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The Trump Administration Is Giving Family Planning Funds to a Network of Anti-Abortion Clinics – Mother Jones

When I walked into the Obria clinic in Whittier, California, one evening in July, a woman in a modest floral-print dress organizing bundles of diapers in a back room greeted me hopefully. She thought Id come for a class. Instead, I asked if I had come to the right place for birth control. Furrowing her brow, she walked around a couch and through a cozy waiting room full of baby toys to the front desk. What sort of services were you looking for? she inquired. I asked if they dispensed the morning-after pill, the emergency contraception often called Plan B. She told me curtly, We dont provide that or refer for any birth control here.

I wasnt surprised. For most of its existence, this clinic has been known as the Whittier Pregnancy Care Clinic, a religious ministry that offers free pregnancy tests and ultrasounds in the hopes of dissuading women facing an unplanned pregnancy from having an abortion. The clinic provides lots of things: free diapers and baby supplies, and post-abortion Bible-based counseling. What the clinic has never provided is birth control.

When the Whittier clinic was strictly saving babies for the Lord, its refusal to dispense even a single condom was a private religious matter in the eyes of its funders. But today, the clinic is part of Obria, a Southern Californiabased chain of Christian pregnancy centers that in March won a $5.1 million Title X grant to provide contraception and family planning services to low-income women over three years. Created in 1970, Title X is the only federal program solely devoted to providing family planning services across the country. Congress created the program to fulfill President Richard Nixons promise that no American woman should be denied access to family planning assistance because of her economic condition. It serves 4 million low-income people nationwide annually on a budget of about $286 million and is estimated to prevent more than 800,000 unintended pregnancies every year.

Historically, federal regulations required that any organization receiving Title X funding provide a broad range of acceptable and effective medically approved family planning methods. But as I discovered during my visit to Whittier and other Obria clinics last summer, the organizations clinics refuse to provide contraception. Nor do they refer patients to other providers for birth control.

Obrias founder is opposed to all FDA-approved forms of birth control and has privately reassured anti-abortion donors that Obria will never dispense contraception, even as she has aggressively sought federal funding that requires exactly those services. Were an abstinence-only organization. It always works, Kathleen Eaton Bravo told the Catholic World Report in 2011. And for those single women who have had sex before marriage, we encourage them to embrace a second virginity.

Mara Gandal-Powers, director of birth control access at the nonprofit National Womens Law Center, does not think Bravos stance is in line with the intent of the Title X family planning program, but obviously they see it differently.

Should the Trump administration survive another four years, Obria may represent the future of the Title X program. In 2019, the Department of Health and Human Services instituted a gag rule that banned clinics getting Title X money from providing patients with referrals for abortions. (Federal law prohibits the program from funding abortions.) Seven state governments and Planned Parenthood, which served 40 percent of Title X patients, decided to drop out of the program rather than comply.

But even before Planned Parenthood was squeezed out, the White House had been pushing to redirect Title X and other federal funds to anti-abortion organizations like the Whittier clinic, which juggles its mandates of health care and family planning with pushing abstinence-only sex education, dissuading women from having abortions, and introducing them to the love of Christ, as its website says. In July, HHS awarded Obria nearly $500,000 from its teen pregnancy prevention program to provide sexual risk avoidance classes.

The Obria grant suggests that the Trump administrations assault on Title X is not just about reducing abortion access. Its part of the broader, if largely futile, culture war still waged by evangelical and other Christian conservatives heaven-bent on making America chaste again. Abstinence-only activists now control key posts at HHS and are driving policies that force their views about contraception onto the vast majority of Americans, who dont agree with them. While Americans opinions on abortion are mixed, only 4 percent think contraception is immoral, and 99 percent of women who have had sex have used it. Which raises a big question: Now that Obria has won millions in taxpayer dollars to provide anti-abortion family planning services, will anyone use what they are offering?

A screenshot of the Obria website

Obria is the brainchild of Kathleen Eaton Bravo, a devout Catholic who set out to build a pro-life alternative to Planned Parenthood. I wanted to create a comprehensive medical clinic model that could compete nose-to-nose with the large abortion providers, she wrote on the Obria Group website. Bravo may seek to emulate Planned Parenthoods organizational model, but she holds a dim view of it otherwise. In a 2015 interview with Catholic World Report, she claimed Planned Parenthood promoted a hook-up, contraceptive mentality among our young people. They teach children as young as 12 that they can have sex without consequences. She went on: Today, Planned Parenthood promotes oral sex, anal sex, and S&M sex.

Bravo did not respond to repeated requests for an interview. But she has said elsewhere that her involvement with the anti-abortion movement began after having an abortion in California in 1980 amid the collapse of a first marriage. Afterward, she remarried, moved to Oklahoma, rediscovered her Catholic faith, and started volunteering at a pregnancy center that tried to convince women to carry unplanned pregnancies to term. Bravo has described driving to Kansas to pray in front of the clinic of Dr. George Tiller, who would be murdered in 2009 by an anti-abortion extremist.

In Bravos public statements, there are echoes of the great replacement theory of abortion thats become popular among white supremacists. Abortion, she told Catholic World Report, threatens our cultures survival. Take the example of Europe. When its nations accepted contraception and abortion, they stopped replacing their population. Christianity began to die out. And, with Europeans having no children, immigrant Muslims came in to replace them, and now the culture of Europe is changing. The US faces a similar future.

After moving back to Southern California in the mid-1980s, Bravo took over a crisis pregnancy center in Mission Viejo called Birthright, whose name she later changed to Birth Choice. Crisis pregnancy centers (CPCs) have been an integral part of the anti-abortion movement for more than 50 years. The founder of the first known American CPC, Robert Pearson, pioneered the deceptive practices that would come to characterize their services to this day. He published a training manual that coached activists to set up CPCs to look like abortion clinics and use misleading ads to trick pregnant women into thinking they could get an abortion there. CPCs have a long, well-documented record of using high-pressure tactics on unsuspecting women and peddling misinformation like the myths that abortion causes breast cancer, infertility, and suicide.

Over the past three decades, pro-choice organizations, Democratic members of Congress, and state attorneys general have tried to expose and rein in some of the CPCs worst abuses. In 2015, California enacted the Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act, which required unlicensed CPCs to prominently disclose that they dont provide medical care (including abortions), and licensed ones to inform clients that the state offers free or low-cost family planning and abortion services. The CPC industry sued, and the Supreme Court struck down the law in 2018.

Obrias clinics dont appear to have ever been sanctioned by any government agencies for deceptive practices, but its Whittier clinic was one of many Los Angeles CPCs that a local public radio station found openly flouting the fact Act before the act was overturned. And Obrias RealOptions, a Northern California CPC chain thats a recipient of its Title X grant, was caught using mobile surveillance technology to target ads at women inside family planning clinics.

In 2015, the company hired a Massachusetts-based ad firm to set up virtual fences around family planning clinics to target abortion-minded women, according to the Massachusetts attorney general. When women entered the clinics, their smartphones would trip the fence, triggering a barrage of online RealOptions ads that said things like Pregnant? Its your choice. You have timeBe informed. The ads, which steered women to the pregnancy centers site, would continue to appear on their devices for a month after their clinic visit. The Massachusetts attorney general secured a settlement with the ad firm to end the practice in 2017 after alleging that it violated consumer protection laws.

Bravos vision for an anti-abortion rival to Planned Parenthood is deeply rooted in the crisis pregnancy center world. Bravo has said she wants to transform CPCs from Pampers and a prayer ministries into a network of life-affirming clinics that provide many of the services Planned Parenthood doesSTI testing, ultrasounds, and cervical cancer screenings, but without the birth control, abortion, or abortion referrals. I would close my doors before I do that, she told the Heritage Foundations Daily Signal in 2015.

By the middle of 2006, Bravo had expanded Birth Choice to include four CPCs. She got the centers licensed and accredited as community clinics and installed ultrasound machines to increase their conversion rate by convincing abortion-minded women to stay pregnant. Grants from the evangelical Christian advocacy group Focus on the Family and the Catholic Knights of Columbus paid for the machines. In 2014, she rebranded the nonprofit chain as Obria (a vaguely medicalized name made up by a marketing firm, ostensibly based on the Spanish word obra, meaning work) and announced an aggressive expansion plan. Bravo became the CEO of a new nonprofit umbrella organization called the Obria Group and essentially turned the operation into a franchise.

The Obria Group doesnt provide any medical services or even start new clinics. Rather, its a marketing arm that recruits existing CPCs to join the Obria network. Affiliated clinics pay a licensing fee to use the Obria name, but they remain separate legal entities with their own nonprofit status. (Bravos Birth Choice clinics are now a separate nonprofit called Obria Medical Clinics of Southern California, and she is no longer employed there or on its board.)

Bravo is politically well connected. On the Obria website, she brags that she has built a network of high-powered supporters over the decades to include former U.S. presidents, Washington lawmakers, senators, prominent mega-churches, spiritual leaders and thousands of behind-the-scene players who move mountains to get things done. Catholic World Report ran a prominent photo of her with President George W. Bush in 2010, when a Catholic business group presented them each with a Cardinal John J. OConnor pro-life award. Obrias advisory board was a whos who of the pro-life movement, including Jim Daly, president of Focus on the Family; Kristan Hawkins, a former official in Bushs Department of Health and Human Services who worked on Trumps pro-life advisory council during the 2016 campaign; and David Daleiden, CEO of the Center for Medical Progress, who was criminally charged in San Francisco for making undercover videos purporting to show Planned Parenthood selling tissue from aborted fetuses.

The Catholic Church and wealthy Catholic donors have provided much of Obrias funding, including a $2.5 million grant from the US Conference of Catholic Bishops for Obrias expansion plans. But Bravo has also secured public funding. In 2005, Birth Choice nabbed a $148,800 congressional earmark to fund three pregnancy centers. Between 2009 and 2016, the Orange County Board of Supervisors gave the Obria Medical Clinics of Southern California more than $700,000 for abstinence-only sex-ed programming, money that had previously gone to Planned Parenthood. Obria has even scored help from Google, which in 2015 gave Obria $120,000 worth of free ads through its nonprofit grant program.

This funding supports limited clinical offerings such as pregnancy testing, ultrasounds, and some STI testing and cervical cancer screening. A few clinics offer abortion pill reversal, the practice of giving women large doses of progesterone to try to halt a medically induced abortion in progress. (The American College of Obstetricians and Gynecologists says the treatment is not supported by science.)

Obrias medical director, Peter Anzaldo, is an Orange County OB-GYN and cosmetic surgeon who offers mommy makeovers in his private practice, using lasers to rejuvenate aging vaginasa controversial procedure the FDA has warned against as unapproved and potentially unsafe. While he provides many forms of contraception, including sterilization, at his office, Obrias contraception offerings consist of educational lectures about its various dangers, with a focus on abstinence until marriage. Despite providing STI testing and treatment, Obria wont dispense condoms, even now that its received Title X money thats supposed to go toward combating STIs.

However, Obria will help women learn the Catholic Church-approved natural family planning, a more complicated version of the rhythm method. Natural family planning requires women to regularly monitor their vaginal mucus and chart their temperature to avoid sex during ovulation. Obria claims on its website that the natural family planning success rate ranges from 75 to nearly 90 percent. The CDC cites a study showing that 24 percent of women became unintentionally pregnant within a year of using natural family planning, making this method one of the least effective forms of birth control.

For years, in speeches and fundraising pitches, Bravo has tried to sell Obria as a health care operation, not just a ministry, and its clinics seem to take great pains to downplay any outward evidence of its religious mission. The California clinics resemble doctors offices, and thats by design. Obrias affiliate application asks CPCs whether their staff is taught not to force religious beliefs or practices on patients, and it checks to make sure they dont have any crosses or bloody fetus photos displayed in their facilities. In a nod to the bad actors of the crisis pregnancy world, it also asks whether the applicant has ever been accused of false advertising. But Obrias implicit religious mission still seems to seep into its medical practice.

In 2018, after taking a home pregnancy test, a 27-year-old woman who asked to be identified as Huong visited the Obria affiliate in San Jose, California, which is part of the RealOptions CPC network. Shed recently been diagnosed with endometriosis with a procedure she hadnt known would temporarily increase her fertility. She was shocked to learn she was pregnant. It was a very difficult time in my life, Huong recalled. I was confused, scared. I just felt like I was 14 again. She was in an on-and-off relationship and strapped for cash. She looked online and found Obria.

Most crisis pregnancy centers appear to be conventional medical offices and are usually located near abortion facilities.

Mother Jones illustration; Google

At first, Huong thought Obria was an ordinary medical clinic. But when she told a clinic worker she was considering an abortion, the woman visibly looked appalled, Huong said. She said, I see here that youre 27. Why dont you just get married? When Huong said she didnt believe in marriage, she recalled that the woman asked, Why dont you just give it up for adoption?

I just felt like the scum of the earth, Huong said. I walked into this clinic thinking they were going to help me, and they were telling me to keep the baby and that Im a piece of trash for even considering abortion.

During an ultrasound, the nurse told Huong that she had friends with endometriosis who had become infertileand that this might be her last chance to conceive, an assessment she later learned was false. The nurse also said that if Huongs boyfriend was unsure about having a baby, the clinic would do the ultrasound again for free so he could see the fetusa practice that CPCs sometimes use to convince women to continue an unplanned pregnancy. Huong ended up having an abortion at Planned Parenthood. She said her experience at Obria was far more traumatic than the abortion itself. I remember feeling the worst Ive ever felt in my life, she said. It just messed me up.

The Obria medical clinic in Long Beach sits in a busy, low-rent strip mall, nestled between a Hong Kong Express and a Rent-a-Center. The clinics tiny waiting room has space for three or four people, but that wasnt a problem when I visited one morning in July. No one was waiting when I asked the woman at the front desk for the morning-after pill. No, we dont do the morning-after pill or any sort of birth control, she said. When I asked if she knew where I might find it, she said no. The morning-after pill is available at most pharmacies without a prescription. And like most crisis pregnancy centers, this one has set up shop near an abortion clinictwo of them, in fact. Its a three-minute walk from one of the states oldest abortion and family planning clinics and a six-minute walk from a Planned Parenthood.

I waited outside the clinic for an hour or so, hoping to find some patients to interview. But none came in. Out of curiosity, I crossed the Metro tracks to FPA Womens Health, which offers a full range of contraception. It isnt a Title X clinic, but it takes Medi-Cal, the state insurance for low-income Californians that Obria also accepts. I counted 16 people in its expansive waiting room. A woman in line was complaining because appointments were running behind schedule. I also paid a visit to the Planned Parenthood nearby. Its waiting room was full.

