Blog competition winner! 'Let's get cliterate - the anatomical discovery that revolutionised female reproductive health'
By Nithya Suresh
Congratulations and very well done to Nithya Suresh who has won the anatomy blog competition! Her essay, detailed below, is extremely well-written, with a fantastic incorporation of reflections and inferences throughout. She also has a brilliant use and application of references - I was intrigued and read through a lot of them after I finished reading her essay! Please find it below, and let us know your thoughts!
Figure 2 - Diagram of the clitoris (Telfer and McWeeney, 2022)
Let’s get cliterate
The anatomical discovery that revolutionised female reproductive health
By Nithya Suresh
A glance at the teachings of great anatomists of the past reveals an insidious insistence that a woman’s reproductive anatomy must always play second fiddle to that of a man’s. Indeed, the etymology of the word “vagina”, which comes from the Latin for ‘scabbard’, or the sheath of a sword, is a telling example of this. Scholars as integral to the progress of anatomy as Aristotle, Galen, and Vesalius have perpetuated gross misconceptions about women. Aristotle described the female as being “a mutilated male” and Galen believed that female genitals were inverted penises situated inside the body (Engelhaupt, 2019). In his radical book De Humani corporis fabrica Libri septem, Vesalius presented an illustration of the female reproductive system that looks suspiciously like a penis, complete with curly pubic hair in Figure 1 (Vesalius, 1543). Against this backdrop of a historical inadequacy in understanding female reproductive anatomy, allow me to present the unearthing of the full structure and relations of the clitoris in 1998 as the most significant anatomical discovery in history (O'Connell et al., 1998).
What does the word ‘clitoris’ call to mind? Aside from the oft-recycled joke about men being unable to find it, the female reproductive system carries a deep stigma in our society that is reflected by a lack of scientific literature. As a young doctor, Helen O’Connell, the first female urologist in Australia (Fyfe, 2018), noticed that while her textbook delved deep into the neurovasculature of the penis and the mechanism of erection, it did not even deign to mention the clitoris. Through her career in urology, she observed time and time again the care that surgeons would take to preserve male sexual function. Due to a lack of knowledge about clitoral anatomy, this was an attentiveness that more often than not escaped them when performing surgeries on women. (Wahlquist, 2020).
Helen O’Connell’s comprehensive study of the clitoris (the first peer-reviewed study of its kind) laid out the intricate structure of the ten percent of female erogenous tissue visible from outside, as well as the ninety percent contained beneath the surface. Hardly a ‘little hill’ that the original Greek kleitoris implies, it is ten times the size that most people thought it was (Nowak & Williamson, 2021). Furthermore, it is a sensitive tissue that can grow to be more than nine centimetres when erect and filled with blood. To visualise this, form a peace sign with your fingers and imagine an organ of that length and shape stretching from above your urethra (the glans) to either side of your vulva (the crura), as illustrated in Figure 2 (Telfer & McWeeney, 2022). Rather than lying flat against the pelvic bone (as commonly illustrated in anatomy textbooks of the time), it has flaring arms that wind close to
and interact with different structures in the region like the urethra, labia, and vaginal wall. It is home to two to three times more nerve endings than the far more well-studied penis and receives an extraordinarily large blood supply (Gross, 2020). This discovery was in direct contrast to the teachings of anatomical textbooks twenty years ago, in which O’Connell highlighted erroneous descriptions of the clitoris as diminutive, contained to one region, and with a very
small nerve supply.
The impact of O’Connell’s dissection of the clitoris on modern women has been and will continue to be far-reaching. Firstly, a well-established complication of pelvic surgery, labiaplasty, or other procedures undertaken in that region includes sexual dysfunction, leading to numbness or pain for women. More extensive knowledge of the nerve supply to the clitoris can aid surgeons in avoiding causing iatrogenic damage. Secondly, for those women suffering the distressing consequences of female genital mutilation, it improves the precision of procedures to repair the clitoris (Gross, 2020). Yet another benefit is the rigour it can lend to gender-affirming surgeries, and the guidance it offers for the treatment of complications like clitoral priapism – a very dangerous case of persistent clitoral engorgement sometimes experienced by transgender people post-surgery (Singh, 2022).
In the vast and rapidly expanding medical field, in which knowledge doubles every 73 days (Corish, 2018), O’Connell revealed in a literature review that there have only been 11 articles on the anatomical dissection of the clitoris published worldwide since 1947 (Wahlquist, 2020). Before the 1998 study, knowledge about the nerve supply of the clitoris had mostly been attributed to nerve studies conducted in cows (Naftulin, 2022). It seems women in the modern world can feel a kinship with their counterparts from the ancient world as we are still, to this day, affected by a systemic disregard for the study of our anatomy.
To understand the true extent of this discovery’s significance, it is worthwhile to investigate the starkly apparent reflection of sexist cultural biases in anatomical and physiological knowledge of the past. I find myself a member of this bisection of the population whose anatomy had been described centuries ago in such an egregiously bad manner. Far from being an innocuous misstep, the dearth of knowledge about female anatomy led to distressing consequences for women. A common theory of the ancient world, described by Aretaeus of Cappadocia in the 2nd century AD, was that of the “wandering womb”. The poorly studied uterus was thought to move freely around the body, bumping into different organs. Asthma in women was attributed to the womb causing problems in the lungs, while a stomach ache was the womb making trouble in the gut (Engelhaupt, 2019).
