If there was one thing Gillian knew, it was that she didn’t want an awl near her genitals.
So in 2018, when a gynecologist recommended a vulvar biopsy to check for signs of cancer, she hesitated.
The doctor suspected that a small area of whitish skin Gillian had found next to her clitoris was lichen sclerosus, a skin condition that is normally benign. For Gillian, a registered nurse, taking a piece of her most sensitive part of her body seemed a little too extreme.
But she eventually consented. He was a doctor, she was a nurse. She supposed he was the authority on that body part. “I’ve never worked in obstetrics and gynecology,” said Gillian, who asked to be identified by her first name only to protect her privacy.
“I didn’t have much of a clue about things.”
For the biopsy, Gillian was placed on a table with leg rests and given an epidural injection to numb the area. After the procedure, to stop the bleeding, the doctor put one hand over the other and put strong pressure on her vulva – the external female genitalia, including the labia majora and minora, the opening of the vagina and the clitoris. Even under anesthesia, Gillian felt the pressure on her public bone. she screamed.
A month later, Gillian was in bed with her boyfriend when she realized she couldn’t bring herself to orgasm anymore. She would get excited, but at the point, “it didn’t go anywhere,” she said. “And so it is to this day.”
When she informed her gynecologist, he speculated that she might have numbness caused by the scarring and said the problem would go away with time. It hasn’t disappeared. Alarmed, Gillian began looking to expert after expert for an explanation and, she hoped, a solution.
That’s when she discovered that no one wanted to talk about her clit.
When he heard about the injury she had suffered, a urologist compared Gillian to a rape victim and said she had possibly suffered a traumatic reaction to the biopsy.
Then a women’s health specialist made the diagnosis of perimenopause and prescribed testosterone cream. Another gynecologist recommended a vaginal rejuvenation procedure.
When Gillian tried to direct the conversation back to her clit, the experts’ reaction was an indifferent stare. “They looked at me like I was completely insane,” she said. “I kept repeating that there was something wrong with my clit, and they did anything but recognize the clit.”
“A secondary consideration, at best”
According to urologist Irwin Goldstein, a pioneer in the field of sexual medicine, some urologists compare the vulva to “a small town in the Midwest.” That is, doctors tend to walk past it, barely stopping to look at it, on their way to their final destination: the cervix and uterus. This is where the real medical action takes place: ultrasounds, Pap smears, IUD insertion, childbirth.
If the vulva as a whole is a small town that no one appreciates, the clitoris is the local roadside pub: little known, rarely considered, probably best avoided.
“He’s completely ignored by pretty much the whole world,” said Rachel Rubin, a urologist and sexual health specialist in Washington. “There is no medical community that has taken on the research, care and diagnosis of vulva-related problems.”
Asked what she learned about the organ in medical school, Rubin replied, “Nothing that sticks in my memory. If it was mentioned at all, it was a minor consideration at best.”
It wasn’t until years later, when she studied sexual medicine with Goldstein, that she learned how to examine the vulva and the visible part of the clitoris, known as the glans. She learned that the entire organ is a deep structure, composed mostly of erectile tissue, that extends into the pelvis and encircles the vagina.
Today Rubin has named himself Washington’s top “clitorologist”. It’s a joke, of course, even because few compete for the title – out of embarrassment, lack of knowledge or fear of disrespecting the patients.
“We doctors like to focus on what we know,” she said. “And we don’t like to show weakness, to let it be known that we don’t know something.”
This almost universal attitude of physicians to avoid the clitoral subject has consequences for patients.
In a 2018 study published in the journal Sexual Medicine, Rubin, Goldstein and colleagues found that failure to examine the vulva and clitoris leads doctors to regularly fail to take note of sexual health issues.
Nearly one in four women who came to Goldstein’s clinic had clitoral adhesions, which occur when the clitoral cap sticks to the glans and can cause irritation, pain and reduced sexual pleasure.
The authors concluded that all physicians who see women should examine the clitoris as a matter of routine. But, they wrote, this is easier to recommend than to do, as most doctors “do not know how to examine the clitoris, nor are they comfortable with doing so.”
This omission can harm women, as well as trans men, and other people with a vulva. There have been documented cases of clitoral injury in procedures that include pelvic mesh surgery, episiotomies performed at birth, and even hip surgery.
When performed incorrectly, labiaplasty — a procedure to reduce the size of the labia minora, one of the fastest-growing plastic surgeries in the world — can also damage nerves, leading to genital pain and a loss of sexual sensation.
For Rubin, many of these injuries could be avoided if doctors devoted more time to studying the clitoris.
