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Clitoral stimulation during penile-vaginal intercourse: A phenomenological study exploring sexual experiences in support of female orgasm.

Penile-vaginal intercourse (PVI) is the most common partnered (hetero)sexual behaviour in North America. Many women participate in PVI but do not acquire the clitoral stimulation they may need to orgasm as desired resulting in a gender-based orgasm gap during partnered sex. This phenomenological study situates itself at the intersection of sexological studies, which validate the importance of the clitoris (e.g. Kinsey and colleagues; Hite), and feminist scholarship that explores the problem of a sexual script constructed in a patriarchy that largely devalues the clitoris (e.g. Koedt; Boston Women's Health Collective) in interrogating and describing solutions to inequitable orgasm experiences during PVI. In this study, 15 cisgender women, who do not orgasm from PVI alone, shared in semi-structured interviews how they acquire orgasmic clitoral stimulation during PVI. Four partners, who were cisgender men, were also interviewed and their perspectives were included when they added greater detail to the primary participants' experiences. Fourteen out of the 15 women learned to induce orgasm during masturbation before experiencing their first orgasm during PVI. Masturbatory experiences helped participants learn effective stimulation techniques. Women then communicated these preferences to partners or self-stimulated during PVI. Orgasmic stimulation was achieved by either stimulating the clitoris against the male body or by creating space around the clitoris (2-3") where preferred stimulation could occur. No two women had the same preferred clitoral stimulation technique. Understanding that one's preferred stimulation technique is likely different and nuanced from others may be key to effective partner communication.

KEY WORDS: Clitoris, gender, orgasm, penile-vaginal intercourse, sexual pleasure

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In 2004, Kerner reported that the top question readers submitted to the editors of Cosmopolitan magazine was "What can I do to have an orgasm during intercourse?" (p. 24). This question belays a culturally induced ignorance of cis-women's (1) sexual bodies and a continuing patriarchal influence on sexual behaviour that has yet to be dismantled on the most intimate levels, let alone on the socio-cultural level. In the late 1960s through the early 1980s, supported by sexological research debunking the earlier prevailing idea that clitoral orgasm was pathological (Kinsey, Pomeroy, Martin, & Gebhard, 1953; Masters & Johnson, 1966), many feminists turned their focus on the clitoris (Atkinson, 1970; Boston Women's Health Collective, 1971; Dodson, 1974; Federation of Feminist Women's Health Centers [FFWHC], 1981). They asserted that vaginal orgasm was a myth (Koedt, 1970) and sexual subjugation was a key component of maintaining patriarchal gender relations (Rubin, 1975). As part of cis-women's empowerment, consciousness-raising groups and publications such as Our Bodies Ourselves helped people learn the location and function of the clitoris (Boston Women's Health Collective, 1971). Feminists viewed the clitoris not only in terms of sexual pleasure, but also as connected to issues of independence and freedom (Dodson, 1974; Koedt, 1970). The idea that the penis was neither central to nor necessary for cis-women's sexual pleasure threatened heteronormativity and perhaps even core ideas about gender roles (Gerhard, 2000; Koedt, 1970). As feminists wrote about dismantling previous notions of vaginal sexuality and explored the boundaries of female pleasure, multiple perspectives existed simultaneously and divisions within the feminist movement occurred (Gerhard, 2000). Then, in 1980, at a national meeting of the Society for the Scientific Study of Sex, Ladas, Perry, and Whipple presented information about experiences of vaginally stimulated orgasm and the Grafenberg spot, or G-spot; they showed that some females could experience orgasm through vaginal stimulation alone (Ladas, Whipple, & Perry, 1982). A short time later, in 1982, tension around competing and divisive views of cis-women's sexuality peaked at The Scholar and the Feminist conference in what came to be known as "The Sex Wars" (Gerhard, 2000). Perhaps some feminists wished to heal divisions within the movement, perhaps some feminists did not want to invalidate the experiences of people who did experience G-spot orgasms, maybe the influence of post-modern and post-structural thinking made many feminists less willing to making definitive statements about the clitoris, or perhaps the clitoris was just too stigmatized to publically discuss during the backlash era (Faludi, 1991); but for whatever reason, feminist scholarship largely quieted its attention to the clitoris. Though Ladas, Whipple, and Perry (1982) wrote, "We now have a new synthesis that validates the experience of both vaginal and clitoral orgasm" (p. 29), the vaginal canal was nonetheless reinforced as the focal sex organ in popular imagination (Flanotaux, Bovon, & Normandeau, 2012).

Currently, much sexological scholarship seems to focus on how the penis might more effectively stimulate female orgasm through the vaginal canal (Benello, Ettinger, Helfand, Weiss, & Canner, 2009; Komisaruk et al., 2004; Levin, 2003; Ostrzenski, 2012). New findings and theories pack the discursive space with possible anatomical sites, structural complexes, medications, or even speculation about the evocation of vaginal electrical waves as potential ways that the penis might activate female orgasm (Benello et al., 2009; Cacchioni & Tiefer, 2012; Foldes & Buisson, 2009; Jannini, Buisson, & Rubio-Casillas, 2014; Shafik, El-Sibai, Shafik, Ahmed, & Mostafa, 2004). While this research and conjecture has resulted in valuable information, discourse based on the assumption of penile centrality in female sexual pleasure and orgasm misses an obvious mark; the primary organ potentiating orgasm in most females is the clitoris (2) accessible on the external vulva (Eschler, 2004; Graber & Kline-Graber, 1979; Hite, 2000; Janus & Janus, 1993; Wade, Kremer, & Brown, 2005; Wilcox & Hagar, 1980). Numerous popular texts address clitoral stimulation; however, little empirical research describing specific clitoral stimulation techniques during PVI has preceded this work with few exceptions, such as that of OMGYES and Indiana University (Herbenick, Fu, Arter, Sanders, & Dodge, 2017).

This study focuses on ways that the clitoris can be stimulated so that female orgasm occurs during PVI if desired. This research is both scientifically and theoretically informed. It considers the context of heteropatriarchal culture as it interacts with cis-women's sexual bodies. Findings demonstrate alternatives to a culturally inherited, androcentric (i.e. male or man centered) sexual script in which 15 cisgender women, who do not orgasm from PVI alone, share in interviews how they acquire orgasmic clitoral stimulation during PVI. Four sex partners (all cisgender men) were also interviewed as a data triangulation method and their input was included to add detail to the primary participants' experiences. Though this research centers on cis-women, additional people with clitorises and vaginal canals (whether congenital or post-operative) who participate in vaginal insertion with a phallic object or body part may find this information transferable regardless of gender identity.

