Fear and loathing of women’s bodies

I recently completed an attachment in general practice as part of the final year of my medical degree. I’ve been lucky with my GP placements and I lucked in again this year, being placed with a skilled and passionate GP supervisor in a high needs, low cost practice in West Auckland.

One of our course requirements is to complete a project for the general practice we are assigned to. You might audit their cardiovascular disease screening processes or review a policy guideline, maybe design a pamphlet. We’re encouraged to find a project that interests us, and I ended up looking into why women decline cervical screening (smear) tests.

Approximately 50 women still die each year from cervical cancer, with Māori women more likely to develop cervical cancer and more likely to die from it than non-Māori. Rates have declined sharply since the introduction of the National Cervical Screening programme, but inequities persist. The programme aims to reach 80 percent of women, a target that it’s falling short of in all ethnic groups, and especially among Māori, Pacific and Asian women. The only group of women who currently exceed the 80 percent target are those who live in the least deprived areas, of whom 82.2 percent are regularly screened. This is compared to only 57.4 percent of those who live in the most deprived areas. Access clearly plays a big role in limiting the opportunities for some women to participate in screening, but what about those who decline the test when it’s offered to them?

A survey of 2000 women in the UK by Jo’s Cervical Cancer Trust found that, of women who declined the cervical screening test, 50 percent were embarrassed about their body shape, 48 percent had ‘concerns’ about the appearance of their vulva and 54 percent were concerned about whether they smelled ‘normal’. Thirty-one percent of all the women surveyed said they would not attend screening if they hadn’t shaved or waxed their bikini area. These findings are consistent with the international literature which also notes additional barriers for Indigenous women and ethnic minorities mostly related to access issues arising from systemic racism and sexism in research, policy and health systems.

Moralising about sexual behaviour has also consistently been found to be detrimental to women’s perceptions of, and access to, cervical screening. We saw in the early days of the HPV vaccination programme that some groups attempted to scaremonger about the increased promiscuity that would, apparently, be an inevitable consequence of the vaccine. In hindsight, this position is breathtaking for its potential to cause harm, as we now know that the HPV vaccination programme has played a major role in getting us to a point where we can envisage the potential elimination of cervical cancer.  

A woman’s uterus was thought to induce hysteria, and the fathers of modern medicine in Ancient Greece believed that part of the uterus’ power to disturb women’s minds came from the organ’s ability to move freely around a woman’s abdomen and chest. They have a point - if I found my uterus was residing unexpectedly in my throat I’d probably err on the side of hysterics myself.

Until recently we couldn’t even cope with the colour red in advertisements for menstruation products. If that bright blue liquid came flooding out of my body I’d head straight to the emergency department. Even the terminology betrays us - they’re ‘sanitary’ or ‘hygiene’ products, as if the physiological process that prepares a woman’s body for pregnancy is inherently unclean.

Our genitals are unclean even when we’re not menstruating, according to other, utterly bonkers, trends. One Canadian woman scorched her vulva, causing second-degree burns, by following advice to ‘steam cleanse’ her genitals by sitting over a pot of boiling water. Dr Jen Gunter, the ‘internet’s gynaecologist’ and author of The Vagina Bible has her hands full debunking all of the pseudo-science myths in gynaecological health. Some of these evidence-deficient phenomena include jade eggs which one inserts inside one’s vagina because Gwyneth Paltrow did it once, ‘keto-crotch’ which is when one’s vaginal secretions change on a very low carbohydrate diet, and the return of douching, last encountered in the early 1900s when women hooked themselves up to small hoses and irrigated their vaginas with the abrasive disinfectant Lysol.  

How does appearance fit in? On a New Zealand website advertising the services of a plastic surgeon who specialises in labiaplasty (surgery to change the appearance of the labia) prospective patients are advised that ‘Overly large labia minora and labia majora can cause both intimate embarrassment and physical discomfort.’ You might wonder, as I did, who gets to define whether a labia is overly large. Some have linked the rise in labiaplasty to pornography. It’s one of those things that seems like it should be true, but the evidence is surprisingly sketchy on the significance of the link, which was disappointing because I had written several paragraphs lambasting the pornographic industry before I fact-checked my reckons.  

This puts me in mind of a particularly revolting obstetric intervention which reflects the historical priorities of the health system. The ‘husband stitch’ is a procedure by which a women’s vagina receives an additional suture or two after a vaginal tear during childbirth. This was so that her husband could continue to enjoy intercourse with an appropriately narrow orifice. Infuriatingly but unsurprisingly, the effect of the ‘husband stitch’ on the woman’s sexual pleasure was not quite so positive, with women often experiencing more painful intercourse as a result.

There is limited research into women’s reasons for declining cervical screening tests in New Zealand. A thesis submitted by Holly Coulter in 2016 for the fulfilment of a Masters in Psychology looked at young women’s experiences of cervical screening and their interactions with the health system. Coulter found that the health system aimed to make women ‘compliant’ with the screening programme, rather than empowering them to choose. This played a role in young women’s ambivalence or avoidance of cervical screening. Most screening occurs in primary care, which has a co-payment model, and research instigated by the National Cervical Screening Programme found that cost was the highest rated barrier among the women surveyed, but shame still featured highly, especially among Māori and Pacific women.

What do we do about it? The cost barrier should not exist, for starters. We can support healthy narratives of women’s gynaecological health. Sure, it’s not much of a dinner party conversation unless you live with me, but circulating resources like the Labia Library to spread awareness of the spectrum of ‘normal’ female genitalia appearance can be done easily from the comfort of your internet browser. You could do worse than buying Dr Jen Gunter’s book and lending it to your mates.

Self-swabs have been trialled, with favourable results among ‘target’ populations like Māori and Pacific women (‘target’ is more diplomatic phrasing than ‘people we’ve failed’). A pilot study has been completed, and this will be factored into determining the suitability of self-swabs for inclusion in the National Cervical Screening Programme from 2021. For eligible women who flat out do not want to undergo a speculum exam, this could provide a welcome alternative.

Our language can be kinder, too. I can understand how a woman who’s just been told to lose weight by her GP might not then want to expose her genitals to that same GP. Even when our evidence tells us that the message we’re delivering is technically correct, it doesn’t make any difference if our patients are too offended and shamed to hear it. I’m in favour of pragmatism in healthcare; it’s a field where the pursuit of the perfect can undermine the opportunity to achieve good, and dealing with issues relating to obesity is an example of this. Researchers at Victoria University and the University of Otago published a study in the New Zealand Medical Journal in 2019 on the role of fat shaming by health professionals in contributing to poor health outcomes. We need to talk about all sorts of health risks with people, but doing it the wrong way can just alienate them further.

You can connect the dots here - our Māori and Pacific women are more likely to be categorised as obese, are more likely to live in areas targeted by unhealthy food retailers and the tobacco industry, and to have income and family stressors which make it difficult to attend even a low cost GP practice for a smear. These outcomes do not happen by accident, they are functions of societal and health system design, and as such they can and should be changed.