Is a hooded clitoris to blame for many women’s failure to reach orgasm with their sexual partners? Whether it is or not, the procedure is becoming more popular among both women and physicians.

In Chicago, a physician with offices on Michigan Avenue offers clitoral unhooding today for $1,000 (plus operating room fees). His intention? To more easily enable a woman to reach orgasm. Clitoral unhooding falls under the larger category of female genital cosmetic surgeries (FGCS), surgeries that are reportedly becoming more popular among women and physicians. Some physicians, even those who don’t perform FGCS, see them as part of the future of plastic surgery.

The assumption is that these surgeries don’t have much of a past. In fact, there is a long history of surgeries on female genitals—especially on the clitoris—as “sexual enhancement” for women, designed to help them achieve their “proper role” as sexual partners. Over a century ago, another Chicago physician also removed clitoral hoods of women, also as therapy to enable them easier orgasms. The use of female circumcision since the late 1800s to treat a woman’s lack of orgasm reveals a medical understanding of the function of the clitoris as sexual­—an understanding held decades prior to the physiological evidence supplied by William Masters and Virginia Johnson.

Understanding the sexual nature of the clitoris and its importance to female sexual pleasure, some physicians have, for well over a century, diagnosed a condition of the clitoris as the physiological cause for a woman’s failure to have an orgasm with her husband. These physicians thus treated the lack of an orgasm in the marital bed as a sexual disorder treatable through surgery.

In the U.S., the first documented use of female circumcision as a sexual enhancement therapy appeared at a time when the espousal of female orgasm during marital sex was increasingly seen as an important component for a healthy marriage.

By removing the clitoral foreskin, some physicians (as well as non-physicians) thought the clitoris would be more exposed to the penis during penetrative intercourse, and would thus receive direct stimulation from the penis. Physicians performed—and some women or their spouses sought out—female circumcision in order to maintain (or conform to) the sexual behavior deemed culturally appropriate for white, U.S.-born, middle- to upper-class women: orgasm with their husbands.

In the United States, the first documented use of female circumcision as a sexual enhancement therapy occurred in the late 19th century, appearing at a time when the espousal of female orgasm during marital sex was increasingly seen as an important component for a healthy marriage. Physicians performed female circumcision to help married women who wanted—or whose husbands wanted their wives to have—orgasms during martial sex.

Practitioners who removed clitoral hoods to enable female orgasm included Chicago gynecologist Denslow Lewis, who presented evidence for the benefits of female circumcision at a meeting of the American Medical Association in 1899. In “a large percentage” of women who failed to find marital passion “there is a preputial adhesion, and a judicious circumcision, together with consistent advice, will often be successful,” according to Lewis. Lewis had treated 38 women with circumcision, and had “reasonably satisfactory results in each instance.”

This procedure continued to be used to treat women for their inability to orgasm throughout the 20th century. In 1900, Chicago gynecologist A.S. Waiss wrote about removing the clitoral hood of Mrs. R., a 27-year-old woman who had been married for seven years and who was “absolutely passionless,” something that greatly upset her. Her unresponsiveness troubled her, or her husband, enough for her to seek a medical remedy. The doctor found Mrs. R.’s clitoris “entirely covered” by its hood. He circumcised the clitoris and the patient “became a different woman”—she was, the doctor wrote, “lively, contented,” and “happy,” and sex now brought her satisfaction.

In 1912, Douglas H. Stewart in New York City saw a “fairly robust woman” who, though desirous for sexual intercourse, when the act was attempted found “there ‘was nothing in it.’” Upon examination, Stewart found the clitoris of the patient to be “buried” and preceded to circumcise the woman to reveal the organ.

Charles Lane, a physician in Poughkeepsie, New York, believed the clitoris “a very important organ to the health and happiness of the female,” and performed circumcision on women who were unable to reach orgasm. In a 1940 article concerning his use of circumcision on a patient—Mrs. W., a 22-year-old woman who had recently married but had yet to experience an orgasm—Lane noted “that little trick did it all right.”

And C.F. McDonald, a physician in Milwaukee, noted in a 1958 article that women who complained to him of difficult or painful intercourse often had a clitoris hidden by foreskin. To reveal the organ, he removed the foreskin, with “very thankful patients” as the reward. McDonald operated in the 1950s—during the height of the Freudian vaginal orgasm theory, a theory that held healthy and mature adult women had vaginal, not clitoral, orgasms—suggesting clitoral circumcision as sexual therapy did not stop; indeed, by some accounts, more women underwent circumcision at mid-century to surgically increase the potential for orgasm than at any earlier time.

Physicians, both in print and at medical society meetings, discussed that “little trick” for decades. By the 1970s, information about the usefulness of female circumcision to enable female orgasm during penetrative, heterosexual sex began to appear with more regularity in popular publications as well, with information about the surgery as a sexual enhancement appearing in books such as The Consumer’s Guide to Successful Surgery.

Magazines, too, including Playgirl and Playboy, ran stories about female circumcision. Playgirl carried two stories by Catherine Kellison, who wrote about her circumcision and how orgasms were easier for her to attain after the surgery. The gynecologist who removed her clitoral hood told Kellison that an estimated three-fourths of women did not reach orgasm because of a hooded clitoris, and that circumcision was the surgical solution to this condition. The doctor told Kellison that she would likely benefit from having her clitoral hood removed, and, after undergoing the procedure, Kellison wrote that she did find orgasms easier to attain following the surgery.

While estimating how many American women underwent female circumcision since the late 19th century is not possible—it was a quick procedure, most often performed by physicians in their clinics—evidence of its use can be found indirectly through insurance reimbursement for it.

In May 1977 the insurance company Blue Shield Association recommended that its individual plans stop routine payments for 28 surgical and diagnostic procedures considered outmoded or unnecessary. Of the 28, one was removing the hood of the clitoris. While this information is not translatable into an actual estimate of how many women elected to have their clitorises circumcised, it suggests the procedure was at least popular enough to warrant the discontinuation of paying for it by an insurance company.

In addition to Blue Shield Association, others have labeled the procedure as not medically indicated, with some being even more critical of the assumptions underlying the use of it as therapy to treat a lack of female orgasm. Feminists interested in women’s health began questioning female circumcision as a surgery for purported sexual enhancement in the 1970s as part of their larger critique of the medicalization of the female body and the feminist embrace of the clitoris as an important sexual organ for women.

More recently, women’s health activists with the New View Campaign in the United States protested practitioners of FGCS and launched a website to educate the public about the diversity of female genitals.

Similar to the New View Campaign, both the popular media and academics have weighed in on what the apparent “rise” in these surgeries means about the female body, female sexuality, and the role of medicine. Some academics have further challenged these procedures for the lack of evidence that such surgeries increase female sexual capacity and that women should feel the need to correct their bodies in order to enjoy sex rather than to, for example, change sexual positions or techniques.

In addition to academics and feminist activists questioning the procedures, medical practitioners have also raised concerns about the lack of established medical need for clitoral unhooding and that there is no evidence that female circumcision, along with the other procedures comprising FGCS, are safe. Indeed, in 2007, the American College of Obstetrics and Gynecology recommended practitioners not perform female circumcision or other FGCS, since the promotion of FGCS as sexually enhancing was not based on empirical evidence, nor were the surgeries medically indicated.

But while feminists and some medical practitioners since the 1970s have been publicly questioning the physiological basis for female circumcision as a sexual enhancement surgery, the surgery today, like a century ago, continues to be performed as an effort to enable women to have a clitoral orgasm during penetrative sex.