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Vulnerable vulvas: female genital integrity in health and dis-ease.

There's only so much it can give before it either splits or you just cry "Uncle?" You know the vulva isn't an easy place to look. You are like 100 percent of women who walk in the door. The vulva gets ... I don't want to say, forgotten.

--Dr. Robichaud, vulva clinic physician

I started thinking about the vulva in earnest in the early 1990s. To be clear, it wasn't a big leap; I was already a gynecological nurse practitioner. But having come of professional age in reproductive health clinics, I was accustomed to directing my attention toward the practices that undermined the sexual health of my patients, rather than toward the more material aspects of their bodies. "Why aren't you using condoms with your new partner?" and "How can I help you to avoid another unwanted pregnancy?" were the typical--and behaviorally laden--circuits through which I assessed my patients' well-being. A current of genital hesitation yeas palpable during these encounters, most of which were literally framed by gynecological stirrups: a drape sheet pulled tightly over the knees, being "grossed out" by explicit references to female anatomy, or a flat refusal of the mirror I routinely offered for mutual genital inspection. During these years, I occasionally speculated about whether this hesitation affected the sexual choices that my patients made. But ultimately their vulvas, like their vaginas and internal pelvic cavities, were more like bodily vehicles through which I worked my women's health magic; canvases upon which I could inscribe the (feminist) rules and regulations for a sexually "healthy" lifestyle.

This changed on the day I saw the before and after photographs of a woman who had undergone a cancer-related radical vulvectomy. I was at a women's health conference, attending a session about gynecological cancers. I didn't specialize in oncology, but the presenter had moonlighted several years earlier at the abortion clinic where I worked. Dr. Nichols was compassionate, bright, and informative, and I was fully expecting to learn something from him; (1) I was not, however, prepared for the larger-than-life images that loomed before me that afternoon. Labia that had once protruded outward from the vaginal opening, touching themselves in their fleshy symmetry, had been replaced by a sheet of shiny white skin; hairless and without a fold in sight, this stretch of skin was interrupted by two openings whose more functional aspects were now very hard to miss. Even Nichols's engaging style could not mitigate the intensity of seeing a woman whose vulva had been cut away so drastically. Nor could it diminish the dismay I felt after hearing that she had been symptomatic for quite some time. Nichols underscored that this case was far from unique and that, although malignancies were often subtle, female genitalia were too often lost because neither women nor their providers adequately understood what constituted a normal vulva.

These days I think about vulvas almost constantly, only now I do so as a cultural anthropologist. Instead of asking questions about the individual behaviors of a particular woman, I examine collective practices, specifically those that structure the hesitation toward female genitalia that I am now certain conditions the reality of vulvar cancer. Recently my research led me to this recommendation, from a 2004 overview of gynecological cancers:
    Because there is evidence of diagnostic delays, that is, women seek
   medical care in advanced stages of the disease, some authors
recommend
   that women perform self-examination monthly and also that
   physicians be made aware of the features of [vulvar] disease. (2) 


Like Nichols, these authors (Duarte-Franco and Franco) ask clinicians to be more proactive in their vulvar surveillance: to promote more self-exams and to learn more about the diagnostic features of malignant abnormalities. Missing from their unfortunately brief discussion, however, are recommendations toward achieving either of these goals. A primary goal of this essay is to initiate a discussion about the challenges involved in promoting vulvar self-examinations in the contemporary United States. As both a former clinician and an anthropologist, I am especially keen on analyzing the bodily reticence practiced by individual women within the context of social discourses that routinely devalue female sexuality.

Vulvar cancer's primary symptom is chronic genital itching that is unresponsive to antifungal or anti-inflammatory agents; left untreated, affected areas develop into visible and palpable genital lesions. Early clinical detection requires that women and/or their providers pay direct attention to the vulva. It is also crucial that both parties have adequate information about the appearance, sensation, and likelihood of vulvar anomalies. Difficulties arise from two main sources: first, precancerous lesions are typically painless and women tend to avoid contact with genitalia that don't hurt; and second, the widespread availability of over-the-counter antifungal preparations leads many clinicians to treat what sounds like an infection without performing a physical exam. Caught up in busy lives and in a set of myths about "hormonally ruled" bodies, many women become accustomed to erratic levels of genital itching and discomfort, unaware of when and if their symptoms merit attention. This is partly why a majority of women with vulvar cancer experience "diagnostic delays," eventually losing their vulvas, or portions of them, to excisional surgery.

I am interested in the details of these delays. Moreover, I am invested in a public and explicit conversation about what a normal vulva is and in delineating some of the cultural factors through which afflicted women find it difficult to identify and communicate various states of abnormality--what I am calling female genital disease. In 1992, Nichols encouraged his audience to pay greater attention to their patients' vulvas, using startling images to demonstrate the stakes that were involved. Twelve years later, a pair of equally expert clinicians reiterated his message, But what concerns me are the assumptions on which these clinical exhortations are based: that women and clinicians need only be told to pay greater attention to the vulva. This belies a contemporary social context in which female external genitalia--in both material and discursive form--are routinely and "richly ignored." (3)

Between the summers of 2004 and 2005, I conducted ethnographic fieldwork in a clinic that specializes in vulvar pain conditions. (4) I chose this site because I wanted to investigate both the cultural and the physiological "symptoms" of female genital disease. Chronic and unexplained vulvar pain is an increasingly visible medical condition in the contemporary United States; current prevalence rates range between 15 and 18 percent. (5) Vulvar pain is characterized by an inability to sit comfortably, wear pants, and/or tolerate vaginal penetration. Despite these seemingly obvious qualities, however, vulvar pain presents numerous diagnostic dilemmas, chief among them the lack of correspondence between objective and subjective evidence of disease. This means that although even untrained clinicians can reproduce the symptoms of vulvar pain with a simple physical examination, the diagnostic efforts of most nonspecialists are stymied by a relative absence of concomitant signs of abnormality.

Although a vocal minority of patients founded a national support group (the National Vulvodynia Association [NVA]) and successfully lobbied for federal funding and recognition, the majority of afflicted women suffer in relative silence. (6) Vulvar pain affects nearly every area of a woman's life--sexuality, work, wardrobe, emotions, childcare, recreation, friendships--but culturally proscriptive attitudes toward female genitalia make the disclosure of "down there" details uniquely challenging. In the words of Ashley, one of the patients with whom I consulted, the subject of the vulva is largely "off-limits," a socially structured mandate from which symptomatic women are not exempt.

In contrast to the subtle presentation of genital cancers, vulvar pain is fairly hard to miss. Women describe their symptoms in terms of texture ("raw," "irritated," "sandpaper"), sensation ("burning," "knifelike," "like someone poured acid on me"), and reactivity ("sensitive," "tensed up," a "wire of pain"), as well as by the havoc they wreak on their sexual relationships (sleeping in separate beds or being afraid that kissing will lead a partner to "want more"). (7) Attending to the disparity between patients' acutely perceived genitalia and culture's chronic negligence of those same genitalia illuminates the tensions unique to female genital disease. The discomfort of vulvar pain, in other words, extends beyond the physical and into the linguistic and affective dimensions of a woman's life. Indeed, talking about her pain is one of the greatest obstacles that a patient must learn to overcome.

