Episode 12: Beyond the Books
Over and over again we hear stories from patients with vulvovaginal and pelvic pain who have struggled for years to find care. These patients have been told things like “just drink a glass of wine” or “you must have repressed sexual trauma.” We wanted to find out, what are medical students and residents taught about these conditions? And why don’t most OB/GYNs know the steps to help?
In today’s episode, we’re getting a peek into another side of the conversation: what’s missing from medical education and training. We hear from medical providers and students who are working to close the gaps and we learn about Tight Lipped’s advocacy work, focused on ensuring that every OB/GYN residency program teaches about pain.
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Credits
Writer: Angela Johnston
Editor: Ava Ahmadbeigi
Executive Producer: Hannah Barg
Associate Producers: Sararosa Davies and Delilah Righter
Production Assistant: Kalaisha Totty
Art: By Sami Aryel
Transcript
Embodied Promo Swap:
[Enter Music - Eggs and Powder]
SARAROSA: Hi there. I'm Sarah Rosa Davies, an associate producer for Tightlipped. I want to tell you about a podcast I think you'll like. It's called Embodied. Journalist Anita Rao Takes on the taboo with folks who are unafraid to talk openly about who they are. In conversations about topics ranging from the history of vibrators to cultural norms about circumcision, this show breaks down narratives we've inherited about our bodies and explores how some seemingly unbreakable rules got written in the first place. Listen and subscribe wherever you get your podcasts.
[Exit Music]
Sponsorship Promo:
[Enter Music - Tiny Putty]
This season is made possible by our generous sponsors: The Vagina Collective, The National Vulvodynia Association, Ohnut, and DiscovHER Health.
The Vagina Collective funds people and organizations changing how society talks about vulvovaginal pain. The National Vulvodynia Association, a patient advocacy nonprofit committed to funding research that will lead to more effective treatments for vulvodynia.
DiscovHER Health offers Healthcare, Education, and Resources that allows patients to overcome the most intimate concerns from painful intercourse to embarrassing leaks.
And Ohnut: For when sex feels too deep, Ohnut is the partner-approved, doctor-recommended solution for more comfortable sex.
[Exit Music]
SCRIPT
[ENTER MUSIC: “Kvelden Trapp”]
NOA: Imagine you’re in your 2nd year of med school. You’ve spent months pouring over textbooks and you feel like you understand the basics – now, it’s time to learn the pelvic exam.
[MUSIC CHANGE: Fade “Kvelden Trapp,” Enter “The Crisper”]
You walk down the hall of what looks like a typical clinic and knock on a door. A voice tells you to come in.
AMICA: So usually there'll be a group of two to four students that comes into the room.
NOA: It looks like a normal doctor’s exam room. With bright fluorescent lights. A sink and cabinets. And Amica Hunter [Uh-mee-kuh] is there, sitting on crinkly paper on an exam table, wearing a hospital gown. Thick wooly socks on their feet.
[EXIT MUSIC, end on post]
AMICA: I say, hi, my name is Amica. I will be your GTA today. That's gynecological teaching associate, my pronouns are they/them. And I guess I'd like to go around the room and ask your name and pronouns and what your experience is with this sort of exam.
NOA: As a GTA, Amica uses their own body to train med students on how to do pelvic and breast exams.
AMICA: And some of them are like, I've never even seen a speculum in my whole life. And others are like, oh, I've, you know, I've done three under super supervision. Um, but either way, it's kind of rare that they're going to get the, the experience of how to communicate respectfully with your patient, from the perspective of the patient, you know?
NOA: Before walking into this space, you may have seen a video...showing you what to do.
AMICA: And they're always like, huh, weird in the video, they said this other thing. Um, and then some programs get the chance to practice with us on a task trainer, which is this synthetic like, honestly it looks like a terrible sex toy.
NOA: Amica tells you to make sure to ask the patient if they’ve ever had a pelvic exam before – and if there’s anything they’d like to share, like their preferred speculum size.
AMICA: but they can also let you know, oh, you know, I've had really traumatic experiences in the past or I'm pretty nervous or that sort of thing as well.
NOA: And then Amica shares something really important, and personal.
[ENTER MUSIC: “Distill”]
AMICA: I actually have a history of having pelvic pain condition and I was never told when I went in for exams that, um, they shouldn't hurt. There'll be times that are, um, a little bit uncomfortable, but nothing should be outright painful.
NOA: When Amica was younger, they just assumed this level of pain was normal for an exam.
AMICA: And I thought, you know, just in, in our culture, like everybody hates pelvic exams and I was like, oh yeah, we all hate them for the same reason. And it's because it hurts so bad, you could cry, but I guess that's not why we all hate them.
[EXIT MUSIC, end on a post]
NOA: Often the first time people realize they have vulvovaginal pain is when they get a routine pelvic exam. That’s what happened to me. I was 19 years old and I went to the gynecologist for my first pelvic exam and pap smear. Only, the doctor couldn’t get the speculum in. I felt this awful stinging pain that was impossible to push through. I didn’t know what was wrong, but it was one of the first times I felt that kind of pain.
