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Examining the vulva: The relationship between female genital aesthetic perceptions and gynecological care

Dissertation
Author: Vanessa R. Schick
Abstract:
Despite the known benefits of gynecological exams, women's concerns about displaying their genitalia may function as a deterrent to care. While little is known about women's genital perceptions, the current rise of female genital cosmetic surgeries suggests that women may be dissatisfied with the deviation of their vulva from a uniform appearance ideal. Thus, the current study investigated the construction of this ideal and the relationship to gynecological care. Specifically, the current study tested a path through which exposure to either a constrained or varied vulva picture set would differentially activate a concatenation of cognitions and emotions that would, in turn, predict gynecological care perceptions and intentions. Young, undergraduate women ( N =485) completed the on-line survey at a computer of their choosing. Contrary to the hypothesis, picture set exposure was unrelated to vulva perceptions. However, as predicted, young women's genital perceptions were significantly related to their gynecological care perceptions and intentions.

ix Table of Contents Acknowledgments ii Abstract vi List of Figures……………………………………………………………….............. xii List of Tables ……………………………………………………………………….. xiii Chapter I.

INTRODUCTION……………………………………………………………. 1

Examining Female Genitalia: A Critical Analysis ……………………...

3

Genital Discontent and Pap Smear Intentions…………………………... 8

Rational-Emotive Behavior Therapy Model………………………… 9

An ABC Path from Genital Discontent to Pap smear Intentions……. 11

Activating Genital Perceptions via Female Genital Images………….

11

Genital Perceptions as an Antecedent to Generalized Genital Concerns……………………………………………………………... 13

The Relationship between Genital Dissatisfaction and Exam Embarrassment..................................................................................... 14

Exam Embarrassment and Anxiety as a Predictor of Pap smear Intentions.............................................................................................. 16

Predicting Pap Smears: The Present Study………………………………

18 II.

METHOD…………………………………………………………………….. 20

Participants……………………………………………………………… 20

Measures………………………………………………………………… 21

Activating event – genital image manipulation………………………

21

Perceptions of genital aesthetics…………………………………….. 21

Genital aesthetic discontent…………………………………………..

21

x

Pap smear exam anxiety……………………………………………... 22

Pap smear exam embarrassment…………………………………….. 23

Pap smear exam behavior…………………………………………….

23

Control variables……………………………………………………. 24

Procedure………………………………………………………………. 25 III.

RESULTS…………………………………………………………………….. 25

Preliminary Analyses…………………………………………………… 25

Path Analyses…………………………………………………………… 27 IV.

DISCUSSION…………………………………………………………………. 29

Findings…………………………………………………………………. 29

Hypotheses 1 and 6: The Experimental Manipulation………………. 29

Hypotheses 2 and 3: Vulva Perceptions and Gynecological Care…... 33

Hypothesis 4: Pap smear anxiety, embarrassment and intentions. …. 34

Hypothesis 5: The Path from Genital Perceptions to Gynecological Care………………………………………………………………….. 35

Limitations……………………………………………………………… 36 Implications and Future Research……………………………………… 39 REFERENCES……………………………………………………………………… 44 APPENDIXES……………………………………………………………………… 53 Genital images from a popular men’s magazine……………………… 53 Genital images from an educational book……………………………… 58 Vulva rating scale (VRS)……………………………………………… 63 Vulva appearance satisfaction scale (VASS)………………………… 64 Dental fear survey (DFS) ……………………………………………… 65 Pap smear fear survey…………………………………………………. 66

xi Pap smear embarrassment survey……………………………………… 67 Netherlands Comparison Orientation Measure (Social Comparison Scale)…………………………………………………………………… 68

xii Figures 1.

Rational-Emotive Behavior Therapy Model …………………….. 75

2.

Theoretical model predicting women’s Pap smear intentions following exposure to female genitalia……………………………

76

3.

Modified theoretical Pap smear intention model based an analysis of model fit for both experimental conditions.……….................... 77

4.

Standardized coefficients for Pap smear intention model.…….. 78

5.

Standardized coefficients for alternative Pap smear intention model………………………………………………………………

79

.

xiii Tables 1.

Vulva Perceptions Means and Standard Deviations ……………….

69

2.

Vulva Size and Satisfaction Perception Frequencies……………… 70

3.

Pap Smear Means and Standard Deviations………………………..

71

4.

Pap Smear Frequencies. …………………………………………... 72

5.

