▪Most women believe it is important for women to be educated about the vagina, and many believe that vaginal health and research have not received adequate attention.
▪Although one-half of women are comfortable having discussions about the vagina, nearly one-half feel that discussions should be held in private.
▪Most women feel that society is more open to discussions about the vagina, but that the topic still generates shock value.
▪Women's awareness of newer contraceptive methods is high, but use of these methods is very low, emphasizing the need for better physician/patient communication about contraception.
Despite some relaxation of general attitudes toward sex over the last 40 years, society still appears to have some difficulty discussing the vagina without embarrassment or crudeness, possibly because for some, “vagina” is seen in a sexual connotation and is categorized as a rude word. Even in relation to childbirth, terms such as “natural” or “normal” are often substituted to describe the option or event of vaginal delivery. Whether the reluctance to say “vagina” is on the part of the person speaking or more to do with the perceived reaction of the listener or both, is unclear; however, the desire not to offend perpetuates the problem.
Should we be concerned about the vagina remaining a very private issue? The fact that the vagina is viewed with mystery and shame (and perhaps fear on the part of men) is concerning because it is central to a woman's sexual, reproductive, and general health. An increased understanding of and ability to discuss the vagina will contribute to women's emotional as well as physical well-being. Furthermore, a general unwillingness to discuss the vagina may also suggest that many women are unaware of or are misinformed about related health issues or advances. For example, vaginal contraception has well-defined benefits and evidence shows that women are very satisfied with this method when they use it. Nonetheless, a disinclination to discuss the vagina will lower women's awareness and understanding of vaginal contraception and its benefits and perhaps deter women from trying it. The Vagina Dialogues survey was, therefore, carried out in the United States to ascertain what women feel and know about the vagina and their comfort levels with discussing the subject, including discussions with physicians.1 An international version of the survey has also been carried out and the results are presented separately.2
Survey methods
To improve the understanding of women's attitudes toward their vaginas and contraceptives in general, the survey focused on three main areas: 1) Women's attitudes toward and perceptions of their vaginas (including public and private discourse); 2) Women's knowledge of the vagina and day-to-day behavioral patterns; and 3) Contraceptive behavior and attribute awareness.
The survey was conducted online through Harris Interactive from July 29 to August 8, 2003. A multiple-choice format was used, which took an average of 21 minutes to complete. Some sections of the survey asked women to express their level of agreement with various statements; other sections asked them to choose from a selection of responses to a question or statement. Data were weighted to adjust for attitudinal differences that may have arisen from using an online panel sample.
Survey participants included 1,117 women who were aged 18 to 44 years (average age, 31 years) and residents of the United States. Women were most likely to be Caucasian (67%), not married (53%), and have one or more children (56%). Some survey responses were analyzed in age group categories (18–24, 25–34, and 35–44 years) that were tested against each other for statistical differences. In addition, some survey responses were analyzed against different responses to identify statistically significant correlations. Statistical analyses were carried out at the 5% significance level using 95% confidence intervals.
Personal attitudes and perceptions
Table 1 outlines women's personal knowledge, attitudes, and perceptions about the vagina. Nearly all women surveyed believe it is important that women are sufficiently educated about their vaginas, and almost one half think the vagina is the body part about which women know the least. Most women agree that understanding one's vagina will help increase sexual satisfaction.
Regarding attitudes to touching and looking at the vagina, women appear to be more comfortable with touching their vagina than looking at their vagina. In addition, most women agree that they are comfortable inserting something such as a tampon or their fingers into the vagina.
When discussing the vagina, most women feel they are able to say “vagina” more freely, and approximately one half of women are comfortable having verbal discussions. However, nearly one half feel that discussions about the vagina should be held in private. Just under two thirds of women think that society has too many misperceptions about vaginas and that vaginal health and research have not received the attention they deserve.