I wasnt just catching Obria on an off day. As a licensed community clinic, Obria is required to provide the state with annual data about services and clients. In 2018, its Long Beach clinic reported seeing 628 patients, fewer than two per day. The clinic didnt report conducting a single Pap smear or HIV test, and brought in just a little more than $10,000 in net revenue from patients. By contrast, in 2018, Planned Parenthoods Long Beach clinic reported seeing more than 9,400 patients. It performed 562 Pap smears. At both clinics, most patients whose income was recorded were on Medi-Cal, and almost half were poor, paying out of pocket for services on a sliding scale. The state insurance plan accounted for a big chunk of Planned Parenthoods more than $3 million in net revenue from patients. (As a private practice, FPA Womens Health isnt required to report its client data to the state.) In fact, Planned Parenthoods Long Beach clinic saw twice as many patients than all of Obrias licensed California clinics combined, which reported serving fewer than 4,500 patients in 2018. Not one of those clinics reported conducting a single Pap smear or HIV test.

Women with choices perhaps arent all that interested in what Obria is selling. Thats no surprise; according to the federal Office of Population Affairs, just 1 in 200 patients in the Title X program use natural family planning as their primary form of contraception. Even if Obria was offering the full range of contraceptive services, which from what Im able to tell they are not, they dont have experience doing family planning and serving these populations, said Gandal-Powers of the National Womens Law Center. Theres something to be said for serving the people who the grants are supposed to help.

Even if the Trump administration showered Obria with more federal funds, its not clear that many more women would use its clinics. In 2013, Texas kicked Planned Parenthood out of its state family planning program, and in 2016, to fill the void, the state funneled millions of dollars to an anti-abortion organization called the Heidi Group. The Heidi Group had promised it would serve 70,000 patients a year through a network of CPCs and other providers. But in 2017, the organization served just over 3,300 people, according to the Texas Observer. The Heidi Groups performance was so bad that in 2018 the state pulled the plug on its contract and began investigating its spending. The group then partnered with Obria to apply unsuccessfully for a Title X grant in Texas. This month, a state inspector general found that the Heidi Group should reimburse the state $1.5 million in misspent contract funds it received for inflated payments and prohibited expenses for things like food, clothing and gift cards.

Despite the lack of demand for her organizations services, Kathleen Bravo has repeatedly claimed that the network is making massive expansion plans. In 2014, she announced a new infusion of funds from the US Conference of Catholic Bishops, and said that Obria would grow to 200 clinics by 2020. Obria did not respond to a request for a full list of its locations, but at a September 2019 anti-abortion conference, Bravo put the number of Obria clinics at just 48. Using California state data, Obrias website, and documents the group provided to HHS as part of Obrias three Title X grant applications, Mother Jones could identify even feweronly 18 brick-and-mortar clinics, plus four mobile clinics.

In 2017, Obria hired Abby Johnson, a former Planned Parenthood clinic director turned pro-life activist, to manage its expansion. Distressed by what she saw on the inside, she ended up quitting Obria after about a year. She has since become one of the networks most outspoken anti-abortion critics in part because she believes Obria is misleading the anti-choice movement about its operations, including how many clinics it actually has. For instance, she said, Obria would tell donors it had five or six clinics in Oregon, when in fact it had one brick-and-mortar clinic in the state, plus a mobile van that would park in a different location every day.

Bravo had convinced the US Conference of Catholic Bishops that they were going to be saving all these babies from abortion, and here they were four years later and none of that [expansion] happened, Johnson said. In fact, the clinics in California were bleeding money. One of the reasons is that Obria was thousands of dollars behind in its Medi-Cal billing. They didnt know what they were doing, she said. They didnt know how to bill.

State data and IRS forms support her account. One of Obrias California clinics closed in 2017 after serving only 45 patients that year. Obrias tax forms show that its Southern California nonprofit was running a deficit and that grants and donations had fallen sharply, from $2.8 million in 2016 to $1.7 million in 2017. While the Southern California clinics were losing money, contributions to the Obria Group jumped from almost zero in 2014 and 2015 to more than $800,000 in the fiscal year ending in September 2017. The Obria Group doesnt provide any health care services or run any clinics, but it does pay Bravo $192,000 a year in salary and benefits, almost a quarter of the $800,000 it raised in 2017.

When she worked at Obria, Johnson said she had argued against applying for Title X funding because she believed it would require the organization to provide referrals for contraception, which would conflict with its values and upset its anti-abortion benefactors. Officials at HHS made it very clear to me that yes, Title X requires a contraceptive referral, she said. There is absolutely no way to get around that. But Obria went after the federal funding anyway.

If we get funded through Title X, we can advance our technology, we can advance our reach, we can serve more patients, we can expand our services, Bravo said in a Facebook video posted by Students for Life. Yet Obrias grant proposal indicates that if it received all the money it was asking forabout $6 million over three yearsthe Obria affiliate clinics in California would still serve only 5,500 patients, about 1,000 more than in 2018. The Title X grant was absolutely a cash grab for them, Johnson said, because they are sinking.

Anti-abortion activist Abby Johnson joined Obria in 2017, but she quit after about a year. She has since become one of the networks most outspoken anti-abortion critics.

Bastiaan Slabbers/NurPhoto/Getty

Over the past few years, the Trump administration has waged war on Title X as part of its larger mission to defund Planned Parenthood. In 2017, HHS forced all organizations receiving multiyear Title X grants to reapply for the funds on short notice. In February 2018, under the leadership of Valerie Huber, an abstinence-only sex-ed activist who was then the acting assistant secretary for population affairs, HHS rewrote the grants rules. The new funding announcement contained no mention of contraception and gave preference to poorly funded faith-based organizations that focused on natural family planning and abstinence.

Historically, an independent review committee evaluated Title X grant applications, and regional HHS career administrators would make the final awards. The process, created in the 1980s to keep politics out of grant-making, has been undone by the Trump administration. In 2018, it announced that the deputy assistant secretary for population affairs, a political appointee, would make final Title X decisions. Since May 2018, that role has been filled by Diane Foley, a pediatrician who through 2016 ran a Colorado Christian anti-abortion group with ties to Focus on the Family and who has promoted abstinence-only sex-ed programs. (She has said that teaching kids to use condoms by, say, putting them on bananas could be sexually harassing.)

Even with the playing field tilted in Obrias favor, Politico reported that HHS rejected the groups 2018 funding application because it refused to offer contraception. So Obria tried a different tack: It reapplied, this time focusing solely on California and promising to provide a broad range of birth control through a partnership with two federally qualified health centers that already offer contraception and sterilization services. Those two subcontractors would serve more than 40 percent of the 12,000 clients Obria promised to handle through the Title X grant. The application angered many in the anti-abortion movement. Other anti-choice organizations that had initially sought Title X funds from the Trump administration eventually withdrew from the process after HHS told them theyd have to provide contraception or refer clients to partner groups that did. These organizations didnt see how Obria could do this without violating their anti-abortion values.

If Obria did find a way to avoid providing or referring for contraception, it would be impressive, and we would applaud them, Christine Accurso, executive director of a consortium of anti-abortion health care centers, told the National Catholic Register not long after HHS announced Obrias Title X award. However, we have confirmed multiple times from HHS leadership that a sub-grantee is required to refer for contraceptives if they do not provide them.

Bravo had privately reassured donors in January 2019 that Obria would never dispense contraception or refer for it. Obrias clinic model is committed to never provide hormonal contraception nor abortions! Obria promotes abstinence-based sexual risk avoidance educationthe most effective public health model for promoting healthy behaviors, Bravo wrote in an email obtained by the Campaign for Accountability, a liberal watchdog group that has sued HHS to get public records about the Obria grant.

In March, HHS awarded $1.7 million for Obrias California proposal, with the potential for a total of more than $5 million over the next three years. Title X was created to help low-income women control their reproductive futures by providing them access to birth control, said Alice Huling, counsel for the Campaign for Accountability. Yet HHS gave these funds to a group that is fundamentally opposed to birth control. It just doesnt make sense.

Many things about the Obria grant make no sense, including where the money is going. In the October 2019 directory of Title X service sites published by HHS, Obria is listed as a grantee, with seven California services sites plus a mobile van. There is no mention of the federally qualified health centers that were supposed to provide the forms of contraception required under the grant. HHS declined to provide any information about the services Obria offered and wouldnt say whether the group is required to provide birth control referrals at its clinics. Obria did not respond to multiple requests for a full list of where its Title X family planning services will be provided, or by whom.

Obrias California proposal did indicate that a community health organization called Culture of Life Family Services would provide Title X services at two sites to at least 750 patients a year. The organizations medical director is George Delgado, a family medicine doctor known for pioneering the bogus abortion pill reversal. Culture of Life doesnt provide contraception and it also wont make referrals for it. Johnson, the former Obria expansion director, said Obria included Culture of Life in its grant application without Delgados permission. She said Delgado only learned about it after Obria submitted the application, and that he had to inform HHS that his pro-life clinic could not participate in Title X. Neither Obria nor Delgado responded to questions about the grant. Obrias grant application doesnt contain a letter of commitment from Culture of Life, as it does for its other partners, and Obrias PR firm told the Guardian in July 2019 that Delgados clinic was not on its final list of subgrantees.

At least one other clinic that was part of Obrias California grant application doesnt appear in the October 2019 Title X provider directory. Horizon Pregnancy Clinic, a CPC in Huntington Beach, was supposed to handle 500 of the 12,000 clients Obria promised to serve annually. Debra Tous, Horizons executive director, said in an email in August that she did not know the details of Obrias Title X grant, which started on April 1. We are still in beginning stages of discussing what is involved, she said before referring further questions to Obria.

The address listed on Obrias website for its Anaheim location is not a clinic but the St. Boniface Catholic Church. When I pulled up there one day in July, I couldnt find any sign of an Obria outpost until a man watering the garden pointed me around back to a nearly empty parking lot, where I found an RVObrias mobile clinic, parked within view of Anaheim High School, a prime target for its services, once students return in the fall.

After a long walk across the lot, I found Keith Cotton, the church and community outreach manager for Obrias Southern California operation, and nurse Judy Parker sitting at a small card table under the RVs awning. They were excited to see me. In its application for Title X funding, Obria said this mobile clinic would serve 500 low-income patients a year. Cotton and Parker clearly hadnt had many, if any, patients that day.

Cotton, who I later learned got his start in activism working at evangelical minister Rick Warrens Saddleback megachurch in Orange County, asked cheerily if Id like an STI test. STIs are on the rise in California and elsewhere, and Obria is supposed to be combating them with its Title X grant. I chickened out at the prospect of having blood drawn. Instead, I asked if they could check me for a yeast infection. Its the sort of ordinary, uncontroversial womens health problem that should be treatable in a bona fide medical practice or at any Planned Parenthood, and fell under the heading of the well-woman care that Obria had promised in its federal grant application. Plus, I had some symptoms, so it was an honest request.

Cotton said Obria could help, but I would have to go to its free-standing clinic in nearby Orange. He and Parker walked me through the costs, explained the sliding-scale fee, and made me an appointment, which involved answering awkward personal questions about my health history and symptoms. Cotton and Parker were nice, but I couldnt imagine a teenager having a conversation about STIs in the middle of this parking lot. Before I left, the pair kindly offered me recommendations for lunch, but not a single condomamong the best defenses against STIs, and a hallmark of legitimate public health prevention programs.

That afternoon, I dropped in at the Orange clinic. The only person in the waiting room was a Latina woman too old to need family planning services. I paid my $69 fee and filled out forms that asked surprisingly invasive questions Id never seen on an OB-GYN or Planned Parenthood intake form, including Who usually initiates your sexual activities? Others, more standard, were about my abortion history, including how I would deal with a positive pregnancy test. And then there was this one: If considering abortion, would you like Chlamydia/Gonorrhea testing today? which seemed like a weird non sequitur. The form also asked patients to specify their religion. I signed a Limitation of Services that read: Obria medical clinics does [sic] not perform or refer for abortions. It didnt mention contraception.

While I was filling out the paperwork, a smiling young Latino couple walked out of the exam area. They seemed excited to be having a baby. After a short wait, a nurse took my vitals and directed me into an exam room. Inside, the young womans sonogram still appeared on an ultrasound screen. On the wall, a scary chart claimed to show how sexual exposure goes up exponentially with every additional partner. If youve had 10 sexual partners, it indicated, youve really had sex with more than 1,000 people! I discovered later that the chart is a staple of Christian abstinence-until-marriage sex-ed programs like the one Obria runs.

Eventually I had to put my feet in the stirrups for an exam by Carol Gardner, a longtime Obria doctor and vocal anti-abortion advocate. There was no lab on-site, so Gardner gave me a prescription for an anti-fungal pill and said the clinic would call in a few days with my results. (A few days later, I found out I tested negative.) The staff and volunteers treated me kindly and with respect. Based on my one visit, I had to conclude that Obrias Orange clinic was not fake, as the groups critics have frequently alleged.

But good intentions are really beside the point. No one is suggesting that Obria shouldnt be able to offer these kinds of limited health services to women who want them. The issue is whether its legal for Obria to take federal money for family planning and STI prevention but refuse to provide contraception and condoms or referrals for them. I couldnt find a single public policy, academic, or legal expert who could answer that question, and HHS declined to comment. Theres also a much broader public policy question in play: Are Obrias scant offerings, however thoughtfully theyre delivered, really the best use of limited taxpayer dollars dedicated to essential family planning services?

The 2019 grant to Obria provided funding that previously went to Californias primary Title X recipient, Essential Access Health. In 2018, Essential Access Health received about $23 million in Title X funds, which it distributed to more than 200 family planning clinics across the state, including city and county health departments and Planned Parenthood. In 2019, that budget was cut to $21 million; the other $1.7 million went to Obria. We are very concerned that this will lead to low-income women facing more delays in access to the care they want and need to effectively reduce their risk of experiencing an unintended pregnancy, said Essential Access Health CEO Julie Rabinovitz. The changes this administration has made to the Title X program have been implemented to advance a political agenda, not public health.

The entire annual Title X budget is a measly $286 million. To fill the unmet need of family planning services among low-income women, the Title X budget would need to more than double, to about $700 million a year, according to a 2016 study in the American Journal of Public Health. Reducing access to programs that provide more effective forms of contraception like IUDs or birth control pills all but guarantees more unplanned pregnancies and abortions.

