Is the closed missionary position a safe and viable option for a healthy adult male with no major medical conditions?

Closed Missionary Position Safety for Healthy Adult Males

The closed missionary position (male on bottom) is safe and viable for healthy adult males with no major medical conditions, as it requires less energy expenditure than the superior missionary position and poses minimal cardiovascular risk. 1

Energy Expenditure and Cardiovascular Demand

• Being on the bottom during missionary position expends less energy than being on top, making it a lower-intensity sexual activity option. 1

• The superior (on top) missionary position generates the most energy expenditure during sexual activity, while the bottom position requires a lesser amount of energy. 1

• Sexual activity in healthy individuals typically equates to 2-3 METs in the preorgasmic stage and 3-4 METs during orgasm—comparable to walking 3-4 miles per hour or climbing 2 flights of stairs at a brisk pace. 1

• For healthy adults without cardiovascular disease, sexual activity poses very low risk, with the increase in cardiovascular risk attributed to coitus being far less than that associated with anger or unaccustomed physical exercise. 1

Position-Specific Considerations

• Real-world studies conducted at home found no significant changes in heart rate and blood pressure when different positions were used during intercourse, suggesting that position choice has minimal physiological impact in healthy individuals. 1

• Maximal heart rate and blood pressure alterations occur during orgasm regardless of position, meaning the cardiovascular peak is position-independent. 1

• Blood pressure and heart rate increase when patients are in unfamiliar positions, so the American Heart Association and ESC recommend that individuals assume their usual coital position or one of comfort. 1

Clinical Algorithm for Healthy Males

For a healthy adult male with no major medical conditions considering the closed missionary position:

1. Confirm absence of cardiovascular risk factors: No unstable angina, uncontrolled hypertension, recent MI, severe heart failure, or high-risk arrhythmias. 1

2. Assess exercise tolerance: If the individual can perform moderate physical activity (walking 1 mile in 20 minutes or climbing 2 flights of stairs briskly) without symptoms, sexual activity including the closed missionary position is safe. 1

3. Position selection: The closed missionary position (male on bottom) is appropriate and requires less energy than the superior position, making it a conservative choice even for those with minimal concerns. 1

4. No special precautions needed: For truly healthy males without cardiovascular disease, no specific monitoring or restrictions apply to this position. 1

Important Caveats

• The closed missionary position becomes particularly relevant for individuals with cardiovascular conditions who need to minimize energy expenditure, but for healthy males, any comfortable position is acceptable. 1

• Regular physical exercise is associated with decreased risk of sexual activity-triggered cardiovascular events, so maintaining fitness enhances safety across all sexual activities. 1

• Symptoms such as chest pain, excessive shortness of breath, rapid or irregular heart rate, or unusual fatigue during or after sexual activity should prompt medical evaluation, though these are not expected in healthy individuals. 1