[ENTER MUSIC: “Line Exchange”]
I often find myself coming back to that pelvic exam. Why didn’t my pain raise alarm bells? We hear so many similar stories at Tight Lipped, and we wanted to figure out why this is happening and how we can change it.
[MUSIC CHANGE: “Gambrel”]
NOA: This is Tight Lipped, a public conversation about a private type of pain. I’m Noa.
On this show, we talk about vulvovaginal and pelvic pain. We share stories about painful sex. And shame. And the politics surrounding these conditions that we often keep secret. We uncover why it’s so hard to get diagnosed and treated – and what we can do to change that reality. Our podcast is part of a grassroots advocacy organization, fighting for patients with these conditions to get the care they need and deserve.
We usually tell stories of patients, but today, we’re giving you a peek into another side of the conversation - what are med students and residents taught about vulvovaginal and pelvic pain? And how did patients end up in a situation where our OBGYNs don’t know the steps to help?
[EXIT MUSIC, fade]
Here’s Amica Hunter again, the gynecological teaching assistant.
AMICA: A lot of times I'll just say upfront, you know, like I have this condition, it was lifelong. I wasn't diagnosed for a long time. And then I had, uh, a surgery that, um, was really beneficial to me, which is why I can do this exam at all.
NOA: Amica tells students about having vestibulodynia. That means pain in the vestibule, or opening, of the vagina. Amica would feel a sharp, cutting, and burning pain. Doctors dismissed them for a while. And Amica tells the students how it took years to finally find a treatment that helped.
AMICA: it's been a whole journey and the fact that I can do the pelvic exams at all feels miraculous.
NOA: Amica is so comfortable with pelvic exams now, that they’re able to teach medical students what to do.
[ENTER MUSIC: “Calisson”]
Most medical students in the US start with two years of basic, pre-clinical instruction. Then they go and do two years of rotations in different areas, like family medicine, pediatrics, obgyn, and surgery. This helps to make sure that all doctors receive a comprehensive education, no matter where they end up. Since after this, they typically go on to do a residency in their chosen specialty.
But, in all those years of medical training, hearing from Amica may be one of the only times students hear about this condition, despite the fact that up to 26% of women and people with vulvas will experience chronic pelvic pain at some point.
[EXIT MUSIC]
The students who learn with Amica , get a little more than they would with another GTA. Amica says usually, no one has heard about vulvodynia.
AMICA: sometimes they just want to know, you know, what the condition was, what it meant. They're curious about the surgery, um, and how that went. No one's heard of it still ever. And a really amazing thing happened yesterday, actually….
NOA: Amica was two thirds of the way through the session and had started talking through their own experience with pain and surgery.
AMICA: And one of the students was like, really? Oh yeah. Cause they always hurt me so bad. And I have to take a Xanax before it every single year. And I could jump off the table. It hurts so bad. And I was like, well, what? And she also was like, yeah, I thought everybody felt that way. And like, she didn't know.
NOA: Honestly, I hear these kinds of stories every day. Medical students who diagnosed themselves through a chance encounter. Instead of from a doctor who was caring for them as a patient.
AMICA: So there’s all kinds of things that you know I like really want to add in, um, which is basically like pain, trauma, and gender. Let's bring, let's fold these into it so that we're actually addressing those things. 'cause I think a lot of times they're just not spoken of or mentioned ever at all.
ACT II
NOA: Amica trains med students in how to do pelvic exams in a caring way – and what to do if someone’s in pain. But that’s just one session – and it’s only if the students are lucky enough have Amica as their teacher.
[ENTER MUSIC: “Ether Ridge”]
And we see the consequences of that training gap every day. A Tight Lipped community member recently told me that her doctor suggested sticking a cucumber in her vagina to help with the pain. Another patient was told that there's no reason the exam should be painful – and she must have repressed sexual trauma.
Clearly there’s still so much that doctors are missing.
The Tight Lipped team has been trying to figure out how we got here – and how we address these gaps in education.
For the past year, over thirty Tight Lipped volunteers have been searching for answers . We had zoom calls with many sexual medicine and pelvic health specialists around the country, we read articles and studies, and chatted with dozens of med students. Like Stephanie Moss, who showed me her medical school textbook.
[EXIT MUSIC]
STEPHANIE MOSS [SIFTING THROUGH TEXTBOOK]: Okay, so I'm going to V.
NOA: She’s a third year med student in Chicago. And when I called her up one day, I asked her to look up words like vulvodynia in some of her textbooks.
STEPHANIE MOSS [SIFTING THROUGH TEXTBOOK]: I see vagina anatomy, postpartum changes, vaginal cancer, vaginal delivery. vaginal exam specifically in labor, discolorations, ring…
NOA: In the first few years of med school - you’re learning the basics and memorizing and marking up text book pages like the one Stephanie is flipping through.