Bravo insists that Obria clinics should get some of that federal funding because women want life-affirming choices for family planning. And some low-income women probably do want to learn natural family planning or find abstinence coaching, or what Bravo describes as a second virginity. But the Trump administrations efforts to shift funding to Obria and groups like it arent just about religious freedom or broadening womens choices under Title X. The conservative Christians in Trumps administration would like to push low-income women to use places like Obria for family planning or reproductive health care. And ultimately, thats no choice at all.

Link:
The Trump Administration Is Giving Family Planning Funds to a Network of Anti-Abortion Clinics - Mother Jones

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Clitoris – Wikipedia

The clitoris ((listen) or (listen)) is a female sex organ present in mammals, ostriches and a limited number of other animals. In humans, the visible portion - the glans - is at the front junction of the labia minora (inner lips), above the opening of the urethra. Unlike the penis, the male homologue (equivalent) to the clitoris, it usually does not contain the distal portion (or opening) of the urethra and is therefore not used for urination. The clitoris also usually lacks a reproductive function. While few animals urinate through the clitoris or use it reproductively, the spotted hyena, which has an especially large clitoris, urinates, mates, and gives birth via the organ. Some other mammals, such as lemurs and spider monkeys, also have a large clitoris.[1]

The clitoris is the human female's most sensitive erogenous zone and generally the primary anatomical source of human female sexual pleasure.[2] In humans and other mammals, it develops from an outgrowth in the embryo called the genital tubercle. Initially undifferentiated, the tubercle develops into either a penis or a clitoris, depending on the presence or absence of the protein tdf, which is codified by a single gene on the Y chromosome. The clitoris is a complex structure, and its size and sensitivity can vary. The glans (head) of the human clitoris is roughly the size and shape of a pea, and is estimated to have about 8,000 sensory nerve endings.[3]

Sexological, medical, and psychological debate have focused on the clitoris,[4] and it has been subject to social constructionist analyses and studies.[5] Such discussions range from anatomical accuracy, gender inequality, female genital mutilation, and orgasmic factors and their physiological explanation for the G-spot.[6] Although, in humans, the only known purpose of the clitoris is to provide sexual pleasure, whether the clitoris is vestigial, an adaptation, or serves a reproductive function has been debated.[7] Social perceptions of the clitoris include the significance of its role in female sexual pleasure, assumptions about its true size and depth, and varying beliefs regarding genital modification such as clitoris enlargement, clitoris piercing and clitoridectomy.[8] Genital modification may be for aesthetic, medical or cultural reasons.[8]

Knowledge of the clitoris is significantly impacted by cultural perceptions of the organ. Studies suggest that knowledge of its existence and anatomy is scant in comparison with that of other sexual organs, and that more education about it could help alleviate social stigmas associated with the female body and female sexual pleasure; for example, that the clitoris and vulva in general are visually unappealing, that female masturbation is taboo, or that men should be expected to master and control women's orgasms.[9]

The Oxford English Dictionary states that the word clitoris likely has its origin in the Ancient Greek , kleitoris, perhaps derived from the verb , kleiein, "to shut".[10] Clitoris is also Greek for the word key, "indicating that the ancient anatomists considered it the key" to female sexuality.[11][12] In addition to key, the Online Etymology Dictionary suggests other Greek candidates for the word's etymology include a noun meaning "latch" or "hook"; a verb meaning "to touch or titillate lasciviously", "to tickle" (one German synonym for the clitoris is der Kitzler, "the tickler"), although this verb is more likely derived from "clitoris"; and a word meaning "side of a hill", from the same root as "climax".[13] The Oxford English Dictionary also states that the shortened form "clit", the first occurrence of which was noted in the United States, has been used in print since 1958: until then, the common abbreviation was "clitty".[10]

The plural forms are clitorises in English and clitorides in Latin. The Latin genitive is clitoridis, as in "glans clitoridis". In medical and sexological literature, the clitoris is sometimes referred to as "the female penis" or pseudo-penis,[14] and the term clitoris is commonly used to refer to the glans alone;[15] partially because of this, there have been various terms for the organ that have historically confused its anatomy.

In mammals, sexual differentiation is determined by the sperm that carries either an X or a Y (male) chromosome.[16] The Y chromosome contains a sex-determining gene (SRY) that encodes a transcription factor for the protein tdf (testis determining factor) and triggers the creation of testosterone and Anti-Mllerian hormone for the embryo's development into a male.[17][18] This differentiation begins about eight or nine weeks after conception.[17] Some sources state that it continues until the twelfth week,[19] while others state that it is clearly evident by the thirteenth week and that the sex organs are fully developed by the sixteenth week.[20]

The clitoris develops from a phallic outgrowth in the embryo called the genital tubercle. Initially undifferentiated, the tubercle develops into either a clitoris or penis during development of the reproductive system depending on exposure to androgens (primarily male hormones). The clitoris forms from the same tissues that become the glans and shaft of the penis, and this shared embryonic origin makes these two organs homologous (different versions of the same structure).[21]

If exposed to testosterone, the genital tubercle elongates to form the penis. By fusion of the urogenital folds elongated spindle-shaped structures that contribute to the formation of the urethral groove on the belly aspect of the genital tubercle the urogenital sinus closes completely and forms the spongy urethra, and the labioscrotal swellings unite to form the scrotum.[21] In the absence of testosterone, the genital tubercle allows for formation of the clitoris; the initially rapid growth of the phallus gradually slows and the clitoris is formed. The urogenital sinus persists as the vestibule of the vagina, the two urogenital folds form the labia minora, and the labioscrotal swellings enlarge to form the labia majora, completing the female genitalia.[21] A rare condition that can develop from higher than average androgen exposure is clitoromegaly.[22]

The clitoris contains external and internal components. It consists of the glans, the body (which is composed of two erectile structures known as the corpora cavernosa), and two crura ("legs"). It has a hood formed by the labia minora (inner lips). It also has vestibular or clitoral bulbs. The frenulum of clitoris is a frenulum on the under-surface of the glans and is created by the two medial parts of the labia minora.[23] The clitoral body may be referred to as the shaft (or internal shaft), while the length of the clitoris between the glans and the body may also be referred to as the shaft. The shaft supports the glans, and its shape can be seen and felt through the clitoral hood.[24]

Research indicates that clitoral tissue extends into the vagina's anterior wall.[25] enayl et al. said that the histological evaluation of the clitoris, "especially of the corpora cavernosa, is incomplete because for many years the clitoris was considered a rudimentary and nonfunctional organ." They added that Baskin and colleagues examined the clitoris's masculinization after dissection and, using imaging software after Masson chrome staining, put the serial dissected specimens together; this revealed that the nerves of the clitoris surround the whole clitoral body (corpus).[26]

The clitoris, vestibular bulbs, labia minora, and urethra involve two histologically distinct types of vascular tissue (tissue related to blood vessels), the first of which is trabeculated, erectile tissue innervated by the cavernous nerves. The trabeculated tissue has a spongy appearance; along with blood, it fills the large, dilated vascular spaces of the clitoris and the bulbs. Beneath the epithelium of the vascular areas is smooth muscle.[27] As indicated by Yang et al.'s research, it may also be that the urethral lumen (the inner open space or cavity of the urethra), which is surrounded by spongy tissue, has tissue that "is grossly distinct from the vascular tissue of the clitoris and bulbs, and on macroscopic observation, is paler than the dark tissue" of the clitoris and bulbs.[28] The second type of vascular tissue is non-erectile, which may consist of blood vessels that are dispersed within a fibrous matrix and have only a minimal amount of smooth muscle.[27]

Highly innervated, the glans exists at the tip of the clitoral body as a fibro-vascular cap,[27] and is usually the size and shape of a pea, although it is sometimes much larger or smaller. The clitoral glans, or the entire clitoris, is estimated to have about 8,000 sensory nerve endings.[3] Research conflicts on whether or not the glans is composed of erectile or non-erectile tissue. Although the clitoral body becomes engorged with blood upon sexual arousal, erecting the clitoral glans, some sources describe the clitoral glans and labia minora as composed of non-erectile tissue; this is especially the case for the glans.[15][27] They state that the clitoral glans and labia minora have blood vessels that are dispersed within a fibrous matrix and have only a minimal amount of smooth muscle,[27] or that the clitoral glans is "a midline, densely neural, non-erectile structure".[15]

Other descriptions of the glans assert that it is composed of erectile tissue and that erectile tissue is present within the labia minora.[29] The glans may be noted as having glanular vascular spaces that are not as prominent as those in the clitoral body, with the spaces being separated more by smooth muscle than in the body and crura.[28] Adipose tissue is absent in the labia minora, but the organ may be described as being made up of dense connective tissue, erectile tissue and elastic fibers.[29]

The clitoral body forms a wishbone-shaped structure containing the corpora cavernosa a pair of sponge-like regions of erectile tissue which contain most of the blood in the clitoris during clitoral erection. The two corpora forming the clitoral body are surrounded by thick fibro-elastic tunica albuginea, literally meaning "white covering", connective tissue. These corpora are separated incompletely from each other in the midline by a fibrous pectiniform septum a comblike band of connective tissue extending between the corpora cavernosa.[26][27]

The clitoral body extends up to several centimeters before reversing direction and branching, resulting in an inverted "V" shape that extends as a pair of crura ("legs").[30] The crura are the proximal portions of the arms of the wishbone. Ending at the glans of the clitoris, the tip of the body bends anteriorly away from the pubis.[28] Each crus (singular form of crura) is attached to the corresponding ischial ramus extensions of the copora beneath the descending pubic rami.[26][27] Concealed behind the labia minora, the crura end with attachment at or just below the middle of the pubic arch.[N 1][32] Associated are the urethral sponge, perineal sponge, a network of nerves and blood vessels, the suspensory ligament of the clitoris, muscles and the pelvic floor.[27][33]

There is no identified correlation between the size of the clitoral glans, or clitoris as a whole, and a woman's age, height, weight, use of hormonal contraception, or being post-menopausal, although women who have given birth may have significantly larger clitoral measurements.[34] Centimeter (cm) and millimeter (mm) measurements of the clitoris show variations in its size. The clitoral glans has been cited as typically varying from 2mm to 1cm and usually being estimated at 4 to 5mm in both the transverse and longitudinal planes.[35]

A 1992 study concluded that the total clitoral length, including glans and body, is 16.04.3mm (0.630.17in), where 16mm is the mean and 4.3mm is the standard deviation.[36] Concerning other studies, researchers from the Elizabeth Garrett Anderson and Obstetric Hospital in London measured the labia and other genital structures of 50 women from the age of 18 to 50, with a mean age of 35.6., from 2003 to 2004, and the results given for the clitoral glans were 310mm for the range and 5.5 [1.7] mm for the mean.[37] Other research indicates that the clitoral body can measure 57 centimetres (2.02.8in) in length, while the clitoral body and crura together can be 10 centimetres (3.9in) or more in length.[27]

The clitoral hood projects at the front of the labia commissure, where the edges of the labia majora (outer lips) meet at the base of the pubic mound; it is partially formed by fusion of the upper part of the external folds of the labia minora (inner lips) and covers the glans and external shaft.[38] There is considerable variation in how much of the glans protrudes from the hood and how much is covered by it, ranging from completely covered to fully exposed,[36] and tissue of the labia minora also encircles the base of the glans.[39]

The vestibular bulbs are more closely related to the clitoris than the vestibule because of the similarity of the trabecular and erectile tissue within the clitoris and bulbs, and the absence of trabecular tissue in other genital organs, with the erectile tissue's trabecular nature allowing engorgement and expansion during sexual arousal.[27][39] The vestibular bulbs are typically described as lying close to the crura on either side of the vaginal opening; internally, they are beneath the labia majora. When engorged with blood, they cuff the vaginal opening and cause the vulva to expand outward.[27] Although a number of texts state that they surround the vaginal opening, Ginger et al. state that this does not appear to be the case and tunica albuginea does not envelop the erectile tissue of the bulbs.[27] In Yang et al.'s assessment of the bulbs' anatomy, they conclude that the bulbs "arch over the distal urethra, outlining what might be appropriately called the 'bulbar urethra' in women."[28]

The clitoris and penis are generally the same anatomical structure, although the distal portion (or opening) of the urethra is absent in the clitoris of humans and most other animals. The idea that males have clitorises was suggested in 1987 by researcher Josephine Lowndes Sevely, who theorized that the male corpora cavernosa (a pair of sponge-like regions of erectile tissue which contain most of the blood in the penis during penile erection) are the true counterpart of the clitoris. She argued that "the male clitoris" is directly beneath the rim of the glans penis, where the frenulum of prepuce of the penis (a fold of the prepuce) is located, and proposed that this area be called the "Lownde's crown." Her theory and proposal, though acknowledged in anatomical literature, did not materialize in anatomy books.[40] Modern anatomical texts show that the clitoris displays a hood that is the equivalent of the penis's foreskin, which covers the glans. It also has a shaft that is attached to the glans. The male corpora cavernosa are homologous to the corpus cavernosum clitoridis (the female cavernosa), the bulb of penis (also known as the bulb of the corpus spongiosum penis) is homologous to the vestibular bulbs beneath the labia minora, and the scrotum is homologous to the labia minora and labia majora.[41]

Upon anatomical study, the penis can be described as a clitoris that has been mostly pulled out of the body and grafted on top of a significantly smaller piece of spongiosum containing the urethra.[41] With regard to nerve endings, the human clitoris's estimated 8,000 or more (for its glans or clitoral body as a whole) is commonly cited as being twice as many as the nerve endings found in the human penis (for its glans or body as a whole), and as more than any other part of the human body.[3] These reports sometimes conflict with other sources on clitoral anatomy or those concerning the nerve endings in the human penis. For example, while some sources estimate that the human penis has 4,000 nerve endings,[3] other sources state that the glans or the entire penile structure have the same amount of nerve endings as the clitoral glans,[42] or discuss whether the uncircumcised penis has thousands more than the circumcised penis or is generally more sensitive.[43][44]

Some sources state that in contrast to the glans penis, the clitoral glans lacks smooth muscle within its fibrovascular cap and is thus differentiated from the erectile tissues of the clitoris and bulbs; additionally, bulb size varies and may be dependent on age and estrogenization.[27] While the bulbs are considered the equivalent of the male spongiosum, they do not completely encircle the urethra.[27]

The thin corpus spongiosum of the penis runs along the underside of the penile shaft, enveloping the urethra, and expands at the end to form the glans. It partially contributes to erection, which are primarily caused by the two corpora cavernosa that comprise the bulk of the shaft; like the female cavernosa, the male cavernosa soak up blood and become erect when sexually excited.[45] The male corpora cavernosa taper off internally on reaching the spongiosum head.[45] With regard to the Y-shape of the cavernosa crown, body, and legs the body accounts for much more of the structure in men, and the legs are stubbier; typically, the cavernosa are longer and thicker in males than in females.[28][46]

