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A camera obscura reflects the world back but dimmer and inverted. Similarly, science has long viewed the bodies, sexuality, and lives of women through a warped lens, one focused narrowly on her capacity for reproduction, and one riddled with biases about our mental capacity, role in society, and our fundamental worth. In short, women have historically, through the lens of science, been seen as little men at best, subhuman at worst.
These biases have led to surgical experimentation without anesthesia on enslaved women in the US, to the medical mistreatment of women and experimental surgeries including dangerous ovariectomies to attempt to cure all sorts of physical and emotional maladies, many of which were undiagnosed medical conditions like endometriosis, or fabricated mental health problems like ‘hysteria’ that were more likely the result of depression and anxiety due to the social treatment of women, and to this day, have led to a persistent knowledge gap when it comes to what we know about half of the bodies on the planet.
Today, a new generation of researchers is turning its gaze to the organs traditionally bound up in baby-making – the uterus, ovaries, and vagina – and illuminating them as part of a dynamic, resilient, and ever-changing whole, where the vaginal microbiome, ovarian stem cells, and the biology of menstruation are leading to a better understanding of our bodies and health.
Welcome to Vagina Obscura. Given unparalleled access to labs and the latest research, journalist Rachel E. Gross takes readers on a scientific journey to the center of a wonderous world where the uterus regrows itself, ovaries pump out fresh eggs, and the clitoris pulses beneath the surface like a shimmering pyramid of nerves. Rachel writes about sexual and reproductive health, medical history, and gender bias in science for publications including The New York Times, The Washington Post, BBC Future, Scientific American, and Slate. She was previously the digital science editor for Smithsonian Magazine, and a 2018-2019 Knight Science Journalism Fellow at MIT.
Her book, Vagina Obscura, was a finalist for the PEN/E.O. Wilson Award for Literary Science Writing and the Carnegie Medal for Excellence in Nonfiction, among many other awards and recognitions.
Rachel's groundbreaking work sheds light on untold stories and silenced narratives, shaping our understanding of female anatomy. Through her detailed research and heartfelt storytelling, we explore the interconnectedness of physical, emotional, and social aspects of women's health, fostering empowerment and self-discovery.
In this episode Rachel and I discuss:
- How bacterial vaginosis inspired Rachel to write this book
- The history of lack of female orgasm in a marriage being grounds for divorce in the US
- How shame has historically been baked into the language of female anatomy
- What the ‘career women's disease' is and how attitudes about women impact our ability to get the care we need
- The truth about female orgasms and the G spot
- Radical women who have paved the way for better scientific understanding of the ovaries, uterus, fertility, and more
- How lean-in feminism puts the blame and responsibility for health conditions back on women
Join us as we embark on a journey into uncharted territories, engaging in an honest conversation about a subject long overdue for exploration. Together, we dismantle the barriers of shame and misinformation, embracing the intricacies of the female body. Let's learn, grow, and celebrate the wonders that lie within!
Thank you so much for taking the time to tune in to your body, yourself, and this podcast! Please share the love by sending this to someone in your life who could benefit from the kinds of things we talk about in this space. Make sure to follow me on Instagram @dr.avivaromm and join the conversation. Follow Rachel on Instagram and grab a copy of her book!
This conversation has been edited for clarity and length.
Aviva:. Rachel, it is so exciting to have you with me. I'm super excited about this particular conversation, so thank you for joining me.
Rachel: Thank you for having me. I'm so excited about your podcast.
Aviva: I'm so excited about everything you write, like your New York Times articles. I'm an avid follower and reader, and it's kind of funny when I say your books – you've come to bed with me every night because for the last couple of weeks you have. I've never read a book on an iPad before, but I didn't know that iPads let you cut and paste and send yourself notes. So I've been sending myself sticky notes like a maniac, these little fun notes from your book. It's so illuminating.
Your book opens with the line, “There comes a time in every woman's life when her body bumps up against the limits of human knowledge. In that moment, she sees herself as medicine has seen her – a mystery.” What led up to that moment for you and how did that experience inspire your book?