Intercorrelations for Measures of Vulva Perceptions and Pap Smears. ……………………………………………………………. 73

1

Introduction In 2006, the American Cancer Society released a report projecting that within the next year over 28,000 American women would die from cancers related to their genital system, and that approximately 3,700 of the annual deaths would be due to cervical cancer. Although cervical cancer is responsible for only a small proportion of the total fatalities in the United States, the annual number of deaths attributable to it is alarming because the majority of these fatalities are preventable. The five year survival rates of women diagnosed with cervical cancer in an early stage is over 92%; however, once the cancer has a chance to metastasize, the survival rate for women diagnosed with cervical cancer in late stages drops to a mere 16.5%. Although not 100% effective, the Papanicolaou (Pap) test is currently recommended by the American Cancer Society (2006) as the most effective means for detecting cervical cancer in an early, localized stage. The Pap test, a procedure commonly performed during a woman’s pelvic exam, is conducted by swabbing a sample of cells from the cervix in order to test for abnormal cells that may indicate cervical cancer. The Pap smear is not only effective in the detection of cancer, it can also be central to the prevention of cervical cancer in that it identifies possible lesions associated with high-risk types of the human papillomavirus (HPV), a virus that is responsible for approximately 93-100% of cervical cancer cases (Saslow et al., 2007). If lesions are identified during a Pap smear, they can be removed in order to decrease the risk of HPV later developing into cervical cancer. Additionally, because Pap smears and pelvic exams

2 are rarely conducted in isolation from other medical procedures, a woman who receives a pelvic exam may also benefit from other forms of cancer screening, including an examination of her ovaries and breasts for malignant tumors. Consequently, the necessity of Pap smear adherence in maintaining women’s health was recognized as a primary goal in Healthy People 2010 (U.S. Department of Health and Human Services, 2000). Currently the American Cancer Society recommends that women receive a minimum of one Pap smear every three years, beginning before the age of 21, or within three years after a woman first engages in sexual intercourse (Saslow et al., 2007). The recommendations for young women to receive Pap smears prior to the age of 21 were suggested in response to the high prevalence rates of cervical cancer within this cohort, a consequence of the widespread pervasiveness of HPV in samples of women under the age of 25 (Dunne et al., 2007). Despite recommendations from the American Cancer Society that sexually active women under the age of 21 receive regular Pap smears, recent reports suggest that approximately 50% of young women do not adhere to these recommendations (e.g., Fletcher & Bryden, 2005; McKee, Fletcher, & Schechter, 2006), pointing to the need to increase Pap smear intentions among this cohort. Regrettably, researchers have been largely ineffective in the construction of interventions designed to increase Pap smear uptake. A recent review of over 20 years of interventions designed to increase gynecological care found that effect sizes were small and occasionally negative despite the fact that many of the interventions were proven to be effective in increasing mammograms and other related cancer screening behaviors (Yabroff, Mangan, & Mandelblatt, 2003). This suggests that there may be a set of barriers that are unique to gynecological exams. One way in which gynecological exams and other cancer screening behaviors may differ from one another is in the component of the body that is inspected during the examination. Gynecological exams require that women make public an area of

3 their bodies that they are conditioned to believe is private and oftentimes shameful (Kapsalis, 1997). Therefore, in the present study, I will focus on the ways in which social norms serve as barriers to gynecological examinations by investigating women’s concerns about making their “privates public” (Kapsalis, 1997). Utilizing Rational Emotive Behavioral Therapy (REBT) as a framework, I will map a cognitive and affective path through which women’s genital exposure concerns impede their gynecological care intentions. Examining Female Genitalia: A Critical Analysis “…gynecology is the quintessential examination of women. Gynecology is not simply the study of women’s bodies-gynecology makes female bodies. It defines and constitutes female bodies. Thus this critical examination of gynecology is simultaneously a consideration of what it means to be female.” (Kapsalis, 1997, p. 6). According to Kapsalis (1997), a woman, her body and the gynecological exam are all inextricably intertwined and the failure to examine one component would lead to an incomplete understanding of the others. Thus, a thorough understanding of Pap smears can only be developed through a critical analysis of gender and bodily constructions within a gynecological care framework. The component of the body examined during the gynecological exam (i.e., the female genital region) has vast social, cultural and historical significance for women. The vagina is viewed by some as the point of differentiation between men and women (Braun &Wilkinson, 2001), rendering it a marker of subordination. The vagina is also the canal of birth, an association which impacts women because being responsible for childbearing has maintained women’s roles as caregivers (Blackledge, 2002). The vagina is not only an indicator of gender and respective gender roles, it is one of the most (if not the most) sexualized components of a woman’s body.

