Taking the 'shame part' out of female anatomy

Anatomists have bid farewell to "pudendum," but other questionable terms remain.

Allison Draper loved anatomy class. As a first-year medical student at the University of Miami, she found the language clear, precise, functional. She could look up the Latin term for almost any body part and get an idea of where it was and what it did. The flexor carpi ulnaris, for instance, is a muscle in the forearm that bends the wrist — exactly as its name suggests.

Then one day she looked up the pudendal nerve, which provides sensation to the vagina and vulva, or outer female genitalia. The term derived from the Latin verb pudere: to be ashamed. The shame nerve, Draper noted: "I was like, What? Excuse me?"

It grew worse. When her teacher handed her a copy of the Terminologia Anatomica, the international dictionary of anatomical terms, she learned that the Latin term for the vulva — including the inner and outer labia, the clitoris and the pubic mound — was pudendum. Translation: the part to be ashamed of. There was no equivalent word for male genitals.

That's when she really got fired up.

Anatomy as a science had its start in 16th-century Italy, as the purview of learned men. At the time it was a stretch to find a female corpse, let alone a female anatomist. Little wonder, then, that some words might sound a little off to modern ears. What surprised Draper was that this one had made it through 500 years of revisions and updates — and virtually no one knew what it meant.

That included her anatomy professor, Doug Broadfield, who had been showing the pudendal canal, nerve and artery to students for 14 years. "I never really gave it a second thought," he said. "You just don't really think about that kind of thing."

Nor was the term limited to academia. Anyone who has gone to medical school has probably learned how to perform a pudendal block, a numbing injection at the site of the pudendal nerve. It is used to diagnose and treat certain forms of pelvic pain, perform vulval and vaginal surgeries and, though less common than the epidural, alleviate the pain of second-stage labour.

Doug Broadfield of the University of Miami's Miller School of Medicine, with the Terminologia Anatomica. Photo / Gesi Schilling, The New York Times

Dr. Antje Barreveld, a pain management specialist at Newton-Wellesley Hospital in Massachusetts, performs around 250 pudendal blocks a year. "It's incredible that this Latin term has really persisted," she said. "What does that say about the medical establishment and their view of women?"

In 2019, with Broadfield's support, Draper began research for a paper arguing that pudendum was inappropriate as a medical term and should be removed. "It was a project of fascination," she said. "I just had to get to the bottom of it."

'Shame,' narrowed to women

In the beginning, shame knew no sex. First-century Roman writers used "pudendum" to mean the genitals of men, women and animals. But it was women to whom the shame stuck.

In 1543, the word made an appearance alongside an odd illustration in an anatomical atlas by Andreas Vesalius, a Flemish physician sometimes called the "father of modern anatomy." The image, although labelled a human uterus, looks unmistakably like a penis, but with a tuft of curly pubic hair near the head, reflecting the idea that women were just men with imperfect, internal body parts. (Also, recall the dearth of female corpses.)

A century later, a Dutch anatomist named Regnier de Graaf highlighted the role of the clitoris in female sexuality. "If these parts of the pudendum had not been endowed with such an exquisite sensitivity to pleasure," he wrote, "no woman would be willing to take upon herself the irksome nine-months-long business of gestation, the painful and often fatal process of expelling the foetus, and the worrisome and care-ridden task of raising children."

In 1895, anatomy officially recognised a pudendal region in both men and women. But 60 years later, only the "pudendum femininum" — the female shame part — was still listed. It would later be simplified to "pudendum" and used as a slightly more formal synonym for vulva. Today, the word appears in almost every medical textbook, including recent editions of Gray's Anatomy, Williams Obstetrics, and Comprehensive Gynaecology.

Draper wasn't the only person bothered by these roots. In 2014, Bernard Moxham, head of anatomy at Cardiff University in Wales, collaborated with Susan Morgan, from the same university, to examine gender bias in anatomy teaching. Most medical textbooks, they found, showed the male body as standard and trotted out the female only when it came time to show the reproductive system, genitals and breasts.