The clitoris has an abundance of nerve endings, and is the human female's most sensitive erogenous zone and generally the primary anatomical source of human female sexual pleasure.[2] When sexually stimulated, it may incite female sexual arousal. Sexual stimulation, including arousal, may result from mental stimulation, foreplay with a sexual partner, or masturbation, and may lead to orgasm.[47] The most effective sexual stimulation of the organ is usually manually or orally (cunnilingus), which is often referred to as direct clitoral stimulation; in cases involving sexual penetration, these activities may also be referred to as additional or assisted clitoral stimulation.[48]

Direct clitoral stimulation involves physical stimulation to the external anatomy of the clitoris glans, hood and the external shaft.[49] Stimulation of the labia minora (inner lips), due to its external connection with the glans and hood, may have the same effect as direct clitoral stimulation.[50] Though these areas may also receive indirect physical stimulation during sexual activity, such as when in friction with the labia majora (outer lips),[51] indirect clitoral stimulation is more commonly attributed to penile-vaginal penetration.[52][53] Penile-anal penetration may also indirectly stimulate the clitoris by the shared sensory nerves (especially the pudendal nerve, which gives off the inferior anal nerves and divides into two terminal branches: the perineal nerve and the dorsal nerve of the clitoris).[54]

Due to the glans's high sensitivity, direct stimulation to it is not always pleasurable; instead, direct stimulation to the hood or the areas near the glans are often more pleasurable, with the majority of women preferring to use the hood to stimulate the glans, or to have the glans rolled between the lips of the labia, for indirect touch.[55] It is also common for women to enjoy the shaft of the clitoris being softly caressed in concert with occasional circling of the clitoral glans. This might be with or without manual penetration of the vagina, while other women enjoy having the entire area of the vulva caressed.[56] As opposed to use of dry fingers, stimulation from fingers that have been well-lubricated, either by vaginal lubrication or a personal lubricant, is usually more pleasurable for the external anatomy of the clitoris.[57][58]

As the clitoris's external location does not allow for direct stimulation by sexual penetration, any external clitoral stimulation while in the missionary position usually results from the pubic bone area, the movement of the groins when in contact. As such, some couples may engage in the woman-on-top position or the coital alignment technique, a sex position combining the "riding high" variation of the missionary position with pressure-counterpressure movements performed by each partner in rhythm with sexual penetration, to maximize clitoral stimulation.[59][60] Lesbian couples may engage in tribadism for ample clitoral stimulation or for mutual clitoral stimulation during whole-body contact.[N 2][62][63] Pressing the penis in a gliding or circular motion against the clitoris (intercrural sex), or stimulating it by movement against another body part, may also be practiced.[64][65] A vibrator (such as a clitoral vibrator), dildo or other sex toy may be used.[64][66] Other women stimulate the clitoris by use of a pillow or other inanimate object, by a jet of water from the faucet of a bathtub or shower, or by closing their legs and rocking.[67][68][69]

During sexual arousal, the clitoris and the whole of the genitalia engorge and change color as the erectile tissues fill with blood (vasocongestion), and the individual experiences vaginal contractions.[70] The ischiocavernosus and bulbocavernosus muscles, which insert into the corpora cavernosa, contract and compress the dorsal vein of the clitoris (the only vein that drains the blood from the spaces in the corpora cavernosa) and the arterial blood continues a steady flow and, having no way to drain out, fills the venous spaces until they become turgid and engorged with blood. This is what leads to clitoral erection.[11][71]

The clitoral glans doubles in diameter upon arousal, and, upon further stimulation, it becomes less visible as it is covered by the swelling of tissues of the clitoral hood.[70][72] The swelling protects the glans from direct contact, as direct contact at this stage can be more irritating than pleasurable.[72][73] Vasocongestion eventually triggers a muscular reflex, which expels the blood that was trapped in surrounding tissues, and leads to an orgasm.[74] A short time after stimulation has stopped, especially if orgasm has been achieved, the glans becomes visible again and returns to its normal state,[75] with a few seconds (usually 510) to return to its normal position and 510 minutes to return to its original size.[N 3][72][77] If orgasm is not achieved, the clitoris may remain engorged for a few hours, which women often find uncomfortable.[59] Additionally, the clitoris is very sensitive after orgasm, making further stimulation initially painful for some women.[78]

General statistics indicate that 7080 percent of women require direct clitoral stimulation (consistent manual, oral or other concentrated friction against the external parts of the clitoris) to reach orgasm.[N 4][N 5][N 6][82] Indirect clitoral stimulation (for example, via vaginal penetration) may also be sufficient for female orgasm.[N 7][15][84] The area near the entrance of the vagina (the lower third) contains nearly 90percent of the vaginal nerve endings, and there are areas in the anterior vaginal wall and between the top junction of the labia minora and the urethra that are especially sensitive, but intense sexual pleasure, including orgasm, solely from vaginal stimulation is occasional or otherwise absent because the vagina has significantly fewer nerve endings than the clitoris.[85]

Prominent debate over the quantity of vaginal nerve endings began with Alfred Kinsey. Although Sigmund Freud's theory that clitoral orgasms are a prepubertal or adolescent phenomenon and that vaginal (or G-spot) orgasms are something that only physically mature females experience had been criticized before, Kinsey was the first researcher to harshly criticize the theory.[86][87] Through his observations of female masturbation and interviews with thousands of women,[88] Kinsey found that most of the women he observed and surveyed could not have vaginal orgasms,[89] a finding that was also supported by his knowledge of sex organ anatomy.[90] Scholar Janice M. Irvine stated that he "criticized Freud and other theorists for projecting male constructs of sexuality onto women" and "viewed the clitoris as the main center of sexual response". He considered the vagina to be "relatively unimportant" for sexual satisfaction, relaying that "few women inserted fingers or objects into their vaginas when they masturbated". Believing that vaginal orgasms are "a physiological impossibility" because the vagina has insufficient nerve endings for sexual pleasure or climax, he "concluded that satisfaction from penile penetration [is] mainly psychological or perhaps the result of referred sensation".[91]

Masters and Johnson's research, as well as Shere Hite's, generally supported Kinsey's findings about the female orgasm.[92] Masters and Johnson were the first researchers to determine that the clitoral structures surround and extend along and within the labia. They observed that both clitoral and vaginal orgasms have the same stages of physical response, and found that the majority of their subjects could only achieve clitoral orgasms, while a minority achieved vaginal orgasms. On that basis, they argued that clitoral stimulation is the source of both kinds of orgasms,[93] reasoning that the clitoris is stimulated during penetration by friction against its hood.[94] The research came at the time of the second-wave feminist movement, which inspired feminists to reject the distinction made between clitoral and vaginal orgasms.[86][95] Feminist Anne Koedt argued that because men "have orgasms essentially by friction with the vagina" and not the clitoral area, this is why women's biology had not been properly analyzed. "Today, with extensive knowledge of anatomy, with [C. Lombard Kelly], Kinsey, and Masters and Johnson, to mention just a few sources, there is no ignorance on the subject [of the female orgasm]," she stated in her 1970 article The Myth of the Vaginal Orgasm. She added, "There are, however, social reasons why this knowledge has not been popularized. We are living in a male society which has not sought change in women's role."[86]

Supporting an anatomical relationship between the clitoris and vagina is a study published in 2005, which investigated the size of the clitoris; Australian urologist Helen O'Connell, described as having initiated discourse among mainstream medical professionals to refocus on and redefine the clitoris, noted a direct relationship between the legs or roots of the clitoris and the erectile tissue of the clitoral bulbs and corpora, and the distal urethra and vagina while using magnetic resonance imaging (MRI) technology.[96][97] While some studies, using ultrasound, have found physiological evidence of the G-spot in women who report having orgasms during vaginal intercourse,[84] O'Connell argues that this interconnected relationship is the physiological explanation for the conjectured G-Spot and experience of vaginal orgasms, taking into account the stimulation of the internal parts of the clitoris during vaginal penetration. "The vaginal wall is, in fact, the clitoris," she said. "If you lift the skin off the vagina on the side walls, you get the bulbs of the clitoris triangular, crescental masses of erectile tissue."[15] O'Connell et al., having performed dissections on the female genitals of cadavers and used photography to map the structure of nerves in the clitoris, made the assertion in 1998 that there is more erectile tissue associated with the clitoris than is generally described in anatomical textbooks, and were thus already aware that the clitoris is more than just its glans.[98] They concluded that some females have more extensive clitoral tissues and nerves than others, especially having observed this in young cadavers compared to elderly ones,[98] and therefore whereas the majority of females can only achieve orgasm by direct stimulation of the external parts of the clitoris, the stimulation of the more generalized tissues of the clitoris via vaginal intercourse may be sufficient for others.[15]

French researchers Odile Buisson and Pierre Folds reported similar findings to that of O'Connell's. In 2008, they published the first complete 3D sonography of the stimulated clitoris, and republished it in 2009 with new research, demonstrating the ways in which erectile tissue of the clitoris engorges and surrounds the vagina. On the basis of their findings, they argued that women may be able to achieve vaginal orgasm via stimulation of the G-spot, because the highly innervated clitoris is pulled closely to the anterior wall of the vagina when the woman is sexually aroused and during vaginal penetration. They assert that since the front wall of the vagina is inextricably linked with the internal parts of the clitoris, stimulating the vagina without activating the clitoris may be next to impossible. In their 2009 published study, the "coronal planes during perineal contraction and finger penetration demonstrated a close relationship between the root of the clitoris and the anterior vaginal wall". Buisson and Folds suggested "that the special sensitivity of the lower anterior vaginal wall could be explained by pressure and movement of clitoris's root during a vaginal penetration and subsequent perineal contraction".[99][100]

Researcher Vincenzo Puppo, who, while agreeing that the clitoris is the center of female sexual pleasure and believing that there is no anatomical evidence of the vaginal orgasm, disagrees with O'Connell and other researchers' terminological and anatomical descriptions of the clitoris (such as referring to the vestibular bulbs as the "clitoral bulbs") and states that "the inner clitoris" does not exist because the penis cannot come in contact with the congregation of multiple nerves/veins situated until the angle of the clitoris, detailed by Kobelt, or with the roots of the clitoris, which do not have sensory receptors or erogenous sensitivity, during vaginal intercourse.[14] Puppo's belief contrasts the general belief among researchers that vaginal orgasms are the result of clitoral stimulation; they reaffirm that clitoral tissue extends, or is at least stimulated by its bulbs, even in the area most commonly reported to be the G-spot.[101]

The G-spot being analogous to the base of the male penis has additionally been theorized, with sentiment from researcher Amichai Kilchevsky that because female fetal development is the "default" state in the absence of substantial exposure to male hormones and therefore the penis is essentially a clitoris enlarged by such hormones, there is no evolutionary reason why females would have an entity in addition to the clitoris that can produce orgasms.[102] The general difficulty of achieving orgasms vaginally, which is a predicament that is likely due to nature easing the process of child bearing by drastically reducing the number of vaginal nerve endings,[103] challenge arguments that vaginal orgasms help encourage sexual intercourse in order to facilitate reproduction.[104][105] Supporting a distinct G-spot, however, is a study by Rutgers University, published in 2011, which was the first to map the female genitals onto the sensory portion of the brain; the scans indicated that the brain registered distinct feelings between stimulating the clitoris, the cervix and the vaginal wall where the G-spot is reported to be when several women stimulated themselves in a functional magnetic resonance (fMRI) machine.[100][106] Barry Komisaruk, head of the research findings, stated that he feels that "the bulk of the evidence shows that the G-spot is not a particular thing" and that it is "a region, it's a convergence of many different structures".[104]

Whether the clitoris is vestigial, an adaptation, or serves a reproductive function has also been debated.[107][108] Geoffrey Miller stated that Helen Fisher, Meredith Small and Sarah Blaffer Hrdy "have viewed the clitoral orgasm as a legitimate adaptation in its own right, with major implications for female sexual behavior and sexual evolution".[109] Like Lynn Margulis and Natalie Angier, Miller believes, "The human clitoris shows no apparent signs of having evolved directly through male mate choice. It is not especially large, brightly colored, specifically shaped or selectively displayed during courtship." He contrasts this with other female species such as spider monkeys and spotted hyenas that have clitorises as long as their male counterparts. He said the human clitoris "could have evolved to be much more conspicuous if males had preferred sexual partners with larger brighter clitorises" and that "its inconspicuous design combined with its exquisite sensitivity suggests that the clitoris is important not as an object of male mate choice, but as a mechanism of female choice."[109]

While Miller stated that male scientists such as Stephen Jay Gould and Donald Symons "have viewed the female clitoral orgasm as an evolutionary side-effect of the male capacity for penile orgasm" and that they "suggested that clitoral orgasm cannot be an adaptation because it is too hard to achieve",[109] Gould acknowledged that "most female orgasms emanate from a clitoral, rather than vaginal (or some other), site" and that his nonadaptive belief "has been widely misunderstood as a denial of either the adaptive value of female orgasm in general, or even as a claim that female orgasms lack significance in some broader sense". He said that although he accepts that "clitoral orgasm plays a pleasurable and central role in female sexuality and its joys," "[a]ll these favorable attributes, however, emerge just as clearly and just as easily, whether the clitoral site of orgasm arose as a spandrel or an adaptation". He added that the "male biologists who fretted over [the adaptionist questions] simply assumed that a deeply vaginal site, nearer the region of fertilization, would offer greater selective benefit" due to their Darwinian, summum bonum beliefs about enhanced reproductive success.[110]

Similar to Gould's beliefs about adaptionist views and that "females grow nipples as adaptations for suckling, and males grow smaller unused nipples as a spandrel based upon the value of single development channels",[110] Elisabeth Lloyd suggested that there is little evidence to support an adaptionist account of female orgasm.[105][108] Meredith L. Chivers stated that "Lloyd views female orgasm as an ontogenetic leftover; women have orgasms because the urogenital neurophysiology for orgasm is so strongly selected for in males that this developmental blueprint gets expressed in females without affecting fitness" and this is similar to "males hav[ing] nipples that serve no fitness-related function."[108]