4 Consequently, the impact of gender and the body in relation to gynecological care is best understood through a critical analysis of female genitalia. A critical analysis of genitalia requires a corresponding analysis of sexual discourse. Sexual discourse dictates that intercourse should only exist within a relational context and that the emphasis should be on penile/vaginal intercourse for reproductive purposes (e.g., Gavey & McPhillips, 1999; Gavey, McPhillips, & Doherty, 2001). By framing sex as only penile/vaginal intercourse, it perpetuates a heteronormative culture by stigmatizing sexual acts that exist outside of that limited reproductive framework. Messages that women receive about their genitalia parallel the messages that they receive about their sexuality in that they emphasize the component of the vulva necessary for sexual reproduction and heterosexual intercourse (i.e., the vagina) and ignore all other components of the vulva (i.e., the clitoris or labia minora/majora). An analysis of the slang terms frequently used to describe female genitalia (e.g., down there; Braun & Kitzinger, 2001) fail to reference the location or the appearance of female genitals, with most references focused on the absence within the vagina as opposed to the visual structure of the genitals. The English language does not have a female equivalent for the term phallus, a symbol which epitomizes the penis in its idealized state (Bordo, 1999), suggesting a deficit in available positive symbolic imagery of external female genitalia. Instead, the limited visual representations of the vulva are often derogatory in nature (e.g., roast beef sandwich), perpetuating feelings of shame and embarrassment that women have with components of their genitalia other than their vagina. Missing symbolic imagery of female genitalia may also mirror another issue: the social censorship of female genitalia. The stigmatization of female genital exposure is maintained by marginalizing those women who expose their genitalia publicly (e.g., sex workers, strippers and nude models) by pointing to their violation of traditional sexual norms. Women interested in viewing female genitalia may be further stigmatized because

5 viewing nude women’s genitalia may violate heterosexual assumptions, decreasing the frequency with which women expose or discuss their own or other women’s genitalia. The social constraints on female genital discourse may limit the information available to women regarding genital aesthetics, as illustrated by the absence of depictions of external genitalia (e.g., the labia minora - a prominent feature of the external genitalia) within mainstream media images of women’s bikini areas (Bramwell, 2002). Consequently, available depictions of female genitalia may be restricted to pornographic materials. However, the use of sexually explicit materials as a reference for female genital aesthetics may be problematic because in the same way that women with various body types are not depicted within the media, only images of vulvas that are consistent with the current societal ideal are portrayed. In a content analysis of recent issues of a popular men’s magazine, Schick, Rima, and Calabrese (in press) found the representations of women’s genitals to resemble a Barbie doll (Braun & Wilkinson, 2001) in that the models’ genital mounds were round, smooth and plasticized with no visible labia minora and little (if any) pubic hair. The idealized genitalia available within the magazines is similar in appearance to the genitalia of a young female in that the genitalia of the models were hairless and small, both characteristics associated with prepubescence. The evaluative assessment of labia minora size is embedded with social and historical meaning. For instance, the degradation of protruding labia minora may derive from the relatively trivial size discrepancy between large female genitalia and small male genitalia, particularly during infancy (Braun & Tiefer, in press). If the clitoris is large or the penis is small at the time of birth, it may be difficult to determine the sex of the child because gender is often deciphered based upon the appearance of the genitalia. Thus, the idealization of minute female genitalia (and large male genitalia) may be rooted in the social sanctioning of distinct gender binaries (Braun & Tiefer, in press; Einstein, 2008).