SEXUAL PLEASURE AS GENDERED

The pudendal nerves supply the penis and the clitoris, as well other areas of the genital skin and musculature (Martin-Alguacil, Schober, Sengelaub, Pfaff, & Shelley, 2008). Though orgasm may be experienced through stimulation of multiple sites on or in the genitals, anus, rectum, and larger body, or through fantasy, most people most of the time require or benefit from touch to the penis or those clitoral structures able to be stimulated externally (i.e. clitoral glans, hood, shaft, and/or suspensory ligament) in order to orgasm (Eschler, 2004; Graber & Kline-Graber, 1979; Herbenick et al., 2017; Hite, 2000; Janus & Janus, 1993; Kinsey, Pomeroy, & Martin, 1948; Kinsey et al., 1953; Paget, 2001; Wade et al., 2005; Whipple, Ogden, & Komisaruk, 1992; Wilcox & Hagar, 1980). Thus most people who experience orgasm usually do so through stimulation of the pudendal nerves. This is because the clitoris and penis develop from the same tissue during embryonic and fetal development (Sajjad, 2010). This tissue (innervated by pudendal nerves) is referred to as the genital stalk or phallus (penile or clitoral shaft) and genital tubercle (penile or clitoral glans) prior to their range of differentiation (Butler, 1993; Healey, 2012). A penis forms when corpus spongeosum tissue surrounds the urethra and joins the underside of the external genital stalk; a clitoris forms when the urethra separates from the external genital stalk. The primacy of the pudendal nerves in orgasm for most people most of the time can be thought of as a kind of orgasmic equity regardless of biological sex assignment.

Gender can be conceptualized as a social power differential based on sex assignment legitimized through the ideology of biological determinism (Butler, 1999). The presence or absence of certain sexual organs determines one's social position (Oyewumi, 1997). This power differential, enforced in the hierarchical binary construction of biological sex and assumed corresponding gender, has devalued the sexual primacy of the pudendal nerves in those assigned female while maintaining the sexual primacy of the pudendal nerves in those assigned male. Because the vaginal canal stimulates the penis during PVI, it continues to be touted as the focal female sexual body part in heteropatriarchal culture. The reproductive imperative reinforces and justifies this gender-based inequality. The imposition of gender ideology onto the body (i.e. as a hierarchical power differential) has overridden biological commonality in orgasmic ability.

The Canadian Community Health Survey (CCHS) and the National Survey of Sexual Health and Behavior (NSSHB) identified penile-vaginal intercourse (PVI) either alone or in combination with other sexual behaviours as the most common partnered (hetero)sexual behaviour in North America (Herbenick et al., 2010; Rotermann & McKay, 2009). Though this finding cannot be generalized to sexual minorities or adults over age 65 (Santos-Iglesias, Byers, & Moglia, 2016), the largest proportion of people in the NSSHB reported having engaged solely in PVI (39% women, 33% men) with no oral or manual stimulation prior to or after PVI. The next most common repertoires were PVI prior to or after oral sex (25.5% women, 23.3% men), followed by PVI prior to or after oral sex and manual stimulation (6% women, 7.2% men) (Herbenick et al., 2010).

Most cis-women require or benefit from direct clitoral stimulation in order to experience orgasm and do not orgasm through vaginal stimulation alone (Eschler, 2004; Graber & Kline-Graber, 1979; Herbenick et al., 2017; Hite, 2000; Janus & Janus, 1993; Kinsey et al., 1953; Wade et al., 2005; Wilcox & Hagar, 1980). Further, most cis-women who can achieve orgasm via other means report that stimulation on or above the clitoris produced the strongest orgasms with least effort (Schober et al., 2004). Herbenick and colleagues (2017) found that only 18.4% of cis-women in their large, U.S. probability sample reported that vaginal intercourse alone was sufficient stimulation to activate their orgasms.

In 1976 and 1981, The Hite Report described a heteronormative construct as following a reproductive pattern: "foreplay," followed by penetration and intercourse (thrusting), followed by orgasm (especially male orgasm), which was then defined as the end of sex. Hite (1981) noted that more than 95% of heterosexual respondents referred to clitoral stimulation and genital touching only as foreplay preceding intercourse. In 1973 Gagnon and Simon described a specific series of actions that constitute the North American sexual script, which had room for manual or oral clitoral stimulation only during arousal:
   First there is kissing, then tongue kissing, then touching of the
   breasts through the clothes (perhaps here a break in sequence),
   touching of the breasts under the clothing or the genitals through
   the skirt or outside the underwear, then finally the genital
   contact with either a branch to mouth-genital contact (in some few
   circumstances) or coitus. Most frequently culmination is in coitus,
   (pp. 75-76)


Gagnon and Simon (1973) and Hite (1976, 1981) delineate an androcentric sexual script that suggests that the clitoris has a small role during partnered (hetero)sexual behaviour. Though NSSHB researchers did not collect data on whether or not direct clitoral stimulation was included during PVI, a third of the population reported no genital touching prior to or after PVI (Herbenick et al., 2010). The most recent nationally representative survey addressing the topic of clitoral touching, OMGYES, defined "regular penile vaginal intercourse" as explicitly not including focused attention on the clitoris: "Thinking about the past year: Overall, how often did you have an orgasm during 'regular' penile vaginal intercourse--that is, without you or your partner doing anything extra to touch or stimulate your clitoris during intercourse?" (Herbenick et al., 2017, p. 3). Specifically defining a lack of clitoral touching as "regular" likely reflects the dilemma of a sexual script constructed in a patriarchy where social messages presume the vaginal canal to be the main sexual organ in females (Laqueur, 1990; Maines, 1999). Anatomical explanations given to children, if at all, are that "boys have a penis" and "girls have a vagina." The clitoris is kept secret (Tisdale, 1994).