In this article, I use the narratives of clinic patients to argue that there is significant feminist work to be done regarding vulvar disease and integrity. These stories highlight the stifled nature of vulvar discourse, which, I further argue, indexes a heteronormatively contoured distaste for female external genitalia. Vulvar pain compels affected couples to "deal with" a part of the body that sexual discourse often marginalizes, and these confrontations reveal the multiple sources and expressions of vulvar disparagement that are available in the contemporary United States. The majority of women diagnosed with genital pain are heterosexual, and this essay brings a critical focus to the relationship between vulvar pain and heteronormativity. My intention in making this connection is not to normalize this demographic profile but rather to elucidate the role that even "non-penetratable" genitalia play in maintaining a heterosexual cultural order.

The relationship between genital dis-ease and heteronormativity is complex. Clinical studies demonstrate that the typical vulvar pain patient is heterosexual, a finding borne out by my own research, during which I met only two lesbian-identified women in a sample of just over one hundred patients. As with women of color, who are also missing from most published demographic profiles, it is difficult to discern whether lesbian women do not experience or do not get diagnosed with vulvar pain. Although researchers have begun to investigate the racial disparities among this population, there has been scant attention paid to the biocultural implications of this being a "heterosexual" condition. My argument is that because vulvar pain constitutes a virtual "refusal" of vaginal-penile intercourse, symptomatic women's stories provide compelling evidence about how phallocentrism is negotiated within heterosexual relationships. While maintaining that genital pain should be understood as physiologically legitimate, that is, as a "real" and life-altering disease worthy of clinical research and a wider array of treatment options, I simultaneously argue that female genital pain should not be analyzed--particularly by social scientists--outside of this important cultural context.

Vulvar dis-ease leaves many US women inadequately informed about the appearance and function of their genital anatomy. In the first section of this essay, I delineate the repercussions of this brand of bodily ignorance, stressing that it is reinforced by popular culture, institutional medicine, and even a few feminists. In the second section, I posit a condition of female genital alienation that uniquely structures, but is not limited to, the experience of vulvar pain. The dis-eased relationship between many US women and their vulvas is aptly captured by the term agnosia, a neuropsychological condition in which an individual cannot properly recognize a part of their body. (8) As extreme--and heuristic--ends of a spectrum, agnosia and pain/ disease exemplify the alienated access that many women have to the genital aspects of their sexuality.

With the suspension of vaginal-penile intercourse, many women reevaluate the sexual desires of their partners, often exploring feelings of anger, disappointment, and confusion about the sexual order in which they have been participating. In my concluding section, I demonstrate that alienation from conventional (hetero)sexual arrangements is illuminated rather than generated by vulvar pain. Vulvar pain compels symptomatic women to confront their external genitalia, literally bringing to life what vaginally focused cultural rhetoric perniciously undermines. Contrasting alienation with (vulvar) animation, I use the work of Luce Irigaray to advance the idea of a vulvar-based sexual morphology around which a wider variety of women might coalesce.

"MOST PEOPLE DON'T PEEK": VULVAR DIS-EASE

A Little Disgust

The diagnostic timeline for vulvar pain averages five to seven years, a delay that I suggest be understood as a medical instantiation of female genital dis-ease. Vulvar encounters are frequently hesitant, even secretive, and many women are only vaguely familiar with their genital anatomy. These reluctant bodily confrontations are in a mutually constitutive relationship with linguistic conventions that evade, disparage, or render inconsequential the sexual bodies of women. In other words, many women struggle with both identifying and speaking about genital abnormalities because of a cultural proscription against "down there."

Despite decades of "pro-genital" art, scholarship, political activism, and cultural critique, contemporary social norms continue to bolster myriad "ways 'n means [for] women [to] learn to hate [their] cunts." (9) "Dirty" jokes about the vulva are miasmic, seeping into our collective pores and contaminating our genital integrity. This kind of humor frequently stymies vulvar education efforts, often admonishing those who aren't laughing to "lighten up." This pop culture dilemma was cleverly grasped in an article that recently appeared in the newspaper parody the Onion. Headlined "Renowned Hoo-Ha Doctor Wins Nobel Prize for Medical Advancements Down There," the article included the following text:
    During the remarkably noninvasive procedure, targeted blasts of
   radiation are delivered to the, err, naughty region through a
   special, well, wand-like device that is--ahem--inserted near the,
   ho boy, "affected area." (10) 


Although it seems clear that the Onion writers "get it," perhaps even sharing my concerns about evasive vulvar discourses, I am drawing attention to their piece for two reasons. The first is that it brilliantly captures a particular structure of feeling: the discourses and practices through which female genitalia are avoided with varying degrees of distaste, including by individuals who might otherwise be regarded as progressive in their gender and sexual politics. For example, although 24 percent of respondents to a recent survey in the feminist magazine Bust stated that examining their "vagina" [sic] was "no big deal," another 44 percent felt "[a] little wonder [and] a little disgust" at the prospect of doing so. An additional 5 percent claimed to have "never looked," while 4 percent identified with the phrase "disgust--it's like an alien." (11) Ironically, both the survey and the article that it accompanies participate in the precise brand of dis-ease they purport to disrupt. Allegedly about the vulva in an age of increasing cosmetic labial surgeries, the article undermines its own call for genital integrity by consistently using the word "vagina" when referring to the vulva. This includes survey question number seven: "Can you identify the different parts of your vagina? (Do you know where your clitoris is, your labia, etc.)" (12)

The author carefully reassures us that she "know[s] the vagina is only the interior tract" and that she is using the word vagina "in the colloquial sense," is But this attempt to minimize her affiliation with a broader project of vulvar erasure needs further contextualization. A clitoris in the vagina reproduces a patriarchal sexual narrative against which many women still struggle: that female orgasm routinely and easily occurs via penile-vaginal intercourse. Eerily reminiscent of Linda Lovelace/Boreman's clitoris-containing "deep throat" (from the 1970 film of the same name), this imaginary anatomy configures female sexual pleasure in primarily penetrative terms. Indeed, it is precisely because it is not "the interior tract" that the vulva exceeds the heteronormative aspects of the vagina, which configures female sexual difference in phallic or reproductive terms. Having the knowledge and ability to make bodily and verbal distinctions between what one patient in the vulva clinic referred to as "all the different parts and stuff" should be a goal shared by all feminists, not just those of us who wish Eve Ensler had titled her play The Vulva Monologues.

Additionally, the article from the Onion draws attention to institutional gynecology's complicity with genital dis-ease. Equipped with an array of facts and investigative tools, clinicians encounter female genitalia from the peak of a medical hierarchy that structures our most basic understandings of corporeality. Biomedicine and the natural sciences delineate the contours through which we come to know and formulate beliefs about the (human) body. Subject to a gaze that Foucault has described as an "awaken[ing]" one, patients and their anatomical normality are literally constructed through the authoritative and evaluative practices of clinical medicine. (14) This dynamic is epitomized in the vulva clinic when a patient and her doctor construct a narrative about how she is "doing" based on the findings of her physical exam, rather than on her subjective bodily experience.

