If there was one thing Gillian knew, it was that she did not want a hole punch anywhere near her genitals.
So when, in 2018, a gynaecologist recommended a vulval biopsy to check for signs of cancer, she hesitated. The doctor suspected that the whitish patch of skin Gillian had found next to her clitoris was lichen sclerosus, a skin condition that is usually benign. To Gillian, who is American, and a registered nurse, taking a chunk out of her most sensitive body part sounded a bit extreme.
But in the end she consented. He was a doctor; she was a nurse. She assumed he was the authority on this part of the body. “I never worked in ob-gyn before,” says Gillian, who has asked to be identified by her first name to protect her privacy. “I was pretty clueless.”
They looked at me like I was completely insane. I just kept on saying there’s something wrong with my clitoris
For the biopsy she was placed in stirrups and given a spinal epidural to numb the area. Afterwards, to stem the bleeding, the doctor put one hand over the other and pressed hard against her vulva — the outer female genitalia, including the inner and outer labia, the opening to the vagina and the clitoris. Even through the anaesthesia she could feel the pressure against her pubic bone. She screamed.
From Baby Reindeer and The Traitors to Bodkin and The 2 Johnnies Late Night Lock In: The best and worst television of 2024
100 Years of Solitude review: A woozy, feverish watch to be savoured in bite-sized portions
How your mini travel shampoo is costing your pocket and the planet - here’s an alternative
My smear test dilemma: How do I confess that this is my first one, at the age of 41?
A month later Gillian was in bed with her boyfriend when she realised that she could no longer reach orgasm. She could become aroused, but at the moment of no return “it ended into nothing”, she says. “And that’s still how it is.”
When she informed her gynaecologist, she says, he speculated that she was experiencing numbness caused by scarring and that it would go away in time. It did not. Alarmed, Gillian began seeing one specialist after another in search of an explanation and, with luck, a solution.
That’s when she discovered that no one wanted to talk about her clitoris.
After hearing about her injury, she says, one urologist compared her with a rape victim and said she must be having a trauma reaction to her biopsy. Next, according to her medical charts, a women’s-health specialist diagnosed her with “perimenopause” and prescribed testosterone cream. Another gynaecologist recommended an “O shot”, or vaginal-rejuvenation procedure.
When she tried to direct the conversation back to her clitoris she was met with blank stares. “They looked at me like I was completely insane,” Gillian says. “I just kept on saying there’s something wrong with my clitoris, and they were, like — it was like they did everything but acknowledge the clitoris.”
Some urologists compare the vulva with “a small town in the midwest”, says Dr Irwin Goldstein, a urologist and pioneer in the field of sexual medicine. Doctors tend to pass through it, barely looking up, on their way to their destination, the cervix and uterus. That’s where the real medical action happens: ultrasounds, Pap smears, IUD insertion, childbirth.
There is no medical community that has taken ownership in the research, in the management, in the diagnosis of vulva-related conditions
If the vulva as a whole is an underappreciated city, the clitoris is a local roadside bar: little known, seldom considered, probably best avoided. “It’s completely ignored by pretty much everyone,” says Dr Rachel Rubin, a urologist and sexual-health specialist outside Washington, DC. “There is no medical community that has taken ownership in the research, in the management, in the diagnosis of vulva-related conditions.”
Asked what she learned in medical school about the clitoris, Rubin replies, “Nothing that sticks out to my memory. If it got any mention it would be a side note at best.”
Only years later, on a sexual-medicine fellowship with Goldstein, did she learn how to examine the vulva and the visible part of the clitoris, also known as the glans clitoris. The full clitoris, she learned, is a deep structure, made up largely of erectile tissue, that reaches into the pelvis and encircles the vagina.
Today, Rubin has appointed herself Washington’s premier “clitorologist”. The joke, of course, is that few are vying for the title — out of embarrassment, a lack of knowledge or fear of breaching propriety with patients. “Doctors love to focus on what we know,” she says. “And we don’t like to show weakness, that we don’t know something.”
This near-universal avoidance has consequences for patients. In a 2018 study in the international journal Sexual Medicine, Rubin, Goldstein and colleagues found that a failure to examine the vulva and clitoris led doctors to regularly overlook sexual-health conditions. Among women visiting Goldstein’s clinic, nearly one in four had clitoral adhesions, which occur when the hood of the clitoris sticks to the glans and can lead to irritation, pain and decreased sexual pleasure.
The authors concluded that all health providers for women should routinely examine the clitoris. But that was easier said than done, they wrote, as most providers “neither know how to examine nor feel comfortable examining the clitoris”.
This oversight has the potential to harm women, as well as trans men and other people with vulvas. There have been documented injuries to the clitoris in procedures including pelvic mesh surgeries, episiotomies during childbirth and even hip surgeries. When performed poorly, a labiaplasty — a procedure to reduce the size of the labia minora, and one of the fastest-growing cosmetic surgeries worldwide — can also damage nerves, leading to genital pain and loss of sexual sensation.
