If you have a vulva between your legs, could you identify the seven separate structures in a mirror? If your partner has a vulva, can you identify theirs? For over half the population, the vulva is a significant part of their body; an exit and an entrance, a site of pleasure and, often, pain, that speaks to core human function and need. In 2021, it can feel as if we’re on the cliff-edge of emancipation from the history of oppression and ick surrounding female genitalia. The booming sex toy market, a growing awareness of hormonal cycles and the messy reality of periods, a sharper focus on female pleasure and evolving conversations about menopause all point to real progress. Yet there remains a well of misunderstanding in society about what’s down there (clitoris, labia majora, labia minora, urethral opening, vaginal opening, perineum and anus, by the way), with tangible consequences. In March 2021, a group of gynaecologists and epidemiologists published the results of a study that involved giving surveys to patients in outpatient waiting rooms of a UK hospital. Participants were asked to label the different parts of the vulva in their own words (“peehole” and “bumhole” were accepted for the urethra and anus respectively). Just 46% identified that there are three “holes”, while almost half left the labelling section blank. Only 9% correctly labelled all seven structures. “We did the research because we were concerned about how many patients expressed confusion around the nature of their problems in gynae clinics,” says Dr Dina El-Hamamsy, a senior obstetrics and gynaecology registrar in Cambridge and one of the co-authors of the study. “This is particularly true for patients who have had pelvic organ prolapse, which can happen after giving birth vaginally.” A prolapse is when organs like the womb or bladder move out of place and press on the vaginal wall, often visible when looking at the vulva. The urethra was correctly labelled by 51% of participants and the clitoris by 37%. Women were more likely to label the vagina and anus correctly than men, but there was no difference for the other structures. The results echo a similar study conducted by the Eve Appeal in 2014. Of 1,000 women interviewed then, just half aged 26-35 were able to label the vagina accurately, with 65% saying they had a problem using the words vulva or vagina. The problem is still as striking as it ever was. There are many complex emotions surrounding the vulva – how it should be; what we should do with it; what we should talk about. El-Hamamsy believes that public conversation needs to evolve from raising bodily awareness to clearly identifying the risks of poor education. “Patients may come in and say they’ve had a bladder repair, but we don’t repair the bladder, we repair the vaginal wall,” she says. “It is worrying when people don’t know if they’ve had a prolapse operation. Going through this surgery is a major event in someone’s life.” This raises critical issues about trust and consent. If we put our faith in doctors to help treat us when something goes wrong, conceptualising potential risk and benefit is crucial. If we don’t understand are we fully consenting? As Stephanie Shoop-Worrall, an epidemiologist at the University of Manchester who was involved in the study says, full consent relies on “being able to have a conversation about exactly what is wrong and what is going to happen to you”. If someone has been “bandied around the system for months and is then handed over to a specialist, they may just agree to whatever that specialist suggests,” she says. This bandying can happen when medical training in gynaecology has been limited. “Medical students only go through a superficial obstetrics and gynaecology rotation, unless they want to specialise,” says El-Hamamsy. Knowledge is inextricable from education, in other words where information has come from, who has given it to us and in what context. Kate Moyle is a psychosexual psychotherapist based in London, specialising in working with people experiencing difficulties with their sexuality and relationships. A “huge part” of her job, she says, is educational. “This means talking about different body parts, explaining functions, looking at diagrams or anatomical models and explaining how our bodies work. There is empowerment in understanding.” People turn to therapy because they don’t know how to communicate their needs or feelings about parts of their body that hold vulnerability. Moyle believes a “lack of formalised, holistic education and the safe spaces to explore these dynamics in” underpins a disconnection with our bodies – and what happens when we share it with others. “Sex education has centred on reproduction, procreation and how to prevent it for so long,” she says. Female pleasure has not been included. “The clitoris is a primary