Feminist critiques of science have long demonstrated that individual practitioners do not operate outside of the social norms through which gender and sexuality are constructed. Providers cannot, therefore, be expected to fully transcend the discourses and practices that marginalize female genitalia. In one of the only thorough analyses of gynecological medicine to have been written in the past twenty years, Terry Kapsalis reminds us that "cultural attitudes about women and their bodies are not checked at the hospital door." (15) The all-too-familiar utterances, made daily by practicing clinicians, of "Oh, everyone hates these exams" and "I'll just take a little peek," complement draping behaviors and visualizing techniques that alienate women from their sexual bodies. The activism of the women's health movement unsettled much of the patriarchal ideology that both produced and benefited from these practices, evidenced by the almost ubiquitous presence of hand mirrors in contemporary exam rooms. But the tenacity of vulvar distaste can undermine even these small steps forward. A clinic patient named Peggy recalled an exchange with a male physician who offered her one of these mirrors during an annual pelvic exam. Once in view, she noticed--and exclaimed--that her external genitalia had "a lot of hair." Her doctor replied: "Well, what do you expects. Your vulva's not supposed to be very vibrant."

Fortunately for women like Peggy, experts at the specialty clinic work to undo this brand of explicit genital disparagement; both Drs. Robichaud and Erlich, the two physicians with whom I worked most closely, sought to establish and affectively neutralize patterns of vulvar awareness that would facilitate their patients' improvement. By hearing their vulvas described as "robust," "juicy," "supple," and even "beautiful," symptomatic women had the opportunity to reimagine their genitalia through uncontaminated vulvar morphologies. Here, I want to emphasize the words "opportunity" and "symptomatic women" in order to highlight one of my central arguments: if the active cultivation of vulvar integrity is limited to women whose physiologies are already afflicted with cancer or a pain condition, for example then we have yet to alter the landscape upon which the rest of us encounter female genital dis-ease. A feminist analysis of the pervasive effects of this condition is still needed in order to develop meaningful social and clinical interventions.

Getting Out of the Comfort Zone
Lily
 : I've been putting it off. It's one of those things
that's
   uncomfortable. It's just ... oh!.... I always feel so strange.
I'm not
   the most comfortable person .... To be honest, I don't think I
examined
   myself until it started to hurt. 


Lily was twenty-seven when she came to the clinic, and she had been symptomatic for four years. Married for five years to her first sexual partner, she experienced pain with intercourse, itching, irritation, and an endless stream of what she called "infections," all of which were precipitated by genital contact. During her first visit with Robichaud, Lily was articulate about the details of her "vulvar area," including that she often noticed a "white substance in [her] vagina" and that she was having "a lot of pain with sex." Lily's vocabulary suggested an ability to both detect and communicate a genital abnormality, a skill that she honed during four years of unexplained pain. But, as the above quotation illustrates, Lily remained uncomfortable with the amount of self-awareness she needed in order to monitor and control her symptoms. Five years into her experience and emotionally invested in getting better, Lily nonetheless declined the mirror offered by Robichaud, saying "Oh, I probably won't watch!" This ambivalence toward her genital body complicated Lily's course of recovery and can be seen as an indicator of a common state of affairs among women with and without symptoms. That is, women who are loathe to, in the words of seventy-three-year-old Barbara, "peek" at their vulvas risk not only a delayed diagnosis of a genital malady but also an inability to imagine their genitalia outside of sexual or penetrative terms.

Daphne, who had also avoided contact with her genitalia until she sensed a problem, made a connection between her behavioral reluctance and traumatic sexual events from her past: "I'm not used to how it feels to be touched there. I haven't done much at all. Since the abuse. Even myself. I couldn't even look for a long time. Until I had to. I haven't looked very much at all." Millions of survivors of sexual abuse and violence share Daphne's story, and clinicians and public health personnel intent on promoting vulvar self-exams should therefore incorporate awareness of genital-avoiding behaviors into their planning efforts. But in order to do so most effectively, these advocates must educate themselves about the history of unexplained genital pain. For many years women with vulvar pain were interpellated--often inaccurately--as "victims" of sexual abuse. Inconclusive physical exams led numerous clinicians to label these patients as frigid or otherwise vaguely "traumatized" by a previous sexual or genital experience. Frustrated with the lack of treatment options generated by this narrative, members of the NVA used some of their earliest resources to demonstrate that symptomatic women were, in fact, no more likely than any other woman to have survived such an experience. This made it clear to clinicians that previous genital trauma could be included in the differential diagnosis for vulvar pain, but that it was crucial to patients that this not be the default diagnosis.

But women like Daphne remind us that it may be time to broaden our notions of genital trauma. Without diluting the bodily and psychic impacts of sexual abuse and violence, we can see that Daphne, Lily, and their "pain-filled" (16) counterparts--along with a host of unafflicted women--have also all been culturally conditioned to understand their genitalia in disparaging terms. This can locate Daphne within a diverse group of women struggling to incorporate their genitalia, rather than pathologizing her history as a psychosomatic cause of her pain. It is also important that Daphne and her peers have access to a full range of treatments, not just those circumscribed by what clinicians often quietly refer to as "a history"--that is, code words for a past that includes sexual trauma. Daphne's coexisting truths--sexual abuse and vulvar pain--both contribute to bodily and affective behaviors that resemble those of women who do not share such a history; genital dis-ease, in other words, exists both in and outside the arena of what is currently defined as sexual trauma. It is therefore critical that we interrogate both its ideological and physiological aspects so that women for whom an abusive past does not resonate can also learn to recognize and resist discourses that leave them chronically underinformed about their bodies.

Though Katie fit into this latter group of women, her exchange with Erlich revealed the distance she nonetheless maintained from her genitalia. Because her vulvar pain had led to a compensatory tightening in the muscles of her pelvic floor, Erlich prescribed therapeutic vaginal dilators in conjunction with physical therapy. Upon hearing that the goal was to eventually replace the dilators with her own fingers, Katie interrupted Erlich by exclaiming "[Put them] inside? I couldn't even find it!" Important here is not so much this patient's literal inability to locate her "inside," as she both used tampons and engaged in coitus with her boyfriend; rather, Katie's reaction to her nonsexualized vulva, the one that she did not encounter through (penile) penetration, was as conflicted and ambivalent as Lily's and Daphne's. "Everything I'm doing is kind of funky and not normal," she told us. "But I'm trying to get out of my comfort zone."

Like some of Bust's readers, Katie called her genitalia "disgusting," and it is tempting to juxtapose her apparent lack of genital integrity alongside that of Nichols's patient, the woman whose vulva might have been spared if she'd been able to "find it" sooner. But if we do this, our analysis must include both an appreciation of the anatomical vulnerabilities shared by these two particular women, as well as a set of theoretical concepts with even broader collective utility. In contrast to the vagina, the vulva has a singular ability to disrupt a multitude of conventions, including the "colloquial" ideas with which Bust's survey is complicit; as such, there is room at the table for art, scholarship, politics, and new media to address the plight of all vulnerable vulvas, including the discursive one(s) through which so many of our genital truths are reckoned. Limiting our analyses of vulvar erasures to the physical or even psychological consequences of individual cases of dis-ease leaves the radical potential of this body part underrealized.