Sexual scripts negating the value of the clitoris have created a gender-based orgasm gap, but only during partnered sex (Fisher, 1973; Haavio-Mannila & Kontula, 1997; Hite, 2000). Though not all people masturbate, orgasm rates during masturbation are just over 90% for cis-women and cis-men alike (Hite, 1981; Kinsey et al., 1948; Kinsey et al., 1953). However, when cis-women have partnered sex, their orgasm rates decline significantly (Eschler, 2004; Fisher, 1973; Haavio-Mannila & Kontual, 1997; Hite, 2000; Kinsey et al., 1953; Janus & Janus, 1993; Maines, 1999; Wilcox & Hagar, 1980). Orgasm is gendered in partnered sex (Armstrong, England, & Fogarty, 2012; Fisher, 1973; Janus & Janus, 1993; Reece et al., 2010). In 2010, cis-men's orgasm rates with a partner were 91% and cis-women's were 64% (Reece et al., 2010).

In order to explore these issues, I conducted semi-structured interviews with 15 cisgender women and four of their partners, who were cisgender men, all of whom had experiences with direct clitoral stimulation concurrent with PVI that led to female orgasm. This research does not intend to devalue non-orgasm focused sexuality nor diminish experiences of female orgasm that occur by means other than clitoral stimulation. Rather, this study describes 19 peoples' experiences of having a high value placed on clitoral stimulation during PVI. Participants provided data answering the following research question: How is direct clitoral stimulation concurrent with PVI acquired in a way that leads to female orgasm?

METHODS

Feminist scholars have questioned ideologies about scientific objectivity arguing that all knowledge claims are situated (Hartsock, 1983; Haraway, 1988). Haraway (1988) stated that there is no "gaze from nowhere ... that makes the unmarked category claim the power to see and not be seen" (p. 581). Axes of social location such as socioeconomic class, gender, race, educational privilege, and dialect affect the overall knowledge perceived and described (Haraway, 1988; Sultana, 2007). These axes not only affect data interpretation, but also access to data. Participants likely categorized me as an insider or outsider across various axes of social differentiation. This categorization affected what information I had access to (i.e. what participants did and did not share). In the interest of promoting researcher accountability for findings and interpretation, I provide the following view of my social identities and experience.

I identify as a white, queer, fat, cis-woman born in the 1970s. I have had remarkable educational privilege and now work as a feminist sexologist. I grew up in a rural, working class, and English-speaking area of the American Midwest. Conservative Catholicism and parents who communicated their sex life positively as part of the sacrament of marriage framed my values around sexuality in childhood and adolescence. More broadly, issues of sexuality were framed in my memory by presumptive heterosexuality along with media portrayals of the sexual revolution in the 1970s and HIV/AIDS in the 1980s.

Recruitment

The population of interest for this study was cis-women who do not experience orgasmic PVI with vaginal stimulation alone, but do experience orgasm during PVI that includes direct clitoral stimulation. Early strategies to recruit participants through announcements on social media and listservs were unsuccessful because initial contacts misunderstood the focus of the study and proved unqualified because their sexual experiences did not match the needed criteria. Though I did not have IRB approval to collect screening data, the most common disqualification was that these contacts orgasm before or after PVI and had not experienced the phenomenon under study.

Due to participants' misunderstanding and likely vulnerability in reporting stigmatized thoughts and behaviours, I realized that potential participants needed to meet me personally. I contacted MeetUp[R] groups actively invested in sexual empowerment and obtained permission to discuss this study at their events; thus all recruitment came about either by personal meeting or snowball recommendation, sometimes via feminist listservs, over a 21 month period (Babbie, 1995; Crabtree & Miller, 1992).

Data Collection and Analysis

Interviews took place either face-to-face or via video call, grounded in the theoretical orientation of phenomenology. Phenomenology fits my feminist frame in that it rejects a belief that an objective view is accessible outside of the standpoint of the researcher and participant (Groenewald, 2004; Haraway, 1988). Phenomenology proposes instead that an experience/ knowledge can only exist as it is perceived and represented by a subject; both the researcher and participant are subjects creating knowledge together (Moustakas, 1994). Thus, data analysis began during the interview itself (Dinkins, 2005). Interviews started with participant's definitions of clitoris, orgasm, and intercourse to establish understanding and meanings of the concepts being studied and as a data reliability measure (Dinkins, 2005). As per phenomenological method, interview questions were aimed at collecting complete descriptions, including constituents of experiences, variations of perceptions, thoughts, feelings, sounds, as well as biological and psychological processes (diverse aspects to be reported in upcoming articles) (Moustakas, 1994). Additionally, I openly identified my assumptions throughout interviews in order to obtain feedback. I paraphrased participant statements as I understood them and asked directly for clarification. One example of this paraphrasing method is, early in interviews, I introduced the idea that I might relate participant's answers back to sexological literature. Participants seemed to enjoy this; one woman said, "By all means relate to research," and responded by providing richer descriptions of her lived experience in comparison to my sexological understanding. In identifying my assumptions in interviews, the participant was central to my initial data interpretation. My aims in interviews were to refrain from reinforcing a pre-given sexual script, to understand the meanings behind participant descriptions while accounting for my own interpretations, and to consolidate reported experiences into an authentic, multidimensional phenomenological description (Groenewald, 2004). Each interview lasted approximately 90 minutes, with one outlier lasting 140 minutes at the participant's request.

After each interview, I wrote analytic field notes describing observed body language, initial impressions, and interpretations of important findings. I transcribed recorded interviews and loaded them along with field notes into Dedoose[R] analytic software for coding. In the first inductive coding cycle, I identified statements or sets of statements that expressed meaningful units of data related to the research question (Bradley, 1993). I assigned multiple codes and sub-codes to overlapping units of data in an effort to both maintain the context of the quotation as well as reduce data to make larger patterns visible when analyzing across interviews (Drisko, 1997; Saldana, 2013; van Anders, 2015). These codes and sub-codes were then grouped into like themes.

Findings were triangulated using a number of strategies. I interviewed the primary participants' partners, when feasible. Partner interviews validated primary participant accounts from another perspective, added greater detail to data (Arksey & Knight, 1999), and further illuminated the phenomenon of clitoral stimulation concurrent with PVI (Burnett, 2009). I coded all interviews twice to check for accuracy of assigned meaning in relation to my evolving understanding of how complex individual experiences circulated around a larger pattern. This was an iterative process, in which I interpreted and reinterpreted qualitative data in relation to the developing sense of the whole (Thompson, Pollio, & Locander, 1994). I finished with 351 codes and sub-codes. I then created a 14-page outline with my analysis, which further clarified major themes and revealed a shared process by which primary participants had come to experience the phenomenon: she masturbated to orgasm; applied masturbation techniques to partnered sex; and then experienced clitoral stimulation concurrent with PVI that led to her orgasm(s).

