I'm all for pragmatism, but the clitoris is idealistic, Utopian, and in the end it's hard to kill a good fantasy. Which may offer us a paradoxical argument against cutting a girl's genitals: the operation doesn't always work. Destroying the clitoris in body may or may not destroy it in spirit. Like Martha Coventry, some African women who have been clitoridectomized, even infibulated, describe themselves as erotic beings who enjoy sex and experience orgasm—very fierce orgasms, they add. Their phantom clitorises, it seems, are like the ghost of Hamlet's father: persistent, present, incorrigible. These women may have been subjected to grave medical risks during their ceremonial evisceration, but ultimately they were not tamed or chastened. So why put a girl's life (or fecundity) in danger, when there's no guarantee that her lust will die? And if a woman remains orgasmic and yet does not—surprise!—walk the path of a Barbary macaque, perhaps we can see here proof that the clitoris has no power over a woman, none at all, beyond what she will receive and what she will give it in return.
5. SUCKERS AND HORNS
THE PRODIGAL UTERUS
HOPE PHILLIPS HAS the sort of job that the brain loves but the pampered body hates. She is a project manager for the World Bank, and she is on the road for months at a stretch, traveling to places where there are no roads. Instead, there are bodily threats: parasites of extravagant variety and design; mosquitoes that hum in malarial choirs; two-fisted heat; the combined effluvia of local sewage and imported toxic waste; and a blood supply that should never again see the inside of anyone's veins. She has traveled throughout South America and Asia, but lately most of her work has been in southern Africa. And it was in Africa that she began to wonder if she could afford the luxury of her body's increasingly fitful behavior.
Phillips is a slender woman in her mid-forties with smooth skin, fine bones, and a precise, thoughtful manner. She is American but was raised in Taiwan, where her father, a physician, studied cholera, and there is the faintest hint in her locution of the Chinese she grew up speaking. I visited her in her home in Arlington, Virginia, a boxy, almost prim little house inspirited with rugs and furniture and carvings scavenged during her forays abroad. I drank coffee and nibbled on Milano cookies; she drank tea, ate nothing, and talked about her medical problems and the solution she had settled on.
For the past several years, Hope had been bleeding in what she considered an extracurricular fashion. "About five days a month, apart from my period, I'd start bleeding at nine o'clock in the evening," she said. "It would come out in a gush." She let her torso and arms fall forward slightly to emphasize gush. At first she didn't make a big deal of it, but eventually she decided, Oh, yes, I'd better consult a doctor. An ultrasound scan revealed the likely cause of her excessive bleeding: a fibroid, a benign tumor that grows in the muscle tissue, or myometrium, that makes up the middle layer of the uterus. The professional term for fibroid is leiomyoma, or simply myoma, to reflect the tumor's muscular origin, but fibroids are as common as freckles and deserve their common name. At least a quarter of women over thirty have fibroids, and the true figure may be closer to half. In most cases, fibroids are asymptomatic and despite their designation as tumors should just be left alone. But if they grow too big or are located in a bad spot, they can cause cramps, bleeding, constipation, and other unpleasantnesses.
Unfortunately for Hope, her fibroid was of a so-called submucous variety. Rather than remaining in the myometrium, it projected up into the endometrium, the layer of mucus membrane that carpets the inside of the uterus. The growth was not painful, but every time she menstruated and shed the endometrial lining, the blood vessels of the richly vascularized fibroid were exposed. Hence, the excessive bleeding that persisted beyond her period. Her doctor suggested that a dilation and curettage, or D & C, might help stem the red tide. In a D & C, the cervix is widened, or dilated, to allow doctors to insert surgical instruments into the uterus to perform a curettage—to scrape off the endometrium beyond what is normally shed in menstruation.
In Hope's case, the old dusting-and-cleaning procedure didn't help and in fact seemed to make things worse. "It got to the point where there were only ten days a month when I wasn't bleeding or spotting," she said. Her condition was inconvenient when she traveled, but she was a trouper, and she mastered the art of biased packing. Forget the change of shoes. When preparing for a three-month trip, she jammed more tampons and napkins into her suitcase than most women need in a year.
