Last month, celebrated journalist Katie Couric interviewed Dr. Jen Gunter, “the internet’s OB/GYN,” about her new book The Vagina Bible;1New York: Penguin-Random House, 2019More Info → the interview was published by the website Medium under the title “The One Word Your Ob/Gyn Wants You to Say More.” I learned about the interview when a friend sent me the link, adding the comment: “Clickbait [for] what seems to be a feel-good feminism book? And that word had better be ‘orgasm’!” Though cheeky and a bit sexually explicit, this exchange was actually a scholarly one for me. Ever since I began studying vulvas, just over two decades ago, I’ve been the recipient of innumerable images, jokes, and news stories about genitalia, and I both love and learn from all of them. Indeed, this one arrived in a timely fashion. I opened it the morning of an all-day writing retreat, during which I had set time aside to compose the first draft of this essay.

The trouble that morning, though, was that I couldn’t bring myself to open the piece. The link in my friend’s text message revealed enough of the first few sentences for me to glean that the word in question was vagina, a word which has become quite vexing to me over the course of my vulvar research. Curious, but wanting to avoid the frustration I often feel when I encounter genital clickbait, I partially covered my eyes and grimaced while taking in the first few sentences. Sighing a little, I went back to my laptop and drafted the essay as I’d planned. Why was I being so picky?

“I know that far too many people confuse and conflate the words vagina and vulva and that this linguistic slippage can have deleterious consequences for people who have vulvas.”

My disappointment sprang from the ill fit between Dr. Gunter’s discussion of her Vagina Bible and the findings from my nearly two decades of research about vulvas and, particularly, vulvar pain conditions. After spending a year in a vulvar specialty clinic, meeting and talking with over 100 women with chronic and unexplained vulvar pain conditions, and following many of these women online since then, I know that the words we use matter. I know that far too many people confuse and conflate the words vagina and vulva and that this linguistic slippage can have deleterious consequences for people who have vulvas. How should someone whose vulva hurts so much they can’t wear pants describe this to their health care provider if the only terms they have available are vaginal ones? Should I describe lower back pain by talking about my anatomically adjacent pelvis, hoping that my provider will understand?

As a self-described feminist (and) healthcare provider, Dr. Gunter seems concerned about this too. In her interview with Couric (which I eventually brought myself to read!), she claims that she was “adamant about no euphemisms” in her book because “when society insists that we don’t speak or write a word the implication is that [that] word is shameful.” She goes on to say, however, that because “the vagina has taken on a broader meaning in society [… which] encompasses … the vulva,” she relegated the word vulva to the subtitle of her book. Dr. Gunter remains clear that vaginas and vulvas are distinct body parts, and that the book is about both of them. For simplicity’s sake, however, and because “society” does so, she performs the conflation.2Gunter further explains that she had to fight Twitter to take the word “vagina” off its list of banned words so that she could promote her book. Knowing this, it’s easy to imagine that vulva would have provoked even more trouble, including with her press.

Researching the vulva

So, what does all this have to do with the Sexuality Research Fellowship Program (SRFP)? My answer is, quite simply, everything. In the 2004–2005 academic year, and under the direction of Diane DiMauro, the SRFP determined that my interest in vulvas and vulvar pain conditions was important enough to fund. With their explicit attention on broader US-based research and away from HIV/STI/public health topics (acknowledging that these topics were well-funded by other organizations), the SRFP made intentional space for a project like mine, a project that suspected that vulvas in the United States had lots to teach us about our particular versions of (hetero)sexuality, embodiment, biomedicine, language, gender, and feminist healthcare. I went to the field with a host of questions, many of which I began to develop during my previous career as a gynecological nurse practitioner: What does it mean to say vagina (or any of its euphemisms) when you really mean vulva? What does it mean to refer to a muscular internal canal—through which menstrual blood, objects, body parts, and babies move and are moved—when what you’re referring to is a fleshy external organ—replete with nerve endings and complex enough to include anatomical parts of its own? What does it mean to refer to the vagina when your vulva is in pain, so much pain that you are unable to participate in heteronormative coitus but also, and perhaps more mundanely salient, ride a bike, wear pants, drive a car, or sit down?

“I argue that the sociocultural reluctance surrounding frank and nonsuggestive talk about the vulva produces a kind of genital alienation that can lead to or exacerbate conditions like chronic vulvar pain.”

As a nurse practitioner, I had observed firsthand how hesitant my patients were about touching and talking about their genitalia. I worried then—and I worry now—about how this reluctance shapes any number of genital-sexual health conditions, including vulvar pain and malignancies, unsatisfying sexual experiences, contraceptive needs, gender affirmation treatment, or pregnancy. My SRFP-supported fieldwork allowed me to ask the above questions and more. I eventually spent a full year with the patients and providers of a vulvar specialty clinic—sitting in on clinic visits, conducting interviews, and following patients to their surgeries and physical therapy sessions. My analysis, published as It Hurts Down There: The Bodily Imaginaries of Female Genital Pain,3Albany, NY: SUNY Press, 2015More Info → concludes that vulvar pain must be understood as a biocultural dis-ease. That is, I argue that the sociocultural reluctance surrounding frank and nonsuggestive talk about the vulva produces a kind of genital alienation that can lead to or exacerbate conditions like chronic vulvar pain.

