Vaginal infection is a major reason that women visit the gynecology office (Brown, Hess, Brown, Murphy, Waldman, & Hezareh 2013; Overman 1993). I knew that going into midwifery. But my god, I never thought I would see so many sad vaginas every clinic day. My patients have a lot of vaginal infections. I spend a lot of time with patients talking about why for optimum vaginal health, less is more. Many have heard before that they “shouldn’t” douche, from other healthcare providers — but even among those patients for whom this is not a new idea, they continue intravaginal practices and don’t necessarily know why they shouldn’t.
This raises two issues for me as a nurse midwife and a feminist — the social roots of intravaginal hygiene practices (IVHP) and how providers educate –or don’t- — their patients about their own health.
Why do women douche?
Many women tell me they feel they need to get clean after menses. They don’t like the residual menses they feel might be hanging around when the bleeding stops, and in particular they worry about the smell. They also think it will help them prevent infections. Commonly, my patients douche because their mothers, sisters, and grandmothers had and taught them these practices. But as one patient asked me this week, “why would they sell all that stuff if it’s so bad for you?” Good question.
And since Summers Eve re-vamped and expanded their product line beyond simple douche products to an impressive array of “yoni” personal products, these commodities are hipper and more attractive to consumers than they have been in a long time.
In a small (141 participants) prospective cohort study of sexually active women 18-65 years old in Los Angeles, researchers found that 66% reported IVHP, 49% of whom admitted using an intravaginal product (other than tampons) and 45% of whom reported intravaginal washing (Brown et. al 2013). This washing could include vinegar, water, soap and water, or commercially available products (Brown et. al 2013). One 2004 pharmacy journal reports that the reasons for these IVHP vary according to geography, racial background, age group, and rates of sexual activity (Pray & Pray 2004). According to Pray and Pray, African American women inherit IVHP from their mothers, while white women learn these habits more from advertising.
There is nothing wrong with your vagina
Wherever women get the specific idea that they need to use special products and habits to keep the vagina clean, smelling like roses (or lilies or citrus or island splash!), no one who lives in a wretchedly sexist society should be surprised that any woman would get the general idea that there is something wrong with how her normal healthy vagina smells, tastes, etc. But if women in modern capitalism can’t be trusted to decide if, when, and under what circumstances she gets pregnant, labors/births babies, and parents — wherein, for instance abortion is expensive, unavailable, often provided under non-compassionate conditions, and women are shamed for considering or choosing abortion (and even using birth control, these days!) — why could they be trusted to take care of their own vagina they way nature made it?
As a matter of fact, the vagina has its own beautiful environment that does all the work you think a douche might do for you — keeping your vagina clean — all on its own, when you are healthy. The vagina likes to be nice and acidic, which is made possible by a wide variety of anaerobic and aerobic gena and species (Overman 1993). Acid-producing bacteria like Lactobacillus keep in check the more basic bacteria that cause the common infection bacterial vaginosis (Overman 1993).
When you douche, you are likely to wipe or wash away the “good” bacteria, leaving lots of room for the “bad” bacteria to take over, causing you bacterial vaginosis (BV). Studies have not shown a direct correlation between douching and BV — for instance, infrequent douching may not directly cause BV (Brown et. al 2013). Overall, however, douching may increase a woman’s risk of contracting a sexually transmitted infection, or HIV if she is exposed to those pathogens, developing pelvic inflammatory disease, or be associated with preterm labor and birth when performed during the second and third trimester of pregnancy (Brown et. al 2013; Pray & Pray 2004).
Then there are all the products designed to make the vagina smell like something it’s not. All the deodorants, sprays, wipes, external washes, creams, and powders designed for vulvar application may place you at risk for yeast infections or irritation, but even if they don’t, their very existence and success on the market contributes to the cultural perception that there is something wrong with your vagina in its natural state. And it makes individual women feel bad about their bodies in a very particular way. As this wonderful columnist for Essence wrote: “There is nothing wrong with the totally natural, completely unaltered smell of your va-jay-jay in its normal state. (Our “down under” isn’t supposed to smell like summer linen, fruits, or fresh mint)” (Lucas, D. L. 2011).
Well, society doesn’t really value anything “natural” about women except for our bodies’ ability to 1. sexually excite men and 2. bear and mother children. So, we are meant to buy cosmetics, sexy clothes, enjoy pole dancing for exercise, be ok with making less money than our male counterparts, do more housework, assume primary responsibility for childcare, etc.
So if we do everything else to bend to society’s desires for who we are as women, why shouldn’t our vaginas be part of that package? As the “EVEangelist” over at Summer’s Eve reminds us, ”It’s time for a shower inventory. If you’ve got a cleanser for everything but your vaginal area, it’s time to make room for our pH-balanced Cleansing Wash.” Products for everything! You are not good enough as you are!
(As an aside, a simple, non-scented soap to cleanse the vulva should do the trick! Avoid body washes and avoid washing in the vagina itself.)
Don’t get me started about the pseudoscience and fake pro-vagina crap over at that website…Barf.