But the bleeding soon bled beyond mere cargo management. During one trip to Zimbabwe, she bled like Saint Sebastian. She worried that she would hemorrhage to the point where she'd need a transfusion, not something one wants to do on the continent where a retrovirus first leaped from monkey to human and in so migrating invented AIDS. Eventually she had another D & C in the United States. Several days later she became seriously ill. Her temperature soared to 102 degrees. She had to cancel a planned trip back to Africa. The doctors said her fibroid had grown so large that they could no longer see her uterus on ultrasound. Eventually she found herself in the office of Dr. Nicolette Horbach, of George Washington University Medical School, talking about removing the only part of the body that is unique to women, the one organ that doesn't have an anatomical equivalent in the male: the uterus.
As we've discussed, Galen and all who followed him for nearly the next two thousand years conceived of the female body as a sock taken off in a hurry—that is, as a male's body turned inside out. The vagina was an inverted penis, the labia a foreskin equivalent, the uterus an internal scrotum, and the ovaries a woman's testicles. Galen was no fool, and he was on the right track in observing the principle of genital equivalency. The adult genitals are homologous, though not entirely as Galen reckoned. Yes, the ovaries do correspond to the testes, but the female analogue of the penis is the clitoris, not the vagina, and the labia are the structural counterpart to the scrotum rather than the foreskin. Both sexes have responsive breast tissue as well, and a man's bosom is capable, under certain hormonal conditions, of swelling to brassiere-ready proportions, a condition known as gynecomastia (which means "female-like breasts").
But when we come to the uterus, anatomical homology breaks down. During the development of a male fetus, müllerian inhibiting factor eliminates the proto-womb when the structure is no bigger than a caraway seed, leaving nothing for the fetus's fidgety androgens to reinterpret. MIF also sweeps away the incipient fallopian tubes, but the second set of primordial pipes is retained and retrained into seminal ducts. The uterus alone offers a clear case of presence versus absence, to have or have not.
And what a weight the monosexual organ has borne. It has borne the weight of humanity, of course. Every one of the six billion people who are alive today, and the billions more who have already died, were coaxed into being through uterine tolerance for an implanted conceptus and uterine generosity in sharing a blood supply with the colonizing fetus. The uterus has borne the freight of extraordinary medical myths. Hippocrates believed that the organ wandered untethered through a woman's body, giving rise to any number of physical, mental, and moral failings; the word hysteria, after all, comes from the Greek hystera, for womb. Hippocrates also believed that the human uterus had as many as seven chambers and was lined with "tentacles" or "suckers." His bizarre errors were the result of laws and religious customs that forbade the dissection of the human body and required the great man of oath to extrapolate from the study of other species, which often do have wombs with multiple cavities and hornlike structures.
Hippocrates' blunder persisted until the Renaissance, when Leonardo da Vinci's gorgeous drawing of an opened uterus, revealing the fetus and its umbilical cord within, showed his awareness that the human womb has only one cavity. But in other anatomical drawings he illustrated a different fable of the time, that a "milk vein" extends from the uterus up to the breast, to transform blood from the pregnant uterus into milk for the newborn child. As recently as the nineteenth century, physicians argued that the uterus competes directly with the brain fo
r an adequate blood supply. Thus any effort a woman made to nourish her mind through education or career could come only at the expense of her fertility.
The war of the womb continues to this day. One of our most bellicose and indefatigable of issues, the abortion debate, distills to a question of who owns the uterus, woman or fetus (or a fetal proxy such as the church or state). Moreover, despite the fact that only half the population is endowed with one, the uterus is the site of the two most common surgical procedures performed in the United States. First is the cesarean section, in which the uterus is sliced open for the swift retrieval of an infant (who may or may not need this Green Beret approach to its delivery). Second is a far more severe storming of the uterus, the hysterectomy. And it is a hysterectomy that Horbach suggested to Hope Phillips as a possible solution to her runaway bleeding.
