Can you see the seven structures of the vulva between your legs if you are wearing a mirror? Can you identify the vulva of your partner if they have one?
The vulva is an important part of the body for more than half of the population. It's an exit and entrance, a place of pleasure and pain that speaks to core human function. It can feel like we are on the edge of freedom from the oppression and ick that surround female genitalia in 2021. Real progress can be seen in the booming sex market, growing awareness of hormonal cycles, the messy reality behind periods, and a greater focus on female pleasure. There is still a lot of confusion in society about what's happening (clitoris and labia majora, labia mina, urethral opening, Vaginal Opening, Perineum opening, and so on), which has tangible consequences.
A group of epidemiologists and gynaecologists published their results from a study in March 2021. The survey involved asking patients to fill out surveys in the waiting rooms of an Outpatient Unit at a UK hospital. Participants were asked to identify the various parts of the vulva using their own words. The peehole and bumhole were accepted respectively for the urethra or anus. Only 46% of participants identified three holes and almost half left the labelling section unfilled. Only 9% correctly labeled all seven structures.
We conducted the research because many patients were confused about the nature of their problems at gynae clinics. Dr Dina El Hamamsy is a senior obstetrics registrar in Cambridge, and one of the coauthors of this study. Patients who have experienced pelvic organ prolapse (which can occur after giving birth vaginally) are particularly affected.
51% correctly labeled the urethra, while 37% correctly labeled the clitoris. The vagina and anus were correctly labeled by women more often than those of men. However, there was no difference in the labels for other structures. These results are similar to a 2014 Eve Appeal study. The results echo a similar study by Eve Appeal in 2014. Only half of the 1,000 women interviewed were able correctly label their vagina. 65% said they had difficulty using the words vagina or vulva. This problem is as severe as ever.
The vulva is a complex topic that evokes many emotions. We need to know how it should be, what we should do with the information and what we should discuss. El-Hamamsy believes the public conversation must move beyond raising bodily awareness to clearly identifying risks associated with poor education. She says that patients may claim to have had a bladder surgery, but the procedure does not repair the bladder. It's worrying that patients don't know if they have had a prolapse surgery. This surgery can be a significant event in someone's life.
This raises important questions about consent and trust. It is critical to understand the potential risks and benefits before we place our trust in doctors to treat us when things go wrong. Are we consenting fully if we don't understand?
Stephanie Shoop-Worrall from the University of Manchester, who was part of the study, says that full consent is based on the ability to have a discussion about what is wrong with you and what will happen. She says that if someone is being dragged around for months, and then given to a specialist to help them, they might just be willing to do whatever the specialist suggests.
If medical training in gynaecology is limited, this can lead to a lot of sex. El-Hamamsy says that medical students are limited to a basic obstetrics rotation and gynaecology.
Knowledge cannot be separated from education. This means that we need to know where the information came from, who gave it to us, and what context. Kate Moyle, a London-based psychosexual psychotherapist, specializes in helping people with difficulties with their relationships and sexuality. She says that education is a major part of her job. This includes explaining the functions of different body parts, looking at diagrams and anatomical models, and explaining how they work. Understanding is the key to empowerment.
The clitoris, a primary sexual organ, is the clitoris. The vagina, a separate structure, serves a different purpose. We were not taught much about the vaginal structure.
Therapy is often used by people who are unable to communicate their feelings or needs about vulnerable parts of their bodies. Moyle believes that a lack formalised holistic education and safe spaces to explore these issues in underpins a disconnect with our bodies. This can also lead to disconnection with what happens when we share this information with others.
She says that for so many years, sexual education has been focused on reproduction and procreation. The pleasure of females has been left out. The clitoris, a primary sexual organ, is not included. The vagina, a separate structure, serves a different purpose. However, they were not taught much about the former. Structure and purpose can be confusing for men. The full structure of the clitoris was discovered only in 1998. Moyle collects extensive information from her clients and tracks their lives from birth. People are shaped by the early messages about their bodies and sexuality that they received. You can carry that anxiety into adulthood for many years if there are no adults to correct your 10th grade playground chatter. The body keeps track.
Dissatisfaction can result from not being taught to have open discussions about our fears and needs. When we are anxious, our instinct is to avoid intimacy and vulnerability in sexual relationships. Repressing powerful emotions can cause them to resurface in stronger ways. Avoidance is a common theme. Fiona Reid is a Manchester-based consultant gynaecologist and co-author of the study with El Hamamsy. She says that there are still people who don't like the idea of their genitalia. In her clinic, a common phrase is "I don't look down there." This can be used by anyone of all ages. This can happen to anyone from teenagers to the elderly.
When she told me this over Zoom, I put my head in mine. She sighs. All the people I interviewed to write Hormonal about female hormones, mind-body relationships, and other topics, come to mind. And I think about the psychic weight of ignorance, guilt, and shame that can play out in peoples lives because they have struggled to understand or aren't educated about what is theirs. This shame is often a sign of a lack in basic anatomical knowledge.
A tweet I sent asking people about their knowledge of vulvas elicited some interesting responses. Many people were still reluctant to use the word. Sarah, 46, from Liverpool, states that it is something she never uses. Although I incorrectly still use vagina in the entire area, I have always advocated for reclaiming cunt.
