Physician experts confirm lack of coverage of clitoral anatomy

All the doctors who have published research on clitoral anatomy have noted the lack of coverage. Most quotes here are from abstracts (if not, screen shot provided) so that everyone, with or without academic library access, can see there is a real problem here.

Dorsal nerve of the clitoris, shown in a 2017 textbook on genital cosmetic surgery, published by a plastic surgeon. This anatomy is still neither shown nor discussed in any peer reviewed literature on techniques.

“Detailed information of the innervation of the clitoris is still missing.” — Ginger et al. (barely cited)

“Ignorance of the DNC neuroanatomy has resulted in distal clitoral amputations and subsequent sexual dysfunction.” — Ginger et al.

“The anatomy and innervation of the penis has been clearly documented in the medical literature, but similar details are lacking for the clitoris.[…] The historical absence of the clitoris in anatomy textbooks has led to many ‘‘rediscoveries’’ of the female sex organ, but has resulted in an astonishing lack of cumulative knowledge.” — Ginger et al.

“The emphasis of the study of female sex organs has long been on understanding its reproductive role rather than sexual responsiveness. The majority of anatomic descriptions for these organs have been from the context of reproduction.” — Ginger & Yang (article available to public)

“The structure of the clitoris has been ‘rediscovered’ many times over the years by anatomists due to the frequent omission or misrepresentation of the organ in historical and contemporary anatomical texts.” — Ginger & Yang

“Not much anatomical research is being carried out in this area” -Lepidi & Di Marino

“All is clear for the anatomy of the pudendal nerve. So much cannot be said for the anatomy of the dorsal nerve of the clitoris. Not many studies have been conducted on this nerve until recently. Considering the importance of this nerve and the observations that we have been able to make during our dissections, its specific study proves to be essential.” — Lepidi & Di Marino

“The dorsal nerve of the clitoris has, up until recent times, rarely been studied and therefore is badly known, especially since few authors have had the curiosity to reread the remarkable work conducted by Kobelt and, even more exceptionally, the will to study the said nerve by dissection. However, respecting the integrity of this nerve guarantees that the functionality of the clitoris will not be compromised and, therefore, that an essential and key part of female sexuality will not be affected. This nerve is at the centre of many surgical acts.” — Lepidi & Di Marino

“The lack of knowledge of the topographical anatomy of the DNC exposes the surgeon to the risk of distal clitoral lesions that may cause chronic pain or contrario anesthesia difficult to reversible in this region, all resulting in disorders of sexual function.” — Balaya (imperfect translation from French)

“Despite its central role in sexual function, we lack a description of the nerve distribution and histology for the central components of the clitoris.” — Oakley et al. (body incorrectly labeled as glans in this article)

“The clitoris is a structure about which few diagrams and minimal description are provided, potentially impacting the preservation during surgery. Specific study of anatomical textbooks across the 20th century revealed that details from genital diagrams presented early in the century were subsequently omitted from later texts.” — O’Connell (2005, but still relevant for context, as this was the first coverage of this anatomy since its deletion in the early 20th century)

“Descriptions of the neurovascular anatomy of this region have been scant or absent.” — Vaze (the illustration provided in this article is incorrect)

“Female genital anatomy was poorly described in majority of anatomical textbooks.” — Stojanovic & Djordjevic

“Female genital mutilation (FGM), the partial or total removal of the external genitalia for non-medical reasons, can affect female sexuality. However, only few studies are available, and these have significant methodologic limitations.” — Abdulcadir et al (severe inconsistencies between methodology, results, and MRIs in this article, which is not as relevant as the others, but it is unacceptable for a problem affecting so many women to not be adequately researched)

Please share and clap! If you have any journalist friends who could cover this, that would be greatly appreciated. If you have medical illustrator friends, also let me know, as I am looking to potentially hire someone to create this drawings. Zoe Mendelson of Pussypedia has offered to post and do a round of PR for them. Note: the current model on the homepage of Pussypedia is incorrect, which the creators are aware of (they received it as a gift). This is constant problem for some reason, which is why I posted photos of real clitorises.

There is a focus on surgical anatomy in these articles, but consider that detailed anatomy of every other organ is studied simply for an understanding of function. Also, safe repairs of tears, which can occur during childbirth for example, cannot occur without adequate understanding of anatomy.

There are many more quotes to be found on the lack of research into clitoral anatomy. These just came from articles I could think of at the top of my head. I can provide more excerpts and testimony regarding the importance of knowing this anatomy if anyone is still not convinced.

Notes on why this needs to change

Though clitoral tears have been reported in childbirth, there is no literature on the subject of repairing such tears. Considering that about 4 million births occur per year, even if the risk of a clitoral tear is low, this would likely affect a significant number of women.

Similarly, 1 in 2000 women are born with ambiguous genitalia. This translates to about 2000 per year in the US. Treatment is normally done by urologists and/or plastic surgeons. However, urology education is certainly much better in this area, coverage is still not great. Plastic surgery education in this anatomy is definitely lacking.

Data on the number of women who undergo clitoral hood reductions is lacking. However, based on NHS data and considering the much larger population of the United States, as well as based on numbers performed by plastic surgeons (10k), and the number of OB/GYNs who say they would offer these surgeries (77% according to one study), I would bet around 50k of these are done per year in the US. I’d welcome any help getting access to real numbers, though this will be tricky due to a lack of a CPT code.

As transpeople gain wider acceptance, FtM gender-reassignment surgeries become more and more common. I’m not sure what the prevalence for these procedures is, but it seems like the people undergoing these procedures would want there to be detailed surgical anatomy and would want standards in place to keep them safe.

Around the internet (sorry, I only have anecdotal evidence), I’ve seen women talk about issues with their clitorises. They have questions about loss of sensation, clitoral pain, etc. These questions cannot be answered adequately or truthfully by doctors who don’t know anatomy.

Sexual dysfunction is common among women. Many women have difficulty with arousal and orgasm. It is often assumed such difficulties, when present in young, healthy women, derive from psychological issues. But such assumptions are invalid when the physiology and anatomy is not adequately studied. Injuries to the dorsal nerve, including compressive injury from riding a bike, are possible. For every woman who has tried to talk about sexual problems with her OB/GYN, this should be relevant.

It is estimated that 200 million women alive today have undergone female genital mutilation. Most of these cases involve excision of the the glans and some of the distal body of the clitoris. In all cases involving the clitoris, some of the clitoral body remains intact. Reconstruction, which can help women regain some clitoral function, is possible but can only occur when doctors fully understand this anatomy.

Lifetime prevalence of vulvodynia is 10–28% among reproductive-aged women in the general population. Meanwhile, among 430 patients with vulvodynia in one study, 15 had clitorodynia. This would indicate a lifetime prevalence of approximately 0.35-.98%. This may not sound very common, but this translates to 0.550–1.54 million women in the US. How can we expect doctors who don’t know basic neural anatomy to treat this competently?