Horbach is an energetic, dark-haired woman who emphasizes her eyes with carefully applied makeup and who takes a pragmatic, even blunt approach to medicine. But blunt does not mean rushed. When she first met with Phillips, the conversation lasted two hours. Phillips described her symptoms, her medical history, and the demands of her job. She also talked about a recent change in her life that made her reluctant to have a hysterectomy. Phillips had been twice married and twice divorced, and in neither marriage had she ever considered becoming pregnant. But lately she had been dating a man with whom, for the first time in her life, she could imagine having children. "It was ironic, as though God were kicking me in the teeth," Phillips told me. Was there something she could do, she asked Horbach, to get rid of the fibroid while preserving her uterus?
Horbach laid out the options. You could take drugs called gonadotropin-releasing hormone agonists, she said, to temporarily block production of estrogen, which feeds fibroid growth. But those drugs tend to work only as long as you take them and have masculinizing side effects.
Alternatively, you could have a myomectomy, she said, the surgical removal of the fibroid from the uterus. Horbach turned on the blunt rigor. You're forty-five years old, she said to Phillips. In the best of circumstances, the chances of your becoming pregnant now are minute. Given the large size of your fibroid, its excision would make childbearing even less likely. Horbach pointed out that a myomectomy can be very bloody, possibly resulting in the need for a transfusion during the surgery, and can cause postoperative infections and complications. Should any of that occur, she warned, recovery could take longer than the standard four to six weeks required for a hysterectomy.
Horbach also said that Phillips could continue to do nothing and just live with the intemperate bleeding until she reached menopause. Once the body's natural estrogen production drops off, fibroids tend to shrink to inconsequential proportions.
Phillips went home to think. Five more years of chronic blood loss. She couldn't stand the thought, particularly not as the bleeding was getting progressively worse. She also considered the myomectomy option. But Horbach's words sat hard. What sort of little fantasy was she constructing for herself, that she might have major surgery, recover from surgery, get married to a man she had only recently met, and, at age forty-five or forty-six, instantly conceive? Her siblings were doing a fine job of reproducing, she thought. The family tree did not need her personal buds. Phillips was also disturbed by the thought of a lengthy recovery time from a myomectomy. "I've never defined myself by my uterus or my ability to bear children," she said. "But I do define myself by my work."
She talked with family and with friends. She mentioned the possibility of a hysterectomy to the man she was seeing, but his response did not exactly warm her heart. "Oh, yes," he said vaguely. "Some of my mother's friends have had that." Finally she decided to go through with the hysterectomy. Because of the size of her fibroid, the surgery had to be done abdominally rather than vaginally or through a laparoscopic tube, as hysterectomies sometimes are performed. She and Horbach agreed that I could watch the operation. I wanted to see what the internal reproductive organs look like: ovaries, fallopian tubes, cervix, uterus. The introduction to a fibroid—a huge, purple, ropy fibroid—was thrown in for free.
The surgical team that assembles at George Washington University Hospital for the hysterectomy early one March morning is delightfully unusual: three female surgeons (Horbach and two residents) and a male nurse. With the bottom half of her face covered by a surgical mask and her eyes rimmed with dark eyeliner, Horbach looks like Cleopatra. Phillips lies naked on the operating table, already in the land of happy. She is not under general anesthesia. Instead she has been given a tranquilizer to calm her and a spinal epidural to block sensation below the belt, a minimalist approach that is easier to recover from than a total knockout. She snores lightly as the staff prepares her for the operation. Her body looks young and athletic, too young for a surgery that has "middle-aged" and "my mother's friends" scrawled all over it. The prep team sprays her pelvis and abdomen with Betadine. They sponge her pubic hair into a froth. Once she has been scrubbed, she is draped to the neck with blue sheets, with only a triangle of flesh left exposed around her stomach. Her head is behind a curtain. She is a disembodied body, a woman en croute.
At Horbach's request, somebody slips a jazz tape into the OR boom box. The surgeons huddle over their pale white playing field. They make a six-inch slice below Phillips's bellybutton, and her skin beams back a bright red greeting. They cauterize the skin to cut off the bleeding. The surgeons then carve through the rectus fascia, the connective tissue beneath the skin that holds everything in place. They cut through Phillips's very thin layer of fat, which looks like the fat that marbles an uncooked chicken. Under the fat are her abdominal muscles, two pink layers of them, which the surgeons do not cut but merely push aside.
