It Hurts Down There

The Bodily Imaginaries of Female Genital Pain

Christine Labuski

• Editorial: SUNY Press
• Año: 2015
• ISBN:
  9781438458878
• Categoría: Sciences sociales
• Categoría: Études relatives au genre

How does a woman describe a part of her body that much of society teaches her to never discuss? It Hurts Down There analyzes the largest known set of qualitative research data about vulvar pain conditions. It tells the story of one hundred women who struggled with this dilemma as they sought treatment for chronic and unexplained vulvar pain. Christine Labuski argues that the medical condition of vulvar pain cannot be adequately understood without exposing and interrogating cultural attitudes about female genitalia. The author's dual positioning as cultural anthropologist and former nurse practitioner strengthens her argument that discourses about "healthy" vulvas naturalize and reproduce heteronormative associations between genitalia, sex, and gender.

1

INSINUATION

A Biocultural Condition

The worst name anybody can be called.

—Germaine Greer, The Female Eunuch

In the spring of 2003, the Journal of the American Medical Women’s Association published a study entitled “A Population-Based Assessment of Chronic Unexplained Vulvar Pain: Have We Underestimated the Prevalence of Vulvodynia?” At seven pages, the article concisely reports the findings of a telephone survey of over three thousand Boston-area women who were asked about symptoms that the authors defined as “chronic vulvar pain”:

a) burning in the genital area for 3 months or longer with or without chronic itching,

b) knifelike or sharp pain in the genital area for 3 months or longer with or without burning or itching, or

c) excessive pain on contact when inserting tampons, during sexual intercourse, or during pelvic examinations that lasted for 3 months or longer. (Harlow and Stewart 2003, 83)

The survey was part of a larger project conducted by the Harvard School of Public Health, nestled between pilot research demonstrating an 18 percent prevalence rate for vulvar pain and a clinic-based follow-up study intended to correlate women’s reported symptoms with objective evidence of disease. The authors of the study (an epidemiologist and a researcher-physician) reported that “the pathophysiology of these conditions [and] … the magnitude of this problem … [were] largely unknown” (82), but that “the true incidence of generalized and localized vulvar dysesthesia” could not be determined “without a complete medical history and physical examination to rule out other causes of genital discomfort” (83; my emphasis).

For these researchers and their clinician audience, “other causes of genital discomfort” include vulvar dermatoses, malignancies, inflammatory conditions, postoperative or postinjury neurological complications, and recalcitrant or atypical presentations of yeast or bacterial infections of the vagina and vulva. Although etiologically and pathologically varied, what links these causes of genital discomfort is the medical certainty that they are physiological and that a resolution of the pain can and should be achieved through pharmacological or surgical means. Reasons for distinguishing between chronic vulvar pain and its possible look-alikes are, in this framework, related not to the nature of its source (i.e., physiological) but rather to the project of constituting and delineating a distinct category of genital disease. Noting that this “highly prevalent condition … is associated with substantial disability” (87), the authors conclude with the hope that suitable prevention strategies can be gleaned from a better understanding of chronic vulvar pain’s distinct “etiological pathways” (87).

This book investigates the contemporary landscape of vulvar pain in order to illuminate a distinctly faceted set of causes and prevention strategies. Chronic and unexplained vulvar pain is indeed an increasingly legitimate medical condition. Though exact causative mechanisms remain unclear, researchers have postulated a wide range of possible factors—including neurological injury, genetic susceptibility, and altered hormone expression—and have developed an expanding array of variably effective treatment options (Bachmann et al. 2006; Danby and Margesson 2010; Haefner et al. 2005; Leclair et al. 2007; NIH 2012). This book argues that vulvar pain is also, and perhaps primarily, a bodily experience, mired in discourses of pollution and taboo that severely restrict a woman’s ability to accurately describe her symptoms. In the words of one informant, vulvas are virtually “off-limits,” including to the women whose bodies they distinguish. Women with vulvar pain bow to the weight of censoring social discourses as they struggle with language, postpone and avoid clinical consultations, and refuse treatment options that necessitate physical encounters with their genitalia. Rooted in a “highly prevalent” social genital dis-ease, these behaviors index a “disability” no less “substantial” (Harlow and Stewart 2003, 8) than the painful conditions described by Harvard’s researchers.

