Jones et al recently published an expert opinion piece questioning whether the phenomenon of blue balls is real and why the answer to this question matters.1 The authors performed a thorough literature review on blue balls and epididymal hypertension, and they included a descriptive analysis of posts on a Reddit forum for women-identified individuals who experienced pressure or coercion due to blue balls. They concluded that evidence for the phenomenon of blue balls is nearly nonexistent and suggested that it might be better understood as a form of somatization rather than a purely physiologic condition. The authors also concluded that scientific circles have largely dismissed this phenomenon because of its perceived harmlessness and that instances of coercion and sexual violence, as exemplified by the examples provided in their piece, highlight the risks of dismissing the potentially devastating effects of blue balls. As a result, the authors called for more research to provide clarity on the phenomenon and possibly prevent sexual violence.
We agree that the phenomenon of blue balls is understudied, is often dismissed, and can lead to sexual coercion. However, we do not agree that evidence for blue balls is nearly nonexistent or that blue balls may be better understood as a form of somatization. To the former point, results from our research, which examined the experiences of blue balls/vulva in 2621 individuals, showed that 56% of respondents with a penis and 42.1% of respondents with a vulva reported experiencing some degree of genitopelvic pain when approaching orgasm after prolonged arousal without ejaculation/orgasm.2 Roughly half of the entire sample reported pain, with 6.7% and 1.4% respectively reporting severe pain, findings that should not be dismissed or used as a sexually coercive tactic.
Should blue balls be understood as a form of somatization? As far as we are aware, there are no investigations of physiologic mechanisms involved in blue balls, so it may be premature to conclude that their cause is psychogenic. In addition, the dichotomization of the experience of blue balls as either a physiologic or psychological condition harkens to outdated and unsupported psychogenic explanations of genitopelvic pain,3-6 which rely on psychoanalytic theory and lack empirical support.7 Unfortunately, even today, identifying the causes of genitopelvic pain can prove challenging during medical examinations, and when no organic cause is immediately apparent, patients’ complaints are frequently dismissed and their experiences invalidated.8 These negative health care experiences can have adverse impacts on patients’ well-being.9
Indeed, for decades, this misdirection in causal understanding hindered the treatment and serious consideration of women with dyspareunia.10 This field of research has significantly evolved to the point that different causes of dyspareunia have been identified11 and diagnoses and treatment plans can be made even when faced with unexplained chronic vulvar pain (eg, vulvodynia, which is diagnosed when the pain is due to unknown causes).12 Current perspectives of genitopelvic pain and chronic pain in general recognize the importance of integrated views of pain through, for example, biopsychosocial approaches13,14 and the inherent subjective nature of pain that is best captured via self-report.15
So, is the pain of blue balls real? Yes, it is real for those who experience it.
Is the pain a valid reason to sexually coerce someone? Absolutely not.
In the end, we agree with Jones et al that what matters in the realm of blue balls is the potential for sexual coercion, of which there is ample evidence. We believe what matters more than the classification of blue balls are sociocultural narratives around the idea that sexual pleasure is more important for some people than for others, typically manifesting in the privileging of heterosexual men’s sexual pleasure (see research on the orgasm gap).16 This view is internalized by many, unfortunately, and dismantling ideas of the privileging of sexual pleasure for some vs others will be key to ending sexual coercion due to blue balls.
Contributor Information
Samantha L Levang, Department of Psychology, Queen’s University, Kingston, K7L3N6, Canada.
Megan Henkelman, Department of Psychology, Queen’s University, Kingston, K7L3N6, Canada.
Caroline F Pukall, Department of Psychology, Queen’s University, Kingston, K7L3N6, Canada.
Funding
The study by Levang et al. (2023) was supported by the Canadian Institutes of Health Research (grant 178118) and Spotify.
Conflicts of interest
None declared.