After drafting findings based on those themes and illustrative quotes, I conducted participant member checks to increase the credibility of findings (Bradley, 1993; Patton, 1990). Ten women (no men) responded. Participant quality checks resulted in the inclusion of missing data, clarification of findings, and more nuanced descriptions from participants. I received overwhelmingly positive responses, not only confirming credibility, but also conveying excitement about contributing and describing how much participants enjoyed reading the findings. One woman said she had benefited from re-reading the paper with her current partner, sharing, "We are enhancing our understanding of each other and clitorises at a whole new level."

RESULTS

Participant Characteristics

Study participants included 15 participants who self-identified as women and four sex partners who self-identified as men. (3) Eleven participants lived in the Pacific Northwest, and eight in other regions of the U.S. including: West (2), Mid-West (2), East (3), and South (1). Primary participants ranged from 23 to 67-years old and included women in their thirties, forties, and fifties. The men's ages ranged from 24 to 54 including participants in their thirties and forties. Seven women identified as racial minorities: Native American (3), African American (1), Asian American (1), Latinx (1), and Jewish (1). One man identified as Latinx and grew up in Guatemala. All other participants identified as White. A range of socioeconomic class backgrounds from poor to wealthy, both in childhood and currendy, was represented. All participants had some college education. Eleven had earned undergraduate degrees. Seven had obtained graduate degrees.

To qualify for the study, primary participants must have had at least one experience of PVI with clitoral stimulation that led to her orgasm. Thirteen of the 15 women typically acquired clitoral stimulation concurrent with PVI in order to orgasm. This was an atypical occurrence for one woman, who usually experienced orgasm before PVI via cunnilingus. Another women experienced orgasmic PVI "infrequently" and stated, "I can count the number of times on one hand with fingers left over."

Findings

Individual interviews provided detailed descriptions of PVI with intentional clitoral stimulation, as well as the primary participant's sexual development leading to the ability to enter into this phenomenon. The major themes reflect a developmental narrative: she masturbated to orgasm; applied masturbation techniques to partnered sex; and then experienced clitoral stimulation concurrent with PVI that led to her orgasm(s).

Masturbating to Orgasm. A developmental step toward PVI orgasm was learning how to masturbate to orgasm; 12 of the 15 women learned how to orgasm through masturbation. Two women learned how to orgasm with partners, orally or manually, but did not orgasm during PVI until after they began masturbating to orgasm. For these women, the main factor related to ease of acquiring clitoral stimulation concurrent with PVI was to be familiar with their vulvas and unique methods of clitoral stimulation on their own before sharing it with a partner. They then translated what they learned during masturbation to partnered PVI. One woman said,
   I think it's been important for me to masturbate and to think about
   what works for me in terms of how I like to be touched and how I
   can help other people touch me in the right way...I think it has
   contributed to the general trajectory of more orgasms as I've
   gotten older.


A striking finding was that none of the 15 women described the same masturbation technique. Variations in specific masturbation techniques included the area(s) of the clitoris stimulated, the involvement of the labia in stimulation, the area of the hand(s) or vibrator used, the type of movement they preferred, and whether or not vaginal penetration was included.

Applying Masturbation Techniques to Partnered Sex. Considering that no woman preferred the same clitoral stimulation technique, applying masturbation technique to partnered sex involved communicating specific preferences. One man stated, "Even if a woman says, 'I like direct clitoral stimulation,' I know that means about 30 different things depending on the woman." Communication becomes multifaceted when considering that four women described how even subtle variations in aspects of their clitoral stimulation (speed, rhythm, pressure, and the part of the clitoris stimulated) might prevent them from experiencing orgasm during partnered sex. The lack of education about the clitoris and lack of cultural examples for clitoral stimulation further complicated communication (no participant reported any education around how to communicate her clitoral stimulation needs to others). One woman described this difficulty:
   Sometimes it's hard cause it's like, "Move over a centimeter;" but
   then like, "No, I meant half a centimeter and a little bit more up
   and then wider; now do it harder." Yeah, it's very tricky to
   pinpoint exactly what I want.


Though communication may be complex, and every woman had experiences where the dominant sexual script was reinforced and her clitoris was ignored, thirteen women have become pro-active in their attempts to assert their sexual needs. Most (73%) of the women and three of the men reported that they typically initiate some type of communication about the need for clitoral stimulation rather than their partners. Four women described experiences of initiating self-stimulation during PVI without explicit communication. One woman emphatically stated, "Of course I initiated it. Flow do men usually initiate clitoral stimulation? They don't care. They don't give a shit about the clitoris! So yeah, I initiated it."

Men and women alike talked about a variety of experiences when they had addressed the need for clitoral stimulation with new partners. The most common finding, reported by all participants, was that clitoral stimulation was often introduced (whether by them or their partner) after sexual activity had begun. Typically, this introduction occurred early in the session during "kissing" or "making out." One woman spoke of introducing her vibrator to new partners after consent for intercourse was established:
   You're making out, doing foreplay, touching, and then somebody's
   asking, "Hey, do you want to have sex?" or "Do you have a condom?"
   and then that's usually when there's a consensual "Okay let's go
   through with it" and then "What do you need? And "What do I need?"


She spoke of taking a break from physical activity to introduce her vibrator either by asking to go to the bathroom or saying, "Hold on. Let me go get some things." Whereas another women introduced the topic by saying, "It's complicated for me" and explained to her partners, "I like it when little circles are made on my clitoris, and I also like it at the same time when my nipples are stimulated." Three of the men described their verbal communication while in the process of clitoral stimulation. One man said:
   I ask questions. "Do you enjoy that? Where is it? Help me find it.
   Do you like the left side? Is it more stimulating than the right
   side? Do you like two fingers on it? Do you like it soft?" And [I]
   just continue a dialogue.