In this book, I treat vulvar pain as a condition that is simultaneously clinical and cultural, an approach reflecting my training in both feminist anthropology and gynecological medicine.¹ Medically, it is an affliction severe enough to preclude vaginal penetration, sitting down for longer than a few hours, and wearing pants or other forms of fitted clothing. Because the etiology of genital pain remains unclear, the diagnostic experience is a protracted one: clinicians attempt to identify the source and best course of treatment for symptoms they don’t fully understand, while affected women’s lives are irrevocably altered (Ventolini 2013). Vulvar pain is a cultural condition in that most women in the contemporary United States²—including symptomatic ones—lack an idiom or sufficient vocabulary through which to name and describe the parts of their body that are in pain. Frequently severe, this limitation is coassembled with a host of cultural institutions and practices through which frank descriptions of female genitalia are contaminated, erased, or otherwise muted.

I argue that distaste toward female genitalia is socially conditioned—neither natural nor inevitable; in Butler’s words (1993), it can be regarded as a “regulatory schema that produce[s] intelligible morphological possibilities” (14). In the chapters that follow, I explore the cultural and clinical conditions through which this dis-ease condition is achieved, how it “produces and vanquishes bodies that matter” (14); I also elaborate some of the risks with which it is associated and describe strategies through which alternative female genital bodies might be recuperated. In this introduction, I insinuate the contours of female genital dis-ease by positioning it within the symbiotic fields (Bourdieu 1993) of phallocentric and biomedical heteronormativity—discourses and practices that prioritize and assume the routine and penile penetration of female genitalia. Following this, I discuss the importance of feminist analyses that foreground the intragenital dynamics of the female sexual body—that is, the important and often hierarchical differences between vulvas and vaginas—and caution that failing to make these distinctions risks missing fundamental insights regarding how female bodies are culturally imagined. Furthermore, I argue that labial anatomies, thought by many to figure only marginally in heteronormative sexual scripts, have the capacity to profoundly disrupt and reconfigure them.

In the final section of this chapter, I offer three concepts without which I do not believe vulvar pain conditions can be properly analyzed: genital dis-ease, unwanted genital experience, and genital alienation. Unpacked in turn, these concepts demonstrate what medical anthropologists often label bioculture (Wiley and Allen 2009) and what “new materialists” refer to as entanglement (Barad 2007; Coole and Frost 2010): that events and ideas thought to be exclusively social are registered and reflected by material bodies, and that disease conditions are constituted by this multidirectional process. In the case of vulvar pain, the paradoxical narratives of excess and inconsequence shape a bodily imaginary in which genitalia are a problem to be avoided rather than confronted. Feminist and anthropological attention, I argue, can complement the clinical strategies of vulvar experts, reorienting symptomatic women away from the former and toward the latter.

FIXING THE PROBLEM

The way he is, I have to fix the problem.

—Sharon, Vulvar Health Clinic patient

Sharon³ uttered this statement to me as we talked over coffee one afternoon, engaged in a formal interview about her vulvar pain. Though symptomatic for over five years, Sharon had been neither properly diagnosed nor adequately treated until the month prior to our interview, when she had finally secured an appointment with the Vulvar Health Clinic (VHC), where, in 2004–2005, I conducted ethnographic fieldwork in order to better understand how symptomatic women and their providers negotiated the difficult “cultural” encounters that talking about genitalia required. For thirteen months, I observed and transcribed patient visits at the clinic and then followed these women through other aspects of their treatment regimens, including surgery and physical therapy sessions. This was in addition to formal interviews and informal conversations designed to glean as much information as possible about the wider contexts of vulvar pain. Sharon was emblematic of many of the women I came to know that year: having just consulted with an expert, she was newly optimistic that her symptoms would eventually resolve. But her buoyancy lay over several years’ worth of sexual and bodily despair, indexed most poignantly by her report of having “shut down,” both emotionally and sexually, a long time ago.

