Why is women’s sexual health so understudied?

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• John Yang:

  When it comes to medical research and innovation, Men's Health has long gotten more attention than women's health. It was only in 1993 that Congress mandated that women and minorities be included in clinical research. But as Ali Rogin reports, even with improvements over the last 30 years, women's sexual health remains vastly under studied.

• Ali Rogin:

  Just about half the world's population has won. In the medical world. It's been discovered, forgotten and declared rediscovered, but it's usually dismissed as an afterthought, and often it's been seen as shameful. The clitoris is considered the only organ that exists solely for sexual pleasure, but it's also a crucial part of female anatomy, just as sexual health is critical to overall well-being. So why is the clitoris and the sexual health of people who have them still so understudied? Joining me to discuss are urologist and sexual health expert, Dr. Rachel Rubin and Rachel Gross, a science journalist and the author of the book, "Vagina Obscura."

  Rachel Gross, I'm going to start with you. Why do we and when I say we, I mean doctors, academics, and the general public, why do we know so little about the clitoris?

  Rachel Gross, Author, "Vagina Obscura": I think, as you said, there's a long history behind this. In general, we know far less about female bodies than male ones. And that's partially because of who's been asking the questions. So throughout medical history, you ended up with a lot of male anatomies to saw the world from their perspective, one way that they looked at women was as sort of walking wombs or baby machines. And that meant a very different focus than sexual pleasure, which is what the clitoris is all about. So, I think we are still recovering from those attitudes. And a lot of stigma and shame still exists today.

• Ali Rogin:

  Dr. Rubin based on what Rachel has just told us, how does that translate to the medical field and how it thinks about the sexual function of these organs?

  Dr. Rachel Rubin, Urologist and Sexual Medicine Specialist: Well, it's a huge problem, right? So, in medical school, I didn't learn about the clitoris. I didn't learn anything about women's sexual health. I then went into a urology residency where I'm a penis doctor, right? I take care of men and men's sexual health. So, when I learned as a medical student how to examine the pelvis, they told us to stay away from the clitoris, that examining it might make our patient feel uncomfortable. Can you imagine me saying the same thing to my male patients if I were examining their genitalia, and there is a very small community of us who do this work, but it's extremely small, extremely undervalued.

• Ali Rogin:

  And Rachel Gross, it seems like in recent decades, there have been lots and lots of advancements in the understanding of this critical organ, including simply how it looks and how big it is. And a lot of that is attributable to gender affirming health care, so I want to ask you about the role of that sort of care and leading to a lot of advancements in the understanding of the clitoris?

• Rachel Gross:

  I'd actually say that a lot of different fields have contributed to these advancements. A urologist in Australia, she really kind of brought the world as understanding that had existed before but never went mainstream, that the head of the clitoris is the part you can see and touch. And it's really just the tip of the iceberg. So, underneath, there's two bulbs, and two arms that kind of flare out into the pelvis, and the bulbs hug the vagina and the urethra, and they're all made of erectile tissue. And basically 90% of this organ is beneath the surface.

  So, there have been several fields that have been getting advancements like this into journals. And what I saw was that they're often kind of siloed. So, they don't talk to each other, and they don't build off each other's work. So, we're sort of reinventing the wheel each time. But the rise of this kind of care means that there's access to parts of the body that normally you wouldn't end up with as a surgeon. And there's an actual focus on sexual sensation and making it better for these patients. So, for one of the first times, we are prioritizing sexual function, instead of shying away from it.

• Ali Rogin:

  I know that you both actually feel strongly that this should not be viewed as it failing of the field of gynecology, which focuses on reproductive health. But I do wonder if you think there is one field or a number of fields, that should take more ownership of the study in the care of the clitoris?

• Dr. Rachel Rubin:

  So, I think there — it's unfair to say that gynecologists are supposed to do absolutely everything for all women's issues, right? They're cancer doctors, they're emergency room doctors, they're baby doctors, they're breastfeeding doctors, they're vulva doctors, they're uterus doctors, there is no way they can do it all and in a 10-minute visit once a year. It's totally unfair and kind of misogynistic in and of itself that we think that that's OK. There is no doctor for men that is responsible for all of men's health issues. And so, the clitoris is in the pelvis. The pelvis has lots of neurologic anatomy, colorectal anatomy, gynecologic anatomy, and actually a lot of musculoskeletal orthopedic anatomy. And all of the nerves from the spine are what innervate and let the clitoris do its thing. And the fact that we don't even understand basic anatomy, orthopedic surgeons don't understand the basic anatomy and the innervations of the clitoris because it's not in the textbooks is a huge problem. Because there are consequences when you operate in a pelvis and a lot of us operate in the pelvis. There can be harm to pelvic organs, which can lead to very intense sexual dysfunction, which I see in my clinic every day.

• Ali Rogin:

  You're a urologist but you're also a sexual health expert. Why is this kind of practice so rare?

• Dr. Rachel Rubin:

  So, after you do finish urology training, which is five years you can do a subspecialty fellowship. We have 27 fellowships in men's sexual health. We have one that even acknowledges women's sexual health. It's the fellowship that I did, and I take care of all genders when I practice sexual medicine, that's a huge problem, but there's no funding there's no support and there's no ability for us to grow and train people if we don't have the fellowships in place and the ability to train people.

  There are a lot of clitorises in the world of that absolutely need help and medical care because sexual health is just health, right? People's quality of life is really important. And we have to start talking about it and demanding that equal care.

• Ali Rogin:

  That's why conversations like this are so important, Dr. Rachel Rubin, thank you for joining us. Rachel Gross, we really appreciate your time.

• Rachel Gross:

  Thank you so much for having us.

• Dr. Rachel Rubin:

  Thank you for having us.