"This is textbook anatomy," Horbach says to her residents. "This is as gorgeous as it gets." Usually the women she operates on are a good hundred pounds heavier than Phillips, and slicing through all the flab is a nuisance. How much nicer to work by the best of the books.
Yet there is blood, blood, blood, and they must sop it up and sop it up and cauterize what they can. Finally they are inside the abdominal cavity. Clamps hold apart the layers of Hope. Her viscera look healthy and sprightly. They sparkle. Hope has become a living museum, open to the world. Thus it is a shock to hear her murmuring behind the curtain. After all, she is not unconscious, but merely in a state of calm, coming in and out of a nap; the epidural is what's doing all the numbing. She talks groggily to the anesthesiologist, and he reassures her that things are going fine. Horbach reaches into the cavity and palpates the various parts, the bladder, the kidneys, the gallbladder, the stomach, checking for abnormalities of any kind. Once you're in there, why not cop a few feels? "We occasionally find something more complicated than what we went in for," Horbach explains.
Not in this case, though: it's textbook anatomy. Horbach points out the ovaries to me. They are each about the size of a large strawberry, and they are smoke-colored and bumpy. They look like moist seedpods. On one is a noticeable white cyst, the probable spot of Phillips's last ovulation, when a ripe egg burst through the follicle and left behind a fluid-filled pocket that is still healing. Horbach also indicates the fallopian tubes, or oviducts, which are attached to the uterus. The tubes are exquisite, soft and rosy and slim as pens, tipped like a feather duster with a bell of fronds, called fimbriae. Gabriel Falloppius, the sixteenth-century anatomist after whom the structures were named, thought that the oviducts looked like trumpets and that they served to expel "noxious fumes" from the uterus. To me they look like sea anemones, flowers of flesh, the petals throbbing to the cadence of blood.
This particular hysterectomy will be a relatively conservative one, Horbach says. She is going to leave the oviducts and the ovaries in place. That doesn't always happen. Often surgeons take out the complete reproductive kit at once, uterus, cervix, tubes, and ovaries, snip, snip, snip. They reason that if a woman is near menopause, the system is about to retire anyway, so why leave things possibly to become cancerous
later on? Beware the seedpods! Ovarian cancer is deadly, the line goes, and it's usually silent until the disease has progressed beyond redemption. As long as we're performing major surgery, let's make it a little more major, eliminate the risk of ovarian cancer, and put the woman on hormone replacement therapy afterward.
But the prophylaxis argument for ancillary organ removal is a dubious one that has outraged many. Unnecessary ovariectomy is rank castration, they say. What is the point of taking out healthy body parts on the small chance that they'll turn cancerous in the future? You might as well take out one kidney before it goes bum, or the 85 percent of the liver you don't need—or, to return to the principle of genital equivalence, the testicles to prevent testicular cancer. Horbach had told Phillips during their consultation that she was strongly in favor of leaving the ovaries and tubes behind, and Phillips saw no reason to disagree.
Before they start removing the uterus, Horbach uses a wire to ligate off the major blood supply to the organ and thus cut down on bleeding. The surgeons scrutinize their target and soon realize that the operation will be more complicated than expected. The main fibroid is very large, and it has grossly deformed the uterus and cervix. It also has grown a big, parasitic blood supply to keep it nourished. Cancerous tumors do the same thing, inveigling the body to sprout new vessels to sustain them; all tissue, whether healthy or malign, needs blood to survive. The surgeons decide they will perform a partial myomectomy, cutting down on the fibroid in an effort to collapse the uterus and make the hysterectomy possible. They discuss how best to ligate and sever the tangle of fibroid blood vessels to prevent hemorrhaging. They find other, smaller fibroids stippling the uterus and making a mess for them. Horbach asks for an injection of vasopressin to constrict Phillips's blood vessels and further diminish bleeding. The doctors reach into the abdominal cavity practically up to their elbows and work with a concentration so palpable that I hold my breath in sympathy.
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