There are good reasons to urge healthcare providers to take vulvar ignorance more seriously. The twenty-year-old campaign to increase public awareness of breast cancer is a powerful example of the impact that directed feminist attention can have on disease prevalence and survival. This history is especially salient in that early advocates of public screening programs struggled with cultural taboos about the breast not unlike those that trouble the implementation of larger-scale vulvar self-examination campaigns. But such work must take the public health factors unique to vulvar embodiment into account. We can no longer ignore the studied innocence of clinicians' lamentations about alarmingly low levels of vulvar (self) awareness. Providers must acknowledge the culturally informed hesitation that many women have toward their genital bodies so that both public campaigns and individual recommendations can be tailored appropriately.

But in addition to fleshing out the reasons why "most people don't peek," we must locate and hold accountable the cultural discourses that are unsettled by an unruly vulva. Chief among these is a heteronormative sexual order in which penile-vaginal penetration constitutes "real sex." Noncompliant vulvas frustrate the routinized practices of heterosexuality and challenge couples to either forego or invent alternatives to traditional coitus. Prompted by their bodily refusals, clinic patients expressed ambivalent investments in coital arrangements that were, according to a patient named Clair, usually "all about him." Faced with this ambivalence, and with genitalia that did not comply with their and their partners' sexual desires, these women began to question and resist cultural narratives through which their pleasure was frequently eclipsed. Although a majority of these women voiced a strong desire for things to be "normal," that is, to "not have to think about [their] vulva[s] every day," they were simultaneously aware that their sex lives required some fine-tuning. In order to preserve the robust and supple vulvas provided by Robichaud and Erlich, they would need to carve out a suitable and embodied space for them to inhabit. Although the supportive environment of the clinic enabled patients to explore such a space, their overall efforts to do so took place within the more generalized-- and often intransigent--experience of what I call genital alienation.

"I JUST THOUGHT THAT EVERYONE HAD THAT PAIN": GENITAL ALIENATION
Robichaud:
  What did [the surgeon] do?
   Colleen:
 A vulvectomy.
   Robichaud:
 What did he remove?
   Colleen:
 I don't know. 


Genital alienation is the risk, if not the reality, of cultural genital disease. Disparaging rhetoric, medical apathy, and linguistic carelessness inform a pernicious estrangement between women and their genitalia. Vulvas make trouble in ways that few other body parts do; as such, they are not only at risk for acquiring disease, they place women at risk if embodied to an impolite or excessive degree. Women know this so acutely--imagine hearing "My vulva feels great today!"--that they disinvest from the corporeal reality of "down there," often coming to know their genitalia solely through external sources. My use of the term alienation speaks to the experiences through which the vulva becomes difficult to recognize, either as an anatomical entity or as one's own. I conceive of vulvar alienation as a spectrum, moored by the absences of silence and erasure at one end and by the hyperpresence of pain, (pornographic) amplification, and felt excess on the other.

This spectrum is a heuristic device that posits two dominant modes through which US women apprehend their external genitalia: absent or uncomfortably present. Rooted in a tension, these two patterns are dynamic, fluid, and well characterized by the Freudian notion of obligation that Elizabeth Wilson recuperates in her book Psychosomatic. Wilson argues that the concept of obligation obviates cause-and-effect models while offering a "way of understanding a relation between psyche and soma in which there is a mutuality of influence, a mutuality that is interminable and constitutive." (17) Wilson's agenda in Psychosomatic is to rehabilitate aspects of the biological body, which she fears feminists have "foreclosed." (18) Her finely honed attention to physiology destabilizes notions of conscious bodily action without fully relying on social constructionism to do so. In short, Wilson suggests that human agency is both circumscribed and expressed by biological processes. Such an assertion provides us with a way to reimagine not only "psyche and soma" but soma and culture as well. That is, women with and without genital symptoms are reluctant to acknowledge their vulvas, a predilection that can scarcely be imagined outside the confines of what I am calling genital dis-ease. The medical conditions of cancer and vulvar pain might therefore be interpreted as culturally and historically specific forms of genital or sexual distress, along the lines of twenty-first-century hysterias. But in addition to the discursive work they may perform, these conditions are also deeply embodied: obligated to the questionably conscious maneuvers of the fingers, vocal folds, and eyes that have learned to routinely avoid the "vulgar" vulva. (19)

In this model, female genital invisibility and reluctance have a relationship with cultural events that interpellate the vulva as excessive, distasteful, or threatening. This dialectical dynamic resonates with one final concept, disavowal, without which I do not believe we can properly understand vulvar dis-ease. Colloquially understood as a denial or abrogation, disavowal is more completely defined by including an element of ambivalence. In other words, female genitalia that are disavowed are infused with an ambiguous desire: we call attention to the vulva in order to make it disappear. Because Freud's earliest use of disavowal involved a boy's confrontation with female genitalia, I will briefly discuss this elaborated definition of the term.

In a 1927 essay, Freud wrote that in confronting his mother's genitalia, a little boy moves from a resolute "lack of interest" to a process of disavowal, during which he "softens... down" his perception "or looks about for expedients for bringing it into line with his expectations." (20) Following this description, disavowal has frequently been defined in terms of repudiation, often as a defense against a traumatic perception. Psychoanalysts continue to refine the term, however, and have emphasized that the experience of disavowal includes ambivalence in ways that other forms of negation do not; indeed, it is this facet of the concept that best distinguishes it from explicit denial. In describing a multilayered and conscious experience of refusal, disavowal helps to delineate important distinctions between being blind to and turning a blind eye to an experience. (21) The difference here is that in the latter case, the rejection of the perceived object--a "cunt," for example--is contingent upon its recognition rather than its repression.

My concept of genital alienation as a spectrum relies on the push-pull sensibility toward the vulva that is conditioned by the process of disavowal. Were female genitalia subject to an explicit and total refusal--individual or collective--there would be no role for the language, jokes, images, and cosmetic surgical procedures through which the vulva is made the object of both desire and disgust. My use of this concept does not, however, rely on the heteronormative assumptions upon which notions of the vulva as castrated absence frequently do. Given the debt that many psychoanalytic perspectives on sexuality often owe to both nuclear/heterosexual family structures as well as to a sex/gender binary through which feminine sexuality has historically been subordinated, I count myself among the many feminists who remain cautious regarding psychoanalytic renderings of the female sex. But however inadequately psychoanalysis may explain the wide variety of ways that women and men actually live their sexuality, theoretical concepts such as disavowal remain useful tools for understanding how the female sexual body is (collectively) imagined.

In the midst of conflations through which all female genitalia are displaced and erased, the vagina offers a safe haven for the procreative and penetrative goals of a phallocentric social order. The vulva, in representing a sexual difference not circumscribed by these goals, unsettles the cultural and collective psyche. For Freud, an aversion to female genitalia was an individual and total phenomenon--the "stigma indelible of the repression that had taken place" within a fetishist's psyche. (22) Denial of the vulva at the collective level, on the other hand, is irregular, uncertain, and resonant with the spectrum of alienated absence and amplification taken up in this essay. For Freud, female external genitalia are experienced with a "vicissitude," and this cultural disavowal is consonant with the troubling--perhaps traumatic--reality of a female sexuality that cannot be subsumed by a heterosexual order. (23) The labiaplasties and "dirty" jokes in which we routinely engage allow us to simultaneously accept and reject this possibility. As a result, the vulva remains both integral and marginal to the narratives through which female bodies are constructed and imagined.

