Psychology professor Caroline Pukall knows a lot about sex. For decades she has studied human sexual behavior, and much of her work has focused on genital pelvic pain and sexual health. In May Pukall and her colleagues published a paper Sexual medicine about the first in-depth study of epididymal hypertension – a sometimes uncomfortable condition of swollen genitals commonly known as ‘blue balls’.
Previous research on this acute condition is practically non-existent. To investigate whether blue balls are a real phenomenon and, if so, how they influence sexual behavior, Pukall and her colleagues from Queen’s University in Ontario teamed up with journalists from Science vs to solicit survey responses from people with penises and those with vaginas — 2,621 in total. Among the takeaways: testicles are not a requirement for what Pukall prefers to call “throbbing crotch syndrome.” Scientific American spoke to Pukall about the pervasive myth that arousal without orgasm is dangerous and why people still use it to pressure a partner into having sex.
[An edited transcript of the interview follows.]
Why is excess blood in the genitals potentially uncomfortable?
There are a lot of things that happen during the process of becoming sexually aroused. One of the main body-related phenomena that occurs is something called congestion, where blood rushes to those erogenous zones. That will account for things like clitoral enlargement and penile erection.
Orgasm is almost like a quick release valve for all these body related processes to return to the normal state of rest, when genitals return to their normal size and blood no longer pools in those erogenous areas. But let’s say a lot of foreplay takes place. It’s more of a very slow relief valve where there’s no explosion to return those processes to that unexcited state.
Are blue balls a legitimate phenomenon?
Yes absolutely. What does it mean to have blue balls? It can range from feeling a little uncomfortable to feeling frustrated that this arousal response has not been completed. It may throb, it may hurt, but in terms of intense pain or frequent pain, that’s exceptionally rare. Is it something that requires immediate medical attention? No. But the experience of that pain is absolutely real. Anyone who has genitals and is physically capable of that physiological sexual response can experience this pain. [This study] justifies this condition all people, whether it’s blue balls or blue vulva or blue genitals. I’ve come to call it “throbbing crotch syndrome.”
Throbbing crotch syndrome is a much better name. Do the testicles and vulva actually turn blue?
[In our study], some people reported that their genitals take on a slightly blue tint. But we could not find any documents proving that this phenomenon leads to a bluish tinge in the genitals. There is [no research] that gives solid evidence that there is hypertension in the scrotal area or in the genitals. All we could find about how it happens are just ideas. There is only one survey of college students from the 1950s and a case study of a 14-year-old from 2001.
Were you surprised that 40 percent of people with a vulva reported experiencing throbbing crotch syndrome?
I actually expected a pretty high number, simply because I don’t see it as the domain of sororities and people with penises. When you think about the way the process works, it doesn’t matter what your equipment is. It’s not like the bloodstream knows it’s going to the scrotal area. Or if there is no scrotal area, it’s not like the blood flow is going to work better.
Did you expect severe pain levels to be low — less than 7 percent in people with a penis?
I actually expected [the level of severe pain] be higher. I’ve worked with genital pelvic pain so I’m used to always validating [people’s experiences]. This is an acute pain condition that is usually easy to resolve, relatively rare, and mild. It is not on the radar of medical professionals simply because it is not dangerous in any way. If the pain is chronic and extremely distressing, you should see a doctor to run some tests and get a thorough assessment. In all likelihood, something else is going on.
Scientists have studied pain for centuries, but this study was the first serious study of blue balls. Considering society love affair with penises, why do you think this topic has been overlooked?
It’s interesting, right? Usually, pain related to penises is taken super seriously, while pain related to vulvas or other types of genital configurations is not. I was really stunned. But I think one explanation could be the story that blue balls are mostly seen in younger men who are sexually frustrated, so it’s treated a bit like a joke and almost like a rite of passage.
It sounds like scientists haven’t studied it because it’s not a big deal medically speaking. Still, more than 40 percent of respondents with a vagina said they felt pressured to “have sexual intercourse because of a partner’s fear of getting blue balls/vulva.”
Yes, just like some people [3.7 percent] with a penis. In our qualitative analysis, we included a section where respondents could add comments, and many people wrote that blue balls should not be used as an excuse to sexually coerce someone. This was one of the most prominent themes that came up in our analyses: although people know it shouldn’t be used as an excuse, it still happens.
The good news is that there are many ways a person can resolve their uncomfortable feelings. We found out from the research that you can wait it out, do distracting activities, exercise or masturbate. These are all things that don’t imply a partner. It’s important to have masturbation as an option, but I think people are just so uncomfortable with the idea of it. Automatically, it’s like, “Oh, someone else has to handle this for me.” Not really. You have to take the problem into your own hands.
Why do you think the myth that blue balls are dangerous is so pervasive?
I think it has a lot to do with gender scripts that people have internalized. In many cases, penile pleasure is emphasized in sexual situations – the patriarchy in the bedroom. Men are seen as the sexual go-getters and proactive; women are seen as the gatekeepers to sex and more passively. This sexual script puts a huge emphasis on men’s performance and their penises. Cisgender women who have sexual activity with cisgender men usually do not benefit at all. This [dynamic] is also reflected in something that the orgasm gap: Men report very high orgasms, while women who have sex with men report the lowest frequencies of orgasm.
How does an excessive focus on orgasm contribute to the pressure to be sexually active that many respondents reported feeling?
Some people really feel like they’re not having real sex unless they’re having an orgasm, that they’re entitled to it. People talk about “reaching” an orgasm, right? It sounds like you’re hiking to the top of Kilimanjaro or something. [Orgasm] is amazing! It’s like icing on the cake! But you don’t have to have the icing on the cake, because the cake itself is delicious.
We want to make sure people have the knowledge to say no – to have confidence in their rejection of continuing an activity if it’s not something they really want.
Are you going to do more research on throbbing crotch syndrome?
We are planning a more in-depth study that will take more into account the genders of people’s sexual partners. [In the recent study] we were only talking about bodies. We also want to look at the context: are there differences [in the frequency or intensity of the phenomenon] if it’s more of a casual meeting than meeting with a committed partner?
It would be cool to research how [throbbing crotch syndrome] happens and if there are ways to prevent it. I have some cool devices in my lab, but I don’t know if it would fit my ethical counsel to let people come in and masturbate to near orgasm and then, like, scan their genitals.
