AN News: “(Not) Talking about Unmentionable Symptoms” by Christine Labuski (Virginia Tech)

How do I tell my health care provider about a pain that I can’t name? How are symptoms experienced when they emerge from a part of the body for which most sufferers literally have no words? These questions framed my fieldwork with women who experienced vulvar pain (vulvodynia); women for whom vaginal penetrative sex, sitting down for extended periods, and wearing jeans were intolerable activities, and for whom the words vulva and labia were rendered unavailable by their socially disruptive nature. While my primary orientation toward these patients was medical, it was impossible for me to ignore the ways that language—and (lack of) access to precise anatomical vocabulary—shaped important dimensions of my informants’ bodily experience. Unable to use words that directly referred to the site and source of their distress, symptomatic women learned to live with their pain for years at a time, deferring and displacing their genital well-being until they located the kind of specialty care, such as the clinic where I conducted fieldwork, that incorporated language skills into its treatment plan. In this column, I explore how a lack of vocabulary resonates with the ways that female genitalia are missing from broader social landscapes, and how both of these forms of absence converged in the bodies of my informants, challenging their abilities to secure care and to feel better.

My fieldwork for this research consisted of thirteen months in a vulvar specialty clinic, where I observed clinical visits, surgeries, and physical therapy sessions, and conducted in-depth interviews with patients. But before studying anthropology, I cared for my own patients as a gynecological nurse practitioner, and I routinely observed the bodily implications of what I have since come to call vulvar disavowal (Labuski 2015). Women who lacked words for their genital anatomy were also alienated from their physical bodies in ways that made it difficult for them to troubleshoot genital and sexual situations, such as recovering a broken condom or recognizing an abnormality. I pursued fieldwork with vulvar pain patients because I wanted to better understand how women negotiated this alienation and whether, as I suspected, it was tenacious enough to deter seeking relief from a pain that most sufferers describe as life-altering.

Like my former patients, I found that the vulvar symptoms of my informants were compounded by a discursive reluctance during medical consultations. Immersed in popular and institutional contexts through which female genitalia are characterized in a wide variety of (mostly) negative ways, women struggle to gain linguistic access to their genitalia, accumulating, instead, terms that disparage (cunt), infantilize (hoo-ha), or phonologically lampoon (va-jay-jay) them. Because clinicians rarely use this genital vernacular during medical exams, many women feel uncomfortable using anything but the anatomically abstract formulation of down there. Indeed, women who attempt to describe their pain with anatomo-clinical speech typically resort to the word vagina, which does not accurately reference the part of their body that is in pain.

This problem of reference compounds the awkward and non-productive exchanges between afflicted women and their providers. Many women stammer through clinical exchanges, hoping to be asked a question that relieves them of narrative responsibility. In other words, when they are asked“Does your vulva hurt inexplicably and without provocation for long periods of time?,” women with vulvar pain are very likely to answer in the affirmative. Without this direct prompting, however, most are reluctant to utter the phrases necessary to accurately communicate their experience. To compensate, many patients employ an assortment of shortcuts, partial reports (“it’s not exactly inside”), and gestures toward their genitalia in order to convey the nature of their distress. Absent this mix of suggestive signs, and the elicitation of a vulvar-specific clinical history from her provider, a woman’s vulvodynia will very likely remain unaddressed.

Unfortunately for these patients, health care providers, including many gynecologists, are unlikely to ask directly about their vulvas: my ethnographic data and a recent NIH report evince a general lack of clinical knowledge about, and interest in, vulvodynia. Indeed, a woman who manages to convey that her down there area hurts is often steered away from the specifics of her vulva(r pain), toward an inadequate and patterned set of reassurances that short-circuit discussion of her genitalia and sexual activity. This is especially likely in the absence of obvious pathology on a physical exam, which is typical for vulvodynia. Most symptomatic women, then, do not secure care by making an appointment with an educated provider about their vulvar pain. Rather, the above dynamics result in a set of diagnostic delays that can last for years (five to seven on average), enabling a more rapid development and greater severity of concomitant problems, such as pelvic floor myalgia. This increased severity reaches well into patients’ lives: into their jobs, where they stand at meetings or sit on special seating cushions; into their friendships, where they feel distanced from discussions about sex and sexual behaviors; and into their intimate relationships, which grow strained and more sexless between each unproductive clinical encounter.

The verbal strategies employed by afflicted women who have learned to keep quiet about their genitalia resonate with biomedicine’s complicity in silencing women’s (external) genitalia. Witness the partial or complete absence of vulvar anatomy from not only medical textbooks but from bodies themselves, as a growing number of surgeons routinely excise healthy but cosmetically undesirable vulvar tissue in a procedure known as labiaplasty. These erasures impact not just the clinical condition of vulvodynia, but the lived bodily experience of millions of other women in the contemporary US who learn the discursive lesson of vulvar disavowal. And for trans and other gender-nonconforming people who might experience this condition (about whom there is currently no clinical data), such erasures undermine their ability to affirm alternative gender-genital configurations.

In my broader project, I argue that vulvar alienation, including its verbal manifestations, both shapes and reveals notable amounts of ambivalence on the part of afflicted women toward heteronormative sexual arrangements. Here, I question the relationship between speaking a body part and investing it with medical care and attention. I hope to illuminate the discursive prohibitions regarding the vulva not only because they contribute to substandard care, but also because they undermine women’s body ownership and genital integration.

Christine Labuski is an anthropologist and assistant professor of Women’s and Gender Studies at Virginia Tech, where she also directs the Gender, Bodies & Technology initiative. Her book It Hurts Down There: The Bodily Imaginaries of Female Genital Pain, tracks the emergence and physiological realization of vulvar pain conditions in the contemporary United States.

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