THE ANATOMY OF THE CLITORIS

The following essay was written by my daughter, Althaea Yronwode, and appeared in the February 11, 1999, issue of Synapse, the campus newspaper of the University of Califonia at San Francisco Medical School. It appears here by permission. My comments follow.


STUDY CLAIMS CLITORIS LARGER THAN THOUGHT

by Althaea Yronwode


Remember the clitoris? In high school sex education class, it was that small bump at the top of the labia minora. The clitoris was a sort of "mini-penis" which, since it didn't directly get anyone pregnant, was lucky to be mentioned at all. In college level texts, such as Cambell's Biology, the clitoris is shown as a small external structure that does not contact the vagina or urethra. Stedman's Medical Dictionary calls it "a cylindric, erectile body, rarely exceeding 2 cm in length."

What these books leave out is something any anatomist knows. The clitoris actually has multiple parts, including two legs (or crura) which extend 9 cm into the pelvis, as well as two bulbs (called "the bulbs of the vestibule") which lie to either side of the vaginal opening within the labia minora.

In an article published in the Journal of Urology last summer [1998], Australian researcher Helen O'Connell claimed that the clitoris is larger than even anatomists previously thought. In fact, when considered in its entirety, the clitoris may even be bigger than the penis. However, most of it lies hidden within the pelvis.

O'Connell went on to suggest that the bulbs of the vestibule should be renamed the bulbs of the clitoris. This name would reflect the fact that the bulbs are embryologically part of the clitoris, and remain connected to the rest of the clitoris by fibrous bands. They are erectile tissue which become engorged during sexual arousal, as does the rest of the clitoris. O'Connell posited that the engorgement of the bulbs may facilitate intercourse by stiffening the walls of the vaginal opening.

Here at UCSF, Adjunct Professors of Anatomy Sexton Sutherland and Hugh ("Pat") Patterson, were not surprised by O'Connell's findings. "As far as the basic anatomy of the erectile tissue, there's nothing new in the article," remarked Patterson. "For the lay person, this would be very informative," added Sutherland, "but anatomy texts show the crura and bulbs of the vestibule already, albeit in a planar view. She has created a three-dimensional drawing, but the anatomy appears the same."

O'Connell's research was originally meant to define the microscopic nerve supply to the clitoris, something which has not yet been done. "That research was done in the 1970s on the male," commented Sutherland. "The study of the specific anatomy of the pelvic nerves in the male did allow surgeons to create approaches which increased the retention of sexual function post-prostatectomy. She [O'Connell] makes a good point that nerves and vessels in the female need to be studied in order to preserve them better during pelvic surgery. Unfortunately, her research only deals with the basic anatomy of the erectile tissue."

Leslee Subak, MD, assistant professor in the Department of Obstetrics and Gynecology, agrees that female sexual function may suffer after pelvic surgery. "Her research is timely because surveys are being developed concurrently to evaluate women's sexual function. We don't have adequate outcome measures to evaluate women's sexual response to determine if we have caused morbidity to that response. Nerve supplies in relation to the clitoris have not been particularly well defined. Anatomy, sexual function, and nerve supply have all been better defined for men."

Subak believes this information could affect the types of operations gynecologists choose to perform in the future. "There are studies now looking at sexual function after total hysterectomy versus after supracervical hysterectomy [in which the uterus is removed but not the cervix]. We have information already that the longterm consequences 10 to 20 years post-hysterectomy include increased incidence of urinary incontinence. O'Connell's data begs the question, 'are we causing sexual response morbidity with the surgeries we are doing?'"

Another claim made by O'Connell is that the clitoris actually surrounds the urethra (the passageway through which urine exits the bladder) on three sides. The fourth, posterior side is embedded in the anterior vaginal wall. Some health workers feel that this could explain the phenomenon known as the "G-spot," an area of increased sexual responsiveness on the upper wall of the vagina, just below the urethra.

Students and professors of anatomy at UCSF were not surprised by the size of the clitoris as described by O'Connell. But one must wonder, could female anatomy be taught correctly starting at an educational level below that of professional school? Although this reporter could not distinguish the subtle differences between drawings in atlases of anatomy such as Grant's and the drawings presented by O'Connell, there was a huge size difference between those drawings and the representations of the clitoris in standard college textbooks.

Whether or not O'Connell's suggestions for changes in nomenclature will be adopted remains to be seen. But perhaps the time has come for the rest of our educational system to acknowledge that there is more to the clitoris than meets the eye.


As Althaea points out, doctors and medical students have long been aware of the actual size and shape of the clitoris, so the splash that O'Connell's 1998 "discovery" made in the media was somewhat without cause. Standard anatomical texts of the 1940s -- for instance, "Human Sex Anatomy" by Robert Latou Dickinson M.D., F.A.C.S. (Williams and Wilkins, 2nd edition, 1949) -- indicate that the structure of the clitoris has been well known for decades. In fact, Dickinson, once known as "the Dean of American Gynecoloigsts," had been publishing detailed renderings of female pelvic anatomy since before World War One. In "Human Sex Anatomy" he estimated that the length of the average adult clitoris from the tip of the glans to the ends of the crura is about 4", with all except the glans located inside the body. He also noted cases in which the clitoris was as long as 8", with from 2" to 3.5 " of shaft "free" or outside the body, resembling a small penis. These latter cases he classified as intersex individuals, but, technology being what it was then, he did not karotype them to determine their genetic sex.

The clitoris and vagina embracing the penis during intercourse as seen facing toward the woman. The outer layers of skin, fat, and muscle have been dissected away, and the penis is shown in simplified cross-section for position only. Atop the pea-shaped clitoral glans, normally the only part visible outside the body, you can see the ascending portion of the clitoral shaft. Upon reaching its apex (which Dickinson calls "the clitoral knee"), the shaft bends downward and divides into the two "legs" or crura which encircle the vaginal opening. Drawing by Robert Latou Dickinson, in "Human Sex Anatomy," 1949.

Why such information was deleted from sexual self-help and teaching books intended for a general audience is unclear; however, one can make a shrewd guess: Based on 19th and 20th century cultural assumptions about women's sexuality and gender roles, it might have seemed somehow "wrong" to sexologists to depict "normal" women with honking big phalli embedded in their bodies! O'Connell's research on the nerve supply to the clitoris has not changed our understanding of its gross anatomy, but it has provided a way to spread the good news about clitorial anatomy to the public at long last.

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