Ever heard the term ‘designer vagina’? This generally refers to a certain type of cosmetic surgery, not to the vagina itself but to the ‘inner lips’ (or labia minora) of the vulva. Surgery here involves removing tissue from and reshaping the appearance of the labia minora- in other words to ‘trim’ it. Many people with vulvas have a labia minora that protrudes so that it appears visible – therefore however large this is it is likely to be ‘normal’. Additionally, in young people biological changes occur during puberty that can change the appearance of the inner labia. For this reason it is often recommended by the NHS that those under 18 do not get this type of surgery. However, there seem to cases of children having labiaplasties. According to one report over 200 people received labiaplasty procedures funded by the NHS in 2015-2016. We know that people with visible labia are more likely to think that their genitals look ‘abnormal’ than those without, even though both are equally common (Lykkebo et al, 2017). Some accounts have blamed this on the prevalence of seeing only vulva with neat and invisible labia minora. Whatever the cause, the desire to have this type of surgery seems increasingly common with a 45% rise seen in labiaplasty numbers worldwide between 2015 and 2016.
Rounding off the year, let’s have a look at penises! We (the societal ‘we’) tend to be a bit more familiar with the constituent parts than we are with vulvas…
Glans: This is the tip or ‘head’ of the penis.
Foreskin: This is a fold of skin that covers the glans of the penis. It can be removed, either at birth or later in life, for either medical or cultural reasons in a process called circumcision. Rates of this practice vary across the world and it isn’t as common in the UK as in other parts of the world.
Urethra: The opening of the penis. Semen, urine and discharge can leave the body here. As with discharge from the vagina, this can be normal. Changes in the discharge (e.g. smell or colour), especially when accompanied by other symptoms (pain, itchiness) can however indicate something’s not quite right and might need checking out.
Shaft: This is the main bit of the penis. Internally are found the tubes that carry urine and semen out of the body, as well as blood vessels supplying the penis – this is part of the mechanism that causes the penis to become hard and bigger during an erection.
The average penis size is 9 cm when not erect, although there is a fairly large and health variation in this.
Thrush is one of the causes of unusual vaginal discharge. Usually not ‘offensive’ smelling, it is often described as ‘cottage cheese’ – it has that kind of lumpy and white quality. Or like the chest of the bird thrush, which is speckled and light compared to the rest of its body!
Unlike other causes of abnormal discharge, it is not a sexually transmitted infection. STIs are spread from person to person, through direct contact such as skin-to-skin or bodily fluids (saliva, mucous, semen, blood, etc). Thrush however, is an overgrowth of a type of fungal yeast (candida albicans) that ordinarily lives in other parts of the body, without causing an infection.
As well as the discharge, it is usually accompanied by an itching feeling. Thrush proliferates in damp parts of the body. As well as being able to cause infection in the vagina, in can therefore cultivate under the foreskin of the penis, or in skin folds around the rest of the body.
Vaginal thrush is treated with a cream, a pessary (i.e. a ‘tablet’ that comes with a device to be put straight in to the vagina), an oral tablet or combinations of these. In the UK, this treatment is available ‘over the counter’ – you can go to a pharmacy and get it without a prescription. However, it’s a good idea to go to your GP if it’s the first time you’ve had thrush. They can then check that this is what it is. It’s important to get further medical help if you’ve had regular infections or tried the treatment before and it isn’t working. You may also need to see your doctor if you have other medical complications as well.
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…
My weakest area at med school was definitely anatomy. I enjoyed it though. Each week, we would go to the anatomy suite where the cadavers were kept and I would learn another thing I was previously mistaken about. The relationship between what we see and understand on the outside and what and where it is on the inside is often not straightforward.
The stomach, for example, is not the low down bit of the abdomen people hold when they have ‘bellyache’ – that’s more like bowels. This is part of the gut, but with has a distinct and different function. What a lot of people think of as the ‘vagina’ (the passage from the external body to the womb) would actually be better described as the ‘vulva’. In my experience, these misconceptions are rife in ideas about our reproductive organs. Let’s have a look at some of the internal xx anatomy…
Vagina: a passage leading from the outside to internal parts. It’s made up of muscular, stretchy tissue that can deform and accommodate various things (tampons, fingers, foreign objects, a baby…).
Cervix: the lower bit of the womb. Roughly tube shaped and typically around 2-3cm long. It has a hole (the cervical ‘os’) which leads from the vagina to the womb. It can change shape, size and consistency under hormonal control – e.g. getting smaller and opening during childbirth.
Uterus: Or ‘womb’. This is where a baby can grow. Sits just behind the bladder in non-pregnancy. The lining of this cavity is called the ‘endometrium’. It is the endometrium thickening and then shedding that is experienced as periods. The top bit of the uterus is called the ‘fundus’.
Fallopian tubes: connect the uterus to the ovaries. Also called the ‘salpinges’ or a ‘salpinx’. Each one ends in a ‘fimbria’. This is a little fringe of tissue that helps convey eggs in to the tubes from the ovaries.
Ovaries: whitish lumps of tissue where eggs are released from. They also produce hormones so have an important endocrine role.
All of these structures sit quite low down in the abdomen. Sometimes problems that feel like they are coming from this reproductive tract can be mistaken for problems with the bowel and vice versa. We’ll have a look at some of these problems another time…
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!