6 The modern idealization of diminutive labia minora may also stem from historical beliefs that elongated labia minora were characteristic of deviance including genetic abnormalities and sexual promiscuity (Braun & Tiefer, in press). Historically, elongated labia have also been tied to marginalized groups of women including Black (e.g., Sarah Bartmann, a.k.a. Venus Hottentot) and homosexual women (e.g., Braun & Tiefer, in press, Gillman, 1985; Terry & Urla, 1995). The social degradation of large/protruding genitalia maintains principles of female conformity and submission by portraying women as uniform and diminutive. Ideal genital aesthetics fits within a framework of gendered sexual conventions in that larger genitalia may be representative of sexual desire as is illustrated by the swelling of components of the external genitalia (e.g., the clitoris) when a woman is sexually aroused (Blackledge, 2002). Accordingly, through the reinforcement of a plasticized genital norm, women who view these genital ideals are made to feel ashamed of their seemingly deviant bodies and their sexualities, diminishing both their social and sexual agency. The association between women’s genital size and sexual passivity parallels associations made by Bordo (1997) in her critical analysis of anorexia. She cites one woman who describes the relationship between the size of women’s bodies and their perceptions of control and agency within society. She says, “You know, the anorectic is always convinced she is taking up too much space, eating too much, wanting food too much. I’ve never felt that way, but I’ve often felt that I was too much- too much emotion, too much need, too loud and demanding, too much there…” (pg. 441-442). In the same way that fears about having too much body may be viewed as indicative of excess, gluttony and greed; small, contained labia minora may similarly reflect an absence of sexual want and desire, complementing theories about the relationships between genital size and gendered sexual conventions.

7 Although the genital ideal may be rooted in the social and historical oppression of women, the internalization of these concerns has only recently become manifest in surgical procedures designed to promote the “designer vagina” (e.g., Braun, 2005, in press; Braun & Tiefer, in press; Davis, 2002; Tiefer, 2008). The recent increase in women’s specific aesthetic concerns about the appearance of their genitalia is evident in the increase in female genital cosmetic surgeries (FGCS), including: 1) vaginal rejuvenation surgery, which is designed to tighten the vaginal canal; and 2) labiaplasty, which is designed to trim labia that women perceive to be large or uneven (e.g., Goodman, 2009). These surgeries pathologize women’s natural genital diversity (e.g., Braun & Teifer, in press; Tiefer, 2008), suggesting a universal recognition of a single, uniform genital ideal. Analysis of trends in plastic surgery may be useful because, as Braun (2006, p. 345) stated, “…it reaches far beyond the experiences of those who undergo it (Frueh, 2003: 11). It seeps from and into our television screen, magazines, and various other sites of discourse. It is not simply a medical intervention in/on bodies; it is obviously culturally influenced and is culturally influencing.” The influence of labiaplasty on young women’s perceptions of genital aesthetics was demonstrated in an experiment in which participants rated pictures of pre-labiaplasty genitalia as significantly less attractive than pictures of genitalia post-labiaplasty (Schick et al., 2008). Additionally, when asked about the labia size for an ideal vulva, only a small minority (1%) of participants stated that it would include large labia minora and no participants believed that it would contain very large labia minora. Thus, although not all women report having looked at their genitalia (Oscarsson et al., 2007), those who are aware of their genital appearance may compare their genitalia against this ideal. Accordingly, a recent survey found that up to 89% of women did not report perceiving their genitals to be attractive, sexy or beautiful (Stewart, 2006).

8 It is important to contextualize women’s genital concerns because the prohibition of genital discussion and exhibition may filter the situations during which women consider the appearance of their genitalia. This contrived genital discourse may modulate the saliency of a woman’s genital concerns such that the concerns present themselves only when she is engaged in an activity that focuses on her genitalia. Research suggests that, even during sexual encounters, the salience of genital discontent may vary as a function of genital focus. Reinholtz and Muehlenhard (1995) found that participants’ genital shame was context-specific, in that women reported increased concerns about their genitalia when engaged in sexual acts during which it was a focal point (i.e., cunnilingus). Other than cunnilingus, the pelvic exam is one of the few times that women’s genitals are displayed to another person and one of the only times when they are examined. Thus, I posit that women may feel shame/embarrassment about the discrepancy between their ideal genitals and their actual genitals in situations during which their genitals are a point of focus (i.e., genital exams). Consequently, I propose that the assessment of genital discrepancy concerns will capture the unique social and psychological barriers that women face when considering a gynecological exam. Genital Discontent and Pap smear Intentions The failure of models to explain variation in women’s intentions to seek gynecological care (e.g., Yabroff et al., 2003) may be due to their failure to account for the socially charged nature of the examination. The exam requires that a woman display her genitalia, an area that she is socialized to believe is embarrassing and shameful. This embarrassment may be heightened if a woman believes that the appearance of her genitalia deviates from the ideal range. As opposed to other models of health which focus on several cognitions, Rational Emotive Behavioral Therapy (REBT; Ellis, 1984) may be a useful framework when mapping the path from a single cognition (i.e., genital concerns) to an outcome (i.e., gynecological care intentions).