Alienation 1: Agnosic Absence

Without a clean or neutral space in which to "have" a vulva, many women oscillate between two alternatives: a no-space and a contaminated one. In an invisible no-space the vulva goes missing--absent from conscious awareness, untouched for its own sake, and attended to only by others. I label this end of my spectrum with the neuropsychological term agnosia. In contrast to the phantoms with which many of us are more familiar, such as painful sensations at the site of a missing limb, agnosia is best described as "the nonrecognition of a part of the body as one's own." (24) The proprioceptive anomalies that fall into this diagnostic category are typically related to brain lesions; I introduce a cultural counterpart in order to suggest that the consequences of both brands of nonrecognition may not be entirely dissimilar. An affective genital agnosia is not constituted by a simple reluctance to perform a vulvar self-exam. Rather, this is the derelict space through which a woman remains clitorally anorgasmic, linguistically unable to describe her genitals, and perceptually unable to recognize a visible or palpable lesion. (25)

At the other end of the spectrum, amplified discourses channel and purvey vulvar disgust and disavowal, including popular rhetoric that renders women's sexual bodies in excessively distasteful terms. These quite visible vulvas neither correct nor preclude the condition of disappearance and neglect, however; the colorful turns of phrase used to colloquially describe female genitalia might send any attentive vulva into hiding. Acutely aware that words such as "cunt" are typically deployed with "the utmost rancor," (26) many US women maintain a cautious genital sensibility.

The experience of nonrecognition is central to the concept of agnosia. On this end of the spectrum, unfamiliarity is structured by a failure to incorporate: This is not apart of me. It does not belong to me. Well characterized by the reluctance examined in the previous section, it stands in contrast to how the vulva is misrecognized at the other end. Amplifying discourses contain a vulva that is alien unsightly, excessive, pornographic, or in pain and that is read as: That is not me. I don't recognize myself in that. In the next section, I will further elaborate what I mean by amplification including the ways that it is obligated to the reticent agnosia considered thus far.

Alienation 2: We're Not Talking about Gray Zones

The felt nature of the excessive aspects of alienation is easily discerned via the increasing consumption of cosmetic labiaplasties and "Brazilian" bikini waxes vulvar confrontations that are, in the United States and elsewhere, characterized by removal. Both procedures are facilitated by the absence of an uncontaminated gauge against which a woman can measure a "normal" vulva. Gynecologists and cosmetic surgeons use labiaplasty to slice away the troubling vulva, signaling their complicity with the discursive erasures to which the vulva is subject. That such excisions are part of a larger set of clinical narratives regarding female genital excess has been demonstrated recently by Katrina Karkazis in her ethnographic account of intersex surgeries in the contemporary United States. By attending to the assumptions on which these physicians base many of their decisions, Karkazis illustrates that the clinical trajectories for anatomically fashioning girls and boys are not only culturally dependent, but they are also wildly dissimilar. Karkazis found that patriarchal and heteronormatively contoured notions of size determined the clinical decisions of her surgeon-informants: make penises as big as possible (to penetrate a vagina), make vaginas big enough (to allow penetration), and make sure the clitoris isn't too big. (27)

In these situations, both surgeons and families operate with a robust set of assumptions about what genitals (are supposed to) do: "[C]linicians state in no uncertain terms that the phallus must be large enough for intromission or intercourse." (28) In order to ensure this, pediatric urologists acquire precise measurements of penile length from which an adult corollary is extrapolated. These informal--although widely adhered to--guidelines not only reify definitions of behavioral sex that are profoundly phallocentric, they illustrate the relative cultural value of assessed genitalia that fall both in and outside of the cultural comfort zone. This is especially evident regarding clitoral reduction. When confronted with a clitoris of questionable size, the same surgeons who are at pains to standardize penile measuring procedures rest comfortably in their ability to "eyeball it."
    As one surgeon told me: "I know one ... when i see it....
We're not
   talking about gray zones. It's usually very, very obvious."
Dr. L, a
   pediatric urologist, comments, "It's an impression of how
it looks. If
   you open the diaper and see a phallic structure then, clearly,
that's
   going to be objectionable. I don't have an actual measurement.
Maybe it's
   my sexism or something, but I've never measured clitoral size.
It's by
   visual. As we're doing the surgery, we'll look at it
stuffed back and
   say, 'That looks good, or it still really looks abnormal.'
It's very much
   a judgment thing." (29) 


I have already stressed that even vulvar specialists routinely lament that clinicians lack adequate knowledge about the range of variation consistent with "normal" female external genitalia. It is crucial, therefore, that we contextualize the certainty with which these urologists claim to "know one when [they] see it." Activists have long voiced objections to the lack of control that intersex individuals have to their genital anatomies, and some have subsequently begun to call the authority of surgeons and other experts into question. This matters not only for sex/gender activists and scholars but also for the underinformed and possibly symptomatic women who think of their genitalia in the "off-limits" rhetoric noted by Ashley, the patient whom I cited earlier. The pediatric surgeons quoted above (re)produce ideas about "which organs or genitals properly sexed subjects can or should have" at the same time that they are products of social structures that discipline female bodies in their excessive state(s). (30) Exactly how much vulva is too much vulva is a question that these clinicians are uniquely positioned to pose, but it is also one for which a surprising number of us would likely have an answer.

Female sexuality debates have largely focused on the clitoris, making political and sexological use of its ability to both liken and distinguish male and female genital anatomy. Because the clitoris is both penile homologue and singularly innervated for sensory pleasure, it has captured the public's imagination and facilitated a twentieth-century redefinition of "mature" female sexuality. In just the past fifty years, the clitoris has serviced numerous agendas, acting as, among other things: a heterofriendly genital accessory, a vindication of an antiphallic sexual repertoire, and a nonpatriarchal penetrator for a new generation of gender variant individuals. But I suggest that a collective and cultural embrace of the clitoris is more apparent than real and that the clitoris's current celebrity is inflected with the vulvar alienation examined in this essay.

The discursive potency of the clitoris is related to sensation rather than size. Minus an established equivalence between physical volume and degree of pleasure, clitoral reductions are spared the outrage that accompanies complete excisions. This is particularly true of allegedly "corrective" procedures, including sexual reassignment surgery. The urologists in Karkazis's ethnography maintain that, although they do not conduct follow-up studies, clitoral sensation is unaffected by the reductions they perform on infants with ambiguously perceived genitalia; were this not the case, the relationship between "normal" genitalia and sexual satisfaction may require reconsideration. (31) In other words, if surgically altering a "too large" clitoris normalizes its appearance but muffles (or erases) its sensation, we face a set of questions about just who benefits from properly sized genitalia.