Overall, women choose neutral words, such as “private” or “neutral,” rather than positive words to describe their own perception of their vagina (56% neutral; 35% positive), and positive words, such as “sexy” or “beautiful,” to describe what they think is their partner's perception (80% positive; 16% neutral). Women also are most comfortable discussing their vaginas with their spouse/significant other (76%) or sexual partner (73%), followed by their sisters (49%), friends (44%), and mother (38%).
Societal attitudes and perceptions
Most women (73%) believe that society is more comfortable with discussions about the vagina, but the topic still has shock value. Only 14% feel that their gender genitalia equality has been reached (ie, women are as comfortable talking about their vaginas as men are talking about their penises), and 10% believe that society has reached enlightenment with no shame attached to discussions. However, 50% of women aren't satisfied with the current level of dialogue in society. Women who are open to discussing their vaginas in public are more likely to view the current level of dialogue as a social issue to be addressed (Figure 1).
Many women (66%) believe that, compared with their mother's generation, they now make an effort to take care of and protect their vaginas (as with their breasts), and some (32%) think that women now realize that the vagina is as important and basic as eyes, hands, and feet. However, few women (8%) believe that the vagina has become an everyday topic of conversation since their mother's generation. The way in which women refer to their vagina also has changed. Compared with their female elders (mother, grandmother), more women use “vagina” as the main term of reference (49% vs 16%). “Private” was the most commonly used term of reference (24%) by the women's female elders when they were children.
Physical interaction
The most common type of physician that women see for vagina-related matters is an obstetrician/gynecologist (Ob/Gyn; 69%), followed by a primary care physician (PCP) or an internal medicine specialist (23%) and nurse practitioner (NP; 6%). Most women have a pelvic examination once a year or more often (70%), particularly those who see Ob/Gyns (79%) or NPs (84%). The percentage of women who have a pelvic exam once a year with Ob/Gyns (64%) or NPs (80%) is statistically higher (P < 0.05) than those who see PCPs (50%), while the percentage of women never having a pelvic exam with PCPs (20%) is statistically higher than women seeing either Ob/Gyns (1%) or NPs (4%) (P < 0.05).
Most women (79%) feel either somewhat or extremely comfortable speaking with their physician about vagina-related issues. Reproductively older women (25 to 44 years) and women who are comfortable inserting something into their vaginas are more comfortable discussing these matters with their physician than those in comparing groups. Overall, more than one half of women are very comfortable talking to their physician about most vagina-related topics (eg, vaginal discharge, vaginal itchiness, sexually transmitted diseases). Vaginal size is the topic women feel least comfortable discussing with their physician, yet 41% still feel very or extremely comfortable discussing this topic (Figure 2).
The physician is also the most important information source for vagina-related issues (64% of women), particularly for older women, with 71% of women aged 35 to 44 going to their physician for information vs. 49% of reproductively younger women aged 18 to 24 (P < 0.05). Correspondingly, younger women are more likely to use women's magazines and books for information on the vagina compared with older women (59% of 18 to 24 year-olds vs. 42% of 35 to 44 year-olds; P < 0.05). Younger women are also more likely to use friends and family as information sources compared with older women.
The majority of women (85%) have discussed contraception with their physician and 28% rely completely and 36% rely somewhat on their physician when it comes to making their contraceptive choice. Women also use their physician as their first source of information for contraception (70%)—women in the two older age categories were significantly (P < 0.05) more likely to go to their physician for information than were younger women (aged 18 to 24), whereas younger women were significantly more likely to use their friends and family as information sources than were older women.
Knowledge and behavior
One half of women (51%) surveyed consider themselves to be very or extremely knowledgeable about their vaginas; 42% feel somewhat knowledgeable and 7% feel not very or not at all knowledgeable. The majority of women (84%) either know exactly what their vagina looks like (47%) or have a rough idea (37%).
Regarding physical characteristics of the vagina, most women know that the walls of the vagina spread to hug an object (84%), that vaginal length varies from woman to woman (81%), and that the vagina slants at an angle toward the lower back (70% answered correctly, but 21% answered “don't know”). Women know less about facts relating to items used in the vagina such as condoms and tampons: 46% of women don't know that a condom or tampon cannot become “trapped” inside the vagina and 57% don't know that tampon use is not associated with yeast infections.
