Both as a Doctor and as a Sex Ed Facilitator, I get asked questions about sex a lot. Sometimes this is in spaces that are designed for that, such as a in classroom sessions. Sometimes it’s a furtive WhatsApp query from a friend or someone ‘@ing’ me. Today I’m starting a collection of some responses to some of the interesting ones.
This one ‘comes up’ in that it’s one we tend to pose to explore assumptions children and sometimes adults have…
There are a wealth of products designed specifically for genitals. Some for aesthetics, some for convenience, some for hygiene, some for pleasure. It’s certainly true that there needs to be less stigma around products to help with basic bodily functions and/or sexual pleasure. Take the stigma surrounding period products for example – literally decades of advertising aimed at showing us how unacceptable and dirty periods are. However, not all products are equal. Some things that are sold to help your genitals are unnecessary or problematic. Here are four of (what I think are) the worst!
Femfresh is a range of products for ‘feminine hygiene’ – e.g. washes and scented wipes. The vagina is self cleaning and the only thing you need to use to keep a vulva clean is warm water and unscented soap. However Femfresh and its ilk push an agenda that they are vital, with their vagina friendly pH balance giving them the edge over soap (which is the same for water, which is free and comes out of the tap). The Femfresh website promotes the products using a smiling face of a gynaecologist, ‘Dr Sara’, with a list of advice on how to ‘care for down there’. Much like the period adverts, euphemisms abound – the implication being that your vulva is smelly and dirty and only buying this type of product can fix that. The branding is phenomenally successful. As a facilitator for Sex Ed classes to young people, I am often asked about this product, by name. It can be quite difficult to assert that it is unnecessary and a person’s genitals are completely normal and healthy in the face of such advertising and branding.
Like Femfresh, but super-charged! Vaginal douches are devices and products that ‘flush out’ the vagina – unfortunately taking all of the natural bugs and secretions that keep the vagina health with them. Just say no!
This is definitely one from the ‘road to hell is paved with good intentions’ department. Sold with the tagline ‘consent is the most important thing in sex’, this is a condom that requires two people (or at least four hands working together) to open the packet. It received quite a backlash when it came out. People were quick to point out that flaws – such as rapists not necessarily caring about using condoms, or having the ability to work in pairs. The consent condom also implicitly buys in to the idea of consent as a single moment of ‘yes’/ ‘no’. Consent should be reversible and always up for discussion. Even if you’re in a long term relationship and sex is something you do regularly. Even if you said ‘yes’ at first and then changed your mind. Even if you helped someone open a condom packet holding two of the four pressure points.
This is underwear marketed as only being able to be removed by the wearer. It is reinforced to prevent cutting and tearing off by an attacker. Originally designed and crowdfunded by a victim of sexual assault, this is probably again something made and marketed with noble intentions in mind as well as profit margins. Given the state of the world, fear of sexual assault is very understandable. However, I just don’t want to live in a society we focus our efforts on designing things to make people less rapeable. We need social and structural change, not ‘rape-proof’ clothing. Additionally, anti-rape wear reinforces the idea that sexual attacks are committed by strangers when a person is out and about in the world. In fact, most victims of sexual assault know their attacker – be it a family member, friend or partner. It is hard to see how anti-rape wear will be of much use unless it is worn at all times and in all places – except for those brief moments when you need to either pee or have penetrative sex with someone and definitely won’t change your mind at any point (which we’ve already established you have a complete right to do).
These are my four. Tweet me if you think of any more or disagree – @squisquasque…
The clitoris used to be represented and thought of as a small ‘pea’ like structure, sitting above the urethra (Enright, 2019). It wasn’t until relatively recently when Professor Helen O’Connell fully investigated and modelled the full extent of the clitoris in 1998 (Fyfe, 2018). O’Connell is a Urologist (a type of doctor, who specialises in surgery in areas of the body including the bladder and urethra). She used cadavers to map fully map out the clitoris, demonstrating that it was a much bigger structure. Like this:
It includes structures that are hidden deep to other tissue, such as the corpus cavernosum and the bulbs of the clitoris. As you can see from the diagram the bulbs of the clitoris are very close to the vagina – even more so when a person is aroused, as they become swollen and more erect by blood being diverted to them, just as the penis does (Drake et al. 2010).
There is an excellent and short French cartoon about the structure, function and history of ‘Le Clitoris’- the only organ that is just for pleasure – here.
Drake, R. L., Vogl, A. W. & Mitchell, A. W. M. (2010) Gray’s Anatomy for Students. Second Edition. Canada: Churchill Livingstone Elsevier.
Enright, L. (2019) Vagina a Re-Education. Croydon: Allen & Unwin.
