How can I call attention to a problem without criticizing?

I started reading Dale Carnegie’s How to Win Friends and Influence People on the plane the other day. After the first chapter, I wrote this.

How can I call attention to a problem without criticizing? How can I write about this problem that hurts me and hurts others without anger? How can I get the man who hurt me to recognize what he did, for the sake of my dignity? How can I get people to listen without responding with defensiveness and denial?

When I was barely 18, I mistakenly thought my labia minora were unusually large after stumbling upon labiaplasty surgeons’ websites. I read protruding labia minora were considered “unfeminine” and “embarrassing.” I read they were caused by excess androgens, which is false. I furthermore read that reduction of the labia minora was a simple procedure, carrying no risk to sexual function.

I went to Dr. X for a labiaplasty. Dr. X had been recommended as the best OB/GYN surgeon at Baylor hospital in Dallas, by the head of the department. My father, a plastic surgeon, chose him because he assumed that he was qualified to do the surgery.

Dr. X did not discuss risks with me before my surgery. All he said was, “You talked to your father about this, right?” He also reminded me that all surgery carries risks. My consent form said, “excision of redundant labia.” When I asked Dr. X what my labia minora were for, he shrugged. They didn’t seem very important. This surgery did not seem like a big deal. It didn’t seem like anything could go wrong.

Dr. X completely amputated my labia minora and cut the nerve supply to the clitoral glans in a clitoral hood reduction performed without my consent.

Dr. X robbed me of normal sexual function for the remainder of my adult life. He made it so I can never again feel cunnilingus. He made it so no man will ever be able to give me an orgasm. These are fundamental human experiences I will never have.

But the worst part of what happened to me isn’t the mistake my doctor made. The worst part is his continued denial.

In the 15 years since my surgery, Dr. X has continually refused to acknowledge what he did. Because I have visible scars proving both my frenulum and clitoral hood were cut, which has been verified by other doctors, he insists those incisions must have been made by another surgeon or by me. As for my absent labia minora, he claims they atrophied.

There are so many reasons behind Dr. X’s error, which are fundamentally systemic in nature. It has been a challenge for me to talk about my doctor’s actions without anger. It has similarly been difficult to talk about the systemic problems that underlie those actions without vitriol and without criticism.

The most fundamental systemic problem behind my doctor’s error is that OB/GYNs are not taught adequate vulvar anatomy. I realize that most people balk at this claim. They tell me it simply isn’t believable that OB/GYNs wouldn’t be knowledgeable about the anatomy they are expected to know. But if you look with a fresh and analytical eye at the content of OB/GYN literature, you will see that the anatomy, physiology, and biomechanics of female sexual function are lacking. Given this paucity in the literature, it is fair to assume it is similarly lacking from curricula.

Many doctors have responded with defensiveness to my claims, which are perhaps threatening and insulting to the professional pride of OB/GYNs. There is a resistance to believing OB/GYN training could be inadequate in any way. I am tasked with the challenge of figuring out how to confront this problem without being eliciting defensiveness and resistance. This has been incredibly difficult.

Perhaps by addressing the cultural context in which neglect of vulvar anatomy and sexual function occurs, I can lift the blame from doctors and help them more easily confront this problem.

There is a historical precedent of denying that women are sexual. Female sexuality has been taboo. Women were long seen as reproductive and not sexual. The clitoris has been threatening, as it represents female sexuality separate from reproduction. There are so many factors here. Medicine does not exist in a cultural vacuum. The omissions and inadequacies of medical education where vulvar anatomy and female sexual function are concerned are a symptom of the historic sociocultural suppression and denial of female sexuality.

Back when female orgasm was suspected to aid in conception, the clitoris was studied. In fact, the most detailed illustrations of clitoral anatomy were published in 1844. However, when doctors learned how conception worked, the clitoris fell in perceived significance. It fell again when Freud determined that clitoral orgasms were immature and that the vagina was the locus of female sexuality. As O’Connell has noted, an active deletion of clitoral anatomy hence occurred in the 20thcentury.

Now that female sexual function is considered integral to women’s health, and now that the importance of the clitoris is well recognized, coverage of detailed vulvar anatomy is warranted. It is senseless for the cultural inhibitions of the past to continue to compromise the healthcare of women. This is a really easy problem to solve if doctors could just get on board with what we have already agreed upon as a society, which is that women have every bit as much right to sexual pleasure as men.

I realize OB/GYNs may be spread too thin. They have so much to know and so many problems to address. However, it is important to note that OB/GYNs did have time to learn detailed penile anatomy in medical school. It seems they should have at least as much time to learn the genital anatomy of the sex they treat.

I also realize that OB/GYNs are most preoccupied with reproductive concerns. However, to view reproduction as separate from sexual pleasure is to deny both gender equality and the importance of female sexual anatomy. Without pleasure, it is simply very unlikely women would choose to reproduce in the first place. If OB/GYNs are too busy to meet the reproductive health needs of patients without compromising sexual health, than perhaps OB and GYN need to be split.

As long as OB/GYN is the specialty that claims to be equipped to address vulvar anatomy and female sexual function, according to their board and professional society, their education should reflect this. The promises of professional organization should not be given lightly, as these are promises patients trust. To violate said trust is to undermine the patient –physician relationship, upon which the practice of medicine depends. What doctors know should be consistent with what they say they know. For this reason, OB/GYN education in vulvar anatomy needs to be improved.

Dr. X’s error occurred largely because education in vulvar anatomy and female sexual function is lacking. This can be improved so easily. Much research has been done. It simply needs to be integrated. More research could help clarify anatomy further and is not particularly difficult, time consuming, or expensive.