At the 2002 conference for Canadian Society of Women in Philosophy, Nancy Tuana argued that the clitoris is unnecessary in reproduction; she stated that it has been ignored because of "a fear of pleasure. It is pleasure separated from reproduction. That's the fear." She reasoned that this fear causes ignorance, which veils female sexuality.[111] O'Connell stated, "It boils down to rivalry between the sexes: the idea that one sex is sexual and the other reproductive. The truth is that both are sexual and both are reproductive." She reiterated that the vestibular bulbs appear to be part of the clitoris and that the distal urethra and vagina are intimately related structures, although they are not erectile in character, forming a tissue cluster with the clitoris that appears to be the location of female sexual function and orgasm.[15][28]

Modifications to the clitoris can be intentional or unintentional. They include female genital mutilation (FGM), sex reassignment surgery (for trans men as part transitioning, which may also include clitoris enlargement), intersex surgery, and genital piercings.[26][112][113] Use of anabolic steroids by bodybuilders and other athletes can result in significant enlargement of the clitoris in concert with other masculinizing effects on their bodies.[114][115] Abnormal enlargement of the clitoris may also be referred to as clitoromegaly, but clitoromegaly is more commonly seen as a congenital anomaly of the genitalia.[22]

Those taking hormones or other medications as part of a transgender transition usually experience dramatic clitoral growth; individual desires and the difficulties of phalloplasty (construction of a penis) often result in the retention of the original genitalia with the enlarged clitoris as a penis analogue (metoidioplasty).[26][113] However, the clitoris cannot reach the size of the penis through hormones.[113] A surgery to add function to the clitoris, such as metoidioplasty, is an alternative to phalloplasty that permits retention of sexual sensation in the clitoris.[113]

In clitoridectomy, the clitoris may be removed as part of a radical vulvectomy to treat cancer such as vulvar intraepithelial neoplasia; however, modern treatments favor more conservative approaches, as invasive surgery can have psychosexual consequences.[116] Clitoridectomy more often involves parts of the clitoris being partially or completely removed during FGM, which may be additionally known as female circumcision or female genital cutting (FGC).[117][118] Removing the glans of the clitoris does not mean that the whole structure is lost, since the clitoris reaches deep into the genitals.[15]

In reduction clitoroplasty, a common intersex surgery, the glans is preserved and parts of the erectile bodies are excised.[26] Problems with this technique include loss of sensation, sexual function, and sloughing of the glans.[26] One way to preserve the clitoris with its innervations and function is to imbricate and bury the clitoral glans; however, enayl et al. state that "pain during stimulus because of trapped tissue under the scarring is nearly routine. In another method, 50percent of the ventral clitoris is removed through the level base of the clitoral shaft, and it is reported that good sensation and clitoral function are observed in follow up"; additionally, it has "been reported that the complications are from the same as those in the older procedures for this method".[26]

With regard to females who have the condition congenital adrenal hyperplasia, the largest group requiring surgical genital correction, researcher Atilla enayl stated, "The main expectations for the operations are to create a normal female anatomy, with minimal complications and improvement of life quality." enayl added that "[c]osmesis, structural integrity, and coital capacity of the vagina, and absence of pain during sexual activity are the parameters to be judged by the surgeon." (Cosmesis usually refers to the surgical correction of a disfiguring defect.) He stated that although "expectations can be standardized within these few parameters, operative techniques have not yet become homogeneous. Investigators have preferred different operations for different ages of patients".[26]

Gender assessment and surgical treatment are the two main steps in intersex operations. "The first treatments for clitoromegaly were simply resection of the clitoris. Later, it was understood that the clitoris glans and sensory input are important to facilitate orgasm," stated Atilla. The clitoral glans's epithelium "has high cutaneous sensitivity, which is important in sexual responses" and it is because of this that "recession clitoroplasty was later devised as an alternative, but reduction clitoroplasty is the method currently performed."[26]

What is often referred to as "clit piercing" is the more common (and significantly less complicated) clitoral hood piercing. Since clitoral piercing is difficult and very painful, piercing of the clitoral hood is more common than piercing the clitoral shaft, owing to the small percentage of people who are anatomically suited for it.[112] Clitoral hood piercings are usually channeled in the form of vertical piercings, and, to a lesser extent, horizontal piercings. The triangle piercing is a very deep horizontal hood piercing, and is done behind the clitoris as opposed to in front of it. For styles such as the Isabella, which pass through the clitoral shaft but are placed deep at the base, they provide unique stimulation and still require the proper genital build; the Isabella starts between the clitoral glans and the urethra, exiting at the top of the clitoral hood; this piercing is highly risky with regard to damage that may occur because of intersecting nerves.[112]

Persistent genital arousal disorder (PGAD) results in a spontaneous, persistent, and uncontrollable genital arousal in women, unrelated to any feelings of sexual desire.[119] Clitoral priapism, also known as clitorism, is a rare, potentially painful medical condition and is sometimes described as an aspect of PGAD.[119] With PGAD, arousal lasts for an unusually extended period of time (ranging from hours to days);[120] it can also be associated with morphometric and vascular modifications of the clitoris.[121]

Drugs may cause or affect clitoral priapism. The drug trazodone is known to cause male priapism as a side effect, but there is only one documented report that it may have caused clitoral priapism, in which case discontinuing the medication may be a remedy.[122] Additionally, nefazodone is documented to have caused clitoral engorgement, as distinct from clitoral priapism, in one case,[122] and clitoral priapism can sometimes start as a result of, or only after, the discontinuation of antipsychotics or selective serotonin reuptake inhibitors (SSRIs).[123]

Because PGAD is relatively rare and, as its own concept apart from clitoral priapism, has only been researched since 2001, there is little research into what may cure or remedy the disorder.[119] In some recorded cases, PGAD was caused by, or caused, a pelvic arterial-venous malformation with arterial branches to the clitoris; surgical treatment was effective in these cases.[124]

With regard to historical and modern perceptions of the clitoris and associated sexual stimulation, for more than 2,500 years there were scholars who considered the clitoris and the penis equivalent in all respects except their arrangement.[125] The clitoris was, however, subject to "discovery" and "rediscovery" through empirical documentation by male scholars, due to it being frequently omitted from, or misrepresented, in historical and contemporary anatomical texts.[126] The ancient Greeks, ancient Romans, and Greek and Roman generations up to and throughout the Renaissance, were aware that male and female sex organs are anatomically similar,[127][128] but prominent anatomists, notably Galen (129 c. 200 AD) and Vesalius (15141564), regarded the vagina as the structural equivalent of the penis, except for being inverted; Vesalius argued against the existence of the clitoris in normal women, and his anatomical model described how the penis corresponds with the vagina, without a role for the clitoris.[129]

Ancient Greek and Roman sexuality additionally designated penetration as "male-defined" sexuality. The term tribas, or tribade, was used to refer to a woman or intersex individual who actively penetrated another person (male or female) through use of the clitoris or a dildo. As any sexual act was believed to require that one of the partners be "phallic" and that therefore sexual activity between women was impossible without this feature, mythology popularly associated lesbians with either having enlarged clitorises or as incapable of enjoying sexual activity without the substitution of a phallus.[130][131]

In 1545, Charles Estienne was the first writer to identify the clitoris in a work based on dissection, but he concluded that it had a urinary function.[15] Following this study, Realdo Colombo (also known as Matteo Renaldo Colombo), a lecturer in surgery at the University of Padua, Italy, published a book called De re anatomica in 1559, in which he describes the "seat of woman's delight".[132] In his role as researcher, Colombo concluded, "Since no one has discerned these projections and their workings, if it is permissible to give names to things discovered by me, it should be called the love or sweetness of Venus.", in reference to the mythological Venus, goddess of erotic love.[133][134] Colombo's claim was disputed by his successor at Padua, Gabriele Falloppio (discoverer of the fallopian tube), who claimed that he was the first to discover the clitoris. In 1561, Falloppio stated, "Modern anatomists have entirely neglected it... and do not say a word about it... and if others have spoken of it, know that they have taken it from me or my students." This caused an upset in the European medical community, and, having read Colombo's and Falloppio's detailed descriptions of the clitoris, Vesalius stated, "It is unreasonable to blame others for incompetence on the basis of some sport of nature you have observed in some women and you can hardly ascribe this new and useless part, as if it were an organ, to healthy women." He concluded, "I think that such a structure appears in hermaphrodites who otherwise have well formed genitals, as Paul of Aegina describes, but I have never once seen in any woman a penis (which Avicenna called albaratha and the Greeks called an enlarged nympha and classed as an illness) or even the rudiments of a tiny phallus."[135]

The average anatomist had difficulty challenging Galen's or Vesalius's research; Galen was the most famous physician of the Greek era and his works were considered the standard of medical understanding up to and throughout the Renaissance (i.e. for almost two thousand years),[128][129] and various terms being used to describe the clitoris seemed to have further confused the issue of its structure. In addition to Avicenna's naming it the albaratha or virga ("rod") and Colombo's calling it sweetness of Venus, Hippocrates used the term columella ("little pillar'"), and Albucasis, an Arabic medical authority, named it tentigo ("tension"). The names indicated that each description of the structures was about the body and glans of the clitoris, but usually the glans.[15] It was additionally known to the Romans, who named it (vulgar slang) landica.[136] However, Albertus Magnus, one of the most prolific writers of the Middle Ages, felt that it was important to highlight "homologies between male and female structures and function" by adding "a psychology of sexual arousal" that Aristotle had not used to detail the clitoris. While in Constantine's treatise Liber de coitu, the clitoris is referred to a few times, Magnus gave an equal amount of attention to male and female organs.[15]

Like Avicenna, Magnus also used the word virga for the clitoris, but employed it for the male and female genitals; despite his efforts to give equal ground to the clitoris, the cycle of suppression and rediscovery of the organ continued, and a 16th-century justification for clitoridectomy appears to have been confused by hermaphroditism and the imprecision created by the word nymphae substituted for the word clitoris. Nymphotomia was a medical operation to excise an unusually large clitoris, but what was considered "unusually large" was often a matter of perception.[15] The procedure was routinely performed on Egyptian women,[137][138] due to physicians such as Jacques Dalchamps who believed that this version of the clitoris was "an unusual feature that occurred in almost all Egyptian women [and] some of ours, so that when they find themselves in the company of other women, or their clothes rub them while they walk or their husbands wish to approach them, it erects like a male penis and indeed they use it to play with other women, as their husbands would do... Thus the parts are cut".[15]

Caspar Bartholin, a 17th-century Danish anatomist, dismissed Colombo's and Falloppio's claims that they discovered the clitoris, arguing that the clitoris had been widely known to medical science since the second century.[139] Although 17th-century midwives recommended to men and women that women should aspire to achieve orgasms to help them get pregnant for general health and well-being and to keep their relationships healthy,[128] debate about the importance of the clitoris persisted, notably in the work of Regnier de Graaf in the 17th century[39][140] and Georg Ludwig Kobelt in the 19th.[15]

Like Falloppio and Bartholin, De Graaf criticized Colombo's claim of having discovered the clitoris; his work appears to have provided the first comprehensive account of clitoral anatomy.[141] "We are extremely surprised that some anatomists make no more mention of this part than if it did not exist at all in the universe of nature," he stated. "In every cadaver we have so far dissected we have found it quite perceptible to sight and touch." De Graaf stressed the need to distinguish nympha from clitoris, choosing to "always give [the clitoris] the name clitoris" to avoid confusion; this resulted in frequent use of the correct name for the organ among anatomists, but considering that nympha was also varied in its use and eventually became the term specific to the labia minora, more confusion ensued.[15] Debate about whether orgasm was even necessary for women began in the Victorian era, and Freud's 1905 theory about the immaturity of clitoral orgasms (see above) negatively affected women's sexuality throughout most of the 20th century.[128][142]

Towards the end of World War I, a maverick British MP named Noel Pemberton Billing published an article entitled "The Cult of the Clitoris", furthering his conspiracy theories and attacking the actress Maud Allan and Margot Asquith, wife of the prime minister. The accusations led to a sensational libel trial, which Billing eventually won; Philip Hoare reports that Billing argued that "as a medical term, 'clitoris' would only be known to the 'initiated', and was incapable of corrupting moral minds".[143] Jodie Medd argues in regard to "The Cult of the Clitoris" that "the female nonreproductive but desiring body [...] simultaneously demands and refuses interpretative attention, inciting scandal through its very resistance to representation."[144]

From the 18th 20th century, especially during the 20th, details of the clitoris from various genital diagrams presented in earlier centuries were omitted from later texts.[128][145] The full extent of the clitoris was alluded to by Masters and Johnson in 1966, but in such a muddled fashion that the significance of their description became obscured; in 1981, the Federation of Feminist Women's Health Clinics (FFWHC) continued this process with anatomically precise illustrations identifying 18 structures of the clitoris.[56][128] Despite the FFWHC's illustrations, Josephine Lowndes Sevely, in 1987, described the vagina as more of the counterpart of the penis.[146]

Concerning other beliefs about the clitoris, Hite (1976 and 1981) found that, during sexual intimacy with a partner, clitoral stimulation was more often described by women as foreplay than as a primary method of sexual activity, including orgasm.[147] Further, although the FFWHC's work significantly propelled feminist reformation of anatomical texts, it did not have a general impact.[97][148] Helen O'Connell's late 1990s research motivated the medical community to start changing the way the clitoris is anatomically defined.[97] O'Connell describes typical textbook descriptions of the clitoris as lacking detail and including inaccuracies, such as older and modern anatomical descriptions of the female human urethral and genital anatomy having been based on dissections performed on elderly cadavers whose erectile (clitoral) tissue had shrunk.[98] She instead credits the work of Georg Ludwig Kobelt as the most comprehensive and accurate description of clitoral anatomy.[15] MRI measurements, which provide a live and multi-planar method of examination, now complement the FFWHC's, as well as O'Connell's, research efforts regarding the clitoris, showing that the volume of clitoral erectile tissue is ten times that which is shown in doctors' offices and in anatomy text books.[39][97]

In Bruce Bagemihl's survey of The Zoological Record (19781997) which contains over a million documents from over 6,000 scientific journals 539 articles focusing on the penis were found, while 7 were found focusing on the clitoris.[149] In 2000, researchers Shirley Ogletree and Harvey Ginsberg concluded that there is a general neglect of the word clitoris in common vernacular. They looked at the terms used to describe genitalia in the PsycINFO database from 1887 to 2000 and found that penis was used in 1,482 sources, vagina in 409, while clitoris was only mentioned in 83. They additionally analyzed 57 books listed in a computer database for sex instruction. In the majority of the books, penis was the most commonly discussed body part mentioned more than clitoris, vagina, and uterus put together. They last investigated terminology used by college students, ranging from Euro-American (76%/76%), Hispanic (18%/14%), and African American (4%/7%), regarding the students' beliefs about sexuality and knowledge on the subject. The students were overwhelmingly educated to believe that the vagina is the female counterpart of the penis. The authors found that the students' belief that the inner portion of the vagina is the most sexually sensitive part of the female body correlated with negative attitudes toward masturbation and strong support for sexual myths.[150][151]