Five women used body language to communicate their clitoral stimulation needs. Three women masturbated in front of their partners to show them how they stimulate their clitorises. One woman described her use of body language in combination with sound; she elicited partnered clitoral stimulation by "tilting my hip or arching my back" and moaning to give him encouraging feedback. Three women mentioned taking a man's hand and setting it on her clitoris. When I asked, "How does he know what to do with his hand?" One woman said she usually does not explain but lets him know if it hurts. She stated:
   I've always wanted to use words more to try to explain what works
   and what doesn't, but I haven't been able to figure out how to do
   that in a short way that's explainable for someone to understand.
   So usually I do use my hands to demonstrate, and that doesn't
   always work. I don't know if they don't realize that I'm trying to
   show them something, or they don't realize that what they're doing
   isn't working. I certainly haven't always been clear about what I
   want in terms of correcting if they try to do something and it
   doesn't work the right way.


It's important to note that not all participants felt empowerment around their need for clitoral stimulation. One woman associated clitoral touching with "awkwardness." She felt it was difficult to communicate her preferred technique, and clitoral stimulation did not fit cinematic images of sexuality. This participant does not typically orgasm with partners. She said, "[Orgasm] is just so inconvenient and takes so much work that I'm just like Tuck if the vast majority of the time."

Importance of clitoral stimulation and female orgasm to the men. All of the men in this study expressed that they valued clitoral stimulation and female orgasm. Their reasons were diverse. One man spoke at length about his value of equity in orgasm; his sentiment being, "She obviously always makes me orgasm. I want to make sure that I do the same; that's important to me... that she also gets the same satisfaction that I do." An additional two men talked about enjoying clitoral stimulation because it increased her pleasure. All four men spoke about a time where clitoral stimulation became important to them because a past or current partner verbally communicated with them about it. Other reasons included feeling helpful (1), feeling like they did a good job (1), feeling more intimately connected in the relationship (2), and feeling power over his partner (1): "Oh God! You're my master!" All of the men spoke about how clitoral stimulation and female orgasm increased their own erotic, physical, or emotional pleasure. One man described his feelings about female orgasm specifically during PVI: "I think that it's validating; it's exciting; it's physically amazing. Yeah, I can't say enough good things about it. I highly recommend it. [Laughter.]"

Clitoral Stimulation Concurrent with PVI Leading to Female Orgasm. Participants used two primary strategies for clitoral stimulation during PVI: intentionally stimulating the clitoris using her partner's body or creating space surrounding the clitoris during PVI so that effective stimulation could take place. As a group, participants reported five entities used to stimulate various areas of the clitoris while PVI was taking place: his pubic bone, his penis, a vibrator, his hand, or her own hand. Participants alternated between these objects and body parts when executing their preferred strategy for clitoral stimulation concurrent with PVI to orgasm.

Stimulating the clitoris against his body: Pelvis or penis to clitoris. Three women described acquiring clitoral stimulation to orgasm by increasing contact between the clitoris and their partners' pelvic area. Two other women described increasing contact between the clitoris and the penile shaft during insertion. Three women occasionally used this strategy, and two others prefer and usually use this method. As one woman said:
   I will never orgasm from a position that isn't body to body like
   that because even if a partner is trying to be very intentional and
   using their finger to stimulate my clit, I just really like having
   a wider area that can be stimulated at once.


Using the body to increase pelvic contact. Women described stimulating their clitorises against their partner's bodies using several strategies: spreading legs wide to increase contact with his pelvis, wrapping legs around his body, leaning her torso forward to find the right pressure on her clitoris, pulling her partners' body closer, or resting her full body weight on his pelvis to get enough pressure. Clitoris-to-pelvis techniques often required substantial physical pressure. One woman said she and her partner stood during PVI with her entire body weight supported by his pelvis and her feet off the floor. Two others spoke of grabbing the man's buttocks and pressing his body into her pelvis. One described her strategy this way, "The contact between my clitoris and the person's body never breaks. There is always touching. But what's stimulating it is the change in pressure from the thrusting." Her partner described his side of the experience:
   She's trying to get really close to me so that I'm deep inside of
   her as I could be, so that the pelvic area is literally as close as
   it could be to her clitoris, literally up against it. I couldn't go
   any further inside.


Increasing clitoral contact with the penis. Two women described clitoral contact with their partner's penis during PVI as a means to experience orgasm. One spoke about clitoral contact with the shaft of the penis, referred to as coital alignment technique in the literature (Farley Hurlbert & Apt, 1995). She described an experience of orgasm where she dragged her clitoris back and forth along the shaft of his penis with penile insertion while on top of her partner. Another woman described alternating penile insertion and clitoral contact with the penile glans as her favorite way to orgasm. She emphasized that when the penis was stimulating her clitoris either she or her partner cups a hand over the penis so that there is enough pressure on the clitoris. She stated:
   I am alternating with PVt ... He pulls out and one of us uses our
   hand to stimulate the clit with his glans. Occasionally it can be
   hand-less, but this doesn't last long because it's not effective
   for me to orgasm ... With all the squishing and wetness and warmth,
   there have been two times where he wasn't even able to tell he
   wasn't inside me. We have simultaneously orgasmed this way too,
   alternating with penetration, but [with] him ultimately orgasming
   outside of my vagina. I usually do this with me on my back and
   him propped up between my legs, but it also has happened with
   both of us lying on our stomachs and him on top, and occasionally
   but less easily in the female superior position.


Despite the effectiveness of these techniques for five women, intentionally stimulating the clitoris on their partners body did not lead to orgasm for the majority. One woman explained:
   When I'm on my back and sometimes the guy wants to be on
   you or kind of hugging embrace and kissing. But everything's
   just closed off though, and I can't get anything to the clitoris.
   Sometimes they say, "Oh, the male's pubic region or whatnot can
   stimulate it [the clitoris]," but that's not my experience. So
   they're propped up with a hand or something.


Creating space around the clitoris to allow for clitoral stimulation. Most participants (74%) mentioned some strategy to create space in the area surrounding the clitoris. Space was needed not only for hands and/or vibrators but also to accommodate the movement required for stimulation. Ten participants noted that they needed only "a little bit of room." When a measurement was given, one man and three women specified two to three inches of space around the clitoris was sufficient. One woman stood out from this trend: "It's one of those bulky vibrators. So it's not easy to just slip it in there."

This space was mandatory for some participants and not for others. One woman described missionary position without enough space: "It makes it harder to masturbate because he's right there and it squashes my hand so I can't move it as much because our bodies are so close together." In contrast, another woman said she does not need this space. She described a rear entry position while she lay on her stomach: "He used his right arm sort of around my hip more than around my thigh. There was very little space, but he got his hand under my hip." I asked, "If there's not a lot of space, was his hand kind of mushed into the bed or something?" She nodded her head affirmatively.

