CAROLINE MOORE
Dear Dr. Miguel Cardona,
RE: Neglect of vaginal health in US health education
I am writing as someone who was educated in the US through high school and was fortunate enough to be given a fairly comprehensive health education. However, for many Americans, this is not the case. My courses in Medical Anthropology at the University College London have taught me to critically assess why some issues are not discussed and who is most impacted by the damage silence can do. Therefore, I wish for you, as the US Secretary of Education, to consider: why is vaginal health education not required across the US, and what can anthropology do for health education?
I believe teaching about vaginal health should not be a taboo topic, especially in health classes. Vaginal health should be treated and taught the same as correct dental care. However, a majority of the time, discussions about vaginal health are grouped with those about sexual health (SH), or disregarded. Because of this, I will be discussing SH education in the US as that is the category vaginal health seems to fall into.
There are currently no federal laws requiring SH education in the US. The decision for what should be taught is typically left to the state and local levels. Because of this, only 39 states (and DC) require HIV and/or some form of SH education. Of those states, less than half of them require the education to be medically accurate with more states stressing abstinence-only programs over medical accuracy (Planned Parenthood 2019). Fewer than half the schools in the US are failing to teach SH topics that the CDC deems essential for everyone (Centers for Disease Control and Prevention 2020). You should be very concerned by this because misinformation, or lack of information, can be incredibly damaging.
A prime and current example of why misinformation or lack of education is harmful is vaginal douching. Douching is a practice thought to cleanse the vagina that people have engaged in since ancient times (Merchant, Oh, and Klerman 1999). Studies have found that vaginal douching disrupts the natural vaginal flora and is linked to the risk of bacterial vaginosis, pelvic inflammatory disease, increased susceptibility to sexually transmitted infections, cervical carcinoma, reduced fertility, and ectopic pregnancy (Grimley et al. 2005; Martino, Youngpairoj, and Vermund 2004; OH et al. 2003). Despite these findings, 28% of reproductive-aged women in the US douche (Merchant, Oh, and Klerman 1999). Studies have also found that 15% of adolescent girls, 15-19 years old, douche and that 56% of those girls do so regularly, showing that douching at a young age is connected to frequent douching throughout one’s life (Martino, Youngpairoj, and Vermund 2004; OH et al. 2003).
Based on these findings, a question we should be asking ourselves is, if there are so many adverse effects to douching, why do so many women and young girls do it? And why is no one teaching them about vaginal health and the harmful effects of douching in the first place? In answer to these questions, ethnographic studies of women’s clinics have found that the most cited reasons women gave for douching were to ‘feel good’ and ‘remove vaginal odour’ (Oh et al. 2003). Additionally, misinformation around the practice of vaginal douching has increased the frequency of douching pre and post-sexual intercourse as a means of preventing pregnancy, and after menstruation in an effort to cleanse the vagina. In the US, commercial products are used more frequently than home remedies by women who douche (Martino, Youngpairoj, and Vermund 2004). Advertisements for douching products talk about being ‘fresh’ and ‘clean’, further emphasising the belief and stigmatisation that vaginas are unclean. With 96% of women reportedly having seen TV commercials for douching products (Oh et al. 2003), and women’s willingness to engage in douching, it can be argued that the stigmatisation of discussions of menstruation and vaginal health is contributing to the pressure women feel to douche and the adverse health consequences they experience. Women have historically been taught that their genitals are shameful which has only enhanced the stigma and reinforced unwillingness to discuss vaginal health (Kaufman and Kimmel 2011). It has been shown that women who are encouraged to quit douching by a healthcare professional are more likely to stop douching and have better vaginal health, which goes to show the benefits and importance of medically accurate education (Grimley et al. 2005). However, because of the lack of accurate and accessible information, many women and girls turn to their friends as ‘informal educators’. Muraleetharan and Brault’s (2021) ethnography of a US university demonstrates how friends who are informed about health and resources and are able to comfortably discuss them hold social capital and are assets for their peers. Because of the stigma surrounding conversations about vaginal health, many young women feel that they can only be vulnerable about concerns with close friends. And while peers can be a great resource, problematic norms, misinformation, or peer pressure increase risk (Muraleetharan and Brault 2021).
