How Can We Know So Little About Clitorises?

The clitoris. Half the world’s population has one but it’s hard to think of any other part of our anatomy that’s quite so shrouded in mystery.

Although the detailed anatomy of the clitoris was first depicted in 1844 by German anatomist Georg Ludwig Kobelt, it wasn’t until 2005 that much of this knowledge was made more widely known because of the work of Australian urologist Helen O’Connell. 

And so what we now know is that the clitoris is much bigger than the pea-sized nub you can see on the surface, with the majority of it hidden internally. Sometimes described as the female pleasure centre, the clitoris has at least twice as many nerve endings as the penis and the internal part is made from erectile tissue, swelling when aroused. 

All that being said, there’s still "surprisingly little" known about the clitoris, explains Dr Janet Barter, a consultant in sexual and reproductive health and vice president of the Royal College of Obstetricians and Gynaecologists’ Faculty of Sexual and Reproductive Healthcare (FSRH).

"I’ve been a doctor now for 30-40 years and I’ve only recently read about the anatomy of the clitoris as we now understand it – with two bulbs going down inside the labia," Dr Barter says.

"My first thought was, Oh my God, I must be the only person who doesn’t know this! But I don’t think that’s the case at all. We definitely weren’t taught it in anatomy, because I had no concept of the shape of the organ. So, if most doctors don’t know, I think it’s likely that most people don’t," she adds.

She’s not wrong. After all, 2016 research by gynae cancer charity The Eve Appeal found that an alarming number of women don’t even know the difference between their vagina (internal genitalia) and their vulva (external genitalia). 

Why is this? I’ve long suspected it’s all caught up in the longstanding taboos surrounding female bodies, sexuality and female masturbation. After all, pleasure and orgasm are the sole biological purposes of this mysterious organ – it has no other function. "Too often when gynaecologists – and I can say this because I am one – talk about the vagina, it is purely in terms of if you can get a penis in and a baby out. That’s all that is ever taught, it’s all that’s thought about," Dr Barter explains. 

"I really do think it’s because, even now, female sexual enjoyment is not seen as important, medically speaking," she adds.

There’s clearly a lot of old school sexism wrapped up in this attitude – not to mention the heteronormative assumption that everyone with a clitoris wants penises and/or babies anywhere near their vagina. In medicine, as in Gilead, women are still largely viewed as vessels for male pleasure and incubators for babies – not as sexual beings in their own right.

This has massive implications when it comes to treating (or not treating) female sexual problems such as vaginismus or female genital mutilation. "I think a typical GP, unless they had a particular interest in women’s health, probably wouldn’t even feel comfortable having a conversation about problems with clitoral stimulation," Dr Barter says. It’s a far cry from how openly discussed and well researched erectile dysfunction is, and how readily available treatments like Viagra are.

"On the surface at least, male sexual problems are much easier because often there’s a physical cause and you can just give them Viagra. That doesn’t work for everyone but male sexual dysfunction is certainly talked about much more," she says.

With female sexual problems, Dr Barter adds, the cause is more often psychological but the best available treatment for this – psychosexual therapy – typically falls between the cracks in NHS funding.

"The way healthcare is commissioned was divided up, so sexual health services – contraception, STI testing, etc. – are all funded by local authorities, under public health. Most other health, including gynaecology, is funded by CCGs (clinical commissioning groups)," she explains.

"What happened with psychosexual work was that it didn’t fall into either camp, so it’s not funded as part of gynaecology or as part of sexual health. In some areas, like where I work, we’ve managed to fight for it by explaining to various commissioners how important it is and getting some joint funding. But in most areas, it’s just not available."

In an ideal world, Dr Barter explains, problems with female sexual pleasure would be treated jointly by a doctor and a psychologist – including an examination to check for any physical problems with the clitoris or the skin around it, as well as psychosexual work and an honest, practical conversation about tools and techniques.

"With clitoral stimulation it’s important to understand who’s doing what to whom, particularly if something is painful. You’d also want to look at lubrication and what sort of lubricants people are using, because there’s no doubt that some are better than others. With a psychosexual therapist, you’d also look at it psychologically in terms of how you explore yourself and find out what you like," she says.

It’s also worth noting that one of the few medical treatments that can be useful for problems with arousal and orgasm – testosterone – isn’t currently licensed for use in women. Although testosterone is sometimes added to HRT (hormone replacement therapy) in menopausal women, using a male preparation, it’s not commonly used to treat younger women with sexual problems.

Clearly, plenty of further research and medical education on the clitoris is needed. As ever, wherever there is a gender health gap it is underpinned by a research and data gap. This matters, and not only because women deserve to have access to as much information about their bodies as men. Understanding the complex nerve structure of the clitoris could also help to improve gender-affirmation procedures and reconstructive surgery for survivors of female genital mutilation, as well as avoid any damage during other pelvic surgeries. 

In the US, health activist Jessica Pin is campaigning for the nerve structure of the clitoris to be added to the American OB/GYN curriculum after she permanently lost all clitoral sensation during labiaplasty surgery. 

Beyond doctors’ consulting rooms, the clitoris is also notably absent from classrooms, where sex education has historically been both heteronormative and focused largely on the mechanics of penis-in-vagina penetrative sex. This is despite the fact that 75% of women do not orgasm from penetration alone and require direct clitoral stimulation.

"Traditional sex education unfortunately doesn’t really address pleasure, as the focus is generally on preventative approaches around pregnancy and STIs, says Megwyn White, a certified clinical sexologist and director of education at Satisfyer.

While male masturbation, erections and wet dreams are fairly common subjects of adolescent chat, female pleasure tends to be overlooked entirely in school – too often leaving young women believing that their enjoyment matters less than their (male) partner’s.

What we do learn – typically from the internet, friends or porn – tends to focus on this idea of the clitoris as a magic button rather than a fuller understanding of its complexities. That said, you’re still far more likely to find a 3D printed clitoris model on a sex positive Instagram account than in the average secondary school classroom.

"The clitoris is mostly an internal organ of pleasure but we’ve been taught that it’s the tiny nub on the outside, which is often difficult to see and hard for some to find. That’s only the tip of the iceberg," White explains.

"Because it’s made of erectile tissue, the clitoris requires stimulation in the same way a penis would – except that it’s internal and often needs to be stimulated indirectly from various angles. Seeing the entire anatomical structure of the clitoris often helps a woman understand how her pleasure can build," she adds.

Again, a lot of this seems to come back to the shame and taboo surrounding women’s sexuality and women’s health. "If doctors and nurses don’t know how to have these conversations, how on earth can we expect teachers and women themselves to talk about it?" Dr Barter concludes.

This, she believes, is a vital next step in improving our collective 'cliteracy'. "Medical professionals should be taught about the clitoris in medical school, as well as how to talk about it in a sensitive and knowledgeable way, so they can actually help people."

And it’s not just women who need to be better aware of the clitoris’ central role in sexual pleasure and orgasm. Research shows that heterosexual women come off worst in the 'gender orgasm gap', with only 65% usually or always orgasming during sexual intimacy, compared to 95% of heterosexual men, 89% of gay men and 86% of lesbian women.

There’s no great mystery or secret around how to make men come but for women – particularly women who have sex with men – it’s still a different story. The clitoris could hold the key to unlocking new depths of female pleasure but we all have to start talking about it more, demanding better education and putting pressure on medical professionals to push for more research.