Some of the married women taking part in the Masters & Johnson laboratory research became pregnant during their participation. Four of them and their husbands volunteered to continue in the programme during and after pregnancy. Two other couples volunteered for the first time early in pregnancy - in one case seven weeks and in the other case eight and a half weeks after the wife's last menstrual period. The six pregnant wives ranged in age from twenty-one to thirty-six. Two had never been pregnant before, while for the thirty-six-year-old this was the fourth pregnancy.
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Thanks to these six couples, Dr. Masters and Mrs. Johnson were able to compare sexual responses during pregnancy with responses at other times under a wide range of circumstances. In most respects, they learned, responses were very much the same during pregnancy. Only a few differences need be noted here.
As described above, the female breasts become engorged during sexual stimulation. They also become engorged during pregnancy. The combination of these two types of engorgement, Dr. Masters and Mrs. Johnson report, led some women who had not had babies before to complain of severe breast tenderness, especially in the nipples and areolas, during advanced stages of sexual arousal early in pregnancy. This tenderness did not recur during sexual arousal later in pregnancy.
All six of the study subjects, Dr. Masters and Mrs. Johnson report, became conscious of heightened levels of sexual interest and responsiveness toward the end of the first three months of pregnancy or early in the second three months. "Two subjects who had never been multi-orgasmic in prior sexual experience described and demonstrated this high-tension response for the first time during the second trimester of their pregnancies." The other four women had had multiple orgasms before pregnancy and continued to have them during pregnancy. Sexual interest and responsiveness continued throughout the second three months and well into the final three months for all six women.
Four of the six described "occasional cramping and aching in the mid-line of the lower abdomen" during and immediately after orgasm; and two of the four complained of low backache after the cramping. Several were aware of uterine contractions following sexual stimulation.
The "orgasmic platform" surrounding the outer third of the vagina was even more noticeable during pregnancy than at other times, so that the penis was even more tightly clamped than usual by the platform. During orgasm, the women experienced the rhythmic contractions of this platform as usual - but the region was so engorged that the contractions were much less visible to an observer.
Dr. Masters was concerned with the effect of maternal sexual activity on the unborn baby. He listened to the fetal heartbeat during orgasm, and reported that while it sometimes slowed down a little, this reaction quickly passed, and the fetal heart resumed its normal rate. Instead of the usual rhythmic series of contractions during orgasm, the uterus late in pregnancy sometimes engaged in a single contraction lasting as long as a minute.
Only the resolution phase differed markedly during pregnancy; it took longer and was less complete. "The study subjects frequently stated that orgasmic experience, although objectively most severe and subjectively quite satisfying, did not relieve their sexual tensions for any significant length of time." It was perhaps for this reason that the two women in the group who had not previously had multiple orgasms experienced them for the first time during pregnancy.
All six women came in for check-ups four or five weeks after their babies were born, again between the sixth and eighth weeks, and again at the end of the third month. Four of the six reported a return of sexual desire before the time of the first check-up; and pelvic examination of all six showed sufficient healing to make intercourse permissible. Sexual intercourse in the laboratory at this time was reported as fully satisfactory subjectively by the six women, particularly among the mothers who were breast-feeding their babies; but both the intensity and duration of the observed physiological responses were diminished.
Three of the six mothers breast-fed their babies. Sexual interest and responsiveness returned earlier after childbirth in these three. The uterus also returned to normal size and position earlier, for an interesting reason. During breastfeeding, the baby's sucking on the nipples causes the pituitary to release a hormone, oxytocin, which contracts the chambers in the breast and squeezes milk out into the channels leading to the nipples. This same hormone also shrinks the uterus; indeed, injections of oxytocin were sometimes given women after childbirth to hasten the uterine shrinking. The Masters-Johnson findings confirm the view that the oxytocin secreted during breast-feeding plays a helpful role in returning the uterus to its normal non-pregnant condition.
Another fascinating observation concerned involuntary secretion of breast milk during orgasm. Two of the three women who breast-fed their babies reported that this happened at home, and the occurrence was confirmed in the laboratory. It strongly suggested that the same hormone, oxytocin, may also play a role in the female orgasm.
Six couples, of course, constitute a very small sample. Hence Dr. Masters and Mrs. Johnson supplemented it with a much larger sample of pregnant women and husbands who agreed to come in from time to time and report verbally on their sexual feelings, behaviour, and responses.
In all, 113 pregnant women were invited to participate in this programme of repeated interviews; 111 of them, aged twenty-one to forty-three, accepted the invitation. All of them, of course, were aware of how dependent pregnant women are on their doctors to advise them concerning sexual intercourse during and after pregnancy; and when told that the programme would help doctors give sounder advice, only two were unwilling to help.