Rachel: I'm sure that I had confronted my own mysteriousness to medicine before this particular incident, but the one that really struck me and happened while I was thinking about this book was a recurrent vaginal infection that now millions of people are familiar with. It's called bacterial vaginosis or BV, and it affects one in three women and people with this anatomy. And it happened to me when I was an editor at Smithsonian Magazine, and it was itchy and uncomfortable and really put a damper in my fun late 20s life.
As I tell in the introduction of the book, it was misdiagnosed several times and I was prescribed rounds of antibiotics, anti-fungals, nothing worked. Finally, as a last resort, my OB/GYN prescribed me what she said was rat poison. It was called boric acid and it's a remedy that's been used for centuries actually, that you put in your vagina and essentially supposed to nuke the ecosystem in there.
And that, I don't know, really caused me to think about how much I knew about my own body, how much medicine knew about my own body, because my doctor presented this as a last resort. Often it doesn't work and this infection comes back again and again, but we're just going to try it because we have no other ideas, which really stunned me. Again, if one in three women get this, then why don't we have better ideas? That was an experience that kind of took me back upon myself, someone who thought she knew a lot about her own body and bodies like mine and vaginas, and it turns out a lot of people don't know.
Aviva: A lot don’t. The statistics were really shocking. There's one study that looked at Ivy League women as students in the United States, and something like 70% of them couldn't identify their major genital landmarks. They didn't know the difference between a vulva and a vagina, they didn't know where their clitoris was. There's a lot that seems to be surprisingly still in the dark in 2023 when we're recording this. Tell me why you think that is. We're pretty liberated about talking about things. I mean things like, I sometimes am watching a TV show and I'll be like, wow, when I was a kid, that would've been an R-rated movie, and that's happening on TV. So how is this body knowledge gap still happening?
Rachel: Yeah, you're right. It's not necessarily like, oh, things are too graphic to show or teach people about. We do see a lot of sexual content. I mean, we've seen the proliferation of online porn, so there's tons of body parts smashing against each other. So why is it that we don't know the landscape of our own bodies, and the knowledge about the parts of our bodies that we deal with in everyday life that either give us a lot of pleasure or are involved in protecting us from infection, or that are, in my case, given me a lot of sass during my life as an editor. Because it is different. I think it's about where the focus has been when it comes to women's bodies and bodies with vulvas and vaginas. I think largely medicine has focused on reproduction – fertility, infertility – and sometimes disease. And that is the message that young girls are getting in sex ed for instance. They're being told, don't get pregnant, don't get an STD, and at some point you're going to start bleeding in class and you'll be wearing white pants and you won't be able to do anything about it.
Aviva: Not super helpful, Is it?
Rachel: Super unhelpful and just also a really bad way to be introduced to your growing changing body and the awesome science happening inside it. Definitely something I would change if I could become dictator.
Aviva: It's crazy because things like rates of sexually transmitted infections in the past year have actually gone up 7 to 21%, depending on what the infection is. But if you don't know what's normal, you don't know how to name a body part or you went to your gynecologist and they don't know what to do, it feels a little bit regressive when I see these rates going up. They should be going down if we're educated and body empowered and science is paying attention to what's going on, but that's not really what's happening.
Rachel: Right, I mean I think, again, what I really argue in my book is that science and medicine have taken a very narrow lens to the female body and have really seen it as primarily reproductive, have looked at us as kind of walking wombs or baby makers, and in doing so, they've really blurred out so many important elements of what it means to have these body parts. I think also haven't encouraged or gotten us curious about exploring our own bodies and what feels good and how to best take care of them. So like you said, it’s against the point of this kind of education. At the very least, we know that doctors and sex educators want to prevent the spread of STDs, and population-wide want to keep us healthy. And even that we're failing at.
Aviva: Well, you have to be able to talk about a condom, for example. If you're pretending that people aren't going to have sex, if you don't talk about it, you're also not protecting them from STIs, which is counterproductive.