How men create space around clitoris in missionary. One man noted that the clitoral stimulation technique depends on the position. The most commonly mentioned technique for creating space in missionary position (32% of participants) was for the man to hold himself up on his knees and arms so that "stomachs are not touching." Often a man bent his knees in missionary, rather than having his legs straight, and spread his knees in a "half split" to support the lower body while creating space around the clitoris. This allowed men to sit up during insertion and have their hands free. Participants spoke of men rubbing the sides of the clitoris between the thumb and forefinger, using a thumb, a finger, a couple of fingers, the hand, or holding a vibrator. One woman described the moment of her orgasm: "It was missionary, but he was kneeling. As he was thrusting he was rubbing [the sides of my clitoris] with his thumb and his index finger." This half split was also combined with men using one hand or forearm to support his upper torso. A man suggested forearm support was easier to maintain for longer periods of time than holding himself up with a hand. His other hand was then free to provide clitoral stimulation: "A lot of times it's just enough room for me to put my fingers... it's usually my thumb cause it's just easier in that position to stimulate the clit with my thumb."

In some instances, men had both of their hands or forearms on the bed in combination with the half split knees; this provided space for his partner to stimulate herself with her hand or a vibrator while he found adequate insertion. This technique could be used in combination with an arch in the male back. A woman commented:
   I've had it successful where it's kind of an arching of the back,
   so they're still able to kiss you and maybe suck on your nipples or
   something like that while keeping this arch where I have two to
   three inches, maybe like two inches, right above the clitoris
   that's available to me.


She suggested that this technique works best with pillows under her head to help limit the back arch he must create.

An alternate strategy to create space for clitoral stimulation in missionary position was for the man to bend only one knee and lean on the opposite outstretched leg. For example, one participant described how her partner began missionary with both legs straight and then bent his right knee up while keeping his left leg straight and leaning on his left side. This allowed him to use the fingers on his right hand to reach down and stimulate her clitoris with his penis inserted.

How women use their legs to create space around the clitoris. Seven women reported how they used their legs to create enough space for clitoral stimulation. Some spread their legs wide for "more area to get in and around" in a variety of positions including missionary, rear entry, and in a perpendicular position with the woman on her back and man on his side. Two women described bringing their legs up toward the shoulders while on their backs. This leg position gave one participant's partner access to stimulate her clitoris with his thumb during PVI. The other reported that this leg location positioned her clitoris at "quite a bit of an angle" and allowed for easier access during self-stimulation when combined with spreading her legs.

In face-to-face positions, four women said they bent a leg forward around his hip to increase depth of penile insertion while keeping the other leg straight down to create space around the clitoris. In spoon position, women described an opposite strategy of stretching her leg backward around his hip to create space around the clitoris and increase his depth of insertion. One woman explained:
   So, I'm lying on my back and he's usually on my right side. My arm
   will be around his neck. He'll have his arm under my neck, so he
   can use his hand to play with my left breast and he can use his
   mouth to play with my right breast. Then it would be his right hand
   to stimulate my clitoris, and if I turn my hips he's able to
   penetrate me. My hip is kind of twisted to meet his hip. My left
   leg is stretched out straight and then my right knee will be open
   and kind of over his leg.


Female superior (woman on top). In positions with the woman on top, participants described several techniques for reaching the clitoris during PVI. The most common technique was kneeling while straddling his body, which allowed access for self-stimulation or partner stimulation. One of the men commented that this position was the easiest of any position for him to stimulate her clitoris. Sitting up was sometimes combined with her leaning back to allow greater access to her clitoris. Alternatively, one woman described leaning forward in order to support her upper torso with her hands on the headboard, thus finding a comfortable means to create enough space for her partner to reach her clitoris. Another woman had a different face-to-face female superior technique; she laid her entire torso on top of her partner with her knees open and tucked a vibrator between her clitoris and his pelvis. She stated that her vibrator stimulates him as well in this position. Another woman noted that her partner bends his knees up when she was on top to allow for deeper penile insertion while still giving her enough room for clitoral stimulation.

Rear entry positions. Eight participants (42%) discussed doggie style as a position where space was easily available around the clitoris, but this position required special torso support to allow the woman to hold a vibrator or have a hand free. Holding her torso up with one hand or forearm was a difficult "balancing act" and penile thrusting could easily disrupt her balance. Almost all participants found support in doggie style by lowering their chest and at least one shoulder onto the bed and lying on the side of their face or forehead with their "ass way up in the air." Though one woman felt that this was "not always the safest for my neck," another obtained additional support in this chest down position by placing pillows under her belly and chest. She was able to reach her arm between the pillows and her body to stimulate her clitoris. She felt this pillow support allowed her to better participate in the thrusting action of intercourse as well. Yet another woman reported that her partner had a great idea for torso support: she and her partner got on their knees on the floor and she bent over the bed. This allowed her to hold a vibrator with one hand while the bed fully supported her torso.

In rear entry positions, some participants reported men reaching the clitoris using two strategies: reaching around the waist, thigh, or hip or reaching through her legs under the penis. A man explained how he could not reach the clitoris using an arm around the waist or hip if a partner had a high-waist or wide hips; though he could reach under his penis between her legs to the clitoris instead. In order to allow him easier access to her clitoris, she arched her buttocks backward. A woman noted that in spoon position she bends her knees up high to create space for him to reach under his penis to access her clitoris.

One of the women described a rear entry position with both people on their backs facing up. She lay on top of her partner and used her vibrator with penile insertion. This position automatically creates enough space in the area of the clitoris.

Perpendicular position. The perpendicular position is worth special mention. In this position a man lays on his side and a woman lays on her back perpendicular to him with her legs over his body. Six participants mentioned that this position allowed for easy access to the clitoris with her hand, his hand, or a vibrator. It allowed for preferred leg positions as well: legs together or apart. Participants also noted that this position allowed for deeper penile insertion.

These findings provide rich descriptions of the phenomenon of direct clitoral stimulation concurrent with PVI leading to female orgasm. This phenomenon began in the mind and body by conceptualizing the sexual body to include the clitoris (Jackson & Scott, 2002) and then 14 out of 15 women learned preferred clitoral stimulation techniques through masturbation. Considering that all women described unique masturbation methods, communicating and honoring unique anatomies is a key to attempting the partner techniques participants described.

