Sexual problems? Urologists know vulvar anatomy and female sexual physiology better than OB/GYNs.

Research on vulvar anatomy and physiology are consisistently either published in urology journals or journals of sexual medicine. Research pertinent to the physiology of female arousal and orgasm is never published in OB/GYN journals. Vulvar anatomy and physiology is not well-covered in OB/GYN textbooks. This, I’m told, is due to a lack of interest.

Unless your problem is one of pain, hormones, or psychological hang-ups, an OB/GYN is unlikely to be of any help, based on the content of their literature. The ignorance of vulvar anatomy and physiology demonstrated in OB/GYN literature stands in contrast to statements made regarding their professional abilities. The American Board of OB/GYN (ABOG) neglects to add the neurovascular anatomy of the clitoris to board exams, despite claiming:

“Training in gynecology also covers women’s general health, including care of reproductive organs, breasts and sexual function.”

The director of ABOG previously assured me that the course of nerves in the clitoris is covered in OB/GYN textbooks, despite the fact it is not (except barely in Williams, only as of 2016). He neglected to provide a single reference.

ABOG and ACGME (responsible for residency accreditatiion) certify that OB/GYNs are qualified to do labiaplasties and clitoral hood reductions despite no training during residency, in concordance with the consistent pattern of disregard for vulvar anatomy and physiology. By assuring ambulatory surgery providers that OB/GYNs are qualified, they stand in the way of responsible privileging practices necessary to protect patients from untrained phsyicians.

The American College of OB/GYN neglects to add adequate vulvar anatomy to CREOG exams. Meanwhile, they approve labiaplasties and clitoral hood reductions, even for women under 18. Regarding their position on these surgeries for adolescents, they explicitly say:

“reconstructive procedures aimed at correction of abnormalities (caused by congenital defects, trauma, infection, or disease) or cosmetic procedures performed to reshape normal structures may improve function, appearance, and self-esteem”

Elsewhere, in a committee opinion on “cosmetic vaginal procedures” (it is completely unacceptable for ACOG to use “vagina” when they mean vulva), they say:

“Medically indicated surgical procedures may include reversal or repair of female genital cutting and treatment for labial hypertrophy or asymmetrical labial growth secondary to congenital conditions, chronic irritation, or excessive androgenic hormones”

Androgenic hormones do not actually cause labial hypertrophy (ask anyone on T). Rather, the labia minora reflect estrogen levels. I have sent them the relevant research on endocrinology and histology of the vulva, as well as showing them this false claim started with an uninformed hypothesis in a case study (n=1, correlation is not causation), but they neglect to correct it. Meanwhile, they also refuse to offer CME (continuing medical education) for these procedures. Thanks to ACOG’s resistence, there are no training standards in place to protect patients from getting harmed by surgeries they actually approve as “treatment for hypertrophy.” Hypertrophy is not consistently defined in the OB/GYN literature, where it has been liberally applied even to labia under 2 cm. Meanwhile, according to published normative data, mean labia size is 2.18 cm.

On the ACOG patient education page for sexual health, they list the following causes:

• Aging
• Hormonal changes
• Stress and anxiety
• Relationship problems
• Illness, including depression
• Past negative sexual experiences

Note the focus on hormones on pschology. This same focus is apparent in the ACOG committee opinion on sexual health. When I contacted the chair of this committee about the need for better OB/GYN education in anatomy and physiology of female sexual function, she neglected to respond.

While professional organizations tell patients they can trust OB/GYNs to know vulvar anatomy and female sexual physiology when they don’t, the American Urologic Association tells patients the following:

“Urology is a part of health care that deals with diseases of the male and female urinary tract (kidneys, ureters, bladder and urethra). It also deals with the male organs that are able to make babies (penis, testes, scrotum, prostate, etc.).”

It would seem that female sexual function is not urology’s purview. Yet vulvar anatomy and female sexual function receives far more coverage in urology textbooks than in OB/GYN textbooks. Let’s look at a few urology textbooks.

Campbell-Walsh — the “bible of the field”

In contrast to every OB/GYN textbook published to date, this textbook actually has an entire chapter dedicated to “Female Sexual Function and Dysfunction.” The anatomy of the vulva is covered in detail, though there was one error I contacted the author about. Unlike authors of OB/GYN textbooks, he responded with a genuine interest in improving coverage of this anatomy.

Smith and Tanagho’s General Urology

These authors have a chapter on “Female Urology & Female Sexual Dysfunction.”

Under “Female Sexual Dysfunction,” the authors have a section on “Physiology.” In the first sentence of this section, the authors note, “The basis of desire and perceived arousal in women is poorly understood.” Statements like this are pervasive due to a lack of research. These authors neglect to cover vulvar anatomy in much detial. However, they at least acknowledge potential non-hormonal, non-physiological causes of sexual dysfunction to a greater degree than any OB/GYN textbooks. While injuries and neuropathy of the dorsal nerve of the penis are considered as a culprit for male sexual dysfunction, the dorsal nerve of the clitoris is not mentioned in this chapter.

However, elsewhere in this textbook, the distal course of the dorsal nerve of the clitoris is shown in greater detail than in any OB/GYN textbook or journal. Unfortunately, the photos presented are taken from fetuses under 24 weeks old! The claim I received from one OB/GYN textbook author that the dorsal nerves of the clitoris are “too small” to dissect or show in detail in OB/GYN textbooks becomes extra hilarious given the nerves in <24 year old fetuses are not too small to show in a urology textbook.

Maybe changing OB/GYN curriculums is not the only solution. Maybe a better solution is to simply direct patients to specialties better equipped to treat them. Plastic surgeons, urologists, and neurologists have, in my experience so far, been more receptive to the need for better vulvar anatomy. Why is that? Maybe if OB/GYNs perceive they are losing business to other specialties, they will step up their game and stop defending and maintaining systemic negligence.

We, as women, trust our OB/GYNs as our primary care doctors, but when it comes to any issues with vulvar anatomy and female sexual function, we really shouldn’t. As patients, we simply trust them because they tell us we can, but nothing in their literature indicates such trust is warranted.