The “he” in Sharon’s remark was her husband, and her observation that the problem was hers to fix speaks to one of vulvar pain’s most onerous realities. The inability to engage in penetrative intercourse, one of the more notable hallmarks of this disease, engenders a unique set of stressors for patients’ intimate relationships. Almost always heterosexually identified, most women adapt to their symptoms by closing off connections to their genital bodies (sometimes for years at a time), participating in painful sex, or engaging in sexual activities that one informant explained were “more about him.” I argue that these limited coping strategies are elements of a pernicious and heteronormative social structure from which many straight-identified women must labor to discern their erotic sensibilities.

Immersed in the notion that vaginal-penile penetrative coitus constitutes “real sex” (Kaler 2006), women and couples affected by vulvar pain enact a set of seemingly natural implications: rather than exploring the nonpenetrative or nonvaginal dimensions of their sexual bodies and desire, they defer an active or generative sex life until symptoms can be wholly resolved (Labuski 2014). Sharon’s sense that it was she who needed to “fix [her] problem”—in other words, be able to “have sex” again—indexes the limited range of options through which many couples live their heterosexuality. In short, her husband’s phallocentric desire is the rule, rendering women who cannot comply with routine intercourse the exception. For both members of this couple, Sharon’s pain functions as little more than an obstacle in that, rather than providing a motive to learn about what (other) parts of their bodies they might also enjoy, it drives them further away from physical intimacy. As I elaborate in subsequent chapters, neither partner is able to perceive the coexistence of vulvar pain and a heteronormative sexual relationship. Rather, both believe that they must choose what Sharon’s body can tolerate: either the pain or her husband.

The situation in which Sharon and her husband are embroiled creates a space for what some scholars would call the queering of their heteronormality. Arguing that radical sexuality need not be solely the province of so-called sexual minorities, Beasley (2010) calls for a “transgressive heterosexuality” that “reject[s] … simplistic accounts of sexual modes” by “refus[ing] to inculcate socio-political determinism” (208). Stevi Jackson (2006) furthers this analysis with a discussion of meaning, concluding that while such determinisms may govern the intelligibility of (sexual) norms, meaning “is also negotiated in, and emergent from, the mundane social interaction through which each of us makes sense of our own and others’ gendered and sexual lives” (112). Here, a “‘natural attitude’” (113)⁴ toward penetrative intercourse can be called into question through beliefs and behaviors in which couples like Sharon and her husband might choose to engage, thus widening the parameters of what it means to be (hetero)sexually “normal.”

For Cacchioni (2007), such practices constitute “sexual lifestyle changes”:

Rather than working towards mastering, strategically mimicking, or carefully avoiding sexual practises, sexual lifestyle changes … involve challenging normative definitions of sex and even the overall importance of sexual activity. [They] might involve … privileging sexual activities typically deemed as foreplay, and/or valuing non-goal-oriented masturbation as an acceptable sexual activity on par with intercourse with another person. They also might entail questioning the overall importance placed on sexual relationships, institutions and practices. (310)

In this analysis, pain can become a catalyst for two kinds of shifts, the first being in one’s sexual repertoire, toward a set of more comfortable behaviors, and the second in the broader gender dynamics that structure a couple’s relationship. As Kaler (2006) argues, vulvar pain produces a category of “unreal women” (50) whose gender identity is threatened by being unable to engage in “an action which makes people into heterogendered men and women” (58). Likewise, Kempner (2014) has shown that this brand of gender transgression extends to the condition of migraine. Women whose debilitating headaches make it hard to care for their children, maintain a household, or participate in sexual activity are pathologized for failing to comply with these gendered norms, particularly by pharmaceutical companies that market remedies that enable them to return to the roles of wife and mother. I want to underscore that both types of pain confound women’s gendered identities by thwarting the aims of patriarchal masculinity; the conditions to be cured are defined as much by the (gendered) work in which symptomatic women cannot fully engage—vaginal intercourse and child care—as by the pain itself. Because of this conflation, and as my ethnography makes clear, sexual relationships that are (re)defined in terms of what her vulva needs rather than what his penis expects can facilitate the reconfiguration of gender norms in other areas of a heterosexual couple’s life.