Rachel: That's a good point. But somehow I feel that female pleasure, unattached from a penis and unattached from penetrative sex is even more taboo in our culture. We don't talk enough to each other about masturbating and how we actually orgasm and what feels good. I think that's just off the radar because it's like, okay, we have to talk about heterosexual sex in sex ed because that happens and people get pregnant. But there's been a lot of silence around a lot of other stuff that I think is a lot more fun.
Aviva: You share in the book that until the 1920s, or even in the 1920s in the US, not having an orgasm during married intercourse could actually be grounds for divorce. So, on the one hand, women were not supposed to masturbate. Women could be cliterally amputated for masturbating. Women were denied pleasure, and yet were supposed to have an orgasm from penetrative heterosexual sex, or they could be divorced. That would be grounds for divorce. How do you bridge that gap of you're not supposed to know what an orgasm is, but you're supposed to have one. You're not supposed to touch yourself, but you're supposed to have this experience and act out this experience if you're not having it.
Rachel: I think this is emblematic of the paradox of not just American womanhood, but of this ideal of womanhood. You're supposed to have a specific type of sexual experience, but other types are demonized and villainized and dismissed as not real, not the experience of a mature woman, as Sigmund Freud would've told us. So yeah, I think there was really a fear of, again, pleasure unlinked from a specific type of sexual experience and – great question of how you're supposed to know your own body and have really any form of pleasure without that kind of exploration and knowledge. I think that women have long been in a double bind in this way and gotten conflicting advice.
Aviva: I was not a friend of Freud before I read your book, but your book really just kind of put him in a, I don't know where he put got put for me, but not somewhere good. What a total misogynist sexist hypocrite – the list goes on.
Rachel: I did focus specifically on his theories about the clitoris and the vagina, and he contributed a lot about the subconscious. He was a pretty interesting and subversive thinker in a lot of ways, but for my purposes, he was not really the good guy.
Aviva: Essentially from what I got of your book about him, which was many things, but the sort of fundamental thing was this idea that orgasm, sexual pleasure, and masturbation were these infantile childish impulses of women and that women who maintained having those as adults were immature, were not emotionally mature, intellectually mature human beings on some level.
Rachel: I mean, I don't know if he thought that women could ever be fully emotionally mature human beings in the way that he saw men as full autonomous, multi-layered. He saw a mature woman as being a wife and mother. The best that you can aspire to is to be a helpmate to your man in this case.
But yes, not only did he not want women masturbating or finding pleasure on their own. He wanted them to have a biologically impossible experience of experiencing only pleasure vaginally with their husbands, and transferring their orgasm from their clitoris to their vagina. So he really set them up to fail by his standards because inevitably, you were going to feel inadequate or broken or not like a true woman if you were going by Freud’s standards. And that's what I have so much beef with him about that he made generations of women feel that way.
Aviva: Yeah. Cause his standards became the basis of how women were interpreted for a very long time in psychology.
Rachel: And were based on zero evidence.
Aviva: Yes. So your book is called Vagina Obscura, but you talk about much more than just the vagina itself, which is the narrow tube that tampons go in and babies come out of, let's just say for landmark's sake. You explore the clitoris in depth, the ovaries, the uterus. It's such an engaging and beautiful book. In fact, you have one quote that is perhaps my favorite sentence in the entire book, which is “The clitoris is an underwater volcano, a pyramid mostly buried in sand, a jellyfish spider reaching its tingling tendrils into every crevice of the female pelvis, an edifice of powerful sensory material.”
I would love to start out with why you called the book Vagina Obscura, but I'd really also love to focus on some of this clitoral anatomy history and what you learned. So I actually saw a camera obscura in Europe. It was amazing. Tell me about vagina obscura.
Rachel: Yes. Okay, well, that is the origin of the title. So yeah, I toyed with whether to have the word vagina in it. Initially, I actually was calling the project Lady Anatomy for a while, and that was actually a reference to a specific anatomy in Italy who – she worked with her husband – but after he died, she became her own thing and she kind of focused on the male genitals and the eyeballs, and she was just like this force, and it was kind of like a tongue in cheek. These were a lot of, in many cases, female LGBTQ anatomists who were remapping this territory, but also is the anatomy of women.