However, I do not have to travel hundreds of years into the past to find a blameworthy reflection of the inadequacy of anatomical and physiological knowledge. Take ‘hysteria’, for instance. It is a now thankfully defunct diagnosis of an excess of emotion attributed almost exclusively to women and previously thought to be closely connected to an inability to conceive or a manifestation of Freud’s theory of ‘penis envy’. It comes from the Greek term for ‘uterus’ and was treated in the 1800s with a clitoridectomy (Russo, 2021). A condition that is laughable to the modern woman, it was only removed from the American Psychiatric Association’s list of modern diseases as recently as 1952 (Tasca et al., 2012). Moreover, it wasn’t until 1994 that the National Institute of Health in America changed its guidelines to require clinical trials to include women. Prone to the same sexist error as scholars an eternity ago, healthcare professionals had till that point assumed that drugs would work the same way in women as in men. From 1997 to 2001, 80% of prescription drugs pulled from the market posed a greater threat to women due to a difference in how they were metabolised (Engelhaupt, 2019).
To this day, there is an underrepresentation of female anatomy in a non-reproductive context in textbooks. The shamefully recent discovery of the true expanse and relations of the clitoris establishes a precedent for more attention to be provided to female anatomy and physiology, and ultimately the management of women’s health. After all, misunderstanding leads to mistreatment. We must remain optimistic that perpetually underdiagnosed conditions, like endometriosis, and side-lined disorders, like premenstrual syndrome, will soon be allotted the appropriate level of resources befitting of the large swathes of the population affected by them. The hope, then, is that as we look back and laugh at the expense of ancient scholars who sustained outrageous theories about female anatomy, so too will future generations laugh at our lack of expertise when taboos are shaken off and knowledge grows in leaps and bounds.
References
Cliteracy crusade. The clitoris. (n.d.). Retrieved February 13, 2023, from https://www.cliteracycrusade.com/the-clitoris
Corish, B. (2018, April 23). Medical knowledge doubles every few months; how can clinicians keep up? Elsevier. Retrieved February 13, 2023, from https://www.elsevier.com/connect/medical-knowledge-doubles-every-few-months-how-can-clinicians-keep-up
Engelhaupt, E. (2019, August 8). The surprisingly, very brief history of the vagina. Healthline. Retrieved February 13, 2023, from https://www.healthline.com/health/vagina-history#Even-today,-we-tend-to-be-vague-about-vaginas
Fyfe, M. (2018, December 7). Get cliterate: How a Melbourne doctor is redefining female sexuality. The Sydney Morning Herald. Retrieved February 13, 2023, from https://www.smh.com.au/lifestyle/health-and-wellness/get-cliterate-how-a-melbourne-doctor-is-redefining-female-sexuality-20181203-p50jvv.html
Gross, R. E. (2020, March 4). The clitoris, uncovered: An intimate history. Scientific American. Retrieved February 13, 2023, from https://www.scientificamerican.com/article/the-clitoris-uncovered-an-intimate-history/#:~:text=Clitoris%20comes%20from%20the%20Greek,bulk%20lies%20beneath%20the%20surface.
Naftulin, J. (2022, November 30). A surgeon looked at 7 clitorises under a microscope and found they're packed with 10,000 nerve fibers. it could be a game-changing discovery. Insider. Retrieved February 13, 2023, from https://www.insider.com/surgeon-counts-human-clitoris-nerve-fibers-for-first-time-ever-2022-11
Nowak, R., & Williamson, S. (2021, July 7). New study of the clitoris reveals truths missed by anatomy textbooks. New Scientist. Retrieved February 13, 2023, from https://www.newscientist.com/article/mg15921455-500-new-study-of-the-clitoris-reveals-truths-missed-by-anatomy-textbooks/
O'Connell, H. E., Hutson, J. M., Anderson, C. R., & Plenter, R. J. (1998). Anatomical relationship between urethra and clitoris. The Journal of Urology, 159(6), 1892–1897. https://doi.org/10.1097/00005392-199806000-00031
Russo, N. (2021, June 22). The still-misunderstood shape of the clitoris. The Atlantic. Retrieved February 13, 2023, from https://www.theatlantic.com/health/archive/2017/03/3d-clitoris/518991/
Singh, A. (2022, November 3). Gender-affirmative surgeries are helping scientists study the clitoris better. The Swaddle. Retrieved February 13, 2023, from https://theswaddle.com/gender-affirmative-surgeries-are-helping-scientists-study-the-clitoris-better/
Telfer, N., & McWeeney, C. (2022, November 30). Everything you should know about the clitoris. Clitoris: Female Pleasure & Anatomy - Diagram, Definition & Location of the Clit. Retrieved February 16, 2023, from https://helloclue.com/articles/cycle-a-z/what-is-the-clitoris
Vesalius “De humani...”, 1543: illustration of a uterus. (n.d.). <a href="https://wellcomecollection.org/">Wellcome Collection</a>. https://jstor.org/stable/community.24736092
Wahlquist, C. (2020, October 31). The sole function of the clitoris is female orgasm. is that why it's ignored by medical science? The Guardian. Retrieved February 12, 2023, from https://www.theguardian.com/lifeandstyle/2020/nov/01/the-sole-function-of-the-clitoris-is-female-orgasm-is-that-why-its-ignored-by-medical-science