A 2005 study reported that, among a sample of undergraduate students, the most frequently cited sources for knowledge about the clitoris were school and friends, and that this was associated with the least amount of tested knowledge. Knowledge of the clitoris by self-exploration was the least cited, but "respondents correctly answered, on average, three of the five clitoral knowledge measures". The authors stated that "[k]nowledge correlated significantly with the frequency of women's orgasm in masturbation but not partnered sex" and that their "results are discussed in light of gender inequality and a social construction of sexuality, endorsed by both men and women, that privileges men's sexual pleasure over women's, such that orgasm for women is pleasing, but ultimately incidental." They concluded that part of the solution to remedying "this problem" requires that males and females are taught more about the clitoris than is currently practiced.[152]

In May 2013, humanitarian group Clitoraid launched the first annual International Clitoris Awareness Week, from May 6 to May 12. Clitoraid spokesperson Nadine Gary stated that the group's mission is to raise public awareness about the clitoris because it has "been ignored, vilified, made taboo, and considered sinful and shameful for centuries".[153][154]

In 2016, Odile Fillod created a 3D printable, open source, full-size model of the clitoris, for use in a set of sex education videos she had been commissioned to produce. This model, first designed with Sculpteo,[155] was subsequently exhibited at the Cit des Sciences et de l'Industrie, the largest science museum in Europe.[156] Fillod was interviewed by Stephanie Theobald, whose article in The Guardian stated that the 3D model would be used in French primary and secondary schools;[157] this was never the case, but the story went viral across the world, demonstrating, according to Fillod, the public's hunger for information about the clitoris.[158]

In 2012, New York artist Sophia Wallace started work on a multimedia project to challenge misconceptions about the clitoris. Based on O'Connell's 1998 research, Wallace's work emphasizes the sheer scope and size of the human clitoris. She says that ignorance of this still seems to be pervasive in modern society. "It is a curious dilemma to observe the paradox that on the one hand the female body is the primary metaphor for sexuality, its use saturates advertising, art and the mainstream erotic imaginary," she said. "Yet, the clitoris, the true female sexual organ, is virtually invisible." The project is called Cliteracy and it includes a "clit rodeo", which is an interactive, climb-on model of a giant golden clitoris, including its inner parts, produced with the help of sculptor Kenneth Thomas. "It's been a showstopper wherever it's been shown. People are hungry to be able to talk about this," Wallace said. "I love seeing men standing up for the clit [...] Cliteracy is about not having one's body controlled or legislated [...] Not having access to the pleasure that is your birthright is a deeply political act."[159]

In 2016, another project started in New York, street art that has since spread to almost 100 cities: Clitorosity, a "community-driven effort to celebrate the full structure of the clitoris", combining chalk drawings and words to spark interaction and conversation with passers-by, which the team documents on social media.[160][161]

Other projects listed by the BBC include Clito Clito, body-positive jewellery made in Berlin; Clitorissima, a documentary intended to normalize mother-daughter conversations about the clitoris; and a ClitArt festival in London, encompassing spoken word performances as well as visual art.[161] French art collective Les Infemmes (a pun on "infamous" and "women") published a fanzine whose title can be translated as "The Clit Cheatsheet".[156]

Significant controversy surrounds female genital mutilation (FGM),[117][118] with the World Health Organization (WHO) being one of many health organizations that have campaigned against the procedures on behalf of human rights, stating that "FGM has no health benefits" and that it is "a violation of the human rights of girls and women" and "reflects deep-rooted inequality between the sexes".[118] The practice has existed at one point or another in almost all human civilizations,[137] most commonly to exert control over the sexual behavior, including masturbation, of girls and women, but also to change the clitoris's appearance.[118][138][162] Custom and tradition are the most frequently cited reasons for FGM, with some cultures believing that not performing it has the possibility of disrupting the cohesiveness of their social and political systems, such as FGM also being a part of a girl's initiation into adulthood. Often, a girl is not considered an adult in a FGM-practicing society unless she has undergone FGM,[118][138] and the "removal of the clitoris and labia viewed by some as the male parts of a woman's body is thought to enhance the girl's femininity, often synonymous with docility and obedience".[138]

Female genital mutilation is carried out in several societies, especially in Africa, with 85 percent of genital mutilations performed in Africa consisting of clitoridectomy or excision,[138][163] and to a lesser extent in other parts of the Middle East and Southeast Asia, on girls from a few days old to mid-adolescent, often to reduce sexual desire in an effort to preserve vaginal virginity.[118][138][162] The practice of FGM has spread globally, as immigrants from Asia, Africa, and the Middle East bring the custom with them.[164] In the United States, it is sometimes practiced on girls born with a clitoris that is larger than usual.[117] Comfort Momoh, who specializes in the topic of FGM, states that FGM might have been "practiced in ancient Egypt as a sign of distinction among the aristocracy"; there are reports that traces of infibulation are on Egyptian mummies.[137] FGM is still routinely practiced in Egypt.[138][165] Greenberg et al. report that "one study found that 97% of married women in Egypt had had some form of genital mutilation performed."[165] Amnesty International estimated in 1997 that more than two million FGM procedures are performed every year.[138]

Although the clitoris exists in all mammal species,[149] few detailed studies of the anatomy of the clitoris in non-humans exist.[166] The clitoris is especially developed in fossas,[167] apes, lemurs, and, like the penis, often contains a small bone, the os clitoridis.[168] The clitoris exists in turtles,[169] ostriches,[170] crocodiles,[169] and in species of birds in which the male counterpart has a penis.[169] The clitoris erects in squirrel monkeys during dominance displays, which indirectly influences the squirrel monkeys' reproductive success.[171] In female galagos (bush babies), the clitoris is long and pendulous with a urethra extending through the tip for urination.[172][173] Some intersex female bears mate and give birth through the tip of the clitoris; these species are grizzly bears, brown bears, American black bears and polar bears. Although the bears have been described as having "a birth canal that runs through the clitoris rather than forming a separate vagina" (a feature that is estimated to make up 10 to 20 percent of the bears' population),[174] scientists state that female spotted hyenas are the only non-hermaphroditic female mammals devoid of an external vaginal opening, and whose sexual anatomy is distinct from usual intersex cases.[175] There are also several mole species with a peniform clitoris.[176][177]

In spider monkeys, the clitoris is especially developed and has an interior passage, or urethra, that makes it almost identical to the penis, and it retains and distributes urine droplets as the female spider monkey moves around. Scholar Alan F. Dixson stated that this urine "is voided at the bases of the clitoris, flows down the shallow groove on its perineal surface, and is held by the skin folds on each side of the groove".[178] Because spider monkeys of South America have pendulous and erectile clitorises long enough to be mistaken for a penis, researchers and observers of the species look for a scrotum to determine the animal's sex; a similar approach is to identify scent-marking glands that may also be present on the clitoris.[173]

The clitoris of bonobos is larger and more externalized than in most mammals;[179] Natalie Angier said that a young adolescent "female bonobo is maybe half the weight of a human teenager, but her clitoris is three times bigger than the human equivalent, and visible enough to waggle unmistakably as she walks".[180] Female bonobos often engage in the practice of genital-genital (GG) rubbing, which is the non-human form of tribadism that human females engage in. Ethologist Jonathan Balcombe stated that female bonobos rub their clitorises together rapidly for ten to twenty seconds, and this behavior, "which may be repeated in rapid succession, is usually accompanied by grinding, shrieking, and clitoral engorgement"; he added that, on average, they engage in this practice "about once every two hours", and as bonobos sometimes mate face-to-face, "evolutionary biologist Marlene Zuk has suggested that the position of the clitoris in bonobos and some other primates has evolved to maximize stimulation during sexual intercourse".[179]

While female spotted hyenas are sometimes referred to as hermaphrodites or as intersex,[173] and scientists of ancient and later historical times believed that they were hermaphrodites,[173][175][181] modern scientists do not refer to them as such.[175][182] That designation is typically reserved for those who simultaneously exhibit features of both sexes;[182] the genetic makeup of female spotted hyenas "are clearly distinct" from male spotted hyenas.[175][182]

Female spotted hyenas have a clitoris 90percent as long and the same diameter as a male penis (171 millimeters long and 22 millimeters in diameter),[173] and this pseudo-penis's formation seems largely androgen-independent because it appears in the female fetus before differentiation of the fetal ovary and adrenal gland.[175] The spotted hyenas have a highly erectile clitoris, complete with a false scrotum; author John C. Wingfield stated that "the resemblance to male genitalia is so close that sex can be determined with confidence only by palpation of the scrotum".[171] The pseudo-penis can also be distinguished from the males' genitalia by its greater thickness and more rounded glans.[175] The female possesses no external vagina, as the labia are fused to form a pseudo-scrotum. In the females, this scrotum consists of soft adipose tissue.[171][175][183] Like male spotted hyenas with regard to their penises, the female spotted hyenas have small penile spines on the head of their clitorises, which scholar Catherine Blackledge said makes "the clitoris tip feel like soft sandpaper". She added that the clitoris "extends away from the body in a sleek and slender arc, measuring, on average, over 17 cm from root to tip. Just like a penis, [it] is fully erectile, raising its head in hyena greeting ceremonies, social displays, games of rough and tumble or when sniffing out peers".[184]

Due to their higher levels of androgen exposure, the female hyenas are significantly more muscular and aggressive than their male counterparts; social-wise, they are of higher rank than the males, being dominant or dominant and alpha, and the females who have been exposed to higher levels of androgen than average become higher-ranking than their female peers. Subordinate females lick the clitorises of higher-ranked females as a sign of submission and obedience, but females also lick each other's clitorises as a greeting or to strengthen social bonds; in contrast, while all males lick the clitorises of dominant females, the females will not lick the penises of males because males are considered to be of lowest rank.[183][186]

The urethra and vagina of the female spotted hyena exit through the clitoris, allowing the females to urinate, copulate and give birth through this organ.[171][175][184][187] This trait makes mating more laborious for the male than in other mammals, and also makes attempts to sexually coerce (physically force sexual activity on) females futile.[183] Joan Roughgarden, an ecologist and evolutionary biologist, said that because the hyena's clitoris is higher on the belly than the vagina in most mammals, the male hyena "must slide his rear under the female when mating so that his penis lines up with [her clitoris]". In an action similar to pushing up a shirtsleeve, the "female retracts the [pseudo-penis] on itself, and creates an opening into which the male inserts his own penis".[173] The male must practice this act, which can take a couple of months to successfully perform.[186] Female spotted hyenas exposed to larger doses of androgen have significantly damaged ovaries, making it difficult to conceive.[186] After giving birth, the pseudo-penis is stretched and loses much of its original aspects; it becomes a slack-walled and reduced prepuce with an enlarged orifice with split lips.[188] Approximately 15% of the females die during their first time giving birth, and over 60% of their species' firstborn young die.[173]

A 2006 Baskin et al. study concluded, "The basic anatomical structures of the corporeal bodies in both sexes of humans and spotted hyenas were similar. As in humans, the dorsal nerve distribution was unique in being devoid of nerves at the 12 o'clock position in the penis and clitoris of the spotted hyena" and that "[d]orsal nerves of the penis/clitoris in humans and male spotted hyenas tracked along both sides of the corporeal body to the corpus spongiosum at the 5 and 7 o'clock positions. The dorsal nerves penetrated the corporeal body and distally the glans in the hyena" and, in female hyenas, "the dorsal nerves fanned out laterally on the clitoral body. Glans morphology was different in appearance in both sexes, being wide and blunt in the female and tapered in the male".[187]

Researchers studying the peripheral and central afferent pathways from the feline clitoris concluded that "afferent neurons projecting to the clitoris of the cat were identified by WGA-HRP tracing in the S1 and S2 dorsal root ganglia. An average of 433 cells were identified on each side of the animal. 85percent and 15percent of the labeled cells were located in the S1 and S2 dorsal root ganglia, respectively. The average cross sectional area of clitoral afferent neuron profiles was 1.479627 m2." They also stated that light "constant pressure on the clitoris produced an initial burst of single unit firing (maximum frequencies 170255 Hz) followed by rapid adaptation and a sustained firing (maximum 40 Hz), which was maintained during the stimulation" and that further examination of tonic firing "indicate that the clitoris is innervated by mechano-sensitive myelinated afferent fibers in the pudental nerve which project centrally to the region of the dorsal commissure in the L7-S1 spinal cord".[189]

The external phenotype and reproductive behavior of 21 freemartin sheep and two male pseudohermaphrodite sheep were recorded with the aim of identifying any characteristics that could predict a failure to breed. The vagina's length and the size and shape of the vulva and clitoris were among the aspects analyzed. While the study reported that "a number of physical and behavioural abnormalities were detected," it also concluded that "the only consistent finding in all 23 animals was a short vagina which varied in length from 3.1 to 7.0 cm, compared with 10 to 14 cm in normal animals."[190]

In a study concerning the clitoral structure of mice, the mouse perineal urethra was documented as being surrounded by erectile tissue forming the bulbs of the clitoris.[166] The researchers stated, "In the mouse, as in human females, tissue organization in the corpora cavernosa of the clitoris is essentially similar to that of the penis except for the absence of a subalbugineal layer interposed between the tunica albuginea and the erectile tissue."[166]

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Testosterone – Wikipedia, the free encyclopedia

Testosterone Systematic (IUPAC) name

(8R,9S,10R,13S,14S,17S)- 17-hydroxy-10,13-dimethyl- 1,2,6,7,8,9,11,12,14,15,16,17- dodecahydrocyclopenta[a]phenanthren-3-one

O=C4C=C2/[C@]([C@H]1CC[C@@]3([C@@H](O)CC[C@H]3[C@@H]1CC2)C)(C)CC4

Testosterone is a steroid hormone from the androgen group and is found in humans and other vertebrates. In humans and other mammals, testosterone is secreted primarily by the testicles of males and, to a lesser extent, the ovaries of females. Small amounts are also secreted by the adrenal glands. It is the principal male sex hormone and an anabolic steroid.