I quickly realized that that was too narrow because we weren't just talking about people who identified as women. We were also talking about trans women, trans men, non-binary people, and intersex people. So I didn't really want to have lady in the title. Then I was thinking of something with vagina, and as we know, there's a problem with conflating the vagina with the entire reproductive system or the vulva, which is the outside parts, the parts you could see and touch, the fun parts as I call them.
But it does have a name recognition, and I mean, the book is about breaking taboos and having vagina on the cover has been an interesting ride to put it lightly. So I was thinking of vaginas and I was thinking of the camera obscura as you mentioned, and how it was this really big leap forward for camera technology. But it is really interesting how it works. It projects an image from the outside onto a wall using this little pinhole camera, but in doing so, it often flips the image upside down or it makes it really blurry and grainy or really, really tiny. It really has to warp the image in order to get it in front of your eyes, and it has to blur out everything around it, like your iPhone in portrait mode basically.
We really focused on specific elements of the female body, I argue, including reproduction, and we blurred out the stuff we weren't interested in. And that was the stuff I was interested in and wanted to center in this book. That was stuff like pleasure, immunity, regeneration, body-wide health, the fact that we call the ovaries reproductive organs, but they're also producing hormones that are supporting every body system, from birth until death, whether or not we get pregnant. That's what I wanted to reframe this narrative to be about.
Aviva: I love that you also focused on some lesser known women players who were incredibly involved in the first IVF, the first exploration of regeneration of the ovary, microbiome research. It's beautiful how you highlight some of these incredible women scientists – some who had to struggle pretty hard to get into a lab or have their work known.
Rachel: Yeah, absolutely. Thank you. I do think it was about recentering the lens with which we choose to look at history, because science is about who's asking the questions and which questions are considered important and which questions are allowed to be asked. It's not that no one was interested in these facets of women's bodies; it's that they face systemic barriers to getting their questions asked and getting resources. I wanted to tell some of their stories. Some of them really were women who transformed their fields or who contributed really new ideas. Others were kind of squelched in their careers and really were left with this idea of what could have been.
I always was saying to myself in reporting this, we could have had nice things. We could have had IVF three decades earlier perhaps, we could have had a very, very different view of female sexuality and what was pathological and what was totally fine. There were people all along the way who were thinking outside the box and weren't trapped by this paradigm of the female body as reproductive and degenerative and weaker and inferior, but they weren't the ones that history remembers, and they weren't the ones that kind of laid the landscape in the way that Freud and Darwin did.
Aviva: You state that if you see women as unimportant, which history has done, then you're not actively studying them, but you're also not actively supporting those women's scientists who are studying those things as well.
Rachel: Yeah, that's right. I think one good example is that when a question or a topic becomes considered women's health or vagina problems, it's instantly downgraded as less important. So in my chapter on the vaginal microbiome, which is this teaming ecosystem in all of our vaginas that's really an extension of your immune system and is super important for not just fertility, but everyday health. I talked to scientists who were working on ideas like vaginal transplants, microbiome transplants, to kind of terraform this ecosystem. And they described getting this reaction from startup funders or big institutions that first of all, this was just vagina problems, like no big deal. This just happens. It's not cancer, it won't kill you. That was a common theme. And also like, ew, we don't want to think about bugs in the vagina. Can’t we just talk about something like IVF fertility. So there was this deadly intersection between gross and not important, both of which are so ridiculously untrue.
Remember, we had fecal transplants like 15 years ago, totally taking off. Everyone was getting over their gross factor because this was lifesaving, and we could see why it was so important and it was working miraculously, and yet somehow vaginas were more gross than that. So, we as a society have a problem with relegating things as women's problems and women's health problems. That’s just absurd to me because women and other people who deal with these problems are more than half of all the people on earth. This is not a niche issue. Calling something a women's health issue should not be reason to ignore it and not put resources into it. And yet it is.