A tradition of neglect
So why don’t we know more about the clitoris? For Rubin, the reason is simple: the organ is intimately involved with a woman’s pleasure and orgasm. And, until very recently, these topics were not at the top of medicine’s priority list, nor were they even seen as appropriate areas of medical research.
Helen O’Connell, Australia’s first women’s urologist, recalled that when she went to medical school herself, the clitoris barely appeared on the scene.
In the 1985 edition of the medical textbook “Last’s Anatomy”, which she studied, a cross-section of the female pelvis omitted the clitoris entirely, and aspects of the female genitalia were described as “underdeveloped” and a “failure” of male genital formation. .
Already the descriptions of the penis stretched for pages. For O’Connell, this widespread medical disinterest helps explain why his urologist peers went to great lengths to preserve nerves in the penis when performing prostate surgery but were not as careful when performing pelvic surgery on women.
O’Connell decided to investigate the complete anatomy of the clitoris, using microdissection and MRIs.
In 2005 she published a comprehensive study showing that the outer tip of the organ – the part that can be seen and touched – is just the tip of the iceberg, equivalent to the glans penis. The complete organ extends below the surface and encompasses two teardrop-shaped bulbs, two arms and a spine.
When they fail to appreciate this anatomy, she warned, surgeons who operate in this region risk damaging the sensitive nerves responsible for pleasure and orgasm that run along the top of the spine.
With procedures like pelvic mesh surgery or urethral surgery, “things can be in a crossfire,” O’Connell said. “You always have to think about what’s underneath, what’s hidden and what you might be changing.”
More and more women are coming forward to talk about injuries they have suffered in this region during routine procedures. One is Julie, 44, an office manager in Essex, east of London.
In 2012 she had minimally invasive hip surgery to resolve a backache, and the procedure caused her to lose her ability to orgasm. Last year she shared her story publicly in The Telegraph newspaper, omitting her last name to avoid the possibility of being discriminated against by future employers.
On a Zoom call in January, Julie said she woke up from the anesthesia feeling excruciating pain in her clitoral area. The surgeon told her that she was left with a bruise, and that the problem would go away. A few months later, she found that she could no longer reach orgasm. When she tried it, “it was literally like someone had pulled a cord out of the socket,” she said. “Everything would die.”
Julie spent two years doing Internet searches before realizing that a cylindrical pole positioned between her legs during the surgery had likely crushed her clitoral nerves. It is known that using the device, known as a perineal post, causes nerve damage, but this fact was not mentioned in the consent form she signed before the surgery.
Julie likened her injury to the loss of taste or smell — a pleasure we think of as something innate, but when we lose it, everything changes. “It’s been ten years and I still can’t believe it,” she said. “And I still haven’t come to terms with it.”
Gillian is still trying to understand the cause of her own injury. Was it the biopsy? The crushing pressure the gynecologist applied afterwards? Four years and 12 experts later, she has come to terms with the fact that she may never get that feeling back. “It changed my whole life,” she said. “It’s overwhelming, it’s something you can’t recover from. Ever.”
A new medical mapping
When Blair Peters, a 33-year-old plastic surgeon at Oregon Health & Science University, began performing phalloplasty for trans men and non-binary people, she was surprised to see how large the clitoral nerves are: about 3 mm in diameter, on average. (For comparison, the sensory nerve of the index finger is 1 mm wide).
“When I went to medical school, we didn’t learn anything specific about the clitoris, other than the fact that it exists, basically,” Peters said. Thanks to that, he created “a subconscious idea that it wasn’t a super-apparent structure. But it is.”
Peters is part of a small group of young doctors, adept at social media, who, like Rubin, are helping to expand the medical map of this territory – and, in so doing, to prevent a repeat of what happened with Julie and Gillian.
As part of his efforts to improve the sexual sensitivity of patients who have had phalloplasty, Peters recently enlarged the clitoral nerves and counted how many nerve fibers they contain.
The number he found — embargoed until he presented his findings at a conference later this month — was “significantly higher” than 8,000, the oft-cited number, which is taken from an outdated study of cows.
In 2020, Victoria Gordon, a medical student at Kansas City University of Medicine and Biosciences, led a study that sought to delineate a “danger zone” around the clitoris to be avoided by plastic surgeons. While performing cadaver dissections, she observed that clitoral nerves sometimes open into tiny, thin branches, like roots, in ways that may be relevant to surgeons but have not been previously described in the medical literature.
She hopes that others in the field of plastic surgery will further study her findings, which have been published in a plastic surgery journal. “I’m just a fourth-year medical student,” she said in late 2021. “I don’t think I’m the one who should be tackling this project. But no one else is.”
Translation by Clara Allain