Andreas Vesalius (1514-1564), a Flemish physician often considered "the father of anatomy." Photo / Getty Images

In 2016, the pair asked hundreds of medical students and anatomists whether they had any concerns about the fact that the word "pudendal" stemmed from "to be ashamed." Most did not. One anatomist added that "it's interesting where it comes from, but it's established terminology now."

This blasé attitude appalled Moxham. It wasn't just the inherent sexism of the term, he said: "There is an element of that, there's no question about it. But it also, I think, is both scientifically and biologically inappropriate." As a general rule, anatomical terms are supposed to be informative and descriptive. "Pudendum" was neither. "This is the only term which has a moral context to it," he said.

There are other terms that reflect antiquated notions about women. The word hymen, which persists in nearly all medical textbooks, shares the same root as Hymen, the Greek god of marriage. Nymphae, a slightly older term for the labia minora, comes from the Latin word for bride or beautiful young maiden. Even the word vagina, which translates into sheath, scabbard or close covering, suggests that this organ's primary function is to house a penis, which is not accurate or scientifically neutral.

Moxham knew that even established terms could be changed, and thought they should be, as part of efforts to weed out racial and gender bias in medicine. He had just stepped down as president of the International Federation of Associations of Anatomists, which was working to release the newest edition of the Terminologia Anatomica.

In 2016, Moxham proposed that the federation's terminology group — which was, at the time, all male and mostly European — remove "pudendum" and related words from its upcoming dictionary. He couldn't tackle all of sexism within anatomy, but removing this one troublesome word seemed like an easy task. "I couldn't see any problem at all," he said. "I just couldn't have imagined."

'That's just not going to fly'

The terminology group describes its mission as stewarding a vocabulary that is "nimble and adaptive so as to remain relevant in a rapidly evolving world of medicine, biomedicine and health-related professions." But in practice, progress is slow. The guiding rule "is to be conservative when considering changes to terminology and logical in implementing changes," Thomas Gest, an anatomist and the former chair of the terminology group, said in an email.

At first, not everyone was convinced that "pudendum" was egregious enough to warrant throwing out. Some argued that the Latin root wasn't just about shame; it could also, in theory, imply virtue or modesty. Also, if you were going to change a word based on its weird Latin root, you'd have to start questioning hundreds of terms. Why does "penis" mean tail? Why does "acetabulum" — the hipbone socket — mean vinegar bowl?

The "pudendum femininum" entry in Allison Draper's copy of Terminologia Anatomica. Photo / Gesi Schilling, The New York Times

"People do not like change," Shane Tubbs, an anatomist at Tulane University who leads the terminology group, said. "There's some people in the anatomy world that are really wedded to the history of where the terms come from."

After some grumbling, however, everyone agreed that "pudendum" had to go. Then came time to change the related words: pudendal nerve, pudendal canal and pudendal artery.

To many members of the group, renaming a nerve that doctors referred to on a regular basis was a step too far. "There's no way anatomists can maintain any credibility with surgeons and other biomedical people if we say they can't use 'pudendal' anymore," Dr. Paul Neumann, a Canadian neuroscientist and member of the terminology group at the time, said. "That's just not going to fly."

"This is important," she said about changing terminology. Photo / Gesi Schilling, The New York Times

"You can't just throw out the only name something's ever been known by," he added. "And that's where the fighting really got intense."

For months, heated emails flew over what to do with the offending terms. One member ultimately resigned. The dispute grew so contentious that, in August of 2019, at Moxham's suggestion, the group agreed to a two-year moratorium so that tempers could cool. "How heated can a bunch of nerds get?" Gest asked. "But as far as nerds go, that was about as heated as we could get."