Aviva: I call myself a vaginal ecologist, jokingly. I've been talking about the vaginal microbiome for about 20 years now. It's an area that's really exciting to me.
One of the things that I saw you highlight in your book, which I've never seen anyone talk about except an article that I published a really long time ago on my website, is that we have this idea that is very Eurocentric, white woman centric, that the healthy vagina is full of lactobacilli, but that doesn't necessarily hold true across ethnic groups. And so that black women, for example, have been found to have much less lactobacillus and not have that be the predominant organism, but that may still be a totally normal healthy vaginal ecology, but may be overtreated and mistreated medically based on these differences. I just want to shout out that you highlighted that – I think it's really important and the way you did in terms of saying, well, isn't one healthy vagina that we know of? There isn't one healthy period, there isn't one healthy kind of standard. And I really appreciate that.
Rachel: Thank you. I talk a lot in the book about how medicine has created certain standards for what is normal and what is ideal. And I talk about it in terms of the ideal body in ancient Greece was male, and the female was an inferior inside out version, with the result that the ovaries didn't have their own name until the 1600s. They were just called female testicles.
But within genders you get the same kind of normalizing only of certain types of bodies, which directly means marginalizing anyone who falls outside that standard, and very often it will be centering a white European Western woman. In this case, it was tricky and complex because there absolutely are differences if you look at it racially. But medicine also has a really unhelpful habit of attributing differences they find to biological and genetic factors. And that has been found often to be unhelpful and rather racist
Aviva: Rather than, for example, looking at the possibility that lower levels of lactobacillus might be due to systemic weathering and stress that affect the immune system or other factors in certain groups that have much higher stress levels just living in a white Western world basically.
Rachel: Exactly. That our microbiome might be a reflection of our living conditions and of living with chronic racism, for instance. There's a lot of unknowns here. It's definitely true that we've kind of centered a specific type of vagina, and as a result, the cures and tools that we're developing are meant for a specific population. But then we're also not investigating what are the factors behind these differences that we could address or disrupt, instead of just saying, your vagina is unhealthy. We’re just starting from the wrong baseline and I think assuming that these are biological racial differences has not served us well historically.
Aviva: Your research uncovers so many misconceptions and assumptions about vaginas and the uterus and the clitoris going back centuries, and some of which persists until recent decades or even now. What are some of the biggest misconceptions that you found in your research about any of these areas? Uterus, clitoris, vagina, da, da, da that most astonished you? When were you reading at night and going, oh my goodness, I cannot believe this,
Rachel: So many times. One thing, it's like it shocked me, but then didn't because I kept seeing it again and again, was this misconception about vaginal orgasms. Just the idea that we have different types of orgasms that are separate. I found that there was really this tendency in medicine to make separations and kind of fragment the female body, and not focus on connections and unity. So, the fact that I grew up with Cosmo magazine telling me how to have a vaginal orgasm and what I'm missing out on, and then later how to have a G-spot orgasm and what I'm missing out on. And so making that connection to Freud and how he made so many women feel inadequate because they weren't having the type of sexual experience he thought they should was stunning. It was really the lack of progress and the fact that these messages that I find toxic were still out there. I would say that's a misconception that struck me.
Aviva: Can you tell the truth for women who are listening and men who are listening, anyone who's listening, all the people who are listening, what you learned about how orgasms happen? And this is significant. You tell the story of this surgery that was developed to relocate the clitoris closer to the vagina so women could experience “vaginal orgasm.” What do you hold, if you will, to be true, to help women understand, help people understand their bodies, help people understand their partner's bodies when it comes to female orgasm?
Rachel: Yeah, so what I understand after talking to the foremost clitoris expert, Dr. Helen O'Connell in Australia, who has done micro dissections of 60 clitoris and MRI imaging and specifically looked at the G-spot, what I understand is that the clitoris is the center of female orgasm, and it's involved in any type of orgasm you might feel. You definitely might experience orgasm differently depending on what you're doing, where you're stimulating… and the time of day. So I just don't want to negate anyone's individual subjective experience, but you're not going to have an orgasm that doesn't involve your clitoris.