…Until there is
Not all vaginas are going to be happy all the time. And vaginal health isn’t just about products you do or don’t put in them or any sexual pleasure/stimulation a vagina might be party to. Vaginas are part of the female body, which may have lots of experiences that can enhance or hurt vaginal healthy: like diet, exercise, sexual consent, history of abuse or assault, body size, and emotional stress.
But none of those things can be rapidly fixed with an over-the-counter product that makes claims that it will fix up your vagina, unless it is medicine designed to treat a real infection, like intravaginal treatment for yeast infections. And I am all for trying things yourself, DIY, and taking care of yourself using health knowledge grounded in non-commercially biased information like that which is found in, say, Our Bodies, Ourselves and Guide to Getting It On. But douching and using these so-called yoni products that are making some CEOs rich over at Hate Your Vagina, Inc. isn’t gonna help.
Where the provider comes in
I’m glad when patients come into the clinic for evaluation of vaginal discharge because it allows for patient education. I like talking to patients about the difference between healthy and abnormal vaginal discharge, and what a healthy vagina might look/smell like, versus what could put it at risk for infection.
And that’s why I’m glad I’m a midwife (do I say that in every post?). Midwifery is about meeting women where they’re at, and working with them to achieve desired health outcome. Women really are the best expert in their own body/experience, and I am just there to facilitate her reaching her optimum health. When women tell me anything about their health habits that I may think is unhealthy or possibly harmful, my first question is “tell me more about that.” If you want to help a patient/client change a health habit, you need to know what motivates her to either continue or change. This is what we do for smoking cessation, nutrition or exercise promotion, and especially for sexual health risk reduction.
This gets back to my initial observation that many patients know they “shouldn’t” douche (or do lots of other health behaviors deemed unsafe/unhealthy, but I digress), but most don’t know why. When I explain to a woman how wonderful her vagina is and how douching disturbs that beautiful environment, she is more likely to understand her own anatomy and how to promote her own health. My hope is that instilling pro-vagina sentiment can also clear the way for greater acceptance of vaginal delivery of medication and contraception and to an increased motivation to use condoms/protect the goods from more dangerous infections and disease. We shall see.
Really sad vaginas
A much riskier health habit than douching, though douching may compound the risk, is practicing unprotected sex with someone whose infection status you don’t know, or having multiple sexual partners, having a partner who has multiple partners, anonymous sex or sex when high or drunk. (You can look forward to my forthcoming Condoms, Part II post for more on that.)
Actually sad vaginas have infections like trichomonas, chlamydia, gonorrhea, herpes, warts, and syphilis. Many of these have no symptoms or barely noticeable symptoms, but none of those can be treated with douching, and all of them require diagnosis and treatment in clinic. And someone who gets one of those infections is at higher risk for sexual transmission of HIV and hepatitis.
I guess a part of me understands that when my patients who are at risk for STIs douche, they may be trying to cleanse themselves of STI risk. (Fortunately, the old myth that douching can prevent pregnancy is much less prevalent these days.) And even here, I can find a good instinct. Douching may not get the desired results (a healthier, happier vagina), but it is a health habit, and I think providers need to recognize that patients do want to be healthy.
Toward a world with happier vaginas
I don’t blame individual women for buying into the crap that the vaginal hygiene industry sells them, any more than I blame women for using makeup, enjoying fashion, partaking in gossip and petty shit among women, or being in abusive relationships, for instance. These are all symptoms of a sexist society, and individual women who make these “choices” are operating in a false set of choices we are allowed to make in capitalism. Sexual liberation (or for the sake of this post, happier vaginas belonging to happier female bodied people) is about a lot more than lack of vaginal infection/STIs, but I do think that would be a good start.
Health care providers–not just midwives–can play a role in that by promoting and practicing in line with Dr. George Tiller’s call to trust women. We need to stop blaming women when they make “poor” choices about their health in a society full of so much sexism, racism, and class inequality. And we can take part in every social movement that confronts sexism, misogyny, and inequality, because health isn’t just about what happens in the exam room — it is determined by the world we live in, and we have to fight for a world that values women and allows for people to make the best possible real choices about our lives and our health.
Brown, J. M., Hess, K. L., Brown, S., Murphy, C., Waldman, A. L. & Hezareh, M. (April 2013). Intravaginal practices & risk of bacterial vaginosis & candidiasis infection among of cohort of women in the United States. Obstetrics & Gynecology 121(4), 773-780. doi: 10.1097/AOG.0b013e31828786f8
Lucas, D. L. (July 21, 2011). Real talk: feminine care 101. Essence. Retrieved 04/14/2014 http://www.essence.com/2011/07/20/real-talk-feminine-care-101/
Overman, B. A. (May-June 1993). The vaginal as an ecologic system. Journal of Midwifery & Women’s Health 38(3), 146-151. doi : 10.1016/0091-2182(93)90038-I
Pray, W. S., & Pray, J. J. (2004). Douching: perceived benefits but real hazards. US Pharmacist 29(1). http://www.medscape.com/viewarticle/490338