In her treatise on the female body, Woman: An Intimate Geography, Natalie Angier suggests that the clitoris is "designed to encourage its bearer to take control of her sexuality." (32) Although this assertion resonates with the discourse of popular women's magazines, research suggests that women do not always harness this genital power. Based on their survey of over eight hundred young women, Wade and colleagues found that while a sizeable number masturbate to satisfaction with clitorally friendly vibrators, the clitoral orgasm often remains marginal to heterosexual activity--experienced, in the researchers' words, as an "incidental" event. (33) There is a friction between these two realities the orgasmic agency invoked by the clitoris and the deferral of those same orgasms by practicing heterosexual women. That friction resonates with the reality of genital reluctance and highlights important questions for feminist sexuality researchers: if sexual difference is marked, even in part, by an anatomical structure that Angier suggests "loves power," (34) why isn't this difference more routinely exploited in women's behavioral repertoires? Put more simply, (why) are heterosexual women more likely to have orgasms by themselves than with their male partners? And what is the relationship between disavowed vulvas and "incidental" orgasms?

In isolating the clitoris from the vulva, (hetero)sexual discourse indexes the penetrative imaginary through which genitalia are lived; positioned as the most reliable site and source of female orgasm, the clitoris is interpreted through a phallic rather than a vulvar order. Absent its corporeal context the rich and contiguous folds of labial flesh that are neither receptacle nor homologue the clitoris is recruited into a phallocentric order by being either "like a penis" or "not like a penis." Reorienting our relationship to the vulva in its entirety, however, provides the clitoris with a discursive and embodied reality that both locates it in space and recontextualizes it in female-centered terms. Unregulated by orgasmic impetus or teleology, the vulva can play anatomical host to the clitoris and reconfigure its relationship to a phallocratic understanding of genital difference. Hence, a vulvar appropriation of the clitoris can disrupt a patriarchal one, making room for the kinds of sexual difference that Irigaray has argued can transcend extant and complementary--models:
    For one sex and its lack, its atrophy, its negative, still does not
add
   up to two.... The feminine has never been defined except as the
inverse
   ... of the masculine. So for woman it is not a matter of installing
   herself within this lack, this negative, even by denouncing it, nor
of
   reversing the economy of sameness by turning the feminine into the
   standard for "sexual difference
"; it is rather a matter of trying to
   practice that difference. (35) 


Alienation 3: Felt Excess

In an either/or genital imaginary, the clitoris is antidote to a vaginal and passive female sexuality. But a more inclusive spectrum allows us to think dynamically about female genital bodies that are rendered both absent and present by discourses for which vulvar vitality is inconsequential. In other words, women who seek less external genitalia through cosmetic labiaplasty participate in a culturally sanctioned erasure; that they do so in the current (hetero)sexual order should come as no surprise. Absent a sustained medical or social dialogue about what constitutes normal female genitalia, these excisions are an embodied and pragmatic solution to the felt problem of vulvar excess and an almost predictable instantiation of discourses that disavow the vulva. These discourses challenge women who struggle to recognize a part of their body for which they have no gauge, a reality made evident to me in a recent conversation with an aesthetician in Houston. When I asked her about Brazilian waxes, she told me that clients routinely asked her to evaluate their labia, frequently intimating that they have considered surgery. She recalled an exchange with a client who was concerned that her vulva did not resemble her four-year-old daughter's; the fact that her daughter's developing labia would someday also no longer resemble their four-year-old version was obfuscated by this mother's own labial dis-ease.

Researchers have carefully noted, often with surprise, that men are not responsible for the recent surge in cosmetic labial alterations. Women who have undergone these procedures deny the involvement of male partners and report their self-consciousness in seemingly self-generated terms: "I'd never have oral sex because I couldn't bear him seeing me up close"; "Ever since I was fourteen ... I felt uncomfortable changing in front of girlfriends"; and "I don't care if men like my nail polish color, and I certainly don't care if men like my vision of an ideal vagina." (36) But a lack of explicit preference on the part of individual men does not preclude the collectively patriarchal nature of discourses that marginalize female external genitalia. The fact that many of these men routinely consume pornographic media in which streamlined vulvas feature prominently also complicates their apparent indifference towards labial size.

Mainstream pornography's vulva is both amplified and obligated to a concomitant absence. In making this point, it is important to clarify what I mean by "mainstream," which is video and print material that can be viewed/downloaded with a basic internet connection and a minimum of technological expertise--what an "average" person would be exposed to on sites such as youporn or redtube. It is also important to note that the same technology that has brought this brand of pornography into the homes and hands of millions is also responsible for an ever-widening array of sexually explicit material, much of which involves vulvas in very positive ways. But it is the former of these two genres, what I am calling "mainstream," that most consistently minimizes nonpenetratable female genitalia; even the most graphic labia depicted in these products function primarily as curtains for the main--and vaginal--stage. Though performers frequently (and pleasurably) refer to their or their partners' pussies, these same genitalia are quickly reduced to behaviorally and visually eroticized orifices, Female genital pleasure is represented in exquisitely coital terms, and close-ups tend to zoom in on areas that are about to be or are being actively penetrated. Cameras often linger on vaginal and anal openings from which a penis has just been withdrawn, inviting the viewer to imagine this anatomy in heteronormativity's receptive terms. The current aesthetic in this brand of pornography is for labia to be minimized and pubic hair that in previous decades was carefully clipped and manicured to be waxed away completely. Such images are the primary gauge used by women considering labiaplasty; it is important, therefore, to properly contextualize the bodily autonomy that allegedly informs these surgeries.

Although longstanding and at times fractious, the feminist debate about mainstream pornography has not attended to the intragenital dynamics of the female sexual body, that is, the differences between the vagina, vulva, and clitoris in a phallocentric order. The concept of alienation offers a new focus for those of us who are unsettled by this media's routine devaluation of female (hereto)sexuality but who remain open to genuine feminist reform and alternatives. Mainstream pornography is a crystallization of heteronormative discourse. As such, I do not believe that it can attend to female orgasm or noncomplementary sexual difference in the vulvar-centric ways proposed here. Nor do I believe that consumers who use this genre of pornography to learn "a lot about what women really want sexually" (37) can meaningfully imagine the female sexual body outside of a penetrative frame of reference. A final set of narratives from my fieldwork illustrates some of the consequences of these narrow sexual imaginaries.

"HE WON'T LIKE THAT": HETEROSEXUAL DISTRESS

Ashley indexed many of the clinic patients whom I came to know in that she expressed a simple desire: to return to a sexual repertoire not circumscribed by her painful vulva. During our interview, we explored some of the more affective aspects of her pain condition, including whose interests were best served by an accommodating vulva:
Author
 : How much do female genitals matter?
   Ashley
: Well, as long as they're usable
 [my emphasis], I
   don't think they care much (laughs). Um, I think if they're
not
, I
   think you'd be hard pressed to find a date for the prom!
(laughs). 


Other patients offered versions of Ashley's usability theory, grimacing over their partners' limited abilities to cope with the sexual disruptions of genital pain. Sheila told us that her husband believed her symptoms to be "just ... a way to get out of sex," while Holly's husband asked Erlich if he needed to "get her drunk" to facilitate intercourse. After describing her husband as "not quite what [she] would call mature" about her symptoms, Judith added: "He's the person that can be the best sex partner in the world, and then it's like 'Where's the hatchet?'" When Robichaud asked Mickey about nonpenetrative sexual activity, Mickey told her that, although she could likely enjoy it, her husband "wasn't into" cunnilingus. When the topic of counseling was broached, Mickey punctuated her disappointment by saying "HE needs to see a sex therapist.... Sometimes I just hate him."

