Clio Reads: A Review of It Hurts Down There: The Bodily Imaginaries Of Female Genital Pain

“Female genital pain” is an umbrella term that encompasses a range of often miserable, frequently perplexing conditions that render women’s genitals, external or internal or both, a zone of persistent, intransigent pain. Yet the names physicians have given these conditions are indicative of little more than their primary symptoms: “vulvodynia,” perhaps the most common diagnosis, simply means “painful vulva,” while another, “dyspareunia,” signifies nothing more specific than “painful sexual intercourse.” If it is the case that, as Charles Rosenberg has famously written, “in some ways disease does not exist until we have agreed that it does, by perceiving, naming, and responding to it,” then female genital pain exists only in a vague and hazy way, defined largely by its impact upon the functioning of women’s genital anatomy in the context of penis-in-vagina intercourse, that signature act of heterosexuality.¹

In It Hurts Down There: The Bodily Imaginaries of Female Genital Pain, anthropologist Christine Labuski argues that this vague, simultaneously prescriptive and dismissive approach to what can be a crippling affliction is both reflective and constitutive of the affliction itself. As the title suggests, the incapacity to get specific with regard to this constellation of genital disorders has profound impact on the understanding of these conditions and the experiences of those who suffer them.

This incapacity, Labuski argues, exists everywhere. It is biocultural, intersectional, theoretical, and practical. There is a lack of specificity on the parts of both physicians, who sometimes can and sometimes cannot locate a specific bodily pathology that accounts for the presence of so much pain, and the patients, who sometimes can and sometimes cannot so much as name the body parts that agonize them or explain how the pain affects them without reference to the sexual demands of a male sex partner. The incapacity for specificity that makes diagnosis and management of female genital pain such a vexing and often frustrating affair is a matter of inability and a matter of unwillingness, not merely of individuals but also of cultures that routinely erase, elide, and avoid consciousness of the vulva as a body part. As we have learned not least from Eve Ensler, it is the vagina, not the vulva, that gets to deliver monologues. Even when it is metaphorically screaming in pain, the vulva, Labuski’s ethnography illustrates, is largely incapable of speaking for itself.

Fortunately, Labuski is uniquely well equipped for what is at root largely an inquiry into what we lack in our capability to engage with the vulva, and the ramifications of that lack. Formerly a nurse, with many years’ experience as a women’s healthcare provider, Labuski brings to the table not only a substantial theoretical expertise in keeping with her academic anthropology training but also an insider knowledge of the conventions, practices, and blind spots of clinical medicine. This enables her to make what seems to me to be a particularly fateful intervention into the slowly-growing discussion about female genital pain, namely, a productive rethinking of the notion of somatization that rescues it from the Freudian-derived “it’s all in your head” gloss that was for many decades genital pain’s most commonly offered etiology.

Psychosomatization gets a fresh assessment here, the biological reality of somatic response to emotional stimulus — the muscular tension that creates pelvic floor myalgia in particular — explored in detail that repudiates the crusty old psychoanalytic blame-the-victim dynamic. Aided materially by Elizabeth Wilson’s work on psychobiological aspects of inflammatory gastrointestinal disorders, Labuski explores the role of what she refers to as “unwanted genital experience” in contributing to the involuntary bodily reflex to tighten muscles in self-protective ways.²

“Unwanted genital experience,” in Labuski’s lexicon, is a useful catch-all that includes everything from misogynist jokes about women’s genitals to experiences of sexual violence as well as the common sexual pressures placed on women by both individual men and society at large. This provides a way to theorize at least some types of women’s genital pain as not being the result of a unique or personal failure of psychological adjustment but rather a side effect of a normal bodily response to chronic, inescapable, and often normalized incursions and assaults. When we begin to perceive systemic cultural misogyny as a source of direct and destructive biopower, Labuski argues, we can begin to imagine different, perhaps more useful ways to treat the types of pain that result from the somatization of its assaults. Currently these treatments largely take the form of specialized vagino-vulval physical therapy and biofeedback and include engagement with both emotional and sensory feelings. They are often effective, including at times when allopathic treatment has proven inadequate. Such treatment, insofar as it offers women strategies for surviving and recuperating from the bodily consequences of living in patriarchy, is, as Labuski points out, inherently political.

Treatment of female genital pain is also — as Labuski also notes — inherently compromised. At the risk of committing the perennial reviewerly sin of criticizing a book for not having been a different book, one could wish that her project had allowed for more discussion of the ways that female genital pain becomes racialized in clinic settings, with white women typically referred to vulvar pain specialists with vulva-specific diagnoses and women of color relegated to general gynecology with vaginal ones. Ethnographically it seems very promising, particularly if framed by a historiographical consideration of eugenic constructions of black bodies as neurologically lesser than white bodies, a history that receives only a sentence en passant in the final chapter. Similarly, one could wish that Labuski followed up more on the significance of physician reluctance to become professionally committed to dealing with female genital pain. Labuski suggests that genital pain’s very multidimensionality, its intersectional combinations of biomedical and psychobiological components, are part of what frustrate doctors into leaving or simply never being willing to consider the specialty. Surely there are stories there about biopower, expectations of authority, interpretive capacity, and bodily imaginaries among medical professionals that would have a lot to teach us too. Fortunately, whatever scholar takes up these questions in future will have Labuski’s well-informed and insightful work to draw upon.­

Hanne Blank

Hanne Blank is a cultural historian of medicine, sexuality, and the body. Her next book, FAT, is forthcoming in the Object Lessons series in Fall 2020. She teaches at Denison University.

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