Women are generally less confident about the size of their vagina: 43% consider their vagina to be the right size, 8% believe it is too big or too small, and 49% do not know. Women who are uncomfortable inserting something into their vagina are more likely not to know if their vagina is the right size than those who are comfortable with insertion (62% vs. 45%, P < 0.05). Similarly, women who are comfortable inserting something into their vagina are more likely to know if their vagina is the right size than those who are uncomfortable with insertion (47% vs. 30%; P < 0.05).
Figure 3 illustrates how the extent of a woman's knowledge impacts her attitude toward the vagina. Women who describe themselves as being very or extremely knowledgeable about their vaginas are more likely to think that vaginas should be talked about in public and more likely to feel comfortable about inserting something into their vagina.
Slightly more than two thirds (69%) of women have looked at their vagina, with 53% doing so in the last month (38% in the last week or more recent; 15% in the last month). Half of the women (49%) also have performed self-examination of their vagina. Most women have engaged in some type of cosmetic behavior—82% have waxed and/or shaved their pubic hair and/or performed vaginal exercises, while 18% of women have never engaged in any cosmetic behavior.
Contraceptive behavior
Women's awareness of different contraceptive methods is high, particularly for oral contraceptives (98%) and male condoms (96%), which are also the two most commonly used methods of contraception (27% for both methods), followed by tubal ligation (11%). However, the largest group of women (34%) is not using any contraceptive method at all. Awareness for newer methods of contraception, such as the transdermal patch and the vaginal ring, are high (92% and 66%, respectively) but usage is low (2% and < 1%, respectively).
Figure 4 shows how women rate various contraceptive attributes using five categories ranging from not-at-all desirable to absolutely essential. Women also were asked to apply the list of attribute statements to three methods: oral contraceptives (“the Pill”), the transdermal patch, and the vaginal ring. Women choose “is taken daily,” “helps to regulate cycle” and “is discreet” as the attributes that most closely describe the Pill. The best descriptor of the patch is that it “provides a steady, constant delivery of hormones over time” (this is the fourth best attribute for the Pill, and only the sixth for the vaginal ring). The most closely associated attribute of the ring is “is discreet” (fourth for the patch), followed by “does not have to be taken every day” (also second for the patch) and then “few side effects.” Women attribute cycle regulation to both the Pill and the patch but not to the vaginal ring.
Discussion
Survey results suggest that while some progress has been made, women and society still have some way to go in raising comfort levels on discussions of the vagina. Although women's knowledge of the vagina and related matters could be improved, the good news from this survey is that women want to be educated about their vaginas. Improving women's knowledge of the vagina is important because it impacts their confidence to discuss the matter publicly, thereby perhaps increasing other women's confidence and comfort levels with the subject.
Women also seem to be investing in their vaginal health, with the majority of women visiting their physician for a pelvic exam at least once a year. Most women are comfortable talking to their physician about vagina-related matters and consider their physician as their most important information source for the vagina and contraception. In addition, many women rely on their physician when choosing a contraceptive, which emphasizes the need for physicians to be aware of women's expectations and needs when it comes to contraceptive choice and to fully understand the contraceptive products they prescribe, given the number of choices available and differences in the benefits that they offer.3
The attribute ratings for different contraceptives suggest that women are interested in alternative methods to oral contraceptives that utilize longer regimens. Vaginal contraception is one alternative that offers many benefits including the attributes rated highest by the women surveyed. The availability of a vaginal contraceptive method may now enable physicians to talk more readily to women about this part of their body, effectively opening up discussions about other aspects of reproductive and general health. As such, it is crucial that physicians also feel comfortable in discussing vaginal matters with patients and, additionally, realize that perhaps more women than they might think are open and willing to discuss these matters.
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