Clinical Sciences.

Book review: Vagina Obscura, Rachel Gross (2022)

       I learned about this book while listening to NPR’s review of books published this past year and the subject piqued my curiosity based on its purported effort to discuss an important female organ that has suffered neglect at the hands of medical researchers. That the book does with a plethora of details, using an unbiased view. The style indeed is free of racial, gender, cultural, historical biases, and that’s a big plus. A clinician reading this book will enjoy it best if we check out our ego beforehand, or better yet exchange it for humility, silo our hubris in the hope of unleashing our shrewdness to enhance our wisdom, aka clinical acumen.

It’s written in clear terms, easily understandable by a literate lay public but the documentation is exquisite, and it constitutes a comprehensive review of the subject matter from a scientific viewpoint. Hence, it’s a useful source and clinicians will find it to be a good reference document.

The book wades into matters that have lit controversy from times immemorial.  It offers facts based on research being done and unearths seminal works that received little notice. It delves into the racial and gender biases permeating medicine from the days of Hippocrates. In a true investigative mode, it chronicles the formulation of the interpretation of female symptoms by male care givers under the basket diagnosis of “hysteria”. That diagnosis was based on some cockamamie notional dysfunction of the uterus and that has resulted in misguided, dangerous therapeutic interventions over the years. No less a luminary than Freud sits on the dock.

The book opens with a bang and openly discusses the dilemma so common among quite a few females: the failure of reaching vaginal orgasm during penetrating intercourse. It skillfully looks at reams of data and helps to conclude that the false debate about clitoral orgasm versus vaginal orgasm belies a misunderstanding of the anatomy of the clitoris. Far from being just a puny crest, called the glans clitoris, it is a large organ encasing the vaginal wall, fitted with the same spongy tissues that become engorged with arousal, just like the penis. The surprising conclusion is that orgasm is all about clitoral excitation that one can provoke in any number of ways. The failure of clinicians to have dissected the clitoris comprehensively during the study of anatomy is an indictment of the medical profession. It brings to the fore the failure of surgeons to carefully consider incidental damage to females’ sensory (orgasmic apparatus) during manipulation of bladder, uterus and other pelvic interventions. The more we learn about anatomy and physiology, the better we become as clinicians and the more patients benefit.

This book reminds me in its detailed approach to physiology of another one, The Gut by Enders that speaks about the importance of the gut microbiome, its intricate multifunction as endocrine, immune organ and its nexus to overall good health. I highly recommend it to patients and clinicians alike. Of course, microbiome in the vagina seems to play an essential role and plenty of real estate goes into discussion of a common diagnosis, bacterial vaginosis and its relationship to the perturbance of the parity of the vaginal bacterial population.

Every organ in the woman’s pelvis gets a comprehensive review. The dearth of data and or the biased introduction of treatment from a historical perspective also passes though a magnifying glass. The vaunted father of modern gynecology, Dr. Sims, obtains an “F” by our standards. He used female slaves as guinea pigs to hone his skills of correcting vesicovaginal fistula using gross techniques: surgery without any anesthesia or consent under very painful conditions. The ovaries and their regenerative capacity, a heretofore unknown ability, is well chronicled also. The presence of stem cells in the ovary offers lots of potential.

Endometriosis, a common diagnosis that goes for years before being discovered encapsulates the bias that male physicians unfortunately to this day still harbor in their failure to promptly make the diagnosis. That type of delay in making the diagnosis can result in infertility due to extensive damage over time of the reproductive system.

In my humble opinion, as clinicians we need to acknowledge past sins committed by previous generations and not fib about such shortcomings so we can regain credibility and also learn from our biased approach. I think this book can serve the purpose of starting a conversation about what can happen when we keep looking at a problem from the wrong perspective, aka biased, and what can happen when a newcomer offers a different approach. One needs not read every chapter of the book to appreciate it.

Some of the subjects discussed can go over the head of the average person not well versed in the rudiments of biology or physiology. However, the beginning chapters that deal with female orgasm, the g-spot discussion, deserve a honest conversation by couples who want to explore the world of Nirvana together but may have a challenge reaching there. Those can reach it can still benefit from the book in its very detailed description of the anatomy of the clitoris and its overall highly sensitive nature.

Certainly, Ob-Gyn physicians should be aware of it and become fluent with the issues discussed, the current research taking place and so on. Primary care physicians who work in the trenches would definitely benefit because the data revealed need to be discussed in an objective manner with patients who trust us. Any surgeon who operates on females should become more sensitive about causing collateral damage when exploring the female pelvis, including hip surgery.


Reynald Altéma, MD.


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