Part of what the CDC states as being good SH education is that it should teach students to critically “analyze family, peer, and media influences”, allowing them to make their own informed decisions about their health (Centers for Disease Control and Prevention 2020). Teaching adolescents in school about vaginal health would help diminish the stigmatisation that stops women from talking about their health, and would create informed women able to critically analyse misinformation and influence. Anthropology would be beneficial for understanding how to shape curriculums, as well as analysing how a lack of policy around health education can be impactful. Muraleetharan and Brault’s (2021) ethnographic research found that understanding the broader social relationships of young people at college was important to understand the sexual health risks most likely to affect them. Similar research across age groups could be helpful in understanding the pressures and collective misconceptions that underpin poor vaginal health and douching practices. This is further expressed by the emphasis placed on social relationships, such as family and peers, shaping an individual’s acceptance or resistance to seeking medical treatment (Muraleetharan and Brault 2021).
While influence from family and peers is important to understanding an individual’s relationship with health, educators are another key factor. Landi (2017), through survey, interview, and participant observation, found that assumptions made by educators about their pupils’ own attitudes and assumptions regarding health based on cultural and religious backgrounds had a large impact on teaching. Teaching was often found to be made reductive when educators factored in ethnicity and religion (Landi 2017). Effects such as these have the potential to minimise the complexity and quality of the education students are given. Assumptions such as boys and men not needing to understand female anatomy and health, while almost everyone is expected to understand male anatomy and health are dangerous, with a majority of women also not being able to name parts of their own vulva (Kaufman and Kimmel 2011).
Anthropology can help us in discovering and understanding these complex social and cultural relationships connected to the education of SH and vaginal health because of its use of mixed methods (Landi 2017). Public health uses epidemiology, making it incredibly helpful for assessing inter populations. Anthropology is generally done at a smaller scale with research tending to take more time. However, anthropology when applied is able to incorporate both quantitative and qualitative methods and work within interdisciplinary teams (Landi 2017). Anthropology also takes a people-centred approach to who it researches with, such as teachers, school officials, families, and students in cases pertaining to health education (Landi 2017). Because of this, mixed methods anthropology, as seen in the ethnographic examples above, can help us to understand the broader picture of what is affecting educational policy, inform educational approaches around vaginal health, and the stigmatisation that leads such a large percentage of women to engage in harmful health practices.
Lack of education and stigmatisation are driving factors for continued inadequate understanding of vaginal health. Stigmatisation is fought through education. That is why you, as the US Secretary of Education, should push for vaginal health education across the US for a healthier and more informed population through the use of anthropology.
Kind regards,
Caroline Moore
Bibliography
Centers for Disease Control and Prevention. 2020. “What Works: Sexual Health Education.” CDC. February 3, 2020. https://www.cdc.gov/healthyyouth/whatworks/what-works-sexual-health-education.htm.
GRIMLEY, DIANE M., M. KIM OH, RENEÉ A. DESMOND, EDWARD W. HOOK, and STEN H. VERMUND. 2005. “An Intervention to Reduce Vaginal Douching among Adolescent and Young Adult Women: A Randomized, Controlled Trial.” Sexually Transmitted Diseases 32 (12): 752–58. https://www.jstor.org/stable/44966761.
Kaufman, Michael, and Michael Kimmel. 2011. The Guy’s Guide to Feminism. Berkeley Seal Press.
Landi, Nicoletta. 2017. “‘Pleasure Is Not in the Science Programme!’: When Anthropology Engages with Sex Education for Teenagers.” Anthropology Matters 17 (1). https://doi.org/10.22582/am.v17i1.479.
Martino, Jenny L., Surasak Youngpairoj, and Sten H. Vermund. 2004. “Vaginal Douching: Personal Practices and Public Policies.” Journal of Women’s Health 13 (9): 1048–65. https://doi.org/10.1089/jwh.2004.13.1048.
Merchant, Jeanne S., M. Kim Oh, and Lorraine V. Klerman. 1999. “Douching.” Archives of Pediatrics & Adolescent Medicine 153 (8): 834. https://doi.org/10.1001/archpedi.153.8.834.
Muraleetharan, Veena, and Marie A. Brault. 2021. “Friends as Informal Educators: The Role of Peer Relationships in Promotion of Sexual Health Services among College Students.” International Quarterly of Community Health Education, July, 0272684X2110346. https://doi.org/10.1177/0272684×211034661.
OH, M. KIM, ELLEN FUNKHOUSER, TINA SIMPSON, PERNELL BROWN, and JEANNE MERCHANT. 2003. “Early Onset of Vaginal Douching Is Associated with False Beliefs and High-Risk Behavior.” Sexually Transmitted Diseases 30 (9): 689–93. https://www.jstor.org/stable/44966123.
Planned Parenthood. 2019. “Planned Parenthood Action Fund.” Plannedparenthoodaction.org. 2019. https://www.plannedparenthoodaction.org/issues/sex-education/sex-education-laws-and-state-attacks.
Image source: https://pixabay.com/photos/read-training-education-well-read-3048651/