Fyfe, M. (October 2018) Get Clitorate: how a Melbourne doctor is redefining sexuality. The Sunday Morning Herald. Accessed online on 21.03.2019 at [https://www.smh.com.au/lifestyle/health-and-wellness/get-cliterate-how-a-melbourne-doctor-is-redefining-female-sexuality-20181203-p50jvv.html}
‘Labia Minora’ is latin for ‘smaller lips’. It’s the word used to describe the flaps of tissue that sit inside the larger labia majora (‘large lips’) and surround the innermost structures of the vulva – like the clitoris and the vagina.
Exactly what an individual’s labia minora look like in terms of shape and size vary hugely. Some have fairly minimal tissue, which doesn’t tend to be visible unless the labia majora are spread (i.e. legs akimbo!). Some people have much larger amounts of tissue. When people talk about having cosmetic surgery to the vulva, they often call it a ‘designer vagina’. However, it is surgery to the labia minora (a ‘labiaplasty’ or ‘vulval surgery’) that they are in fact referring to, not surgery to the vagina itself. Some people feel that this type of surgery is almost always unnecessary and related to unfounded fears that people have about larger labia minoras being ‘abnormal’.
The information here is adapted from an exercise from Sexplain UK, used as part of their SRE lessons. In short, it involves using play dough to build genitals. This exercise can be used to teach people about external genitalia (both penises and vulvas). As an arts and crafts activity, it can be fun and engaging and help to give something concrete to talk around in terms of things like physiology, variation and health. I have also included the recipe I use for homemade play dough.
To make your dough.
2 cups plain flour
1 cup of salt
2 teaspoons cream of tartar
1 tablespoon of vegetable oil
2 cups of boiling water
Something to colour the dough with (optional) such as food dye, paint powder, or a crushed soft pastel
Put all of the ingredients except for the water and colouring in to a large mixing bowl. Boil water and add this to the mix whilst still very hot. Mix immediately using a wooden spoon. Once the mixture is cool enough to handle, put some flour on a surface and lightly knead the mixture for a short time. If you are adding colouring, now knead this in until the dough is roughly all the same shade throughout.
Make sure the dough is left uncovered until it is cool, then cover in an airtight container. It should last for about a week. This recipe makes enough for about twelve people if doing the exercise below.
So, all foetuses have the same general genital structures, regardless of what sex they will become. They then typically (but not always) differentiate in to either a penis or vulva. These are the external genitalia (i.e. the bits you can see).
We’ll look at vulva first, as this is the one people tend to find a bit trickier.
Take your ball of play dough and divide it in to four pieces. With one of these quarters, make a left or diamond shape:
This is the vestibule of the vulva.
Next, take another quarter and roll it in to a sausage shape, about the length of one side of the vestibule and attach it to one side:
This is the labia majora, the fatty tissue that covers the whole vulva and tends to be covered in hair after puberty. Complete it by making another sausage to attach to the other side:
Next, divide the last quarter in to two. With one piece, make a smaller sausage to attach inside one side of the labia majora. This can be flattened if you like:
This is the labia minora. In about half of people with vulvas, the ‘inner lips’ of the labia minora sit outside of the bigger ‘outer lips’ of the labia majora. Let’s complete these. As with the labia majora, it’s not a problem if they aren’t exactly symmetrical:
Next, let’s make a very important structure: the clitoris. Either take a little ball of extra dough, or pinch a piece off from your existing structure:
The bit we can see here only represents the external part – it extends to be a much bigger structure internally. The clitoris is made of very sensitive tissue, with lots of nerve fibres. Some people find it arousing or stimulating when touched gently.
To complete, let’s make the ‘holes’ in the vulva. Get people to guess how many ‘holes’ the vulva contains (guesses I’ve heard range from one to twenty!). For this model, we’ll be looking at two (you can explain that some people talk about a third, the anus, which is actually outside/below the vulva). The first is about a third of the way down and can be marked with a finger or a pencil:
Get students to guess its name – the urethra, and it’s function – carries urine away from the body. It is separate from the next hole we’re going to make. This hole is nearer the bottom of the vestibule and can be marked by making a hole all the way through:
Again, you can get people to guess the name (vagina) and point out that this is the name people often use (incorrectly) to refer to the vulva. You can talk about things that come out of the vagina – i.e. blood (periods), babies and discharge (either healthy or a sign of otherwise, such as thrush or bacteria).
Next, we’ll make a model of a penis.
This time, divide the dough in to two pieces. With the first piece, make a sausage shape:
This represents the shaft of the penis. We can then make a little distinct area by marking out the end:
This is the glands of the penis, which tends to be more sensitive than the shaft. Next we can make a hole in the end (with a pencil or finger). This is the urethra or the penis. Three things can come out of this – urine, ejaculation or discharge.
Give people the option of making a foreskin – pinch off a little bit of dough and fashion in to a thin rectangle to cover the glans. This is a good point to talk about hygiene – e.g. washing with water and changes during puberty, as well as circumcision.