The G-spot was an interesting one because I came in being like, this is definitely a myth. There were scientific papers that to have found a cluster of grape-like tissues that was definitely the G spot. And those were all ridiculous. But there's some truth to it in that there is a spot that's on the belly side of the vagina that's about an inch or two up depending on your anatomy, which varies widely. And that's where the back of the clitoris is. So basically where the bulbs of the clitoris, the arms of the clitoris and the shaft, because guess what, we have a shaft, lady boners are real, all of this is erectile. But they all come together in sort of a juncture that wraps around the vagina and the urethra. And that juncture is where people have reported feeling a different sensation and what was eventually called the G-spot named after a man. So totally, you could have a different sensation there. You could imagine that because it's a junction of very sensitive erectile tissues, but it's not like its own organ. It's not like a magic button. It's not this mythical center of a very, very different type of pleasure.
Aviva: And it's not really the vagina per se; it's still the clitoris that's being stimulated through the vaginal wall essentially.
Rachel: And I think that is important actually, because there are some glands there and you know can absolutely feel it as being part of your vagina, your vaginal walls. But the vaginal orgasm myth kind of posited that there was something special going on deep in the vagina and suggested that there was some different tissue or organ. And that's not the case. This is part of your clitoral complex that's interacting with the rest of your pelvis.
Aviva: Which Is really huge. I mean, the complex is really, really significant in terms of its tissue, its size, its innervation, circulatory system.
Rachel: Yeah, I think that's the part that it maybe reframes it for people and for me is kind of empowering, is that historically medicine has always minimized the clitoris and just referred to the tip, the part you can see and touch, which is less than 10% of the organ. But if we do really take seriously the idea that this is an extensive and significant organ that again interacts with all these other parts of the pelvis, like your urethra and your vagina, then it just makes sense why you would have these deep, rich sensations that could change depending on where they are.
Aviva: In an article you published in the New York Times, you described the clitoris in what I thought was such a visually evocative way. So I'm just going to read this. You say that “if the vulva as a whole is an under-appreciated city, the clitoris is a local roadside bar, little known, seldom considered, probably best avoided,” but I'm going to suggest that maybe it's a little roadside bar that we should be visiting more often.
Rachel: That was actually what I was thinking. I was like, this is my local karaoke bar that I absolutely love and is essential. And I go every Wednesday. Yes. Thank you for noticing that.
Aviva: I love it. You have a great way with words. It's so fun. Okay, speaking of words, before we started officially recording, you and I were jamming about the importance of language in healthcare and well, it's funny, in Rastafari, I know a lot of Jamaicans, a lot of Rastafarians, and there's an expression word- sound-power.
And what it means is that essentially the words we use influence the experiences we have. We do know that words that have been used historically in medicine like incompetent cervix when somebody's cervix won't stay closed, which is actually often the result of a medical procedure that might not have even been needed like a LEEP or a cone biopsy, or we were talking about how every medical chart, the first thing on the medical chart says chief complaint. And you had an experience, you said you were going in for a concussion evaluation, and they said, what? You were complaining of a concussion.
Rachel: Yeah, they were just writing and talking out loud, and they were like, patient complaints of concussion. I was like, no, no, no. I'm just looking for an examination here. I'm not complaining.
Aviva: No, you're not complaining. So one of the things that you've written about in articles and I think comes through as a powerful theme in the book is shame around female sexuality and how that has deeply impacted our understanding of female anatomy. And then the consequences of that are lack of research, lack of adequate treatment, sometimes treatments that are extreme.
But one of the words that you talk about that, I learned this as a midwife when I was in my teens, is the term pudendum. Can you explain what the pudendum is anatomically, what the word means, and what you think that the origin and persistence of this term says about medicine and women in medicine and how medicine sees women's bodies or the female body?
Rachel: Absolutely. I saw this word come up a few times in my research. It would be in gynecological textbooks, it would say pudendum, and I think it would usually have vulva and parentheses because they're equivalent. That's the crazy thing. There's a totally good word for this.