DISCUSSION

Penile-vaginal intercourse (PVI) is the most common partnered (hetero)sexual behaviour in North America until age 65, though still common in older adults (Reece et al., 2010; Rotermann & McKay, 2009; Santos-Iglesias et al., 2016). Although most cis-women require or are assisted by attentive clitoral stimulation in order to experience orgasm (Eschler, 2004; Graber & Kline-Graber, 1979; Herbenick et al., 2017; Hite, 2000; Janus & Janus, 1993; Kinsey et al., 1953; Wade et al., 2005; Wilcox & Hagar, 1980), the traditional sexual script for partnered sex may incorporate manual or oral clitoral stimulation in arousal and does not include focused clitoral stimulation during genital-to-genital contact (Gagnon & Simon, 1973). By reflecting a historically supported androcentric focus on the vaginal canal as the main female sex organ (Laqueur, 1990; Maines, 1999), this script has helped create a gender-based orgasm gap during partnered sex (Reece et al., 2010).

In the late 1960s through the early 1980s, feminists (e.g. Boston Women's Health Collective, 1971; Dodson, 1974; FFWHC, 1981; Koedt, 1970) argued that a sexual script negating the clitoris subjugated women, erroneously defining cis-women's sexuality in terms of cis-men's pleasure. They argued that sexual practice was a site for the reproduction of gendered power. As a solution, Koedt in 1970 stated, "We must discard the 'normal' concepts of sex and create new guidelines which take into account mutual enjoyment" (p. 186). Though Koedt suggested a "sex" concept not necessarily associated with PVI, PVI alone could be reconceptualized based on Koedt's guidelines to include the most sexually sensitive part of the female body, the clitoris. Nearly 50 years later, in a nationally representative survey, Herbenick and colleagues (2017) defined "regular penile vaginal intercourse" as explicitly not including focused attention on the clitoris: "... how often did you have an orgasm during 'regular' penile vaginal intercourse--that is, without you or your partner doing anything extra to touch or stimulate your clitoris during intercourse?" showing that the androcentric sexual script is still relevant today.

This phenomenological study describes the lived experiences of 15 cis-gender women and four cis-gender men in adjusting the normative sexual script to focus on both clitoral and penile stimulation. My recruitment methods of contacting MeetUp[R] groups actively invested in sex positivity (e.g. Sex Positive World) and snowball recommendation, sometimes via feminist listservs, gave me access to participants actively seeking sexual empowerment. Thirteen of the 15 women usually acquired clitoral stimulation during PVI; whereas this was an atypical experience for only two women. In interviews, participants conceptualized a sexual script centering mutual pleasure using three main means: participants obtained preferred clitoral stimulation and accommodated preferred penile penetration while finding comfortable support for the body. Obtaining preferred clitoral stimulation was conceptually simple: women either stimulated their clitorises against their partners' bodies or the couple used their bodies to create enough room around her clitoris so that partner or self-stimulation could occur.

The majority of participants (74%) used the strategy of creating space around the clitoris for him to stimulate her clitoris or for her to self-stimulate. Women and men alike described numerous techniques of supporting and positioning their upper and lower bodies that allowed enough space around the clitoris for effective clitoral stimulation. When a measurement was given, about two or three inches of space around the clitoris was sufficient. However, one participant had a larger vibrator and needed more room. The simplicity of the techniques participants described to accommodate clitoral stimulation makes all the more astounding the resilience of a sexual script (Gagnon & Simon, 1973; Hite, 1981) that has not yet fully evolved to include direct clitoral stimulation concurrent with PVI; the clitoris was often within reach in a variety of positions.

Hite (1981) described pelvis to clitoris as an indirect form of clitoral stimulation, whereas this study's participants expressed that clitorises were directly stimulated against the male body. Techniques rubbing the clitoris against the pelvis were always woman controlled in this study; they were intentional and often required substantial pressure. Women spoke of gripping their partner's buttocks and pressing his body into her clitoris. One couple spoke of PVI while standing where her entire body weight was on his pelvis with her feet off the floor in order to create desired pressure on the clitoris.

Female masturbation was revealed to be an important step toward PVI orgasm. Understanding how to stimulate one's own clitoris to orgasm made acquiring effective clitoral stimulation with a partner easier. In this study, each woman reported a unique masturbation technique; no two were the same. Unique masturbation styles could reflect pudendal nerve cluster distribution distinctive to that individual. Understanding that preferred stimulation techniques vary greatly may be key to successful partner communication. Although there are probable drawbacks to socially reinforcing the idea that clitoral touching preferences are unique and therefore "complicated" (Richters, 2009), the idea, or even expectation, that a person may need to describe what they like to a partner is simple.

However, an out dated and often unconscious sexual script centering the penis puts pressure on people to ignore the clitoris. One woman spoke about how images in movies did not include the clitoral stimulation that she would need to orgasm, so she typically did not communicate her needs to partners. There is clearly a need for acknowledgment and expanded discussions about the prevailing sexual script and its patriarchal historical context, as well as conversations about masturbation, the importance of the clitoris, and sexual communication in educational, therapeutic, and feminist settings. These discussions should include efforts to normalize the clitoris and its function and provide information beyond an anatomical label and location. Facilitators in these venues should be conscious of the sociohistorical context of the clitoris and invite critiques of penis-centered models of sexuality (Freud, 1905; Gagnon & Simon, 1973; Maines, 1999). It may also be helpful to encourage females to self-assess their areas of clitoral sensitivity through masturbation, prior to communicating to partners, for those wishing to improve PVI orgasm likelihood.

Women may fear that having a need for direct clitoral stimulation during PVI will make their partners feel inadequate (Salisbury & Fisher, 2014) due to messages reinforcing the false notion that the penis should be central to sexual pleasure. Further, 34% of participants in Wade and colleagues' (2005) study thought that the clitoris was being directly stimulated during PVI. However, men spoke enthusiastically of the pleasure, self-esteem, and connection they gained in ensuring clitoral stimulation during PVI that led to her orgasm. No man in this study spoke of this adjustment to the sexual script in negative terms. Educators and therapists can reduce anxieties and increase knowledge by providing examples of various female masturbation techniques to show clitoral stimulation methods and reduce stigma, as well as show specific techniques for including direct clitoral stimulation during diverse sexual activities.

