The Female Pleasure Anatomy That Medicine Spent Fifty Years Ignoring
There are four distinct anatomical structures involved in female sexual response. For most of the twentieth century, the medical literature described one. Here is what the anatomy actually is — and why the science matters beyond pleasure.
“'The anatomy of the clitoris has not been described in anatomical textbooks, or if it has, it has been inaccurate.' — Helen O'Connell, Journal of Urology, 2005. Twenty years later, the surgical implications of this finding are still not in standard consent discussions.”
In 2005, urologist Helen O'Connell published a paper in the Journal of Urology that was, depending on your perspective, either a minor anatomical correction or one of the most significant reframings in the history of the specialty. O'Connell, working at the Royal Melbourne Hospital, had spent years dissecting cadaveric specimens with more precision than the standard anatomical studies that had informed surgical training and medical education for decades. What she found was that the anatomical descriptions in the textbooks were wrong — specifically, they were dramatically underrepresenting the size and extent of the clitoral complex.
The clitoris, as it appears in most medical textbooks published before the mid-2000s, is described as a small external organ approximately the size and shape of a pea. This description corresponds to the visible external portion — the glans and the clitoral hood. What O'Connell's dissections revealed, and what has been confirmed by subsequent MRI studies (notably the work of French researcher Odile Buisson and gynecologist Pierre Foldes published in 2009), is that the clitoral complex is substantially larger: it includes two crura extending internally along the inferior pubic rami, two vestibular bulbs lying on either side of the vaginal opening, and a body and shaft that extend several centimetres internally. The full structure, in many women, is approximately nine to twelve centimetres in length.
The four anatomical structures involved in female sexual response are: the clitoral complex (in its full anatomical extent, not the external glans alone); the G-spot region, now more precisely identified as the internal surface of the anterior vaginal wall at the point where it overlies the internal clitoral structures; the A-spot (anterior fornix erogenous zone), located on the anterior wall of the vagina approximately 5-7 centimetres deeper than the G-spot region, described in clinical literature since Chua Chee Ann's 1997 research; and the cervix, whose role in sexual response has been documented in studies involving women with spinal cord injuries — demonstrating a separate neural pathway (vagus nerve, bypassing the spinal cord) that had not been included in the standard anatomical models.
The reason this matters beyond pleasure — and it does matter beyond pleasure — is surgical. Procedures performed on female pelvic anatomy, from hysterectomy to certain cancer surgeries to episiotomy and perineal repair, have been performed with limited awareness of the full extent of the clitoral vasculature and innervation. O'Connell's 2005 paper explicitly raised this concern: 'The anatomy of the clitoris has not been described in anatomical textbooks, or if it has been, it has been inaccurate.' The surgical implications are significant for any procedure in the pelvis.
The neural anatomy of the clitoris — which is innervated by the dorsal nerve of the clitoris, a branch of the pudendal nerve — means that pelvic floor procedures, particularly those involving the levator ani muscle group, carry potential risks to clitoral sensation that are not routinely included in surgical consent discussions. This is beginning to change: the 2023 update to the British Association of Urogynaecology guidelines included specific reference to clitoral nerve preservation as a consideration in pelvic reconstructive surgery.
The hormonal dimension is equally underreported. Oestrogen receptors are present throughout the clitoral tissue and the vaginal mucosa. The oestrogen withdrawal of menopause produces measurable changes in clitoral sensitivity and arousal response — specifically, reduced vascular engorgement, thinner vestibular tissue, and decreased lubrication — that have been documented in studies since the 1990s but that have not historically been part of the standard menopause medicine consultation. Low-dose topical oestrogen applied to the vulvar and vaginal tissue has Level A evidence (RCT-supported) for improving genitourinary symptoms of menopause, including reduced sexual pain and improved arousal response.
The clinical gap between what the anatomy shows and what the medicine has addressed is closing, but slowly. The work of practitioners like O'Connell in Australia, the Foldes-Buisson collaboration in France (Foldes has also performed over 3,000 clitoral reconstruction surgeries in survivors of female genital cutting, using his anatomical maps as the surgical foundation), and researchers like Caroline Pukall at Queen's University in Canada — who has produced some of the most thorough clinical studies of vulvodynia and provoked vestibulodynia — represents a body of work that is finally producing the anatomically accurate medical education that the previous century failed to provide.
For the reader managing perimenopausal or postmenopausal symptoms: ask specifically about topical oestrogen. It is not systemic hormone therapy. It does not carry the same risk profile. It has strong evidence for genitourinary symptoms including those affecting sexual response. It is underutilised because it is underprescribed. It requires, in the current system, a patient who knows to ask.
BY OONA CHANEL
