of degree) scrotum, ear, skin between scrotum and anus, neck, breast/nipples, buttocks, anus (exterior skin), anus (inside with penetration), wrist, and axilla, but many pair differences were not significant.
The reliability sample included 38 healthy men (median age 26 years, range 22–64) from the same source. The number of men entering the reliability analysis varied between items, depending on the type of sexual activity and experience. Most of the anatomy items showed little or no variability, so that reliability could not be validly assessed. Only six men were uncircumcised and therefore foreskin‐related items were excluded from reliability analysis. Of the function items, ratings of pain/discomfort showed insufficient variability for assessing reliability. Among the remaining 45 function items with sufficient variability and sample size, retest reliability values (Pearson r) were distributed as follows: seven were ≥0.80, 16 ≥0.70, 15 ≥0.60, four ≥0.50, two ≥0.40 and one ≥0.30 (of marginal significance).
DISCUSSION
In previous studies of the analogous questionnaire for women, SAGASF‐F, we showed the ability of women to discriminate between genital areas in terms of erotic sensitivity, etc. [46, 47], as well as a high test‐retest reliability [48]. A separate confirmation of the same for men was indicated because of the obvious differences in genital anatomy. Moreover, for men, genital self‐assessment might be different, not the least because their genitals are much more visible. Also, men have different, possibly less passive, requirements for successful sexual intercourse, and this might modify their reflections on sexual sensitivity. Sexual sensitivity and arousal might increase as erection increases, and might be modified by testosterone level [49]. The degree (size change) and turgidity of penile erection are greater than the comparable response of clitoral erection. Erection of the penis is different from clitoral erection because of the difference in corporal coverings and exposed surface area [50]. Also, overall areas of genital engorgement differ between females and males. In women, the labia and the vaginal epithelium constitute additional areas of engorgement [51, 52]. In any case, our data show that men are also able to discriminate reasonably well between various genital and nongenital areas in terms of erotic sensitivity.
The present study provided somewhat surprising data on orgasmic sensitivity. Both the ventral penile shaft and the area of the ventral glans penis were rated at an almost equal level of orgasmic sensitivity and sexual pleasure, significantly above the levels of all other areas rated. This is different from what might be expected, considering the nerve density shown by Yucel and Baskin’s example of the fetal penis. The terminal nerves there end in the foreskin and dorsal glans. The difference noted in the present study might be a consequence of the high circumcision rate of the respondents of the study. When terminal nerves are excised, a dermatome might migrate. It could also be that sexual sensitivity ratings include a pressure‐related sensation rather than only a fine‐touch or tactile sensation. Sexual position during intercourse could vary pressure points on the phallus, changing sensory details. As in other mammalian species, areas outside the median fields can still provide a ‘summation’ sensation, but require stimulation of a larger area and greater pressure to yield a sexual response. It is interesting that Kaneko and Bradley [24], in their exploration of penile peripheral innervation, noted overlapping of peripheral innervation of the penis by the dorsal nerve and the perineal nerve on the ventral aspect of the glans and distal shaft. The summation illustrated appears to correspond to the colour depth generated by response means of the men we studied. Assuming replicability in future studies, our preliminary findings support important implications for genitoplastic surgery, i.e. limiting repeated incision and excision of tissue from the ventrum of the penis might be helpful to limit sensory changes.
Currently, there is no better way to discriminate areas of sexual sensitivity in a graded fashion than to ask questions about target areas and their value for erotic sensation. In this respect, a man’s judgement of his sensation is the critical variable. The new assessment tool used in the present study appears to be promising. Where retest reliability could be assessed in this unoperated sample with restricted variability or small numbers for various items, the size of the coefficients ranged from acceptable to excellent for most variables, and we would expect that the coefficients would increase with greater functional variability, as expected for samples with a history of genital surgery. Comparative assessments, if not direct quantitative measurements, of aspects of the genital anatomy and function by professional experts, i.e. plastic surgeons or urologists, will be important for future studies. Although a strict criterion validation of subjective ratings is not possible, showing construct and discriminant validity will require the inclusion of samples representing different severity of genital surgery in terms of expected neuronal and vascular damage.
In conclusion, the SAGASF‐M discriminates reasonably well among various genital and nongenital areas in terms of erotic sensitivity, when administered to men varying widely in age and socio‐economic level and who have no history of genital surgery.
ACKNOWLEDGEMENTS
This collaborative research was stimulated by the North American Task Force on Intersexuality (Chair: Ian Aaronson, MD) and facilitated in part by its travel support to members of its Research Protocol Work Group. Michael D. Flack, BFA, performed the colour coding for the thermal graphs. Cory Lino provided assistance and artistic modification of representative figures. Diane R. Voelker provided word processing assistance.
CONFLICT OF INTEREST
None declared.
Notes :
- † In paired t‐tests, P ≤ 0.05;
- * indicate that after Bonferroni adjustment (for 45 comparisons) the respective areas remain significantly different (P ≤ 0.05).
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