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Peeling Away the Fig Leaf

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(Ed. note: This review also appears on Medpundit)

The nether regions of our bodies are too often slighted by everyone, patient and doctor alike. Sure, there are gynecologists and urologists who are supposed to take care of those parts, but their knowledge tends to be concentrated on the inner workings of the reproductive system. Develop a skin problem “down there” and you are often hard-pressed to find anyone who’s comfortable handling it. A dermatologist will squirm and say he’s not comfortable performing a biopsy of the labia or the penis. But the gynecologist or urologist may just as likely squirm and say he’s not comfortable diagnosing rashes. The external genitalia are the red-headed stepchildren of medicine.

The V Book: A Doctor’s Guide to Complete Vulvovaginal Health is an attempt to correct that. Written by Dr. Elizabeth Stewart, a specialist in vulvovaginal medicine, it’s a comprehensive guide to the anatomy and the disease of female external genitalia. Very well written, I suspect due to the efforts of co-author Paula Spencer, and well-organized, the book lays out the ground work for understanding diseases of the external genitalia by first ably introducing their normal anatomy and development. Interspersed throughout are little interesting sidebars to keep things from getting too dull – a timeline of vulvovaginal art, menstrual facts, and first-person accounts of the diseases under discussion.

Most important, the book provides good, sound advice on various vulvovaginal conditions, both common and uncommon. It was refreshing to read Dr. Stewart drive home again and again that all that itches is not yeast, and that telephone consultation alone is inadequate to diagnose vulvovaginal problems. (The same is true for most health problems, actually.) She provides very good and understandable explanations of the meaning of pap smear results, of the natural history of herpes, and of skin conditions that often plague that area of the body, making sex painful and difficult. The chapters on vulvodynia, or as the author(s) call it, “depressed vagina” are excellent, and I would highly recommend them to anyone who has been diagnosed with this difficult problem. In fact, I recently recommended the book to a patient of mine who had been given a diagnosis of lichen sclerosis by her gynecologist but was having trouble understanding exactly what it was or what it meant for her future health. Come to think of it, it’s a book that a lot of doctors would benefit from reading. I know this doctor did.

Having said all of that, I do have two quibbles with the book. Both are small. The first is a medical issue, and that is the recurring advice in the section on yeast infections to use cornstarch instead of talc or baby powder to keep the area dry. Cornstarch should not be used on skin rashes, especially in moist dark areas like the groin. It’s a starch, and the fungi that cause yeast infections can feed on it and make the skin version of a yeast infection (jock itch) worse. The other is a philosophical complaint. It in no way detracts from the book’s value as a reference on vulvovaginal complaints. That is this – the author(s) have a bad case of penis envy. The book is peppered throughout with envious references to men, as in “I feel pretty sure that a man would not allow some important part of his terrain to go uncharted for so long,” or this quote from a patient with a precancerous lesion, “But by not understanding all my body parts, I really lost it for a little while. I bet a guy would never do that.” But men have and do. They are just as ignorant of and just as frightened by diseases of their genitalia as women. Perhaps even more so because they don’t have articles in popular magazines or books like The V-Book to help explain things to them.

At least one doctor has attempted to address this state of affairs. The result is Under the Fig Leaf: A Comprehensive Guide to the Care and Maintenance of the Penis, Prostate, and Related Organs, by Angelo S. Paulo, a Florida urologist. Like the V-Book it’s a comprehensive catalogue of the ills that can befall the male genitalia. (The prostate’s included, too, even though it’s internal. No urologist could pass up the chance to write about their most beloved organ.) Unfortunately, unlike The V-Book, Dr. Paulo didn’t have the help of a professional writer, and it shows. The book lacks the polish and the organization of The V-Book, although the medical knowledge it contains is just as comprehensive, and just as sound. It reads, unfortunately, like a medical textbook, with frequent references to “the patient,” and frequent lapses into medical lingo. Because there are no chapters on the normal anatomy and development of male genitalia, it’s often difficult to understand the doctor’s explanations – unless you have a background in medicine or are exceptionally well-read in matters genital. He does provide a helpful glossary, but it’s a bit of a pain to keep going back and forth from text to glossary.

The book is also hampered by its illustrations. Dr. Paulo’s book was put out by a small publishing company, Health Information Press, and as a result, the illustrations are very basic and schematic. The V-Book, on the other hand, has very well-done pen and ink drawings as well as an occasional photograph to illustrate its points. But then, The V-Book was put out by a major publishing house.

Here’s an idea. Maybe Paula Spencer could collaborate with Dr. Paulo and bring Under the Fig Leaf up to the caliber of The V-Book. Then we could see some equality of the sexes.

(Ed. note: Amazon says Under the Fig Leaf is out of stock, but you can order it from the publisher here.)

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