In men, testosterone plays a key role in the development of male reproductive tissues such as the testis and prostate as well as promoting secondary sexual characteristics such as increased muscle, bone mass, and the growth of body hair.[1] In addition, testosterone is essential for health and well-being[2] as well as the prevention of osteoporosis.[3]

On average, in adult males, levels of testosterone are about 78 times as great as in adult females.[4] As the metabolic consumption of testosterone in males is greater, the daily production is about 20 times greater in men.[5][6] Females are also more sensitive to the hormone.[7] Testosterone is observed in most vertebrates. Fish make a slightly different form called 11-ketotestosterone.[8] Its counterpart in insects is ecdysone.[9] These ubiquitous steroids suggest that sex hormones have an ancient evolutionary history.[10]

In general, androgens promote protein synthesis and growth of those tissues with androgen receptors. Testosterone effects can be classified as virilizing and anabolic, though the distinction is somewhat artificial, as many of the effects can be considered both.

Testosterone effects can also be classified by the age of usual occurrence. For postnatal effects in both males and females, these are mostly dependent on the levels and duration of circulating free testosterone.

The prenatal androgen effects occur during two different stages. Between 4 and 6 weeks of the gestation.

During the second trimester, androgen level is associated with gender formation.[11] This period affects the femininization or masculinization of the fetus and can be a better predictor of feminine or masculine behaviours such as sex typed behaviour than an adult's own levels. A mother's testosterone level during pregnancy is correlated with her daughter's sex-typical behavior as an adult, and the correlation is even stronger than with the daughter's own adult testosterone level.[12]

Early infancy androgen effects are the least understood. In the first weeks of life for male infants, testosterone levels rise. The levels remain in a pubertal range for a few months, but usually reach the barely detectable levels of childhood by 46 months of age.[13][14] The function of this rise in humans is unknown. It has been speculated that "brain masculinization" is occurring since no significant changes have been identified in other parts of the body.[15] It is interesting to note that the male brain is masculinized by the aromatization of testosterone into estrogen, which crosses the bloodbrain barrier and enters the male brain, whereas female fetuses have alpha-fetoprotein, which binds the estrogen so that female brains are not affected.[16]

Pre- Peripubertal effects are the first observable effects of rising androgen levels at the end of childhood, occurring in both boys and girls.

Pubertal effects begin to occur when androgen has been higher than normal adult female levels for months or years. In males, these are usual late pubertal effects, and occur in women after prolonged periods of heightened levels of free testosterone in the blood.

Skin:Sebaceous gland secretion thickens and increases (predisposing to acne) [19]

Adult testosterone effects are more clearly demonstrable in males than in females, but are likely important to both sexes. Some of these effects may decline as testosterone levels decrease in the later decades of adult life.

Falling in love decreases men's testosterone levels while increasing women's testosterone levels. There has been speculation that these changes in testosterone result in the temporary reduction of differences in behavior between the sexes.[31] However, it is suggested that after the "honeymoon phase" endsabout one to three years into a relationshipthis change in testosterone levels is no longer apparent.[31] Fatherhood also decreases testosterone levels in men, suggesting that the resulting emotional and behavioral changes promote paternal care.[32] Men who produce less testosterone are more likely to be in a relationship[33] and/or married,[34] and men who produce more testosterone are more likely to divorce;[34] however, causality cannot be determined in this correlation. Marriage or commitment could cause a decrease in testosterone levels.[35] Single men who have not had relationship experience have lower testosterone levels than single men with experience. It is suggested that these single men with prior experience are in a more competitive state than their non-experienced counterparts.[36] Married men who engage in bond-maintenance activities such as spending the day with their spouse/and or child have no different testosterone levels compared to times when they do not engage in such activities. Collectively, these results suggest that the presence of competitive activities rather than bond-maintenance activities are more relevant to changes in testosterone levels.[37]

Men who produce more testosterone are more likely to engage in extramarital sex.[34] Testosterone levels do not rely on physical presence of a partner for men engaging in relationships (same-city vs. long-distance), men have similar testosterone levels across the board.[33] Physical presence may be required for women who are in relationships for the testosteronepartner interaction, where same-city partnered women have lower testosterone levels than long-distance partnered women.[38]

It has been found that when testosterone and endorphins in ejaculated semen meet the cervical wall after sexual intercourse, females receive a spike in testosterone, endorphin, and oxytocin levels, and males after orgasm during copulation experience an increase in endorphins and a marked increase in oxytocin levels. This adds to the hospitable physiological environment in the female internal reproductive tract for conceiving, and later for nurturing the conceptus in the pre-embryonic stages, and stimulates feelings of love, desire, and paternal care in the male (this is the only time male oxytocin levels rival a female's).[31]

Testosterone levels follow a nyctohemeral rhythm that peaks early each day, regardless of sexual activity.[39]

There are positive correlations between positive orgasm experience in women and testosterone levels where relaxation was a key perception of the experience. There is no correlation between testosterone and men's perceptions of their orgasm experience, and also no correlation between higher testosterone levels and greater sexual assertiveness in either sex.[40]

An increase in testosterone levels has also been found to occur in both men and women who have masturbation-induced orgasms.[41][42]

Studies conducted on rats have indicated that their degree of sexual arousal is sensitive to reductions in testosterone. When testosterone-deprived rats were given medium levels of testosterone, their sexual behaviors (copulation, partner preference, etc.) resumed, but not when given low amounts of the same hormone. Therefore, these mammals may provide a model for studying clinical populations among humans suffering from sexual arousal deficits such as hypoactive sexual desire disorder.[43]

In one study, almost every mammalian species examined demonstrated a marked increase in a male's testosterone level upon encountering a novel female. P.J. James et al. investigated the role of genotype on such so-called reflexive testosterone increases in male mice. They also concluded that this response is related to the male's initial level of sexual arousal.[44]

In non-human primates it has been suggested that testosterone in puberty stimulates sexual motivation, which allows the primate to increasingly seek out sexual experiences with females and thus creates a sexual preference for females.[45] Some research has also indicated that if testosterone is eliminated in an adult male human or other adult male primate's system, its sexual motivation decreases, but there is no corresponding decrease in ability to engage in sexual activity (mounting, ejaculating, etc.).[45]

Higher levels of testosterone were associated with periods of sexual activity within subjects, but between subjects testosterone levels were higher for less sexually active individuals.[46]

Men who watch a sexually explicit movie have an average increase of 35% in testosterone, peaking at 6090 minutes after the end of the film, but no increase is seen in men who watch sexually neutral films.[47] Men who watch sexually explicit films also report increased motivation, competitiveness, and decreased exhaustion.[48] Previous research has found a link between relaxation following sexual arousal and testosterone levels.[49]

A 2002 study found that testosterone increased in heterosexual men after having had a brief conversation with a woman. The increase in testosterone levels was associated with the degree that the women thought the men were trying to impress them.[50]

Men's levels of testosterone, a hormone known to affect men's mating behaviour, changes depending on whether they are exposed to an ovulating or nonovulating woman's body odour. Men who are exposed to scents of ovulating women maintained a stable testosterone level that was higher than the testosterone level of men exposed to nonovulation cues. Testosterone levels and sexual arousal in men are heavily aware of hormone cycles in females.[51] This may be linked to the ovulatory shift hypothesis,[52] where males are adapted to respond to the ovulation cycles of females by sensing when they are most fertile and whereby females look for preferred male mates when they are the most fertile; both actions may be driven by hormones.

In a 1991 study, males were exposed to either visual or auditory erotic stimuli and asked to complete a cognitive task, where the number of errors on the task indicated how distracted the participant was by the stimuli. It concluded that men with lower thresholds for sexual arousal have a greater likelihood to attend to sexual information and that testosterone may have an impact by enhancing their attention to the relevant stimuli.[53]

Sperm competition theory: Testosterone levels are shown to increase as a response to previously neutral stimuli when conditioned to become sexual in male rats.[54] This reaction engages penile reflexes (such as erection and ejaculation) that aid in sperm competition when more than one male is present in mating encounters, allowing for more production of successful sperm and a higher chance of reproduction.

Androgens may modulate the physiology of vaginal tissue and contribute to female genital sexual arousal.[55] Women's level of testosterone is higher when measured pre-intercourse vs pre-cuddling, as well as post-intercourse vs post-cuddling.[56] There is a time lag effect when testosterone is administered, on genital arousal in women. In addition, a continuous increase in vaginal sexual arousal may result in higher genital sensations and sexual appetitive behaviors.[57]

When females have a higher baseline level of testosterone, they have higher increases in sexual arousal levels but smaller increases in testosterone, indicating a ceiling effect on testosterone levels in females. Sexual thoughts also change the level of testosterone but not level of cortisol in the female body, and hormonal contraceptives may have an impact on the variation in testosterone response to sexual thoughts.[58]

Testosterone may prove to be an effective treatment in female sexual arousal disorders.[59] Currently there is no FDA approved androgen preparation for the treatment of androgen insufficiency, however it has been used off-label to treat low libido and sexual dysfunction in older women. Testosterone may be a treatment for postmenopausal women as long as they are effectively estrogenized.[59]

Testosterone levels play a major role in risk-taking during financial decisions.[60][61]

As testosterone affects the entire body (often by enlarging; males have bigger hearts, lungs, liver, etc.), the brain is also affected by this "sexual" differentiation;[11] the enzyme aromatase converts testosterone into estradiol that is responsible for masculinization of the brain in male mice. In humans, masculinization of the fetal brain appears, by observation of gender preference in patients with congenital diseases of androgen formation or androgen receptor function, to be associated with functional androgen receptors.[62]

There are some differences between a male and female brain (possibly the result of different testosterone levels), one of them being size: the male human brain is, on average, larger.[63] In a Danish study from 2003, men were found to have a total myelinated fiber length of 176,000km at the age of 20, whereas in women the total length was 149,000km (approx. 15% less).[64]

A study conducted in 1996 found no immediate short term effects on mood or behavior from the administration of supraphysiologic doses of testosterone for 10 weeks on 43 healthy men.[17] Another study found a correlation between testosterone and risk tolerance in career choice among women.[65][66]

The literature suggests that attention, memory, and spatial ability are key cognitive functions affected by testosterone in humans. Preliminary evidence suggests that low testosterone levels may be a risk factor for cognitive decline and possibly for dementia of the Alzheimer's type,[67][68][69][70] a key argument in life extension medicine for the use of testosterone in anti-aging therapies. Much of the literature, however, suggests a curvilinear or even quadratic relationship between spatial performance and circulating testosterone,[71] where both hypo- and hypersecretion (deficient- and excessive-secretion) of circulating androgens have negative effects on cognition.

Most studies support a link between adult criminality and testosterone, although the relationship is modest if examined separately for each sex. Nearly all studies of juvenile delinquency and testosterone are not significant. Most studies have also found testosterone to be associated with behaviors or personality traits linked with criminality such as antisocial behavior and alcoholism. Many studies have also been done on the relationship between more general aggressive behavior/feelings and testosterone. About half the studies have found a relationship and about half no relationship.[72]

Testosterone is only one of many factors that influence aggression and the effects of previous experience and environmental stimuli have been found to correlate more strongly. A few studies indicate that the testosterone derivative estradiol (one form of estrogen) might play an even more important role in male aggression.[72][73][74][75]

It has been empirically shown that boys who had a history of high physical aggression, from age 6 to 12, were found to have lower testosterone levels at age 13 compared with boys with no history of high physical aggression. The former were also failing in school and were unpopular with their peers. Both concurrent and longitudinal analyses indicate that testosterone levels were positively associated with social success rather than with physical aggression.[76]

A study at the Universities of Zurich and Royal Holloway London with more than 120 experimental subjects has shown that the sexual hormone can encourage fair behavior. For the study subjects took part in a behavioral experiment where the distribution of a real amount of money was decided. The rules allowed both fair and unfair offers. The negotiating partner could subsequently accept or decline the offer. The fairer the offer, the less probable a refusal by the negotiating partner. If no agreement was reached, neither party earned anything. Test subjects with an artificially enhanced testosterone level generally made better, fairer offers than those who received placebos, thus reducing the risk of a rejection of their offer to a minimum. Two later studies have empirically confirmed these results.[77][78][79]

Estradiol is known to correlate with aggression in male mice.[80] Moreover, the conversion of testosterone to estradiol regulates male aggression in sparrows during breeding season.[81]

The primary use of testosterone is the treatment of males with too little or no natural testosterone productionmales with hypogonadism.[citation needed] This is known as hormone replacement therapy or testosterone replacement therapy (TRT), which maintains serum testosterone levels in the normal range. Decline of testosterone production with age has led to interest in androgen replacement therapy.[82]

Testosterone levels decline gradually with age (see andropause). The Food and Drug Administration (FDA) stated in 2015 that neither the benefits nor the safety of testosterone have been established for low testosterone levels due to aging.[83] The FDA has required that labels on testosterone include warning information about the possibility of an increased risk of heart attacks and stroke.[83]

Testosterone insufficiency (also termed hypotestosteronism or hypotestosteronemia) is an abnormally low testosterone production. It may occur because of testicular dysfunction (primary hypogonadism) or hypothalamic-pituitary dysfunction (secondary hypogonadism) and may be congenital or acquired.[84] An acquired form of hypotestosteronism is the decline in testosterone levels that occurs by aging, sometimes called "andropause" in men, as a comparison to the decline in estrogen that comes with menopause in women. In Western countries, average testosterone levels are receding in men of all ages.[85][86]

Testosterone supplementation is effective in the short term for hypoactive sexual desire disorder.[87] Its long term safety, however, is unclear.[87]

Treating low androgen levels with testosterone is not generally recommended in women when it is due to hypopituitarism, adrenal insufficiency, or following surgical removal of the ovaries.[87] It is also not usually recommended for improving cognition, the risk of heart disease, bone strength or for generalized well being.[87]

Testosterone may be used for depression in men who are of middle age with low testosterone. However, a review did not show a benefit on the mood of the men with normal levels of testosterone or on the mood of the older men with low testosterone.[88]

To take advantage of its virilizing effects, testosterone is often administered to transgender men as part of the hormone replacement therapy,[89] with a "target level" of the average male's testosterone level. Likewise, transgender women are sometimes prescribed anti-androgens to decrease the level of testosterone in the body and allow for the effects of estrogen to develop.

Testosterone therapy may improve the management of type 2 diabetes.[90] Low testosterone has been associated with the development of Alzheimer's disease.[69][70] A small trial in 2005 showed mixed results in using testosterone to combat the effects of aging.[91]

Males with borderline testosterone levels and sexual dysfunction may benefit from a trial of testosterone.[92]

Testosterone can be used by an athlete in order to improve performance, but it is considered to be a form of doping in most sports. There are several application methods for testosterone, including intramuscular injections, transdermal gels and patches, and implantable pellets. Hormone supplements cause the endocrine system to adjust its production and lower the natural production of the hormone, so when supplements are discontinued, natural hormone production is lower than it was originally. This is known as the Farquharson phenomenon.[citation needed]

Anabolic steroids (including testosterone) have also been taken to enhance muscle development, strength, or endurance. They do so directly by increasing the muscles' protein synthesis. As a result, muscle fibers become larger and repair faster than the average person's.

