De Crée, Carl

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Ghent University Academic Bibliography

FillerDown there—you know . . . whatchamacallit!BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g5759 (Published 17 November 2014) Cite this as: BMJ2014;349:g5759ArticleRelated contentArticle metricsRapid responsesResponseEffective participation in “vagina dialogues” requires morethan health practitioners no longer beating around the bush.According to Berry1, female patients frequently use all sorts of euphemisms to describe their genitalia,implying some sense of shame associated with the anatomically correct terms. The author asserts thatmedical specialists in obstetrics by avoiding to use appropriate nomenclature actively contribute to the tabooand undermine the empowerment of women.I could not help thinking that there exists a long history of euphemisms regarding activities that refer to ourbody’s hygiene. For example, while the word “dining room” clearly identifies what we actually use the room for(i.e., to have dinner), virtually no language refers to a toilet by the activities it is commonly used for. The list ofeuphemisms to refer to what is nothing more and nothing less than a “pee and poop room” is endless,featuring words such as “lavatory” (from Latin lavāre meaning “to wash”), “bath room” (most toilets in publicplaces do not even contain a bath), or “rest room” (most people do not visit the place to take naps). Somelanguages contain even more flowery terminology, such as, for example, “keshōshitsu” in Japanese, of whichthe literal translation would be “powder room”.The use of euphemisms in language has been the focus of several research studies. Goffman4 developed the“face-work theory” of which the underlying ratio is that people are living in a society and strive for saving theirface rather than losing it. Because the “face” in this context is so fragile and can easily fall prey to injury ordamage by others, members of society in the process of communicating with each other are in charge ofmaintaining not only their own face, but also the face of the protagonists they interact with4. “Face” in thissense then becomes the positive social value which a person effectively claims for himself through theposition that others assume she or he has taken during such conversation. In other words, “face” is an imageof the Self, delineated in terms of approved social attributes4. That which we commonly refer to as"politeness" really is nothing else than something that intends to reduce the threat of causing the other to loseface4. These dialectical tensions are also very present in the consultation room, to the extent that they areeven anticipated to occur rather than that are merely hitting by surprise.Going back to Berry’s assertion, in my opinion the issue of terminology is perhaps somewhat more multi-facetted than we are led to believe. The genitalia fulfill the ambiguous double role of being at the same timeorgans responsible for the removal of waste and organs of lust. Our society historically seems to beconcerned with attempting to maintain a clear separation between the two, probably because conflating themmight easily escalate towards threatening the boundaries of the family entity as well as other people’sindividual private borders. Waste control is primarily an individual function, but lust is a function that veryfrequently is not delineated by the Self, but extended to another person of interest with whom one desires toshare and satisfy that lust. The patient visiting a health practitioner is conditioned to emphasize the separationof those functions and so does the health practitioner himself or herself to avoid awkwardness, confusion andevery consequence ―legal or professional― that comes with it in case confusion prevails.Professionally also being a sexologist, I would argue that in that role, women tend to use far less ambiguousterms with me to describe their problems or organs involved when seeking help than when visiting a familyphysician or perhaps an obstetrician. There are two likely reasons for that. Firstly, when they seek help from asexologist they do not need to make any qualms about the role of lust for lust is now implied in the context ofwhich their medical problem needs to be considered. Secondly, there is the issue of specific competency andtrust. Women do not consider every health provider or physician as an appropriate professional to discusstheir sexual concerns with.Yulevitch et al.7, using multivariate regression analysis, found that genital self-image was the major significantpredictor of women’s comfort level with discussing sexual problems with a gynecologist. Furthermore, Fahs etal.2 showed that, overwhelmingly, women used strong emotional language when discussing their genitals,often evoking descriptions of anxiety, excess, and need for control. The same authors also observed fusionsbetween sexuality and body image, and connections between “genital panics” and internalized racism, sexism,and homophobia2. This suggests that the major issue is not the term that is used to refer to their genitalorgan, but what any reference to their genitals emotionally evokes in them. Because of those strongemotions, not only is the professional competency of the health provider at issue, but the connection thehealth provider is able to establish with the women. In other words, women seem most inclined to discusssexual health if they perceive that important patient-provider conditions, such as trust and rapport, were inplace5. Hughes et al., in a theory-based qualitative study observed that despite situational obstacles andperceived norms, women hold strong beliefs about their abilities to discuss sexual health topics withproviders5. None of these studies suggest that women per se would have anymore objection against usingspecific terminology (provided that they are familiar with the term) than against using more flowery language.Additional problems in health provider/patient communication that involves the topic of genitalia may beencountered when dealing with “special populations”, i.e. people with various types and degrees of linguisticand learning difficulties, such as those where the patient (or physician) is a not native speaker of thelanguage they use, has limited education, has mental limitations, or is child. In particular, all communicationwith children and adolescents with disorders of sex development must be age-appropriate and tailored to theirdevelopmental levels and needs6. A characteristic pattern tends to arises in which both educator/healthprovider and addressee jointly produce only a superficially correct response when verbal prompts involve longsentences and abstract concepts3. Nordenström and Thyen6 point out that communication is as much aboutinformation concerning the factual nature of the medical or sexual situation as it is about listening to theindividual’s thoughts, questions and anxieties. When dealing with the very young, these are best reachedthrough the parents. Additional awareness should be devoted to eventual ethnocentric attitudes exhibited bythe health provider, whether subconsciously or not, and which might raise additional barriers that preventeffective communication with the patient, particularly about delicate topics.In conclusion, I believe that choice of terminology is a multi-factorial issue. Effective communication requiresthat the patient is central rather than the health-provider, or that which the anatomy textbook dictates.1 Berry M. Down there ―you know … whatchamacallit. BMJ 2014; 349: g5759. doi: http://dx.doi.org/10.1136/bmj.g5759.2 Fahs B. Genital panics: constructing the vagina in women's qualitative narratives about pubic hair,menstrual sex, and vaginal self-image. Body Image. 2014; 11 (3): 210-8. doi: 10.1016/j.bodyim.2014.03.002.3 Finlay WM, Rohleder P, Taylor N, Culfear H. 'Understanding' as a practical Issue in sexual health educationfor people with intellectual disabilities: a study using two qualitative methods. Health Psychol 2014 Aug 25.4 Goffman E. The presentation of self in everyday life. Garden City, NY: Doubleday Anchor Books; 1959.5 Hughes AK, Lewinson TD. Facilitating communication about sexual health between aging women and theirhealth care providers. Qual Health Res 2014. pii: 1049732314551062.6 Nordenström A, Thyen U. Improving the communication of healthcare professionals with affected childrenand adolescents. Endocr Dev 2014; 27: 113-127. doi: 10.1159/000363636.7 Yulevitch A , Czamanski-Cohen J, Segal D, Ben-Zion I, Kushnir T. The vagina dialogues: genital self-imageand communication with physicians about sexual dysfunction and dissatisfaction among Jewish patients in awomen's health clinic in southern Israel. J Sex Med 2013; 10 (12): 3059-3068. doi: 10.1111/jsm.12322.Competing interests: No competing interests22 November 2014Carl De CréeMedical Sexologist and Senior Research ProfessorB-2800 Mechelen, BelgiumClick to like:6

Effective participation in the 'vagina dialogues' requires more than health practitioners no longer beating around the bush

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Effective participation in the 'vagina dialogues' requires more than health practitioners no longer beating around the bush

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