Ask Dr. Bob

Orgasms, cellulite and chronic fatigue: Who could ask for anything more?

Published August 30, 1999 4:00PM (EDT)

What is the difference between a clitoral and a vaginal orgasm?

Half an hour. Sad to say, the Salon Health & Body editors weren't satisfied with this answer! Off to Medline to find out the real poop. Not a straight answer anywhere. But I did find a few titillating bits.

Where is the orgasm located? I wondered. Patients with complete spinal cord transection can experience all phases of orgasm. The response can be elicited by manual stimulation, even when the patient has no skin sensation. On the other hand, Andrea Dworkin to the contrary, women can achieve orgasm exclusively through visual imagery. (Hello, Hallmark, do I have an idea for you.)

Good news for you poor marksmen. There is no specific G-spot; rather there are multiple vaginal areas that are erotically sensitive. Take your pick.

Bad news for those with certain fantasies: The so-called female ejaculate is biochemically indistinguishable from urine!

During orgasm, brain metabolism preferentially increases in the right frontal region -- the same brain area that is used to recall old memories. Is fantasizing about old lovers merely biochemical overflow? Or an evolutionary visual aid?

The best good news: The ultimate physiology of the orgasm remains a mystery. Which means goodbye to Teutonic sex manuals and specific guidelines. A whole generation went neurotic trying for simultaneous orgasm. Forget it. Anything goes. Even explanations.

Mechanical? Reflex? In the mind? Asking, "What is an orgasm?" is akin to opening Pandora's box.

I have cellulite and it's driving me insane. I don't go to the beach because of it. I see things like Cellasene that advertise to get rid of it. Is it possible?

I confess total ignorance as to what cellulite actually is, but I know it when I see it. Not a pretty sight, but not the end of the world, either. I know a very pretty woman with one leg, and she never worries about cellulite. Thigh and hip dimpling is a physical breakdown of subcutaneous tissue just beneath the skin with bits of fatty tissue bubbling up through small connective tissue defects like tiny hernias. It is exclusively mechanical, more common in women for reasons unknown, not some metabolic screw-up or accumulation of dread toxins, nor is it directly related to fat or caloric intake. It's simply bad luck that gets under your skin.

If you can't accept nature, try high fishnet stockings or dim lighting, or forego doggie-style. All are cheaper and have better results than the current crop of snake-oil drugs on the market.

Bottom line, don't worry about the bottom lines. And be reassured; none of the remedies is as effective as self-deprecation. As for Cellasene, the company talks of success in unpublished studies (the medical equivalent of "the check is in the mail"), but a Medline search revealed the big nada. Sorry.

What is chronic fatigue syndrome and how could one of those gals on the U.S. women's soccer team have it and still play? I don't get it!

I am sick and tired of chronic fatigue. Talk about mass hysteria, this is a case of a non-diagnosis becoming a national epidemic. You can thank a bunch of self-important doctors and ill-informed, self-righteous support groups revving up a populace primed to enjoy poor health. If crucifixes were still in vogue, I am sure that there would be no shortage of volunteers.

Once upon a time chronic feelings of lassitude, lack of energy, generalized aches and pains and sleep disturbances were considered typical of depression. In fact, when I was in medical training, the euphemism was "masked depression," which meant that the doctor recognized that the patient was depressed, but the patient didn't. Of course, forgive me for saying this, but such a diagnosis presumed that the doctor might know something about the patient that the patient didn't know. That was a perfectly reasonable presumption until psychiatry went into the toilet. Now you can't tell people they're depressed. You need a new medical vernacular. Hmmm. Let's see. How about Chronic Fatigue Syndrome (CFS)?

"Way excellent," said the pseudo wise men.

The term means NOTHING.

In what we call CSF, there are no specific lab-test abnormalities or alterations in muscle function. If you have any question about the non-physiological nature of the fatigue, watch an elite-class athlete compete day after day in Women's World Cup soccer, functioning at a physical-fitness level most of us can't even imagine, yet she is feeling that she is ill. Right ... And Tiger Woods should be able to hit the ball 50 yards farther.

In all fairness, there are plenty of well-respected physicians who firmly believe that CFS is real. And, perhaps for a small minority of patients with the complaint of chronic fatigue, there is a yet-undiscovered physiological basis. Perhaps, perhaps. I am not convinced. The last word is not in, but my last words on the subject: Freud was plenty wrong, but better than many of the alternatives. Recommended link: Depression in Primary Care, Vol 1.

Why are doctors so defensive when the patient asks lots of questions and does his own research?

Why shouldn't we be? What gives you, the intelligent, well-informed patient, the right to think that you are actually capable of conversing with HMO-crazed, constantly harassed, so-busy-curing-the-ungrateful-that-there's-no-time-for-reading, but medically sophisticated (a minimum of eight years of grueling training) former God figures? It is the height of naiveti and thoughtlessness to believe that you can actually understand medical information without sacrificing your young adulthood staying up all night in order to save chronic alcoholics from self-immolation and cellulitis. (And at a fraction of post-MBA salaries, though I do not want you to think that self-sacrifice and lack of participation in the recent economic bonanza has triggered any subliminal bitterness.)

Medicine is a fraternity. No one can join without proper hazing. Pay your dues, then we will listen.

By the way, would you mind covering for me this weekend? I've got two tickets to the Stones. Just slip on my white coat and keep talking over the patients. No one will know the difference. Besides, you already have all the answers.

A practical tip: Doctors are human, are exactly the same as the rest of us/them/me/you, but have been tainted by a taste of power and drama unequalled in any other profession. It's only natural that they (to varying degrees) believe their own sales pitch. If you want the best care, ignore their pomposity and imperiousness. Pretend that they are maitres d' and that they are going to get you the best seat in the health restaurant. Seduce them with compliments, a gracious smile, a thank-you note. Once you have them on your side, anything goes. You can send back the wine, rip up the tablecloth or bring in a zillion questions.

Another tip: If possible, interview your general practitioner before signing on. Offer to pay for the time. Most blind dates start over coffee, not by going directly to the pelvic and rectal exams. Don't be shy or coy in the beginning. Think colonoscopy, and ask every question that stands between you and comfort. Remember, you are hiring the doctor.

By Robert Burton

Robert Burton M.D. is the former chief of neurology at Mount Zion-UCSF Hospital and the author of "On Being Certain: Believing You Are Right Even When You're Not" and "A Skeptic's Guide to the Mind." A former columnist for Salon, he has also been published in the New York Times, Aeon and Nautilus, and currently writes a column at the Cambridge Quarterly for Healthcare Ethics.

MORE FROM Robert Burton

Related Topics ------------------------------------------