Review of Williams Gynecology
This is one popular GYN textbook, written here in Dallas at UTSW. There is a disregard for vulvar anatomy and female sexual function (as a concrete phenomenon that isn’t just about feelings).
1. This is the extent to which the gross anatomy of the clitoris is covered — one small paragraph in a ~280 page textbook. Compare this small paragraph to the ~160 page anatomic study by Di Marino and Lepidi. While they mention nerve endings of the glans here, they neglect to include that the body of the clitoris is also sensitive. The 2 cm measurement for the body is inadequate for describing anatomy that has both an ascending and descending segment with an acute angle between [1][2]. They also should probably be including the vestibular bulbs, though I’m not really picky about that personally, as long as the vestibular bulbs are acknowledged as erectile, which they are. In fact, the vestibular bulbs get 3 times as coverage as the clitoris in this textbook.
2. This is how much they describe the innervation of the clitoris. Note how they do not describe the course of the dorsal nerve.
3. They have commendably updated this textbook, as of 2016, to show one side of the clitoris degloved, with one branch of the dorsal nerve shown. However, the course of this nerve in the clitoris (superficial above the body ) is shown from only one angle and is not described. This is the most in depth coverage ever shown in OB/GYN textbooks to date. This illustration is actually incorrect as the descending segment of the clitoral body should never be shorter in length than the overlying clitoral hood.
4. This is what they say about the labia minora. It is incorrect to say that the labia minora surround the glans. They do not. Describing the prepuce as part of the labia minora leads to clitoral hood reductions being performed without patients’ consent. It also makes the later claim in this book, that labiaplasties are safe and effective, completely false. The proximal prepuce is effectively clitoral shaft skin. Injuries to the dorsal nerves can occur, especially at the hands of surgeries who do not know the anatomy. Note no discussion of protective or sexual function of the labia minora. Note no discussion of innervation.
5. This is the only context in which female sexual function is mentioned. Note how female sexual function is described as “sexuality” — a broad, wishy washy term, and closely associated with “psychosocial issues.” Should not female sexual function and dysfunction function be discussed in a separate chapter, where anatomy and physiology of sexual function are adequately addressed?
6. The entire section on “female sexuality” looks like this. Note all the bs about emotions and relationships. How relevant is this to the practice of medicine? Shouldn’t understanding of physiology not be so eclipsed by a discussion of psychology?
7. Note the disclaimer about how complicated and emotional women are. Note how much more focus there is on vaginal physiological arousal than clitoral.
8. Note approach to sexual dysfunction. First of all, is it at all believable that 64% of women have no or low sexual desire? This seems completely ridiculous. Secondly, note how there is no discussion of examining patient for injuries or other physical causes of dysfunction? Iatrogenic causes of female sexual dysfunction are not addressed, despite vulvectomies including excision of the clitoris being discussed later in this textbook (without mention of sexual sequelae).
9. Finally, labiaplasty is described as “safe and effective.” Risks to sexual function are not described. Surgical anatomy and functions of the labia minora are not addressed.
10. Surgical techniques for vulvar surgeries do not address anatomical and functional considerations in at all the same way you see with other surgical procedures. This can be seen throughout.
Considering how long this book is and what else is covered, there is clear academic negligence regarding vulvar anatomy and female sexual function. The theme is that women are reproductive and emotional, not sexual. Consider also that Williams Gynecology is separate from Williams Obstetrics, which should allow for better coverage of vulvar anatomy and female sexual function than combined OB/GYN textbooks.
[1] Di Marino V, Lepidi H. Anatomic Study of the Clitoris and the Bulbo -Clitoral Organ. Heidelberg: Springer; 2014.
[2] Abdulcadir J, Botsikas D, Bolmont M, et al. Sexual anatomy and function in women with and without genital mutilation: A cross‐sectional study. J Sex Med. 2016;13:226–237.