Ten of the women who had volunteered lost their babies during the first six months, leaving 101 who participated throughout pregnancy. Of these, nine were unmarried. The husbands of the ninety-two married women who continued to the end were also invited to report their reactions to their wives' pregnancies - and seventy-nine accepted.
Sixty-eight of the 111 women who participated had had babies before; the other forty-three had not. During the first three months of pregnancy, the sixty eight women who had had previous babies reported very little change in sexual interest or responsiveness. The main exceptions were four women who reported an increase, and seven who reported a decrease; these seven all suffered from nausea and vomiting during early pregnancy. Most of the women having their first baby did report a reduction in erotic interest and responsiveness - perhaps due in part to an unwarranted fear that the unborn baby might be injured, and in part to the chronic fatigue or other symptoms of early pregnancy they were experiencing.
"During the second trimester," Dr. Masters and Mrs. Johnson stated, "sexual patterns generally reflected a marked increase in eroticism and effectiveness of performance regardless of the parity or ages of the women interrogated. This evidence of elevated sexuality was reported by the women not only as interest in sexual encounter, but also as planning for sexual encounter, fantasy of sexual encounter, and sex-dream content." Basic sexuality was increased not only as compared with the first three months of pregnancy, but also as compared with the period before pregnancy. The increase was reported by eighty-two of the 101 women who continued through the second three months.
Responses during the final three months were affected by the fact that seventy-seven of the 101 women were warned by their own physicians not to engage in sexual intercourse during pregnancy until after the baby was born. Some doctors forbade intercourse during the entire last three months; others specified periods as short as one month. Many women reported that they gradually lost interest in sex during the last three months quite independently of the medical warnings; and twenty of the 101 women reported that their husbands gradually lost interest in having sex with them - either because of the gross physical signs of their pregnancy, or because of fear that sex would be uncomfortable for their wives, or for fear of hurting the baby.
After the babies were born, strong sexual interests returned within two or three weeks in some women, while others were still sexually uninterested when questioned during the third month after childbirth. Twenty-four of the mothers were breast-feeding their babies at the time of the third-month check-up; and these mothers as a group reported a prompter return of sexuality and a return to higher levels of sexuality than the others. These women also expressed an interest in resuming sexual intercourse with their husbands earlier in the post-partum period.
The mothers who breast-fed their babies reported another very interesting physiological phenomenon: sexual stimulation during breast-feeding. Frequently this stimulation carried them to plateau levels of response, and on three occasions orgasm was experienced during breast-feeding - another indication that the hormone oxytocin, released during breast-feeding, may also play a role in female orgasm.
On the psychological side, six of the twenty-four women who breast-fed their babies expressed deep guilt-feelings about their sexual arousal during nursing; and six of the women who were not breast-feeding gave as their reason the fact that they had found themselves sexually aroused during breast-feeding of a previous baby. (Several psychologists and psychiatrists have reported this sense of guilt some women feel on discovering that breast-feeding is sexually arousing.) Dr. Masters and Mrs. Johnson reassured them that there is nothing "perverse" in these feelings; indeed, this may be just another of nature's subtle ways of encouraging mothers to take good care of their babies during the early months, and of establishing close rapport between mother and baby. It is a shocking commentary on American prudery and rejection of sex at the time that a significant number of women felt guilty, and some even refused to breast-feed their babies, because sexual feelings accompany breast-feeding. Young girls need educating on this point. All of the married women, except those whose physicians forbade it, had full sexual intercourse with their husbands within two months or less after childbirth - and some whose physicians did forbid it also resumed despite the prohibition. A few, in defiance of their doctor's advice, had intercourse as early as three weeks after childbirth. There is some excellent advice on sex positions during pregnancy here.
Meanwhile, what of the husbands?
In many cases, to follow medical advice would have meant going without sexual intercourse for six successive months - three before and three after delivery.
Of the seventy-seven women whose physicians had warned against sexual intercourse, sixty-eight expressed concern, in their talks with Dr. Masters and Mrs. Johnson, over the effect of the prohibition on their husbands, and forty-nine reported that they made deliberate efforts to relieve their husbands sexually during the period of medically recommended continence by masturbating them or in other ways. Three women reported that they knew their husbands were finding sex elsewhere during this period.
Of the seventy-nine men participating in the interview project, seventy-one were married to women whose doctors had forbidden intercourse for periods of from two to six months. Only twenty-one of the seventy-one stated that they understood, agreed with, and honoured the prohibition.