References
- 1. Jones JM, Cedermark K, Barham D, Gross MS. Does blue balls exist, and why should we care? J Sex Med. 2024;21(2):88-89. 10.1093/jsxmed/qdad161 [DOI] [PubMed] [Google Scholar]
- 2. Levang S, Henkelman M, Neish R, et al. “Blue balls” and sexual coercion: a survey study of genitopelvic pain after sexual arousal without orgasm and its implications for sexual advances. Sex Med. 2023;11(2):qfad016. 10.1093/sexmed/qfad016 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Dodson MG, Friedrich EG. Psychosomatic vulvovaginitis. Obstet Gynecol. 1978;51(1):23s-25s. [PubMed] [Google Scholar]
- 4. Fenichel O. The Psychoanalytic Theory of Neurosis. W W Norton & Co; 1945. [Google Scholar]
- 5. Kaplan HS. The New Sex Therapy: Active Treatment of Sexual Dysfunctions. Routledge; 1974. 10.4324/9780203727317 [DOI] [Google Scholar]
- 6. Steege JF. Dyspareunia and vaginismus. Clin Obstet Gynecol. 1984;27(3):750-759. 10.1097/00003081-198409000-00023 [DOI] [PubMed] [Google Scholar]
- 7. Binik YM, Meana M, Berkley K, et al. The sexual pain disorders: is the pain sexual or is the sex painful? Annu Rev Sex Res. 1999;10(1):210-235. 10.1080/10532528.1999.10559780 [DOI] [PubMed] [Google Scholar]
- 8. Kleinplatz PJ. Adding insult to injury: the classification of dyspareunia as a sexual dysfunction in the DSM. Arch Sex Behav. 2005;34(1):36-38. 10.1007/s10508-005-7468-9 [DOI] [PubMed] [Google Scholar]
- 9. Meana M, Binik YM, Khalife S, Cohen D. Psychosocial correlates of pain attributions in women with dyspareunia. Psychosomatics. 1999;40(6):497-502. 10.1016/S0033-3182(99)71188-6 [DOI] [PubMed] [Google Scholar]
- 10. Meana M, Binik YM. The biopsychosocial puzzle of painful sex. Annu Rev Clin Psychol. 2022;18(1):471-495. 10.1146/annurev-clinpsy-072720-014549 [DOI] [PubMed] [Google Scholar]
- 11. Meana M, Binik YM, Khalife S, Cohen DR. Biopsychosocial profile of women with dyspareunia. Obstet Gynecol. 1997;90(4):583-589. 10.1016/s0029-7844(98)80136-1 [DOI] [PubMed] [Google Scholar]
- 12. Bornstein J, Goldstein AT, Stockdale CK, et al. 2015 ISSVD, ISSWSH and IPPS consensus terminology and classification of persistent vulvar pain and vulvodynia. Obstet Gynecol. 2016;127(4):745-751. 10.1097/AOG.0000000000001359 [DOI] [PubMed] [Google Scholar]
- 13. Bergeron S, Reed BD, Wesselmann U, Bohm-Starke N. Vulvodynia. Nat Rev Dis Primers. 2020;6(1):36. 10.1038/s41572-020-0164-2 [DOI] [PubMed] [Google Scholar]
- 14. Cohen SP, Vase L, Hooten WM. Chronic pain: an update on burden, best practices, and new advances. Lancet. 2021;397(10289):2082-2097. 10.1016/S0140-6736(21)00393-7 [DOI] [PubMed] [Google Scholar]
- 15. Dworkin RH, Turk DC, Farrar JT, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain. 2005;113(1):9. 10.1016/j.pain.2004.09.012 [DOI] [PubMed] [Google Scholar]
- 16. Frederick DA, John HKS, Garcia JR, Lloyd EA. Differences in orgasm frequency among gay, lesbian, bisexual, and heterosexual men and women in a US national sample. Arch Sex Behav. 2018;47(1):273-288. 10.1007/s10508-017-0939-z [DOI] [PubMed] [Google Scholar]