It’s not just this strange, mythical area that’s supposed to give you orgasms. You should know what is what and where things are coming from
Many of these injuries could be prevented, Rubin says, if doctors just spent more time getting to know the clitoris. In January she made this point to a roomful of mostly male doctors at the annual convention of military urologists in Palm Springs, California, during a lecture on female sexual health. Practical, animated and unflappable, she was voted as having the best lecture at the conference.
This anatomy, she stresses, isn’t magic, just biology. “It’s not just this strange, mythical area that’s supposed to give you orgasms,” she says in her office in Rockville, Maryland, in early July, surrounded by penile prostheses, pelvis models and a large Hitachi wand. “You should know what is what and where things are coming from.”
So why don’t we know? To Rubin the reason is simple: the clitoris is intimately bound up in female pleasure and orgasm. And until very recently those themes have not been high on medicine’s priority list, nor considered appropriate areas of medical pursuit.
Even in fields like urology, where male sexual pleasure and orgasm are considered integral, women’s sexual health “is seen as hysteria, Pandora’s box, all psychosocial, not real medicine”, says Rubin, who is also the education chair of the International Society for the Study of Women’s Sexual Health. “Sexual health and quality of life is not something we focus on for women.” (In contrast, Viagra is one of the most lucrative pharmaceutical drugs in recent decades, bringing in tens of billions of dollars to Pfizer since being introduced, in 1998.)
Gynaecology, for its part, is far more focused on fertility and preventing disease. “We don’t do a great job about talking about sex from a pleasure-based perspective,” says Dr Frances Grimstad, a gynaecologist at Boston Children’s Hospital. “We talk about it from a prevention standpoint. We’re trying to prevent STIs,” or sexually transmitted infections. “We’re trying to prevent pregnancy, unless you’re trying to get pregnant. We don’t talk about sexual pleasure.”
You always need to be thinking of what’s underneath, what’s hidden from view that you’re potentially altering
Dr Helen O’Connell, Australia’s first female urologist, recalls that in her own medical training, the clitoris barely made a cameo. In the 1985 edition of the medical textbook Last’s Anatomy that she studied, a cross-section of the female pelvis omitted the clitoris entirely, and aspects of the female genitals were described as “poorly developed” and a “failure” of male genital formation. Descriptions of the penis went on for pages. To her this widespread medical disregard helped explain why her urology peers worked to preserve nerves in the penis during prostate surgeries but not during pelvic surgeries on women.
O’Connell set out to investigate the full anatomy of the clitoris using microdissection and magnetic resonance imaging. In 2005 she published a comprehensive study showing that the outer nub of the clitoris — the part that can be seen and touched — was just the tip of the iceberg, equivalent to the head of the penis. The full organ extended far beneath the surface, comprising two teardrop-shaped bulbs, two arms and a shaft.
By failing to appreciate this anatomy, she warned, surgeons working in this region risked damaging the sensitive nerves responsible for pleasure and orgasm, which run along the top of the shaft. In procedures like pelvic mesh surgeries or urethral surgeries, “things are potentially in the crossfire”, O’Connell says. “You always need to be thinking of what’s underneath, what’s hidden from view that you’re potentially altering.”
Increasingly, women are speaking out about injuries they sustained to this area during routine procedures. One is Julie, a 44-year-old office manager in Essex, east of London, who lost her ability to orgasm in 2012 after a minimally invasive hip operation to address back pain. She shared her story publicly in the Telegraph newspaper last year, using only her first name to avoid discrimination by future employers.
Julie describes waking up from anaesthesia to a searing pain around her clitoris. Her surgeon told her that it was just bruising and would fade. A few months later she found that she could no longer orgasm. When she tried “it was literally like someone had pulled a plug out of the socket”, she says. “Everything went dead.”
This changed my whole life. The devastation from this is something you can never repair. Ever
It took two years of internet searching for her to realise that a cylindrical post placed between her legs during the operation had likely crushed her clitoral nerves. Use of the device, called a perineal post, is known to cause nerve damage, but this was not mentioned on her consent form.
Julie compares her injury with losing the sense of taste or smell — a pleasure that is taken for granted but, when lost, changes everything. “It’s 10 years, and I still can’t believe it,” she says. “And I 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 her gynaecologist applied afterwards? Four years and 12 specialists later she has resigned herself to the fact that she may never recover that sensation. “This changed my whole life,” she says. “The devastation from this is something you can never repair. Ever.”
When Dr Blair Peters, a 33-year-old plastic surgeon at Oregon Health & Science University, first began performing phalloplasties for trans men and nonbinary people, he was surprised to see how large the nerves of the clitoris were — about 3mm in diameter, on average. (By comparison, the sensory nerve of the index finger is about 1mm wide.)
“When I went through medical school we did not learn anything in particular about the clitoris beyond the fact that it exists, basically,” Peters says. As a result, he says, he developed “this subconscious bias that it’s not going to be this superapparent structure. But it is.”
[ Vaginal mesh injury: ‘I really thought I was going to die’Opens in new window ]
Peters is among a handful of young, social media–savvy doctors who, like Rubin, are helping expand medicine’s map of this terrain — and, in doing so, ensure that what happened to Julie and Gillian doesn’t happen again. As part of his efforts to improve sexual sensation for phalloplasty patients, Peters recently magnified clitoral nerves and counted up how many nerve fibres they contained. The number he found — embargoed until he presents his findings at a conference later this month — was “significantly more” than 8,000, the figure often cited, which is drawn from an outdated study on cows.