The inside of the vagina was not what I was taught. Olivia, a 35-year-old NHS midwife from South London, said that there was never any discussion about what you should call your own parts. I didn't feel comfortable using the vagina and vulva when I was a midwife until that point. These words are used purely anatomically. People spend their days with us at very vulnerable times, which leads to staff being more open.
I was struck by one response: Elizabeth, 35, who lives near Coventry and attended a Catholic school. She says that I was nine years old when I became aware of my vulvae and clitoris. However, I felt ashamed to admit that these feelings were something that I liked. I learned about anatomy of my vulva when I was older. The only thing I knew about conception was what my school taught. I didn't know I urinated from the urethra, I assumed it was from the clitoris.
What can be done if the consequences of poor education are so severe? People who experience incontinence, prolapse or vulvodynia (persistent and unexplained pains in the vulva), or vaginismus (when their vaginal muscles tighten when penetration attempts are made) need to be educated more. There are many products available that can help you to see, understand, and solve problems.
Sarah Tyler, a pelvic health and physiotherapist, is based in Hertfordshire. She specializes in diagnosing and treating the above-mentioned problems. She provides guidance for the reconditioning of pelvic floor muscles that are involved in urinary, bowel, and sexual function.
Sometimes shame can be traced back to a lack basic anatomical knowledge
She says it is amazing how much this type of physiotherapy can help people. Many people I see are suffering from chronic pain for years and believe their problems are due to having children or getting older. They don't have to be.
This is, naturally, emotional work. My clients often cry with me. It's a huge thing. It is a huge thing. People can sit wide-eyed and drink in information that has never been given them. Our approach is slow and focuses on consent. We also emphasize the ability to stop at any time.
Tyler has often discovered a hypertonic pelvic floors, which is when the muscles of the pelvic floor become overtense and cannot relax. This can cause any type of penetration to be painful and is often linked to stress, interstitial cystitis or chronic thrush. Emotions and anxious bodies are responsible for this tension. As she speaks, I can see that my pelvic floor is being tightened. It was something that I hadn't considered. Surprisingly, I have seen more hypertonic pelvic floor during the pandemic than in my eight years of working here. She says that the body is constantly gripping unconsciously.
Moyle often refers to pelvic physiotherapists. They are extremely helpful and people don't know they exist. Although pelvic health physiotherapy can be found on the NHS, it is not widely available. Many people in pain and experiencing problems with their vulvas or vaginas can't afford to go to the private sector. This raises the question: Where else can these important conversations be held? Shoop-Worrall states that their study data showed that higher education and white ethnicity were associated with correct anatomical labels. It is clear that education reform must be mandated if socio-economic status or ethnicity are associated with awareness gaps.
Yoan Reed, a consultant in relationship and sex education (RSE), is the co-founder of Outspoken Sex Ed. This organisation offers support for parents as they talk to their children about sex and bodies. She believes that children should be taught about their bodies from an early age. She says that she was a midwife and became aware of the lack knowledge regarding the female body. My caseload had a high number of teenage pregnancies. I was surprised at the lack of knowledge about anatomy and reproduction. This is why I decided to study education.
Only in 2015 was RSE made compulsory in UK schools. Because of how children learn, it has been long overdue for an upgrade. More than a third (8 to 11 years old) own smartphones. 20% of them use social media. Protests and criticisms were raised when the government suggested that 2019 would include instruction about same-sex relationships. It became mandatory to teach RSE in all ages starting September 2020, although primary schools have the option to choose what they will teach.
Reed says that the challenge is to adopt a whole-school approach. Reed says that everyone needs to be aware and sensitive to their own emotions, language, and experiences. Denmark is a country where body awareness, seeing naked bodies, and normalising variance happen very early. It is very different. As a child, I realized that it was the perfect word to describe my anatomy. It does not take away innocence, and it isn't about sex. It is not possible to empower the body by implying that children are being corrupted by anatomical terms. If they know the right words, they will be able to tell you if they are feeling wrong.
Reed heard comments from parents of primary school-aged children that it was easier to discuss boys' private parts than girls when he chaired focus groups. Gender inequality is not new. There are long-standing ideas about dominance to undo. It is a huge mistake to ignore the clitoris.
Reed acknowledges that the UK is multi-cultural and, generally speaking, very tolerant. However, there are still many myths to be broken. This country did not have the resources to encourage parents to take on primary education. While the government gives parents rights to have their children removed from sex education by law, it is important to support this right.
The Netherlands, which is very egalitarian and open, is one of the most gender-equal nations in the world. It is easy to draw a direct line from education. The Dutch sex education curriculum Kriebels In Je Buik (Butterflies In Your Stomach) begins with four-year olds discussing reproduction, their own pleasure, boundaries, and the differences between female and male bodies. Research shows that children who are inclusively educated have a lower tendency to bully and are more likely to help when their LGBTQ+ peers are being attacked. However, young people in the Netherlands report high levels sexual satisfaction. These clear outcomes in public health are hard to dispute.
Reed sends me artwork created by girls aged five and six during a recent workshop on wombs, vulvas and women's art. Fluorescent pipe-cleaners and pompoms with glitter are used to show labia, clitorises and fallopian tubes. Some googly eyes are available. They are happy. I feel a strange sensation: Hope.