In all, eighteen of the seventy-one husbands for whom intercourse with their wives was forbidden admitted to Dr. Masters and Mrs. Johnson that they engaged in extramarital sex activities during this period. Several insisted that this was the "first time" they had been unfaithful. Of the twelve who began extra-marital sex activity before the baby was born, all twelve continued it after the baby was born.
Nearly a third of the men reported that they did not understand the reason for the prohibition, or were not sure that the doctor had really said it, or wished that he had explained it to them as well as to their wives. Several clearly suspected that their wives had made up the story in order to avoid intercourse.
Here was a major problem of pregnancy which had never been adequately explored before. Several basic changes in obstetrical advice were indicated.
The first is very simple: Whenever a physician forbids sexual intercourse - before pregnancy, after pregnancy, during or after an illness, or at any other time - he should take pains to explain the reasons in full to both husband and wife. It is unfair to both partners, and hazardous to the marriage, to leave one partner in the dark, with all the misunderstandings and suspicions that can arise.
The second is more complicated. Some physicians no doubt prescribe long periods of abstinence during pregnancy, or after pregnancy, or at other times, in order to "play safe." In the absence of precise information, they think it prudent to prohibit intercourse. The Masters & Johnson data indicate that far from being prudent, an unnecessary sexual prohibition, or one that is not fully understood by both partners, gravely jeopardizes the marriage in a substantial proportion of cases.
But what of the physical risk to mother and baby? Marital psychology aside, what should a doctor tell his patient and her husband about sex during pregnancy? The four most important points emerging from the research work of M & J can be summed up as follows:
(1) For the overwhelming majority of women, there is no reason whatever to refrain from sex during the first three months of pregnancy.
The major exceptions may be a small group of women who have already lost three or more babies through spontaneous abortion during the first trimester, and who want very much to carry this baby to term. For this small group of women, physicians customarily recommend no sexual intercourse during the first three months. Here, perhaps, is a group for whom it really is prudent to refrain. But the prohibition must go further if it is to have its intended effect. Their studies clearly show that masturbation to orgasm triggers even more intense contractions of the uterus than does orgasm following intercourse. Thus a woman like this who refrains from intercourse during the first three months should also be instructed to refrain from orgasm achieved in other ways.
(2) For the overwhelming majority of women, there is no reason whatever to refrain from sexual activity during the second three months of pregnancy.
(3) Late in the final three months, as delivery day approaches, the problem becomes more complex. Some physicians warn against intercourse toward the end of pregnancy for fear of infection. This maybe was "a residual of the pre-antibiotic days." There is no more risk of vaginal or cervical infection late in pregnancy than at any other time, stated Masters and Johnson; and if infection should occur, it can be as readily and effectively controlled as at any other time.
More relevant is the fact that in some women toward the end of pregnancy, the baby's head engages in the cervix, and the cervix descends into the main axis of the vagina. After this descent occurs, vigorous coital thrusting may cause the glans of the penis to strike the infant-laden cervix. A little "spotting" or bleeding may result. In this case, Dr. Masters and Mrs. Johnson concluded, coition should be given up. But they point out that in many women, especially those who have had babies before, the baby's head does not engage and the cervix does not descend until labour actually begins. There seems little reason to prohibit intercourse for these women merely because the head has descended into the cervix in some other women.
Further, there is a possibility that an orgasm on the eve of a baby's birth may actually trigger the onset of labour. Dr. Masters and Mrs. Johnson described four cases - none of them in their research programme - in which women continued to have intercourse through the ninth month, and in which labour began immediately after an orgasm. Similar cases have been described by others. In none of these, however, was the baby born prematurely. "Whether or not premature labour can be or has been induced by orgasmic response is of major clinical moment," Dr. Masters and Mrs. Johnson stated, going on to say: "There is no secure information available on this subject."
(4) After the baby is born, three factors may properly delay resumption of sexual intercourse. The wife may not feel like it. The surgical incision made to ease the birth of the baby - the episiotomy - may not have healed fully. And there may still be some uterine or vaginal bleeding or spotting. All three of these conditions usually (though not always) end after the third week.
In sum, then, they recommended that "the whole problem of coition during the third trimester of pregnancy and the post-partum period should be individualized." A physician should advise each woman and her husband on an individual basis. "Their situation should be discussed, personal reasons examined, fears explained away, and a firm understanding between both members of the marital unit reached." In most cases it will not prove necessary to forbid sex for prolonged periods - such as six weeks before and six weeks after the baby is born. In those selected cases where there is good reason to abstain, a doctor following this individualized procedure can, with sympathy and clear explanation, minimize any stress.