In 2020, Victoria Gordon, a medical student at Kansas City University of Medicine and Biosciences, led a study that sought to define a “danger zone” around the clitoris for plastic surgeons to avoid. During dissections of cadavers she noticed that clitoral nerves sometimes branch out into fine tendrils, like roots, in ways that might be relevant to surgeons but were not previously described in the literature.
This omission appears to be caused by sociocultural discomfort with the clitoris and a pervasive lack of regard for female sexual response
She hoped that others in the plastic-surgery field would follow up on this finding, which was published in a plastic-surgery journal. “I’m just a fourth-year medical student. I don’t think I should have to tackle this project,” she said in late 2021. “But no one else is.”
Doctors are not the only people urging medicine to recognise the full anatomy of the clitoris. In 2018 Gillian was searching online to make sense of her injury when she came across a Medium post by a woman in Dallas, Jessica Pin, whose situation sounded eerily like hers. Pin, who is now 36, had lost most of her clitoral sensation after undergoing a labiaplasty at the age of 18.
After scouring the major obstetrical-gynaecological textbooks Pin learned that the nerves of the clitoris were rarely well represented, if at all — a key oversight that she believes left the clitoris at risk in a number of procedures. “This omission appears to be caused by sociocultural discomfort with the clitoris and a pervasive lack of regard for female sexual response,” she writes on Medium.
Gillian was intrigued. “She was the only one talking about this on the internet,” she says. She sent the woman a Facebook message.
Pin eventually began a social-media campaign to get ob-gyn textbooks and training standards updated to cover this anatomy. Gillian quietly helped her build followers, then joined Pin on Instagram, using the handle @nursevulvaadvocate. She found herself fielding hundreds of queries from around the world from people who had lost genital sensation as a result of medical procedures on or near the clitoris.
Gillian tried to respond to everyone, she says, but could not offer the medical advice that many of them sought. After six months she closed her account. Today her efforts are more local: she often drives to doctors’ offices to drop off posters of clitoral anatomy. In her work with older patients she pays close attention to any genital concerns, from vulvar itching to pain after cancer surgery.
[ Survivors accuse HSE of blocking treatment for women with mesh implantsOpens in new window ]
Pin pressed on. In the past few years she has lobbied the publishers of several textbooks and anatomical resources to update their diagrams of the clitoris and its nerves. Her efforts have reached the front page of Reddit, racked up more than 160,000 followers on TikTok and landed her a guest spot on the The Daily Show with Trevor Noah. In 2019 she co-published a dissection study with her father, a plastic surgeon, on clitoral nerves.
Yet her tactics are not without controversy. She has been embroiled in numerous social-media disputes and has been accused of harassment for her persistent and sometimes inappropriate efforts to reach gynaecologists and anatomy-textbook authors.
Now, after four years of advocating, “I want to be done,” she says. “It would be amazing if doctors start picking up the cause and start talking about this.” The fact that a few medical professionals have, including Rubin, is “a really big deal”, she adds.
Every patient who enters Rubin’s office, regardless of age, is taken on a tour of their own vulva. No longer is a sheet draped over a patient’s legs for the pelvic exam — a convention that Rubin believes helps keep women’s “private parts” shameful and hidden. Instead Rubin starts by handing her patient a long-handled mirror to see the same anatomy that she will be examining.
With a cotton bud, Rubin probes each part of the vulva for pain, pointing out the labia minora, labia majora and vaginal opening as her patient follows along. Then she checks under the clitoral hood for adhesions or other skin conditions. The entire exam usually takes under five minutes. “We go at your pace,” she says in an exam with a 62-year-old woman who has been experiencing pain after sex. “You’re the boss of this show.”
Rubin and her colleagues believe that their field is uniquely positioned to champion the clitoris and female pleasure. After all, says Dr Barbara Chubak, a urologist at the Icahn School of Medicine at Mount Sinai Hospital in New York, “urologists are all about the phallus” — which the clitoris technically is, as it arises from the same embryological structures and is made up of the same erectile tissues as the penis.
“So, by definition, clitoral anatomy could, and should, also be a urologic thing,” Rubin adds.
I truly believe we are just several decades behind on the female side. But we have to do the work
Moreover, urologists are perfectly comfortable waxing poetic about things that other providers are too squeamish to discuss. “Urology is all about peeing and all about sex,” Chubak says. “The stuff that people are embarrassed to talk about, urologists want to talk about. Clitoral medicine belongs with the urologists.”
Still, it will take more than passionate “penis doctors”, Rubin says, to give the vulva its due; there must be a concerted movement, one that transcends medicine’s traditionally siloed specialties, to understand and map this anatomy. And, for that to happen, other fields need to recognise female sexual pleasure as essential and worth preserving.
“I truly believe we are just several decades behind on the female side,” Rubin says. “But we have to do the work. And we have to have people interested in doing the work.” — This article originally appeared in The New York Times