Then there'd be a footnote at the bottom, and it would explain the Latin for all of these medical terms in these books. And so it would say Latin, the part for which you should be ashamed, and it would have no other context. It just told me that was the shame part. And I was like,[1] what?
Then there were a few feminist books that used this as an example, that this persisted, and then talked about the shame parts and it said something about how medicine viewed women, but I guess more like female sexuality and the clitoris. It also was only one line in these feminist books. So, I just saw that pattern. And later on, I think I actually just finished the book, a medical student came out with a paper that looked at the origins of this, and it turned out there's this huge debate among the largely white European male heads of this anatomy global organization about whether or not to remove this word from the official terminology book – the Bible of anatomy. It was a very contentious and heated debate, which shocked me. It seemed incredibly easy to remove a word for which already had…
Aviva: Especially when you have another equally good word that's easier to say.
Rachel: Exactly. Instead, they just argued about it for a year and even suggested, why don't we have a male pudendum – let’s just add another word so we can put shame on men as well. That's what got my attention. I think debates in science and medicine are really interesting, especially when emotions run high.
But I realized it wasn't just this one sort of jargony word that only some doctors use. A lot of people were telling me, oh, in my language also, we have schamlippen in German, which means the labia and ‘shame lips.’ There's a similar word in Swedish that now they’re trying to replace it with – snippa – which is a neutral word for the vulva. And as I was going through the history, there were anatomists who were like quote, discovering the clitoris, and they would also name it the shame part.
So, there was this pattern here that anything that was to do with the female vulva was attached to shame, modesty, this need to cover up. I think it was this kind of prudish anti-sexuality attitude that basically said, this is inappropriate. We don't want to focus on this. It's the shame parts. And you can see the results – that gynecology largely overlooks the vulva and female sexuality and instead goes straight for the uterus and the vagina and the parts that are more involved with baby making and reproduction.
Aviva: Another area where women have historically been blamed is around endometriosis. And you talk about endometriosis in a beautiful way. Endometriosis, and I talk about this in my book, Hormone Intelligence, has been blamed on the career woman or the woman who doesn't want to do her duties, meaning being the stay at home wife. And of course, we know that endometriosis is a complex, primarily immunologic problem. Can you talk about what you learned about endometriosis and maybe how that fits into this thesis of blaming women and what some of the consequences are of that?
Rachel: Another shocking thing to me was that as late as the 90s in endocrinology textbooks, it was described as, word-for-word, a career disease which affects primarily white, neurotic, anxious women who forwent childbirth in order to have careers. And what was really interesting to me was that some scholars call endometriosis the new hysteria, not because of how it works, but because of how it's been treated by doctors.
Hysteria initially was a medical diagnosis in Greek times. It was like your womb is literally wandering around in search of sex and motherhood. And again, it was very blamey because you had not fulfilled your duties and occupied the oven that is your uterus and so it was mad at you. And endometriosis was also often treated as a reproductive system gone haywire because women weren't living up to their biological destiny.
It was also at the same time, often dismissed as menstrual pain that in some ways might be psychological. So many women I talked to were initially sent to a therapist and put on antidepressants in their multi-year search for a diagnosis. I think finally endometriosis was considered incredibly medically elusive and mythical and mysterious, and was called by an early researcher, the pelvic chameleon, to show how difficult it was to pin down, how it transformed and hid itself. I think that really plays into the idea that the female body is mythical and mysterious and impossible for medicine to figure out. So why even bother?
There's so many myths surrounding endometriosis that it was really hard to just see it as, like you said, a complex immunological disease of chronic inflammation and something that ultimately, I truly believe, medicine can and will solve. If you take these layers of shame and myth and cultural attitudes off of it. It's a disease like any other, which is what the endometriosis researcher who I profile in the book was saying. She was saying, stop making this its own weird special women's disease and use the rigorous tools we already have to get to the bottom of it.