9 Rational-Emotive Behavior Therapy Model REBT (Ellis & Barnard, 1985) not only provides a framework for constructing a path from cognitive perceptions of Pap smears to Pap smear intentions, it is also useful in providing information about the variables that precede the cognition by way of one of the primary tenets of REBT, the ABC theory of irrational thinking and emotional disturbance (see Figure 1). The (A) within the ABC framework indicates the ‘activating event’ for subsequent cognitions and emotions, which may trigger a host of consecutive cognitions and emotions related to the event (See Figure 1). The activating event may take both tangible forms (e.g., a current event) as well as more abstract ones (e.g., a conscious or subconscious memory). REBT is frequently used to negate anxiety directed at select stimuli. For example, fears about flying are commonly corrected using REBT. Within REBT, the therapist may begin by concentrating on the event (e.g., a news article) that activates the cognitions and emotions related to air travel. The beliefs (B) triggered by the activating event may differ on several criteria and can be classified into several categories including rational beliefs, irrational beliefs and self-defeating beliefs. Rational beliefs are defined as those which are logical, consistent with the person’s goals and valid from an empirical standpoint. In contrast, irrational beliefs differ in that they are illogical, inconsistent with the person’s goals and invalid from an empirical standpoint (Dryden & Digiuseppe, 1990). Although the activating event may trigger a single belief, there may also be a concatenation of rational and irrational beliefs (Path 2). For instance, after reading an article about a plane crash, it would be rational to conclude that a small percentage of flights are unsuccessful; however, it would be irrational if this grew into a belief that plane travel would likely have a fatal outcome. Within the ABC framework, irrational beliefs may instigate self- defeating thoughts (Path 3), which can predict future psychological disturbances (Ellis & Bernard, 1985). Returning to the previous example, the person who is afraid of flying

10 may have negative thoughts about the flight process (e.g., the take-off will be anxiety- provoking and I will be unable to escape). Depending on the nature of the irrational belief, the sequelae may include anxiety, depression, anger, guilt, hurt, jealousy and/or shame (Path 4). In the above example, the person will likely feel increased anxiety when engaging in actions related to plane travel (e.g., booking tickets, driving to the airport, etc.) in response to the path of negative thought processes. Finally, the negative affect that follows the irrational beliefs may have negative consequences (C) that impinge on his/her ability to reach his/her goals (Path 5). Utilizing the previous example, the person who is anxious about flying may avoid air travel, even if the destination is desirable or necessary. As with the person who is anxious during plane travel, fears related to certain health behaviors may also be explained using the REBT framework. The components of REBT have been effective in predicting and intervening in a host of behaviors (Freeman, Felgoise, Nezu, Nezu, Reineke, 2005), including Pap smears. The utilization of a cognitive behavioral approach was effective in designing an intervention that differentiated between Pap smear self-efficacy and intentions for married Korean women in a control group and an experimental group (Park, Chang, & Chung, 2005). Thus, in accordance with the findings of Park et al. (2005) and the documented effectiveness of REBT in predicting behavior, I will utilize the ABC framework (Ellis, 1984) to predict Pap smear intentions within a young American sample. I propose a path through which Pap smear intention is inhibited by negative affect, which is initiated by a multitude of beliefs in response to an activating event. Specifically, I propose that genital aesthetic concerns will be activated after presenting young women with several genital images which will, in turn, indirectly predict Pap smear intentions (see Figure 2).

Full document contains 93 pages
Abstract: Despite the known benefits of gynecological exams, women's concerns about displaying their genitalia may function as a deterrent to care. While little is known about women's genital perceptions, the current rise of female genital cosmetic surgeries suggests that women may be dissatisfied with the deviation of their vulva from a uniform appearance ideal. Thus, the current study investigated the construction of this ideal and the relationship to gynecological care. Specifically, the current study tested a path through which exposure to either a constrained or varied vulva picture set would differentially activate a concatenation of cognitions and emotions that would, in turn, predict gynecological care perceptions and intentions. Young, undergraduate women ( N =485) completed the on-line survey at a computer of their choosing. Contrary to the hypothesis, picture set exposure was unrelated to vulva perceptions. However, as predicted, young women's genital perceptions were significantly related to their gynecological care perceptions and intentions.