Why The Vagina Bible instead of The Vagina and Vulva Bible? Because that is how we collectively talk about the lower reproductive tract (the vagina and vulva). Medically, the vagina is only the inside, but language evolves and words take on new meaning. For example, “catfish” and “text” both have additional meanings that I could never have imagined when I was growing up. “Gut” is from the Old English for the intestinal tract, usually meaning the lower part (from the stomach on down) but not always. It’s actually a very imprecise term; yet it has been embraced by the medical community and is even the name of a leading journal dedicated to the study of the alimentary (digestive) tract, the liver, biliary tree, and pancreas.
I have been in medicine for thirty-three years, and I’ve been a gynecologist for twenty-four of them. I’ve listened to a lot of women, and I know the questions they ask as well as the ones they want to ask but don’t quite know how.
The Vagina Bible is everything I want women to know about their vulvas and vaginas. It is my answer to every woman who has listened to me pass on information in the office or online and then wondered, “How did I not know this? ”
You can read the book in order from front to back or visit specific chapters or even sections as they speak to you. It’s all good! I hope over the years many pages will become worn as you go back to double-check what a doctor told you in the office, to research a product that makes wild claims about improving vaginas and vulvas, or help a friend or sexual partner out with an anatomy lesson.
Misinforming women about their bodies serves no one. And I’m here to help end it.
—Jen Gunter, MD
Getting Started
Image 1: The vulva. ILLUSTRATION BY LISA A. CLARK, MA, CMI.
CHAPTER 1
The Vulva
NO WOMAN HAS EVER BENEFITED by learning less about her body.
The vulva is the ultimate multitasker—it is the most important organ for sexual pleasure, it protects the tissues at the vaginal opening, it is built to handle the irritation of urine and feces, and it can deliver a baby and heal as if nothing happened. And do it all again.
Oh, yeah—and multiple orgasms.
The penis and scrotum have nothing on the vulva.
The problem? The vulva is often neglected. A lot of this vulvar neglect is a result of patriarchal society’s lack of investment in and fear of female sexual pleasure. When we exclude the vulva from conversations about women’s bodies and sexuality, we erase the organ responsible for female orgasm. We also make it harder for women to communicate with their health care providers.
The most important basic anatomic point of the lower genital tract: the vulva is the outside (where your clothes touch your skin) and the vagina is the inside. The transition zone between the vulva and vagina is called the vestibule.
The main structures of the vulva are as follows (refer to Image 1 on page 2):
• Mons
• Labia majora (outer lips)
• Labia minora (inner lips)
• The glans clitoris (the part of the clitoris that is visible)
• The clitoral hood
• The vestibule
• The opening of the urethra (the tube that drains the bladder)
• The perineum (the area between the vestibule and the anus)
We are also going to invite the anus to the vulva’s party, even though technically it is part of the gastrointestinal tract and not the reproductive tract. Many vulvar conditions affect the anus, and women often have a hard time getting help for anal concerns—doctors often hear “woman” and “down there” and deflect to the gynecologist. Some women are also interested in information about anal sex, and fecal incontinence can be a consequence of vaginal delivery.
The History of Clitoral Neglect
Going way back, medically speaking—as in Hippocrates (although there is a belief among many academics that Hippocrates wasn’t even a real person) —male physicians rarely performed pelvic exams on women or even dissected female cadavers, as it was considered inappropriate or insensitive for a man to touch a woman outside of a marital relationship. As there were no female physicians, everything first written about women’s bodies in ancient medical textbooks and taught to the first physicians was what women and midwives passed along to men, who in turn interpreted the information as they saw fit. So medicine has been steeped in man-splaining from the start.
Most ancient physicians, probably like many other males of the time, were unsure of the role of the clitoris and likely thought it unimportant. This stands in sharp contrast to the anatomic glory of the penis. In medicine, all body surfaces are assigned a front or back, which we call ventral (front) or dorsal (back). If you look at a person standing straight in a neutral position (arms at the side and palms facing forward), the face, chest, and palms of the hands are on the ventral side, and the back and the back of the hands are dorsal. This convention is applied differently to the penis, because of course it is. The neutral stance for a man, according to the anatomists of old, was a massive, skyward-pointing erection. Except, of course, men don’t walk around with constant erections, and so when you look at a man in what most people would consider the resting state—meaning a flaccid penis—the part that faces you is not the “front” of the penis but actually the dorsal or back surface, and the undersurface is the ventral.
It’s not really a small point; it is a wonderful (in a tragicomic kind of way) encapsulation of how society, including medicine, is obsessed with erections, while the clitoris barely registers as a footnote. The clitoris, when it was considered by ancient physicians at all, was believed to be the female version of the penis. But lesser. (I’m sorry, but the organ, capable of multiple orgasms, that only exists for pleasure is not lesser. It is the gold standard.) Clitoral neglect wasn’t confined to medicine. Think about all those ancient Greek statues with defined scrotum and penises (although the penises are on the small side because sexuality was apparently at odds with intellectual pursuits and so a big brain, not a big penis, was the ideal). The vulvas of the time were but mysterious mounds concealed by crossed legs.
Around 1000 A.D., Persian and Arab physicians began to take more interest in the clitoris, but given the constraints imposed on male physicians touching a naked woman or even a female cadaver, work was slow. By the end of the 17th century, descriptions of female anatomy, including the clitoris, were quite accurate, anatomically speaking. Some anatomists who made these advancements are memorialized in the names of the structures they accurately described—Gabriele Fallopio (fallopian tubes; also invented the first condom and studied it in a clinical trial!) and Caspar Bartholin (Bartholin’s glands).
By 1844, the anatomist Georg Ludwig Kobelt published such detailed work that his anatomic descriptions of the clitoris rival those we have today. However, his work was essentially ignored (as was almost everything that had led up to it), likely due to a combination of the expansion of Victorian beliefs (essentially the dangers of female sexuality) and Freud popularizing the false belief that the clitoris produced an “immature” orgasm.
For many years, discussing female sexuality in the doctor’s office was taboo, but that oppression is not a failing unique to medicine. In 1938, a Los Angeles teacher, Helen Hulick, was held in contempt of court for daring to show up in pants to testify as a witness and for refusing to change into a dress when the male judge insisted. She was given a five-day jail sentence. Much of women’s health, especially sexual health, was deemed unimportant or irrelevant because that is how women were viewed.
Physicians