sexual organ. The vagina is a separate structure with a completely different purpose. But we’re only really taught about the latter. For men, structure and purpose are kind of overlapping.” (The full structure of the clitoris, incidentally, was only discovered in 1998.) Moyle takes an extensive history from her clients, tracking their life experiences from infanthood. “People are imprinted with the early messages they had about their bodies and sex. If there is no one to correct the scary playground banter you hear at 10, you can internalise that anxiety for years. The body remembers.” When we are not taught how to have open conversations about needs and fears, this can lead to dissatisfaction. Sex is intimate and vulnerable, and our instinct when we’re experiencing anxiety is to avoid. When we repress powerful feelings, they tend to resurface in more potent ways. Avoidance is a common thread. Dr Fiona Reid, a consultant gynaecologist in Manchester and co-author on the study with El-Hamamsy, says there are still “many people who just don’t like the concept of their genitalia, full stop”. A common phrase people use in her clinic is “I don’t look down there.” This happens across the age-span. “It can be from 14-year-olds to elderly patients.” I put my head in my hands when she tells me this over Zoom. “I know,” she sighs. I think of all the people I interviewed for my book, Hormonal, on female hormones and mind-body relationships. And I think of the psychic weight of ignorance, the guilt and the shame that plays out in people’s lives, because we’ve struggled to connect with – or haven’t been educated on – what is ours. Often, that shame speaks to a lack of basic anatomical understanding. When I posted a tweet asking about people’s knowledge of their vulvas, I had some interesting responses. Many said they were still squeamish about the word. “It’s something I never use,” says Sarah, 46, from Liverpool. “I still, incorrectly, use vagina for the entire area, but have long advocated reclaiming ‘cunt’.” “I was never taught that the vagina is only the inside. There was no talk about what to call your own parts,” says Olivia, 35, an NHS midwife from south London. “It wasn’t until I became a midwife that I was comfortable using ‘vagina’ and ‘vulva’ with birthing people.” I ask what made it feel easier. “I guess because we are using these words purely anatomically. We spend our days around people at a very vulnerable time, which probably leads to staff being more open.” One response stood out to me: that of Elizabeth, also 35, who lives in Coventry and went to a Catholic school. “I became physically aware of my vulva and clitoris aged nine, but felt ashamed of liking the feelings,” she says. “I didn’t know about the anatomy of my vulva until I was much older. My school covered conception and that was it. I didn’t even realise I urinated from my urethra; I thought it came from the clitoris.” If the implications of poor education are so stark, what needs to happen? For people experiencing incontinence, prolapse, vulvodynia (persistent, “unexplained” pain in the vulva), vaginismus (when the vaginal muscles tighten up whenever penetration is attempted), more public messaging that we don’t have to just cope is crucial. Unfortunately, at the intersection of capitalism and patriarchy is a whole raft of products that help to catch, or hide, what shouldn’t be leaking or smelling – obstacles, perhaps, to really understanding how we work, or examining problems with professionals. Sarah Tyler is a pelvic health physiotherapist, based in a private practice in Hertfordshire. She specialises in assessing and treating many of the aforementioned problems. With internal examination, she provides guided plans for reconditioning the pelvic floor muscles involved with urinary, bowel and sexual function. “It is staggering how much this kind of physiotherapy can help people,” she says. “But often I am seeing people who have been suffering for ages, believing their issues are just part of having babies, or getting older. They don’t have to be.” Naturally, this is emotional work. “Two-thirds of my clients cry with me. It is such a big thing. People sit wide-eyed, drinking in information that has never been given to them.” The act of calm, considered touch and dialogue can be both therapeutic and empowering for people who have experienced sexual or birth trauma. “People can become quite disconnected from their vulvas and vaginas, so our approach is slow, with an emphasis on consent and being able to stop whenever they want to.” A common discovery for Tyler is something called a “hypertonic pelvic floor”, when the muscles in the pelvic floor become too tense and are unable to relax. This can make any kind of penetration painful, but is also linked to stress incontinence, interstitial cystitis, chronic