The nature of female genital pain ("it just hurts!") ruptures the seamlessness through which the vulva is typically lived. Couples who have never had to question the (hetero)sexual order of things become embroiled in sexual drama for which they have extremely limited resources. Even Debbie, who used therapy to explore a sexual assault and guilt over an abortion, found that she couldn't describe the physiological nature of her symptoms without concluding: "It's kind of embarrassing. My husband and I have been dealing with this. We haven't really dealt with it."

The ambivalent nature of their anger and disappointment weighs heavily on these women, and many find themselves questioning the (hetero)sexual patterns in which they--via their previously healthy bodies--had long been complicit. Having acquiesced to her husband's scheduled desire for more than thirty years, Anharrad noticed that her pain-related refusals generated some unfamiliar feelings. Expressed initially as anger--"I have to work to not be resentful of my husband, because he wants sex"--these feelings shifted into tearful remorse as her symptoms improved. In our last conversation, Anharrad wondered aloud if her difficulties were a "punishment" for having "participated dishonestly" in a sexual relationship with her husband "all these years," Shelly, whose husband wanted "to pretend that everything [was] hunky-dory," became increasingly resigned to the widening gap that her symptoms were carving between their respective sexual needs: "The way he is, I have to fix the problem." When I asked whether they had explored nonpenetrative options, she told me, "We haven't talked about it.... This is just kind of the icing on the cake for my husband and [me]. It's like a weight, you just keep adding to it."

What these ruptures unsettle is the precarious nature of heteronormativity itself. The sexual pause that pain compels these women to take is the first noticeable crack in the stability of an arrangement that is, in fact, "more about him." I do not wish to imply that these relationships are less stable in any conventional sense since most of the patients that I knew described partnerships that, because they were "not about sex," transcended what they had imagined romantic relationships could be. Rather, in examining the conflicted desires of a group of heterosexually invested women, I am drawing our attention to the less anatomical--and less clinically amenable--manifestations of an abnormal vulva, and to a relationship that is in need of attention, the one between invisible vulvas and patriarchal heterosexuality.

Toward Vulvar-Based Morphologies

In unpacking this relationship, I am engaging in a critical heterosexual inquiry enabled by queer studies as well as with the question of sexual difference posed most consistently by Luce Irigaray. Although both literatures partially reframe the female genital body, neither adequately addresses the issues that are evidenced by vulvar pain. Queer theory highlights the nonnormative aspects of patients' bodies and behaviors, locating them alongside a host of variant sexualities, In this analysis, the proscriptive nature of vulvar pain can engender widened exploration of sexual alternatives, facilitating entry into a "brave new worm where sexualities publicly cavort detached from either genitals or gender." (38). This move is important both theoretically and politically; destabilizing the institution of heterosexuality compels us to rethink sexual identity and to imagine the kinds of alliances that binarized categories foreclose. Alternatives imply a choice, however, and women for whom vaginal-penile intercourse is impossible are less able to move sideways from a heterosexual center that they do not fully occupy. While it can be liberating to redefine "real sex" outside of traditional coitus, this is distinctly challenging for women whose access to this norm is involuntarily circumscribed.

Irigaray's vulva is unruly and excessive, and it is impossible to discuss its radical potential without invoking her earliest work. In a spirited rejoinder to Freud and Lacan, and to the intellectual misogyny of which they were often accused, Irigaray used her first two books to theorize sexual difference in vulvar rather than vaginal terms. (39) By drawing explicit attention to the vulva's plentiful folds, Irigaray reoriented sexual difference around an excess that could neither be contained nor characterized by a psychoanalytic lack. Irigaray insisted that these female bodies--different from men, not receptacles for their bodies--were missing from hegemonic discourse, and she made the stakes of vaginal identity politics clear: "I had not begun to exist. I was nothing but your sheath, your other side, your inverse. Miming you. Doubling, redoubling your organ." (40)

Irigaray's work is problematic in that it does not disrupt--indeed at times it reifies--the sex/gender binary that many feminists are invested in deconstructing. Comfortably asserting that the basic social unit is the couple, she destabilizes the practices of heterosexuality while leaving its normativity relatively unquestioned. Although "the feminine" is recuperated in poetic and irrepressible terms, it functions primarily as complement to a scantily theorized masculinity. Nevertheless, Irigaray's critique of a heterosexuality in which women and men relate vertically rather than horizontally is both incisive and heartbreaking in its candor:
    You had form, I was matter for you.... Each time you separated me
from
   myself, power flowed out of me.... Leaving myself far behind, I would
   espouse your penetration; responding to your pressure I would set
aside
   my supple, elastic fluid density and espouse your strength, your
   hardness.... Made phallic.... I forgot what my jouissance
 could
   have been. (41) 


These words resonate with the disappointment and invisibility that some clinic patients expressed. For Clair, whose husband "never could find" her clitoris, and Libby, whose husband had "no interest" in looking at her post-surgical vulvar stitches, Irigaray captures an important affect: that of a woman who, now acutely aware of her vulva's existence, struggles with whether and where it belongs in her (hetero)sexual relationship.

Irigaray's labial sexuality can, even when penetrated, "re-touch [it]self with the help of--nothing," and she insists that women (re) claim their ability to know pleasure in the excess. (42) Elsewhere, I have suggested that Irigaray "animates" female genitalia, and that without these three-dimensional contours, women cannot generate a sexuality that is truly their own. (43) This issue is critical for two reasons. First, as an anatomical and embodied feature, the vulva effectively eludes cultural dynamics that interpellate women as heterosexual receptacles and reproductive vessels in ways that the vagina cannot; it is a horizontal marker of sexual difference by which female, male, and otherwise "sexed" bodies can identify outside the tenacious terms of inversion and complementarity. Second, a feminist incorporation of external genitalia invites bodies with a variety of vulvas--including transwomen, cancer survivors, intersex individuals, pain patients, and women whose afflicted genitals have eroded or been excised--to collectively generate novel bodily morphologies that transcend extant sexual orders. In other words, if genitalia are to be a part of the feminist project of interrogating sexual difference, then they must be adequately differentiated across those bodies that position themselves as women. An "unusable" vulva makes the entire female genital body evident, a body that remains inadequately theorized by feminists. A vulvar-based sexual imaginary creates a space in which female genitalia exist in all their corporeal potential, offering more than symptomatic women an investment in labial, clitoral, and pelvic floor sensation. Such an imaginary is not available to alienated vulvas, locating women who recuperate their genitalia through disease treatment on the cutting edge of alternative female sexualities.