Next, we’ll finish off with making the testicles (scrotum). There is a good chance that students will already have made them with the other half of the dough by making two balls and attaching these to the base of the penis:
This is fine and validate this. Also explain that you can make them from a ‘teardrop’ shape and attach that. You can talk about the misconception that ‘balls drop’ (i.e. they get bigger and hang lower after puberty, but don’t actually ‘drop’ further out of the body).
It can be a nice idea to get the students to look at and reflect on how different all of the bits are. Lots of them seem to ask what ‘normal’ is – this can be a good place to point out that this is something that is highly individual.
We often talk (briefly) about the concept of it being possible to be biologically ‘intersex’ – i.e. it is possible to have someone who doesn’t have external genitalia that fall neatly in to either of these categories.
It can also lead on nicely to talking about internal genitalia and reproductive functions.
I joined the lovely voluntary organisation Sexplain (‘Bringing sexual and relationship education into the 21st Century’) as a volunteer facilitator based on two things. The first was an array of terrible personal experiences of Sex Ed over two decades ago during my time at school. The second was professional surprise at how little people (particularly those with vulvas!) appeared to know about the intimate parts of their own bodies when I started working on a Gynaecology ward.
One of the things that I found a little unrelenting about my own school SRE learning experiences was how much the emphasis around sex was ‘not getting pregnant’. It’s all very well to encourage and teach healthy sexual practices. However, I feel the message went beyond this. In my classroom, romantic intimacy amounted to sex and sex meant penetrative, penis-in-vagina sex only. Pleasure, consent and masturbation were not on the curriculum. Sex was problematic, dangerous, risky – never ‘fun’ or ‘fulfilling’. The ultimate hazard was pregnancy and STIs. Nothing good could come out of sex but if for some reason you found yourself having it, the ultimate consideration was to NOT GET PREGNANT.
It turns out that this world view prepared us badly for adult reality. We learnt how effective a condom was versus a diaphragm, but not how to procure or negotiate the use of either. We learnt that STIs cause discharge from orifices that we had only a crude understanding of.
Another classroom illusion that was challenged, by both my personal life and professional experience, was that there is a ‘perfect’ choice of contraception for each person. For many, contraception can be a compromise, a ‘best match’, or a pragmatic move. It can take in to account what you feel able to negotiate with a sexual partner. Or what you can afford or have the time and resources to obtain. Or choosing something you feel is a bit shoddy, but doesn’t leave you with the terrible side-effects of some methods.
I created ‘contraception top trumps’ because I wanted to look at contraception not as a set of absolutely rational, clear-cut decisions (you fulfil criteria x so you should use y) but as a work in progress. You can learn about and develop an approach to contraception, depending on what is important to you… and unfortunately there’s an element of luck to the whole thing.
I’ve published a printable pdf of contraception top trumps – I would advise printing four pages to an A4 sheet for large print cards and eight for more portable ones!
The link above is for a smartened up and downloadable version of the top trumps game I published earlier this year here on this blog. One of the lovely things about doing this was the interesting and open conversations this prompted with friends. For example -the one person who confessed she’d had a blazing row with her GP about removing the hormonal implant because she couldn’t cope with the emotional changes that came once it was fitted and had been told simply to ‘persevere’. Or the friend informed that they couldn’t have the copper coil fitted because ‘she hadn’t had children’. Or the disbelieving faces that meet you when you look at failure rates of condoms, many peoples’ go-to! Please download, play, share and learn these with whoever you can and start your own conversations.
My estimate of 20% effectiveness from ‘a wing and a prayer’ was based on a statistic I saw that said 80% of couples having sex regularly would conceive within one year. So it’s probably a bit low for one single instance of sex. However, I can’t for the life of me find that and the current online NHS advice on infertility suggests that 84% of such couples would conceive within a year, suggesting a figure of 16%. Either way, it’s not a great method and is incredibly less reliable than actively doing something. I just wanted to show that it was not guaranteed that you would get pregnant every time you had sex, even once, which is definitely the impression that I got from Miss Hargreaves in Year 9…
The inspiration for this one came from a pub conversation. It’s time for…
The hymen is a often described as a ‘membrane’. It is membranous tissue, but this can lead to some confusion-
This is called an ‘imperforate hymen’. The main reason it needs treatment (i.e. surgical removal) is that it means that menstral blood cannot drain during a period.
So, as with many aspects of genitals, individuals can be VERY different and this is completely normal.
References (a note):
When I have an idea for something, I usually start by looking at some standard Gynae textbooks and then try to find reliable looking online sources (e.g. NHS, clinical guidelines). They failed me somewhat on this topic. I’ve found a teeny tiny amount of information from my textbooks (mainly on imperforate hymen). This is basically a way of explaining why my main source is a wiki page (here)!
A friend of a friend reckons reports that as a child they were told that babies were made by ‘mummy and daddy having a very special hug’. Subsequently they were terrified every time their grandparents tried to hug them, convinced that this would leave them impregnated!