thrush and constipation. This tension is underpinned by emotion; anxious bodies that are scared to let go. As she speaks, I’m aware that I am tightening my own pelvic floor. That my pelvic floor could “hold” my anxiety is something I had never considered. “Interestingly, I have seen more hypertonic pelvic floors over the course of the pandemic than I have in eight years of doing this job. The body is just constantly gripping, unconsciously,” she says. Moyle frequently refers to pelvic health physiotherapists, with “massively helpful” results, but says people often don’t know they exist. Pelvic health physiotherapy is available on the NHS, but provision is slim. Many people who are in pain or experiencing difficulties with their vulvas and vaginas cannot afford to turn to the private sector, which begs the question: where else are these important conversations happening? Shoop-Worrall says that, in the analysis of their study data, “the number of correct anatomical labels were associated with higher education and white ethnicity”. If socio-economic status and ethnicity correlate with gaps in awareness, the need for mandated education reform is overwhelming. Yoan Reed is an independent relationship and sex education (RSE) consultant and co-founder of Outspoken Sex Ed, an organisation that offers guidance for parents when talking to their children about sex, bodies and relationships. She believes we need to start educating children about their bodies, with the correct terminology, from a very young age. “I became very aware of the lack of knowledge about the female body when I was working as a midwife,” she says. “I had a disproportionate number of teenage pregnancies in my caseload and was shocked by the low level of understanding about anatomy and reproduction. This is why I went into education.” Relationships and sex education (RSE) was only made mandatory in UK schools in 2015. It has long been due an upgrade because of the way children’s learning is influenced. (More than a third of children aged 8 to 11 own smartphones, with 20% already using social media.) When the government proposed, in 2019, to include teaching about same-sex relationships, they were met with protests and criticism. But from September 2020 it became compulsory to teach RSE across the age span, though primary schools can decide themselves what to teach. “The challenge is to get a full-school approach,” says Reed. “We all need to be aware of our own language, emotions and experiences. I come from Denmark, where body awareness– seeing naked bodies and normalising variance – happens very young. The culture is different.” She is a firm advocate of using the word vulva with children. “I learned as a child that it was just the right word for my anatomy. It doesn’t take away innocence and isn’t about sex. The idea that we corrupt children by using anatomical terms does not contribute to body empowerment. If they have the right words, they can tell you if something feels wrong.” When chairing focus groups for parents of children of primary school age, Reed has heard comments on how it is “easier to talk about boys’ private parts than girls, because they are visible. There is a long history of gender inequality and ideas of dominance to undo. Leaving out the clitoris is a big mistake.” Reed also acknowledges that, although the UK is multicultural and, broadly, tolerant, there are “many myths” to cut through. “There was nothing in this country to engage parents in their responsibility as the primary educator. The government still gives rights to parents to remove their children from sex education, but with this right comes responsibility – something that needs to be supported.” If we want to know what an egalitarian, open culture looks like, the Netherlands is one of the most gender-equal countries in the world, with a very low teen-birthrate. A direct line to education can be drawn. In the Netherlands, the sex education curriculum, Kriebels in Je Buik (Butterflies in Your Stomach), begins with four-year-olds talking about reproduction, their own pleasure, boundaries and the differences between male and female bodies. Research has shown that children who are inclusively educated are less likely to bully others and more inclined to step in when female or LGBTQ+ peers are under attack, while young people in the Netherlands generally report high levels of sexual satisfaction. It is hard to argue with such clear public health outcomes. After we speak, Reed emails me some artwork made by a group of girls in years five and six in a recent “wombs and vulvas” workshop. Fluorescent pipe-cleaners, pompoms and glitter are arranged to depict labia, clitorises, ovaries, urethral openings, vaginal openings, wombs and fallopian tubes. There are some googly eyes. They are joyful. An unfamiliar feeling creeps up on me: hope.