In addition to gaps in anatomy education, training standards for labiaplasty are also lacking. This constitutes an oversight and missed opportunity of professional organizations to protect both patients and doctors. Training standards protect patients from suffering harm. They also protect doctors from causing harm via egregious, unintentional errors. For physicians who chose their profession to help people, causing harm to patients can be devastating.

Due to gaps in anatomy education and an absence of training standards for labiaplasty, Dr. X did a surgery he was not trained to do on anatomy he did not know. While this was partly a case of poor judgment on his part, this judgment error is both understandable and common. It is clear, based on the literature on techniques for labiaplasty and clitoral hood reductions, that even published experts lack knowledge of the surgical anatomy involved. It is also clear, based on the lack of training in the procedures during residency and lack of CME, that not many OB/GYNs doing these procedures are trained. Yet both ABOG and ACGME tell surgery centers that OB/GYNs are qualified.

As one OB/GYN who specializes in female genital plastic surgery (both cosmetic and medically indicated) has explained, “Errors happen because many OB/GYNs don’t know what they don’t know.” This problem may extend to plastic surgeons as well, but my examination of my adverse event has focused primarily on OB/GYNs, as it was an OB/GYN who harmed me. It is OB/GYN literature, training standards, and privileging which I have examined most thoroughly.

If you hire someone unqualified for a job and reassure him or her they are qualified, whose fault is it when the unqualified person makes a mistake resulting from inadequate training? In my opinion, such a mistake is to be expected in this case.

There is also a systemic cultural problem in medicine, which precludes the recognition of error and learning from mistakes. In a litigious climate, doctors are rarely rewarded for honest self-reflection in the wake of adverse events. In a culture where doctors are expected to be infallible, they are rarely rewarded for recognizing their mistakes. The expectation of infallibility is an injustice to both doctors and patients as it precludes learning and denies patients dignity when they are harmed.

The more status doctors attain, the more infallible people expect them to be. Dr. X is an extremely reputable surgeon, who has held several important leadership positions. Held in such high esteem, how could he question his ability to do any procedures his board, professional society, and OB/GYN colleagues consider him qualified to do? And how could he recognize his error, when his identity and reputation does not allow for human fallibility? It seems, perhaps, that the more status a physician gains, the more dangerous to his patients he becomes.

Patients and physicians have the same goal: to improve the health and wellbeing of patients. As such, the patient physician relationship should be collaborative. Given the shared objective, there is no need for things to become adversarial when mistakes are made. But a construction response to error is impossible when physicians cannot be honest with themselves or with their patients.

All I have wanted all these years is for Dr. X to admit what he did. I also have wanted his help to change this for others.

To me, it is a tragedy that I am helping a woman who had the same thing happen to her with her lawsuit 15 years after my surgery. Had learning occurred at scale at any point since my adverse event, her injury simply could not have happened.

Today, it is every bit as probable that what happened to me would happen to someone else as it was 15 years ago. My doctor, or someone like him, could still easily get privileges to do a labiaplasty at the same surgery center where mine occurred. Detailed vulvar anatomy is still lacking from OB/GYN literature. Training standards for labiaplasty have yet to be established.

Given the inadequate coverage of anatomy and lack of training standards, adverse events like mine are both predictable and preventable. So much could be done to render what happened to me extremely unlikely, if not impossible. Yet, according to experts, botched female genital surgeries are increasingly common, as more and more surgeons are doing them without appropriate training and without adequate knowledge of the anatomy involved.

For lack of a better term, these gaps in education and training amount to systemic negligence. For such negligence to remain unchecked for decades is an affront to the dignity of all the women who have been harmed.

Doctors may not believe many women are harmed, but please consider my story and those of others who have contacted me. We have been told our sexual problems were psychological or hormonal. We have all been told something akin to “that can’t happen.” In addition, other women who never had genital plastic surgery have contacted me with similar experiences. The theme is that physical causes of female sexual function are routinely dismissed. Injuries to female sexual organs are not properly diagnosed. Given that female sexual function and dysfunction is covered in OB/GYN chapters on “emotional issues” and “psychological issues,” while detailed anatomy is neglected, I find this unsurprising.

There is also the issue of how hard it is to talk about having one’s genitals mutilated, especially in surgeries patients sought out. Talking about what happened to me made my injury significantly harder to deal with, as I was met with incredulity, dismissal, and victim-blame. All the same things that rape victims face are amplified here. Meanwhile, the damage left is not just to the psyche, but also to the physical body. It is permanent and irreparable. Many women feel damaged and ashamed. It is very difficult to get them to speak out. Most I have talked to simply see no point.

It has also been difficult to get doctors to speak up when patients are harmed. Though one OB/GYN expressed horror at what happened to me, she said it was none of her business to let me know of the opportunity to report my doctor. I had no idea there was any recourse. When I asked her to inform others if she ever encountered someone like me again, she refused and was very defensive. Given the barriers to reporting, I think most women like me are simply invisible data points.

Meanwhile, other doctors who have agreed with me regarding inadequate training, especially where anatomy is involved, have said they don’t want to be seen as criticizing their OB/GYN colleagues. Again, there is this reticence to speak up. There is even a tone of apathy, as if it’s not important enough. And, of course, there is the victim blame. “Women shouldn’t be seeking those surgeries,” some will say.

It is senseless for women to be harmed at the hands of a profession dedicated to their wellbeing. This is easily preventable, if only doctors would listen and speak up.

Also, the problem is bigger than just one of patient safety in female genital plastic surgery. The fact that education in anatomy and female sexual function is lacking has wide-reaching ramifications for women’s health. Women’s’ sexual organs should be treated with the same respect, attention to detail, and consideration as other body parts.