After a series of scandals and publicity in the 1980s (such as Ben Johnson's improved performance at the 1988 Summer Olympics), prohibitions of anabolic steroid use were renewed or strengthened by many sports organizations. Testosterone and other anabolic steroids were designated a "controlled substance" by the United States Congress in 1990, with the Anabolic Steroid Control Act.[93] Their use is seen as a seriously problematic[citation needed] issue in modern sport, particularly given the lengths to which athletes and professional laboratories go to in trying to conceal such use from sports regulators. Steroid use once again came into the spotlight recently as a result of the Chris Benoit double murder-suicide in 2007, however, there has been no evidence indicating steroid use as a contributing factor.[citation needed]

Some female athletes may have naturally higher levels of testosterone than others, and may be asked to consent to a therapeutic proposal, either surgery or drugs, to decrease testosterone levels to a level thought acceptable to compete fairly with others.[94]

A number of methods for detecting testosterone use by athletes have been employed, most based on a urine test. These include the testosterone/epitestosterone ratio (normally less than 6), the testosterone/luteinizing hormone ratio and the carbon-13/carbon-12 ratio (pharmaceutical testosterone contains less carbon-13 than endogenous testosterone). In some testing programs, an individual's own historical results may serve as a reference interval for interpretation of a suspicious finding. Another approach being investigated is the detection of the administered form of testosterone, usually an ester, in hair.[95][96][97][98]

The Food and Drug Administration (FDA) stated in 2015 that neither the benefits nor the safety of testosterone have been established for low testosterone levels due to aging.[83] The FDA has required that testosterone pharmaceutical labels include warning information about the possibility of an increased risk of heart attacks and stroke.[83]

On January 31, 2014, reports of strokes, heart attacks, and deaths in men taking FDA-approved testosterone-replacement led the Food and Drug Administration to announce that it would be investigating this issue.[99] The FDA is requiring warnings in the drug labeling of all approved testosterone products regarding deep vein thrombosis and pulmonary embolism.[100]

Adverse effects of testosterone supplementation may include increased cardiovascular events (including strokes and heart attacks) and deaths based on three peer-reviewed studies involving men taking testosterone-replacement.[101] In addition, an increase of 30% in deaths and heart attacks in older men has been reported.[102] Due to an increased incidence of adverse cardiovascular events compared to a placebo group, a Testosterone in Older Men with Mobility Limitations (TOM) trial (a National Institute of Aging randomized trial) was halted early by the Data Safety and Monitoring Committee.[103] On January 31, 2014, reports of strokes, heart attacks, and deaths in men taking FDA-approved testosterone-replacement led the Food and Drug Administration (FDA) to announce that it would be investigating the issue.[104] Later, in September 2014, the FDA announced, as a result of the "potential for adverse cardiovascular outcomes", a review of the appropriateness and safety of Testosterone Replacement Therapy (TRT).[105][106][107]

Up to the year 2010, studies had not shown any effect on the risk of death, prostate cancer or cardiovascular disease;[108][109] more recent studies, however, do raise concerns.[110] A 2013 study, published in the Journal of the American Medical Association, reported "the use of testosterone therapy was significantly associated with increased risk of adverse outcomes." The study began after a previous, randomized, clinical trial of testosterone therapy in men was stopped prematurely "due to adverse cardiovascular events raising concerns about testosterone therapy safety."[111]

Testosterone in the presence of a slow-growing cancer is assumed to increase its growth rate. However, the association between testosterone supplementation and the development of prostate cancer is unproven.[112] Nevertheless, physicians are cautioned about the cancer risk associated with testosterone supplementation.[113]

Ethnic groups have different rates of prostate cancer.[114] Differences in sex hormones, including testosterone, have been suggested as an explanation for these differences.[114] This apparent paradox can be resolved by noting that prostate cancer is very common. In autopsies, 80% of 80-year-old men have prostate cancer.[115]

Other significant adverse effects of testosterone supplementation include acceleration of pre-existing prostate cancer growth in individuals who have undergone androgen deprivation; increased hematocrit, which can require venipuncture in order to treat; and, exacerbation of sleep apnea.[116] Adverse effects may also include minor side-effects such as acne and oily skin, as well as, significant hair loss and/or thinning of the hair, which may be prevented with 5-alpha reductase inhibitors ordinarily used for the treatment of benign prostatic hyperplasia, such as finasteride or dutasteride.[117] Exogenous testosterone may also cause suppression of spermatogenesis, leading to, in some cases, infertility.[118] It is recommended that physicians screen for prostate cancer with a digital rectal exam and prostate-specific antigen (PSA) level before starting therapy, and monitor PSA and hematocrit levels closely during therapy.[119]

Testosterone is contraindicated in pregnancy and not recommended during breastfeeding.[120]

Like other steroid hormones, testosterone is derived from cholesterol (see figure to the left).[121] The first step in the biosynthesis involves the oxidative cleavage of the sidechain of cholesterol by CYP11A, a mitochondrial cytochrome P450 oxidase with the loss of six carbon atoms to give pregnenolone. In the next step, two additional carbon atoms are removed by the CYP17A enzyme in the endoplasmic reticulum to yield a variety of C19 steroids.[122] In addition, the 3-hydroxyl group is oxidized by 3--HSD to produce androstenedione. In the final and rate limiting step, the C-17 keto group androstenedione is reduced by 17- hydroxysteroid dehydrogenase to yield testosterone.

The largest amounts of testosterone (>95%) are produced by the testes in men.[1] It is also synthesized in far smaller quantities in women by the thecal cells of the ovaries, by the placenta, as well as by the zona reticularis of the adrenal cortex and even skin[123] in both sexes. In the testes, testosterone is produced by the Leydig cells.[124] The male generative glands also contain Sertoli cells, which require testosterone for spermatogenesis. Like most hormones, testosterone is supplied to target tissues in the blood where much of it is transported bound to a specific plasma protein, sex hormone-binding globulin (SHBG).

In males, testosterone is synthesized primarily in Leydig cells. The number of Leydig cells in turn is regulated by luteinizing hormone (LH) and follicle-stimulating hormone (FSH). In addition, the amount of testosterone produced by existing Leydig cells is under the control of LH, which regulates the expression of 17- hydroxysteroid dehydrogenase.[125]

The amount of testosterone synthesized is regulated by the hypothalamicpituitarytesticular axis (see figure to the right).[126] When testosterone levels are low, gonadotropin-releasing hormone (GnRH) is released by the hypothalamus, which in turn stimulates the pituitary gland to release FSH and LH. These latter two hormones stimulate the testis to synthesize testosterone. Finally, increasing levels of testosterone through a negative feedback loop act on the hypothalamus and pituitary to inhibit the release of GnRH and FSH/LH, respectively.

Factors affecting testosterone levels include:

98% of testosterone in plasma is bound to protein. 65% is bound to beta-globulin called Gonadal steroid-binding globulin ( GBG) or Sex steroid-binding globulin and 33% to albumin. Plasma testosterone level in the body( free or bound):10.4-2.43 nmol/L) in adult men. In women:30-70ng/dL A small amount of circulating testosterone is converted to estradiol, but most of the testosterone is converted to 17-ketosteroids, principally androsterone and its isomer etio-cholanolone, and excreted in urine.[143]

Approximately 7% of testosterone is reduced to 5-dihydrotestosterone (DHT) by the cytochrome P450 enzyme 5-reductase,[144] an enzyme highly expressed in male sex organs and hair follicles.[1] Approximately 0.3% of testosterone is converted into estradiol by aromatase (CYP19A1)[145] an enzyme expressed in the brain, liver, and adipose tissues.[1]

DHT is a more potent form of testosterone while estradiol has completely different activities (feminization) compared to testosterone (masculinization). Also, testosterone and DHT may be deactivated or cleared by enzymes that hydroxylate at the 6, 7, 15 or 16 positions.[146]

The effects of testosterone in humans and other vertebrates occur by way of multiple mechanisms: by activation of the androgen receptor (directly or as DHT), and by conversion to estradiol and activation of certain estrogen receptors.[147][148] Androgens such as testosterone have also been found to bind to and activate membrane androgen receptors.[149][150][151]

Free testosterone (T) is transported into the cytoplasm of target tissue cells, where it can bind to the androgen receptor, or can be reduced to 5-dihydrotestosterone (DHT) by the cytoplasmic enzyme 5-alpha reductase. DHT binds to the same androgen receptor even more strongly than testosterone, so that its androgenic potency is about 5 times that of T.[152] The T-receptor or DHT-receptor complex undergoes a structural change that allows it to move into the cell nucleus and bind directly to specific nucleotide sequences of the chromosomal DNA. The areas of binding are called hormone response elements (HREs), and influence transcriptional activity of certain genes, producing the androgen effects.

Androgen receptors occur in many different vertebrate body system tissues, and both males and females respond similarly to similar levels. Greatly differing amounts of testosterone prenatally, at puberty, and throughout life account for a share of biological differences between males and females.

The bones and the brain are two important tissues in humans where the primary effect of testosterone is by way of aromatization to estradiol. In the bones, estradiol accelerates ossification of cartilage into bone, leading to closure of the epiphyses and conclusion of growth. In the central nervous system, testosterone is aromatized to estradiol. Estradiol rather than testosterone serves as the most important feedback signal to the hypothalamus (especially affecting LH secretion).[citation needed] In many mammals, prenatal or perinatal "masculinization" of the sexually dimorphic areas of the brain by estradiol derived from testosterone programs later male sexual behavior.[citation needed]

A number of synthetic analogs of testosterone have been developed with improved bioavailability and metabolic half life relative to testosterone. Many of these analogs have an alkyl group introduced at the C-17 position in order to prevent conjugation and hence improve oral bioavailability. These are the so-called "17-aa" (17-alkyl androgen) family of androgens such as fluoxymesterone and methyltestosterone.

Some drugs indirectly target testosterone as a way of treating certain conditions. For example, 5-alpha-reductase inhibitors such as finasteride inhibit the conversion of testosterone into dihydrotestosterone (DHT), a metabolite more potent than testosterone.[153] These 5-alpha-reductase inhibitors have been used to treat various conditions associated with androgens, such as androgenetic alopecia (male-pattern baldness), hirsutism, benign prostatic hyperplasia (BPH), and prostate cancer.[153] In contrast, GnRH antagonists bind to GnRH receptors in the pituitary gland, blocking the release of luteinising hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary.[154] In men, the reduction in LH subsequently leads to rapid suppression of testosterone release from the testes. GnRH antagonists have been used for the treatment of prostate cancer.

There are many routes of administration for testosterone. Forms of testosterone for human administration currently available include injectable (such as testosterone cypionate or testosterone enanthate in oil),[155] oral, buccal,[156] transdermal skin patches, transdermal creams, gels,[157][158] and implantable pellets.[159] Roll-on methods and nasal sprays are currently under development.

A testicular action was linked to circulating blood fractions now understood to be a family of androgenic hormones in the early work on castration and testicular transplantation in fowl by Arnold Adolph Berthold (18031861).[160] Research on the action of testosterone received a brief boost in 1889, when the Harvard professor Charles-douard Brown-Squard (18171894), then in Paris, self-injected subcutaneously a "rejuvenating elixir" consisting of an extract of dog and guinea pig testicle. He reported in The Lancet that his vigor and feeling of well-being were markedly restored but the effects were transient,[161] and Brown-Squard's hopes for the compound were dashed. Suffering the ridicule of his colleagues, he abandoned his work on the mechanisms and effects of androgens in human beings.

In 1927, the University of Chicago's Professor of Physiologic Chemistry, Fred C. Koch, established easy access to a large source of bovine testicles the Chicago stockyards and recruited students willing to endure the tedious work of extracting their isolates. In that year, Koch and his student, Lemuel McGee, derived 20mg of a substance from a supply of 40 pounds of bovine testicles that, when administered to castrated roosters, pigs and rats, remasculinized them.[162] The group of Ernst Laqueur at the University of Amsterdam purified testosterone from bovine testicles in a similar manner in 1934, but isolation of the hormone from animal tissues in amounts permitting serious study in humans was not feasible until three European pharmaceutical giantsSchering (Berlin, Germany), Organon (Oss, Netherlands) and Ciba (Basel, Switzerland)began full-scale steroid research and development programs in the 1930s.

The Organon group in the Netherlands were the first to isolate the hormone, identified in a May 1935 paper "On Crystalline Male Hormone from Testicles (Testosterone)".[163] They named the hormone testosterone, from the stems of testicle and sterol, and the suffix of ketone. The structure was worked out by Schering's Adolf Butenandt.[164][165]

The chemical synthesis of testosterone from cholesterol was achieved in August that year by Butenandt and Hanisch.[166] Only a week later, the Ciba group in Zurich, Leopold Ruzicka (18871976) and A. Wettstein, published their synthesis of testosterone.[167] These independent partial syntheses of testosterone from a cholesterol base earned both Butenandt and Ruzicka the joint 1939 Nobel Prize in Chemistry.[165][168] Testosterone was identified as 17-hydroxyandrost-4-en-3-one (C19H28O2), a solid polycyclic alcohol with a hydroxyl group at the 17th carbon atom. This also made it obvious that additional modifications on the synthesized testosterone could be made, i.e., esterification and alkylation.

The partial synthesis in the 1930s of abundant, potent testosterone esters permitted the characterization of the hormone's effects, so that Kochakian and Murlin (1936) were able to show that testosterone raised nitrogen retention (a mechanism central to anabolism) in the dog, after which Allan Kenyon's group[169] was able to demonstrate both anabolic and androgenic effects of testosterone propionate in eunuchoidal men, boys, and women. The period of the early 1930s to the 1950s has been called "The Golden Age of Steroid Chemistry",[170] and work during this period progressed quickly. Research in this golden age proved that this newly synthesized compoundtestosteroneor rather family of compounds (for many derivatives were developed from 1940 to 1960), was a potent multiplier of muscle, strength, and well-being.[171]

A number of lawsuits are currently underway against testosterone manufacturers, alleging a significantly increased rate of stroke and heart attack in elderly men who use testosterone supplements.[172]

Precursors/prohormones

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Agonists

Antagonists

Precursors/prohormones

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