Strengths and Limitations

As with all qualitative research studies, these findings must be considered exploratory (Bradley, 1993). Small sample size and voluntary samples negate generalizability of these participant's experiences to the larger population, though findings may be transferable (Lincoln & Guba, 1985). I also faced challenges recruiting qualified participants who understood the sampling criteria: "direct clitoral stimulation that takes place during penile vaginal intercourse and leads to female orgasm." This suggests that many people have not typically been well informed about their bodies and sexual response to be able to identify with this phenomenon. This led to an over-sampling of highly educated participants. This education level must be considered a privileged position in terms of experience with female orgasm because social privilege in general and educational privilege specifically is linked to higher female orgasm rates (Angier, 1999; Fisher, 1973; Gonzales & Rolison, 2005). For example, in this study, books introduced a third of the women and one man to the functional anatomy of the clitoris. Educational privilege also increased the level of data articulation I was able to obtain, which was a major strength in this study.

There is a great deal of dispute in the literature regarding official language for female anatomy relevant to this phenomenon (Buisson, Foldes, & Paniel, 2008; FFWHC, 1981; O'Connell et al., 2005; Puppo & Puppo, 2015; Shih, Cold, & Yang, 2013; Tuana, 2004). This social reality affected all study stages including phone screenings and in interviews. For example, in one interview a woman used the term "labia" when discussing the clitoral hood. Confusion about language describing female sex organs created limitations in data collection.

Continual self-checking of my interpretations of participant's responses in interviews likely improved credibility of findings (Dinkins, 2005). My preconceptions informed my understanding of participant's meanings and I used my presumptions to offer participants the opportunity to explain misunderstandings and to think more deeply about personal experiences. However, my contributions to interviews may also have been a study limitation. The meanings and information that I shared may have influenced the accuracy and authenticity of findings, as participants have a tendency to aim to please researchers (Bradley, 1993).

The strengths of this research related directly to my ability to obtain data. Participants were highly educated, and half of them were recruited through communities working to increase sex positivity. This resulted in a high level of articulation and willingness to talk about sexuality openly. The inclusion of women's sex partners triangulated data by offering another perspective on the phenomenon and provided additional details to the women's accounts increasing the depth of findings. Conducting member checks after data analysis as a triangulation method also provided more data and improved credibility of findings (Bradley, 1993; Patton, 1990).

Recommendations for Future Research

Additional research is needed on the topic of including orgasmic clitoral stimulation with PVI; this study did not reach data saturation. There are also many ways researchers could build off this study both qualitatively and quantitatively. Adjunctive research questions that would extend findings from this study include: What is similar and different about clitoral stimulation during vaginal insertion for partners who use a strap-on dildo (e.g. lesbians, trans masculine people, people with erectile dysfunction)? How does the role of the clitoris change for trans masculine people after hormonal gender confirmation? Is the clitoris part of gender identity? What is the role of an intact clitoris in self-concept in cultures where clitorectomy is common? What experiences do people have of their inner labia in sexual response? What are peoples' experiences of mutual orgasm? What is the phenomenon of orgasm resulting from cunnilingus? What experiences do people have with couple's vibrators during PVI?

CONCLUSION

By focusing on the clitoris, I shed light on a valuable part of female anatomy that is often viewed, in regards to sexual stimulation, as secondary to the vagina, if acknowledged at all. This research does not intend to oppress the experiences of female orgasm that occur by means other than the topic of this study. Rather, this research describes potential methods for producing mutual pleasure and orgasm for those people who enjoy PVI and require or benefit from direct and consistent clitoral stimulation, which constitutes the majority of people with clitorises (Eschler, 2004; Graber & Kline-Graber, 1979; Herbenick et al., 2017; Hite, 2000; Janus 8r Janus, 1993; Kinsey et al., 1953; Wade et al., 2005; Wilcox & Hagar, 1980).

Acknowledgments: The author would like to express great appreciation to Dr. Betsy Crane, Eric van Meter, and the Intellectual Circle at Kansas State University for their reviews and contributions to this article.

Correspondence concerning this article should be sent to Angela Towne, Kansas State University, College of Arts and Sciences, Gender, Women, and Sexuality Studies, 1128 N 17th St, 101C Leasure Hall, Manhattan, KS 66502-1005, United States. E-mail: AngelaTowne@ksu.edu

doi:10.3138/cjhs.2018-0022

NOTES

(1) In this article, the term "female" refers to the biological sex assigned to people assessed as having vulvar, clitoral, and vaginal anatomy. "Male" refers to the biological sex assigned to people assessed as having a penis. "Female" and "male" are not used here as gender identities. Biological sex will be used to distinguish female from male orgasm. The term "cisgender" refers to a person whose self-described gender identity aligns with the socially assumed corresponding biological sex. For example, the term "cis-woman" refers to a person who is both assigned biologically female and identifies as a woman. Scholars cited in this literature review rarely followed up self-reported gender identities with biological sex assessments; however, their use of the terms "women" and "men" likely refer to a cisgender majority. Participants in this study were screened for cisgender identity and are introduced as such. The terms "woman/women" and "man/ men" are thus used throughout to refer to participant's self-reported gender identities.

(2) Clitoral structures exist externally and internally (FFWHC, 1981). The clitoral glans is the only clitoral structure that is technically external (O'Connell, Sanjeevan, & Hutson, 2005), though several other clitoral structures are available to be stimulated externally including the clitoral hood, shaft, and/or suspensory ligament. Internal structures that can be named "clitoral" are a matter of significant debate (see Buisson, Foldes, & Paniel, 2008; FFWHC, 1981; O'Connell et al., 2005; Puppo & Puppo, 2015; Shih, Cold, & Yang, 2013; Tuana, 2004). Research addressing "clitoral" stimulation, including this study, refers to those structures available to be stimulated externally and do not refer to clitoral structures that can only be stimulated through the vaginal canal.

(3) When reporting on results specific to the women I use their self-identification" women" or"primary participants. "When results are specific to men I use their self-identification "men." When results pertain to both women and men as a group, I use the general term "participants."

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Angela Towne (1)

(1) Department of Gender, Women, and Sexuality Studies, Kansas State University, Manhattan, KS
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Author:Towne, Angela
Publication:The Canadian Journal of Human Sexuality
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Date:Apr 1, 2019
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