Sexual Medicine Reviews

Barry R Komisaruk, Maria Cruz Rodriguez del Cerro, Irwin Goldstein, Orgasm utilizes the pain pathway: is orgasm “nonaversive pain”?, Sexual Medicine Reviews, 2023;, qead037,


There are limited resources available when attempting to understand orgasm and orgasmic dysfunction in Sexual Medicine Reviews (SMR), The Journal of Sexual Medicine, Sexual Medicine, or other publications. Responding to the need to better understand this crucial sexual health function, the International Society for the Study of Women’s Sexual Health assembled a multidisciplinary expert panel to investigate and publish a consensus document on orgasm. The society’s process has generated much communication, development of new hypotheses, and further discussion. In the spirit of advancing contemporary concepts of orgasm, this editorial reviews evidence that, neurologically, the orgasm system is inextricably linked to the pain system; thus, the feeling of orgasm can be considered, paradoxically, a form of “nonaversive pain.” For example, the intense facial grimace expressed during pleasurable orgasm can be surprisingly similar to that of persons in extreme pain1 (Figure 1).

Consider the following points that address the link between orgasm and pain. Orgasm attenuates pain without affecting tactile thresholds2; conversely, pain (eg, vestibulodynia) is well known to block orgasm. Orgasm occurs with concurrent activation of the sympathetic and parasympathetic systems, a striking exception to the general rule of their reciprocal activation. Of note, in the event of trauma within the spinal cord, selective interruption of the pain pathway (ventral) but not the tactile pathway (dorsal) blocks orgasm and pain but not tactile genital sensation.3 Finally, the brain regions that classically respond to pain4 are also selectively activated during orgasm,5,6 and those regions contain inhibitory interneurons that could provide a reciprocal inhibitory link between the systems.7