I’ve decided to review every major OB/GYN textbook in hopes people start to see the problems I see. Moving down a list of books recommended for board exam review, this is the next one after Williams Gynecology (skipping Williams Obstetrics). This book makes Williams look like it was written in a feminist utopia. Keep in mind that, at 1040 pages, it should have room for better coverage of vulvar anatomy and female sexual response.

1. No chapter devoted to female sexual function

Try to guess which of the following sections a discussion of female sexual function and dysfunction is in.

The answer is “Reproduction Basics.” Note how the emphasis is on reproduction. This is the key reason behind why vulvar anatomy gets neglected. Though the vulva is the locus of sexual pleasure, and though sexual pleasure is the primary reason female humans have sex, we don’t conceptualize vulvar anatomy as particularly important to reproductive function. Just think about how rapey that is for a second please. Why would women want to have sex if they don’t enjoy it? And how would humans be reproducing if women didn’t enjoy sex? Rape.

2. Completely ridiculous illustration of the vulva

How many vulvas have you seen that look even remotely like this? I really hope everyone’s answer is “0.” Note just how much this vagina is gaping. Completely unrealistic, gaping vaginas are typical in medical illustrations. It is reflective of how people conceptualize female genital anatomy as a cavity, Think about what it means that a cavity is seen as so much more important that it is represented in this exaggerated way.

I remember when I was a teenager, I really strugged to relate to medical illustrations of the vulva. This experience is not uncommon. Like many women, I had difficulty learning my anatomy when female genitals “look a lot different in real pictures than on drawings or models.”

3. Labia minora incorrectly described as “folds of skin”

The labia minora are more than just skin folds. The labia minora are specialized folds of tissue rich in neural and vascular elements. They engorge upon arousal (up to two to three times the size) and play an essential role in the female sexual response. The abundance of neural fibers and receptors, is mentioned in various texts and has been demonstrated by a number of studies. Free nerve endings, Krause-finger and genital corpuscles, and Meissner and Pacini (or “Pacinian-like”) have been identified. Neural staining attests to this abundance of neural elements, as shown. Neural elements of the clitoral glans, stained using the same methods, are shown for comparison.

S100 antibody stain. Bar=100.

The World Health Organization identifies labia minora, alongside the clitoris, as “the primary sensory organs in the female sexual response.” The biomechanics of the labia minora also faciliatate stimulation of the clitoris.

4. Restrictive range of labia minora size

They define the labia minora as “measuring 2–3 cm at its narrowest diameter to 5–6 cm at its widest.” The term “diameter” is confusing in this context, but I presume they mean the labia minora vary from 1–3 cm in length (proximal to distal). This range only includes women within about 1 standard deviation of the mean (so only about 68% of women) according to normative studies.

5. Incorrect, inconsistent description of clitoris

It is extremely annoying how no one can ever agree on what the clitoris is, even within the context of the same textbook. These authors describe the clitoris as 2 cm long. But a length of 2 cm describes the average length (approximate — reports vary greatly) of external portion only, which includes the distal body and glans. However, these authors later describe the clitoris as including the full extent of the cavernosa and glans, which is a triplanar complex.

The following sentence is so incorrect I don’t know quite what to say:

The erectile body, the corpus clitoridis, consists of the 2 crura clitoridis and the glans clitoridis, with overlying skin and prepuce, a miniature homologue of the glans penis.

Correction: the clitoral crura are the unpaired portions of the corpora cavernosa. The crura join to become the body of the clitoris, and the glans is attached at the distal end of the body. The external body of the clitoris is covered by the prepuce, which functions as shaft skin. Only the distal portion of the prepuce resembles a “hood,” which can be retracted to expose the glans.

6. No image or description of the course of the dorsal nerves in the clitoris

They do say that a “terminal branch” of the pudendal nerve terminates in branches within the “glans, corona, and prepuce.” This is essentially correct aside from the part where they say “corona.” The corona of the clitoris, if you can say the clitoris even has one, is part of the glans, so to mention it separately is redudant. The dorsal nerve is only named once in this textbook in subsection entitled “Anatomy of Pain,” in a chapter on “Obstetric Analgesia & Anesthesia.”

So basically the nerve most critical for female sexual pleasure is only mentioned in the context of “Anatomy of Pain.”

7. Barely any coverage of physiology of female sexual response

This is all that is said about female sexual response in this entire 1040 page textbook!

During sexual excitation, the vaginal walls become moist as a result of transudation of fluid through the mucus membrane. A lubricating mucus is secreted by the vestibular glands. The upper part of the vagina is sensitive to stretch, while tactile stimulation from the labia minora and clitoris adds to the sexual excitement. The stimuli are reinforced by tactile stimuli from the breasts and, as in men, by visual, auditory, and olfactory stimuli. Eventually, the crescendo or climax known as orgasm may be reached. During orgasm, there are autonomically mediated rhythmic contractions of the vaginal wall. Impulses also travel via the pudendal nerves and produce rhythmic contractions of the bulbocavernosus and ischiocavernosus muscles. The vaginal contractions may aid in the transport of spermatozoa but are not essential for it, as fertilization of the ovum is not dependent on orgasm.

8. Sexual dysfunction only covered in the chapter on “Menopause & Postmenopause”

I’m just going to leave this quote here and let it sit.

The determinants of sexual behavior are complex and interrelated. Sexual function is believed to be regulated by 3 general components: the individual’s motivation (also called desire or libido), endocrine competence, and sociocultural beliefs.

Note how genital integrity is not highlighted here. The importance of physical, genital function is not discussed, as it is in men. This is especially ridiculous considering injuries to the vulva can occur during birth and straddle injuries. Female genital cosmetic surgeries are common. Vulvar cancer is far more common than penile cancer. FGM is also common. There is clearly a need for understanding, avoiding causing, and treating physical causes of sexual dysfunction. Omission of such consideration is illogical and can only be explained by a sociocultural discomfort with vulvar anatomy.

9. Barely any discussion of sexual considerations in treatment of vulvar cancer

The most frequently encountered complication is actually loss of sexual sensation … But we are talking about women, so that’s no big deal.