And though these interpersonal tensions take their toll on vulvar pain patients, the struggle in which most of these women are even more intimately engaged is the one with their own bodies. It is these bodies—female,⁵ genital, sexual, and in pain—that are the protagonists of this book. I believe that the intrapersonal efforts of women afflicted with vulvar pain should be of concern to feminists for two important reasons: first, because their recuperative efforts locate them on the cutting edge of a radical and nonphallocentric sexuality; and, second, because they provide a uniquely embodied perspective on how female genitalia are lived in the contemporary United States. As anatomy and physiology—as skin, muscles, blood, and nerve endings—the genitalia of women with vulvar pain are “bodies that matter” (Butler 1993) apart from the erotic behavior in which they might or might not engage. But as I demonstrate throughout this book, this singular bodily fact is routinely undermined, in ways both astonishing and ordinary, by the erasure and muting of female genitalia.

MY BIRTH IN THE CLINIC

It’s tricky to physically inhabit a part of the body from which you have been otherwise taught to disassociate, through, for example, the “shaming words and dirty jokes” to which Gloria Steinem refers in her introduction to The Vagina Monologues (Ensler 2001, xi). Throughout this book, I use the term “dis-ease” to convey the awkwardness of encounters with the vulva, as well as to underscore the role this awkwardness plays in not only our general understanding of vulvar pain but also in its rates of complication and severity. It is the mutuality of these dimensions to which I refer when I use the phrase “Vulvar Disease,” which I capitalize in order to provide increased analytical weight to this relationality. As a formal theoretical concept, Vulvar Disease emphasizes the biocultural nature of a physiological pain saturated with gendered meanings and expectations, a real disease shot through with beliefs and sensibilities that contour its progression.

Freud’s notorious assertion that “the sight of female genitals gives … rise to ‘horror, contempt, or pity’” (Gatens 1996, 34)⁶ speaks to only one of the more explicit legacies through which women encounter dis-eased genitalia. These affects of disgust are compounded by what Harriet Lerner describes as the “persistent misuse” and substitution of the word “vagina” for “vulva,” a practice that “impair[s] a girl’s capacity to develop an accurate and differentiated ‘map’ of her … genitals” (2005, 28). When symptoms arise in this unmentionable (and therefore unspecified) place, the familiar act of uttering the words necessary for a focused medical history (“It hurts when I breathe”; “The itching seems to be much worse at night”) requires a delicate and difficult set of negotiations among the woman, bodily ignorance, propriety, and the urgency of her painful situation. “Having accurate language to distinguish the vulva from the vagina is crucial for every girl,” continues Lerner. “Inaccurate labeling … increases shame and complicates healing” (2005, 28; see also Frueh 2003).

It was through my work as a gynecological clinician—working first as a nurse and then a nurse practitioner in Planned Parenthood and other so-called sexual health clinics—that I initially came to speculate about the vulnerability of genitalia from which my patients seemed to be detached. As a health care provider, I was initially concerned about the disease-related outcomes of this detachment: the malignant progression of an undetected vulvar lesion, for example, or the potentially life-threatening complications of a sexually transmitted infection (STI). My fellow clinicians and I routinely lamented that our patients couldn’t talk about the very same sexual bodies that they physically shared with their partners (Braun and Kitzinger 2001; Devault 1990), and I began to wonder about the wide gaps that existed between what I taught my patients to do and what they later (at times sheepishly) told me they actually did. And though I am not suggesting that these problems are not shared by other areas of medicine, I am saying that genital health matters occupy a distinct cultural sphere, and that both clinicians and patients are challe...