These alternatives are infused with possibility; with the carnal potential of a profuse, expansive, and largely untapped source of female pleasure and corporeality; with a sex that Irigaray insists can never be just one, Rendered sexually variant by their marginal relationship to penetrative coitus, many women with vulvar pain remain steadfastly invested in heteronormality, becoming sexually paralyzed by the impossibility of these contradictions. Feminist and critical theory that makes space for their experiences can unseat the assumptions on which this stagnation rests, transforming an ambivalent vaginal refusal into a recoded and generative orifice. If we read afflicted genitalia as a way in to the conflicted desires, anger, and disappointment of (some) heterosexual women in the contemporary United States, we have established a new opening in sexuality studies through which to analyze the apparent investment that straight women make in penetrative coitus. The narratives of my informants allow us to construct a horizon where genitals may indeed matter tremendously, although perhaps not in the ways to which we have become accustomed,

NOTES

(1.) All names in this essay are pseudonyms.

(2.) Eliane Duarte-Franco and Eduardo Franco, "Other Gynecologic Cancers: Endometrial, Ovarian, Vulvar and Vaginal Cancer," BMC Women's Health 4, suppl. 1 (2004): 7.

(3.) Eduard Friedrich, Vulvar Disease (New York: W.B. Saunders, 1983), 8.

(4.) Between 2001 and 2005, I spent fourteen months with a vulvar specialty clinic. After gaining access through institutional review boards at both my university and the research hospital in which the clinic operated, I observed patient visits--both new and returning--and recruited interview participants from that pool of women. The clinic was open one-half day per week and was staffed by two female physicians--Robichaud and Erlich. I moved between them each week, sitting in on the consultations of up to five patients per clinic session; the total number of patients that I encountered in the clinic was just over one hundred. In addition to my time in the clinic, I interviewed a smaller group of patients (n = 44) outside of the hospital setting--typically in a restaurant or coffee shop, but occasionally in their homes. Interviews were semi-structured and usually ran from one-and-a-half to two hours. From this group, I followed a slightly smaller sample through their follow-up care, which included surgery and/or multiple physical therapy sessions. During my year-long intensive fieldwork, I attended a local support group, as well as the first national conference on vulvar pain conditions, cohosted by the National Vulvodynia Association and the National Institutes of Health.

(5.) For comprehensive overviews, see especially Gloria Bachmann et al., "Vulvodynia: A State-of-the-Art Consensus on Definitions, Diagnosis and Management," The Journal of Reproductive Medicine 51, no. 6 (2006): 447-56; and Bernard Harlow and Elizabeth Stewart, "A Population-Based Assessment of Chronic Unexplained Vulvar Pain: Have We Underestimated the Prevalence of Vulvodynia," Journal of the American Medical Women's Association 58, no, 2 (2003); 82-88.

(6.) See the National Vulvodynia Association website, http://www.nva.org.

(7.) All of these words and phrases come directly from my (unpublished) field notes, including transcripts from clinic visits.

(8.) Oliver Sacks, An Anthropologist on Mars (New York: Vintage, 1995), 114-15.

(9.) Inga Muscio, Cunt: A Declaration of Independence (Seattle: Seal, 1998), 27.

(10.) "Renowned Hoo-Ha Doctor Wins Nobel Prize For Medical Advancements Down There," The Onion, March 30, 2009, http://www.theonion.com/ content/news/renowned_hoo_ha_doctor_wins_nobel.

(11.) Jo Gohmann, "The Vagina Dialogues," Bust, June 2009, 50.

(12.) Ibid., 53.

(13.) Ibid., 50.

(14.) Michel Foucault, The Birth of the Clinic (New York: Vintage, 1973), xiv.

(15.) Terri Kapsalis, Public Privates: Performing Gynecology from Both Ends of the Speculum (Durham, NC: Duke University Press, 1997), 63.

(16.) Jean Jackson, "Chronic Pain and the Tension Between the Body as Subject and Object," in Embodiment and Experience: The Existential Ground of Culture and Self, ed. Thomas Csordas (Cambridge, UK: Cambridge University Press, 1994), 201-27.

(17.) Elizabeth Wilson, Psychosomatic: Feminism and the Neurological Body (Durham, NC: Duke University Press, 2004), 22.

(18.) Ibid., 8.

(19.) This is my reference to Microsoft Word's spellcheck function and its treatment of the word "vulvar," which it underlines in red to mark it as a misspelling and gives as the first alternative spelling the word "vulgar."

(20.) Sigmund Freud, "Some Psychical Consequences of the Anatomical Distinction Between the Sexes," in his On Sexuality: Three Essays on the Theory of Sexuality and Other Works, vol. 7, The Pelican Freud Library, trans. James Stachey, ed. Angela Richards (Harmondsworth, UK: Penguin, 1977): 331-43.

(21.) Arnold Goldberg, review of Difference and Disavowal: The Trauma of Eros, by Alan Bass, Journal of the American Psychoanalytic Association 51, no. 2 (2003): 678-81.

(22.) Sigmund Freud, "Fetishism," in his On Sexuality: 351-57.

(23.) Ibid., 353.

(24.) Elizabeth Grosz, Volatile Bodies: Toward a Corporeal Feminism (Bloomington: Indiana University Press), 89.

(25.) Lisa Wade, Emily Kremer, and Jessica Brown, "The Incidental Orgasm: The Presence of Clitoral Knowledge and the Absence of Orgasm for Women," Women & Health 42, no. 1 (2005): 117.

(26.) Muscio, Cunt, 3.

(27.) Katrina Karkazis, Fixing Sex: Intersex, Medical Authority and Lived Experience (Durham, NC: Duke University Press, 2008).

(28.) Ibid., 100.

(29.) Ibid., 151.

(30.) Ibid, 11.

(31.) Karkazis, 2008. See especially chapters 4 and 5.

(32.) Natalie Angier, Woman: An Intimate Geography (New York: Anchor, 2000), 76.

(33.) Wade, Kremer, and Brown, "Incidental Orgasm," 117.

(34.) Angier, Woman, 78.

(35.) Luce Irigaray, This Sex Which Is Not One, trans. Catherine Porter (Ithaca: Cornell University Press, 1985), 159. Emphasis in original.

(36.) Simone Weil Davis, "Loose Lips Sink Ships," Feminist Studies 28, no. 1 (2002): 27; Virginia Braun, "In Search of (Better) Sexual Pleasure: Female Genital 'Cosmetic' Surgery," Sexualities 8, no. 4 (2005): 411; Gohmann, Vagina Dialogues: 50.

(37.) Robert Jensen, Getting Off: Pornography and the End of Masculinity (Boston: South End Press, 2007), 44.

(38.) Lynn Segal, Straight Sex: Rethinking the Politics of Pleasure (Berkeley: University of California Press, 1994), 156.

(39.) Luce Irigaray, The Speculum of the Other Woman, trans. Gillian C. Gill (Ithaca: Cornell University Press, 1985); and Irigaray, This Sex Which is Not One.

(40.) Luce Irigaray, Elemental Passions, trans. Joanne Collie and Judith Still (New York: Routledge, 1992), 60.

(41.) Ibid., 60-61. Emphasis in original.

(42.) Irigaray, The Speculum of the Other Woman, 230.

(43.) Christine Labuski, "Virginal Thresholds," in Luce Irigaray: Teaching, ed. Luce Irigaray and Mary Green (London: Continuum, 2008), 13-23.
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