View from the doctor's office

The decision came quietly. Draper learned about it in late 2019 from a paragraph at the bottom of a medical article: "Pudendum" would no longer appear as an official term in the upcoming version of Terminologia Anatomica. However, the article noted, the pudendal artery, canal and nerve would remain relatively unchanged "because the use of the word pudendalis in terms for structures present in both sexes cannot be interpreted as sexist." In other words, if the shame was spread equally, maybe it wasn't so bad.

Not everyone was satisfied. Even if clinicians were reluctant to adopt new words, "this is not a reason for perpetuating the use of incorrect/offensive terms," Beverley Kramer, a South African anatomist and the current president of the anatomical federation, said in an email. Moxham agreed. "There will always be people who will be antediluvian," he said. But "what is the point of having any terminology group unless it's willing to grasp nettles on occasion?"

Draper, her original goal accomplished (albeit by others), saw an opportunity to start a larger conversation about gender bias in medicine. In her article, published this year in the journal Clinical Anatomy, she argued that the same sexist attitudes that had allowed pudendum to persist in the medical lexicon for centuries had real-life consequences in health care today.

Allison Draper, who will graduate in 2022. Photo / Gesi Schilling, The New York Times

"This isn't just people arguing about semantics," she said. "This is important because women, especially women of color and especially gender-nonconforming women, are not getting the same health care or access to health care that they deserve."

Shame is one factor that contributes to women, transgender men and nonbinary people with vulvas receiving worse or delayed care. A 2014 survey by British charity The Eve Appeal found that one-third of young women avoided going to the doctor for gynaecological health issues, and 65 per cent struggled to say the words vagina or vulva. That same year, American public health researchers found that up to half of those with vulva pain never raised their concerns with their doctor, at least partly because of stigma.

Leilani A., 30, never had trouble talking about her sexual anatomy. Then, in November 2018, she started feeling a persistent pain between her legs. "When I say burning vulva, I mean on fire," she said. Sex was excruciating; doctors suggested she try a glass of wine.

"It feels like the shame nerve," she said. "I had so much shame that I was like, Oh, my God, because I've been such an open, sex-positive person, is this my punishment?"

More than a year later, she was diagnosed with pudendal neuralgia, a chronic pain condition in which the pudendal nerve becomes injured, irritated or compressed. It occurs in men and women and is more common in athletes who cycle or ride horses, as well as women who have given birth or undergone pelvic surgery.

She eventually found treatment. But Barreveld, the pain specialist, says that many sufferers — particularly men, who make up one-third of her patients with pudendal neuralgia — are either reluctant to seek help or don't know where to turn. To put her patients at ease, she has made a tweak to her own language: She started calling the pudendal nerve "the undercarriage nerve."

"It's maybe a little bit more of a gentle way of referring to a very private area," she said. "It makes people chuckle and removes a little bit of that shame response."

In a practical sense, officially renaming the nerve would pose a challenge for clinicians like Barreveld, who refer to it every day. At the same time, "I think it's the right move," she said. "It's hard to make these changes, but at the same time it's a really powerful statement."

Turning the page

In a way, the pudendum debate can be seen as an extension of the movement to remove the names of unsavoury "discoverers" from medicine.

In recent years, there have been petitions to rename the instrument commonly known as the Sims vaginal speculum, a tool used daily by obstetricians and gynaecologists to observe the cervix. It was named for James Marion Sims, a Southern gynaecologist and slaveholder who made his advancements by experimenting on enslaved women.

"We're looking closer into the meaning of words," said Dr. Sabine Hildebrandt, an anatomical educator at Harvard Medical School and author of "The Anatomy of Murder: Ethical Transgressions and Anatomical Science During the Third Reich." (Hildebrandt attended medical school in Germany, where the lay word for labia is Schamlippen: the shame lips.)

It is the younger generation — future doctors like Draper, who will graduate in spring 2022 — who are leading this charge. "We'll have to see where this goes," Hildebrandt said. "We're in the middle of a movement here, that's for sure."

This article originally appeared in The New York Times.

Written by: Rachel E. Gross
Photographs by: Gesi Shilling
© 2021 THE NEW YORK TIMES