My SRFP-supported fieldwork was invaluable, particularly because I was able to spend time in a clinic where I wasn’t the healthcare provider. I learned a lot from this participant-observer role, including why Dr. Gunter might feel the need to accommodate popular vernacular in her outreach efforts. Indeed, most of the clinic patients I met initially used the word vagina to discuss their symptoms; vulva was either unfamiliar or too explicit.4The programmers at Microsoft Word were not immune from this reluctance. While I wrote my dissertation, the program would routinely suggest that I replace the word “vulvar” with “vulgar.” But I’m also a feminist scholar which, for me, means outlining the stakes of my rhetorical and discursive choices. And what I also learned at the clinic—and what drives the perspective of this essay—was that women shifted in their ability to cope with and benefit from treatment plans for their pain when they could talk about it vulvar terms; when they were given permission to describe and inhabit all of their genitalia.

Including the vulva in gender and sexuality research

Lest this essay suggest that Dr. Gunter is alone in erasing/displacing the vulva, a semi-quick search of the academic literature suggests that gender and sexuality scholars have also been ignoring what the vulva can tell us when it constitutes our point of departure. Entering the search term “vulva” into Google Scholar produced 10 pages of articles, almost all of which were clinical in nature (carcinomas and other biomedical conditions); “vulva + sexuality” led to a similar number, most of which were based in psychology, but including a few feminist critiques of labial cosmetic surgeries, and; finally, “vulva + gender” produced a small interdisciplinary mix more attuned to intersexuality and queer perspectives on anatomy and genitalia. Missing, however, were feminist, critical cultural, materialist, linguistic, and activist perspectives on vulvas and why they matter. This feels like an especially missed opportunity in the wake of post-Trump Women’s Marches, and the wide-ranging discussions of what role “the (pink) pussy” should play in inclusive spaces.

“Why are the majority of specialty clinic patients white, when epidemiologic research suggests that, when asked, women of color are more likely to complain of these symptoms?”

Beyond the medical and psychological research, and expanding on interdisciplinary work already happening, new perspectives on vulvas could explore some of the following: How do the recipients of vulvar surgeries—cosmetic, gender affirming, and therapeutic (e.g., to remove a cancerous lesion)—understand their reconfigured genitalia? Do vulvar pain patients challenge heteronormative sexual scripts that routinely marginalize their labia, as my research suggests they have the capacity to do? Why are the majority of specialty clinic patients white, when epidemiologic research suggests that, when asked, women of color are more likely to complain of these symptoms?5I try to answer this question in Christine Labuski, “A Black and White Issue? Learning to See the Racial and Intersectional Dimensions of Gynecological Pain,” Social Theory & Health 15, no. 2 (2017): 160–81. See also Bernard L. Harlow and Elizabeth G. Stewart, “A Population-based Assessment of Chronic Unexplained Vulvar Pain: Have We Underestimated the Prevalence of Vulvodynia?” American Medical Women’s Association 58, no. 2 (2003): 82–88. Is vulvar pain experienced as a disability? Why or why not? And how might any of these questions translate into intersectional feminist research projects?

It’s 2020 and I’m still worried. I’m worried that if, like the women that I worked with during my research, my vulva hurts, or if it has cancer, or if I’ve acquired a new vulva and have questions about it, or even if it just feels really good for you to touch it and I want to tell you that, I will likely struggle to have all the words I need. Or want. I’m worried that if we leave vulvar discourse to clinicians like Gunter, we run the risk of understanding vulvas through an impoverished set of medicalized narratives that center the reproductive and cis-/heteronormative “function” of nonpenile genitalia. I suspect that wider access to frank conversations about vulvas might have helped with some of the pussy hat concerns: vulvas don’t have to be defined strictly by labia, nor should they be solely imagined as pink, for example. So though I agree with my friend in that I also “want that word to be orgasm!,” because I want my healthcare provider to talk as much about orgasmic pleasure as they do about genital risk and pathology, I also think it’s time for my Ob/Gyn—along with my friends, my sexual partners, the media, policymakers, and the #MeToo movement—to say two words more often: vulva and vagina. It’s high time, in other words, for the vulva to get promoted, from subtitle to headline.

References:

1
New York: Penguin-Random House, 2019More Info →
2
Gunter further explains that she had to fight Twitter to take the word “vagina” off its list of banned words so that she could promote her book. Knowing this, it’s easy to imagine that vulva would have provoked even more trouble, including with her press.
3
Albany, NY: SUNY Press, 2015More Info →
4
The programmers at Microsoft Word were not immune from this reluctance. While I wrote my dissertation, the program would routinely suggest that I replace the word “vulvar” with “vulgar.”
5
I try to answer this question in Christine Labuski, “A Black and White Issue? Learning to See the Racial and Intersectional Dimensions of Gynecological Pain,” Social Theory & Health 15, no. 2 (2017): 160–81. See also Bernard L. Harlow and Elizabeth G. Stewart, “A Population-based Assessment of Chronic Unexplained Vulvar Pain: Have We Underestimated the Prevalence of Vulvodynia?” American Medical Women’s Association 58, no. 2 (2003): 82–88.