Aviva: Well, looking at it as an immunologic disease really is much more accurate. And I think one of the other things that we share in common in what we write about is the tendency to blame the female body, whether psychologically, emotionally, or actually physically, and not looking at the context of, for example, endocrine disruptors that we think of as impacting our hormones, but we forget also impact our immune systems. W're not looking at the 20 rounds of antibiotics that we might get as girls and women that may disrupt our vaginal microbiome, which may not just be protecting our vaginal health, but may actually have a role in endometrial health, in pelvic health in general. So there's so many layers.
Also, I think as the wellness movement tries to look at ways that we can take our health more in our own hands, which we need to because we're not getting the information that we need from our doctors, there is a transfer of responsibility to the individual rather than industry and government having to be accountable. So, we're doing all these things. We change our diets, we do the boric acid, we do these, this, that, and the other. We turn ourselves inside out to solve endometriosis, to solve PCOS, to solve our fertility without external agencies that really actually are contributing a lot of these problems to our health ever having to be accountable for.
Rachel: Yeah, this is kind of a point that I was going to make with the language stuff. Basically this language blames the patient, blames the individual, kind of makes this all feel like a ‘ you problem,’ an individual thing. And, that's dangerous because you don't realize the systemic failures and the ways that potentially medicine in our society has failed us. It isolates us instead of lets us connect over these shared experiences and pool our resources.
So yes, I think that the rise of the wellness industry points out a really important and deep knowledge gap that we are all trying to fill in our own way. But it also seems to imply that we can use “lean in feminism” to fix our problems and that we can do it on an individual basis. And I don't think we can. I think as a society, we need to invest more in what we like to call female health, but is really just human health, and admit that we have kind of done very badly on behalf of half the people on Earth.
Aviva: We really have. I'm excited though for books like yours, conversations like this that I think start to help illuminate where the gaps are. And one of the things I've experienced as a midwife, as a physician, is that medicine is very slow to change. It's a very entrenched institution and there are physicians within it that want to change it and there are other healthcare providers within medicine – nurses, nurse practitioners, physicians assistants – often who are female, often who are making changes, and other folks who are represented in the field of medicine who are change bringers, whether they're LGBTQ, non-binary, who are also in that field.
I’ve also though have seen that what it takes to change medicine is financial incentivization. So the more, as consumers, we are educated, I don't love the word consumers when it comes to healthcare, but more as individuals who need healthcare demand that you the change, expect the change, use our voices or saying, “Hey, have you read this? Have you heard about this? Can we consider this?” That's what leads to the sea change. And so I feel like books like yours, books like mine, we're bringing attention, just even using the word vagina.
And I love the title Vagina Obscura because it just really says so much about how we've obscured women's health, how we've obscured the female body. It's a brilliant book. I don't say that lightly. There were things that were familiar, but there were things that were really new. You really have such a fun and yet poignant way of phrasing things. And for anyone who's just interested in learning more about your body, more about your partner's body, if you're a parent who wants to help raise children who are educated about their bodies, you're a healthcare provider and you just really want to know more about the science of women's health and women's scientists, which I found just incredible, it's a brilliant read – I'm so glad you wrote it.
Rachel: Thank you. I mean, it's moments like this when someone really connects to it, someone who really deeply knows the field and knows those problems that make it worth it and make me feel like, okay, I did put my hand on some of the patterns and trends and knowledge gaps that are really important for us to keep highlighting. And, like you said, I do think that getting people empowered and sometimes angry, reading the book, listening to podcasts like this, it is a first step and it's not the last step, but we have to spread awareness and explain sort of why these knowledge gaps exist so that we can begin to fill them in.
Aviva: So we're going to link up to your book, we're going to link up to your phenomenal article on the clitoris. Thank you. Thank you for all you do and for being a phenomenal writer and researcher and for being here.
Rachel: Likewise. Thank you for this great conversation and excited to be in conversation with your community.
Aviva: Total pleasure. Thank you everyone for joining us. Grab Rachel's book. It's a great read. You can go to bed with it too, or read it during the day, and let's talk about it over in the comments with the social post that's related to it, and we'll see you next time.