STEPHANIE: We have hypoactive sexual desire disorder, sexual aversion disorder, sexual arousal disorder. Female orgasmic disorder. Vaginismus: persistent involuntary spasm of the muscles which interferes with sexual intercourse.
NOA: dyspareunia is the word for pain with sex. I wonder if you looked at the does dyspareunia show up anywhere else?
STEPHANIE: dis D Y S yep. Um, 330. Manage: by surgery, vaginal estrogen, pelvic floor therapy, changing positions. // um, take experience, assess physical factors, if they've had surgery, psychological again. And then the last, point is past partner's lack of sexual skills
[ENTER MUSIC: “Transit Alias”]
NOA: The thing is, this culture of dismissing patients in pain, isn’t a coincidence. It comes from somewhere. One culprit: study materials. I asked a different medical student to look up “dyspareunia,” in another medical study guide called Boards and Beyond. Dyspareunia appeared twice – once under endometriosis. But the second time, it was listed as a symptom of “Somatic and Factitious disorders, which literally means “artificially created,” it’s psychological, with real or made up physical symptoms.
While vulvovaginal pain is mentioned very rarely in the textbooks, lectures, and overall training, male sexual health isn’t hard to find. I heard this from med students like Jen Romanello and fellow student Nicolette Codispoti.
[EXIT MUSIC, end on a post]
JEN ROMANELLO: There was a lot about physiology of, erection, um, and ejaculation.// there were all these like cross sections of the penis and, um, that really was not the case with the clitoris.
NICOLETTE: We talk so much about Viagra, we talked about Viagra since day one, literally since day one, cause it's relevant to like biochemistry.
NOA: There’s plenty of education on male anatomy. But little, if any, on female anatomy . Let alone pain. This is frustrating for doctors like Dr. Rachel Rubin, a urologist and sexual medicine specialist. She’s vocal on social media about the need for better education and care on sexual health.
DR. RACHEL RUBIN: You've got to be kidding me that I am, uh, in a way famous academically, famous for teaching people how to do a basic vulvar exam.
NOA: Because there aren’t enough loud voices advocating for women’s sexual health and teaching basic information…
DR. RACHEL RUBIN: Women's sexual health is always going to be last on the order of things that are important to talk about, right? Men sexual health, that's going to get covered. Women's sexual health is not going to get covered, which is insane. The clitoris is not even diagrammed correctly in any of our textbooks.
NOA: If it’s missing from textbooks and from pelvic exam training, what about in lectures? Or clinical rotations?
RACHEL RUBIN: There is no standard medical curriculum devoted to the vulva exam or to female sexual health complaints.
[ENTER MUSIC: “Plasticity”, fade build up and then beat drops right after Rubin select]
NOA: Med schools are required to teach students to perform pelvic exams. Just like how to take someone’s blood pressure But for vulvar health and anatomy, students learn different things at different schools. It’s a matter of chance if you happen to learn about vulvovaginal pain or even detailed anatomy.
DR. RACHEL RUBIN: when you’re learning pelvic exams, you should learn that the vulva is a part of the pelvis. And you should look with eyeballs at the vulva and think in a way that this is part of anatomy and anatomy I need to look at. Unfortunately, what it's taught now is this is a speculum which goes through the vestibule bypasses, and we don't look at the vulva in any critical thinking way.// Um, and we just go straight into find the cervix and that is the mistake.
[EXIT MUSIC: “Plasticity,” fade out on a post]
NOA: it’s important for all med students, regardless of which speciality they end up in. Because imagine you’re a med student training to be a pediatrician. What would you do when a preteen comes in, complaining of pain when they try to insert a tampon? Or if you’re training to be a dermatologist, or a family medicine doctor. Often patients first pap smears are with primary care doctors. Every med student should know how to properly do a pelvic exam and diagnose vulvar pain so they can at least refer someone to an OBGYN. But often the OBGYNS are lost, too.
I spoke to an OBGYN to see what they’re required to learn in residency. Here’s Dr. Sara McKinney an OBGYN at Beth Israel Hospital in Boston. She’s also the director of their Vulvar Clinic.
SARA MCKINNEY: There's no specifics, like must be able to diagnose vulvodynia must be able to diagnose like, like these words are not even mentioned on those requirements.
NOA: And that’s the biggest problem–even OBGYNs—the doctors we’d expect to know about vulvas—aren’t getting adequate training during their residencies. Luckily, Dr. McKinney happened to have a great vulvar specialist as a teacher during her residency, but she says that’s a rare exception.
SARAH MCKINNEY: Only twice in the four years I was a resident did we have, um, 45 minute lectures on vulvar related conditions // and if you were on your nights rotation or on vacation that week, you missed that lecture.
NOA: Dr. McKinney is trying to address this issue by teaching the residents she supervises.
But that’s not the norm. OBGYN residents don’t typically learn about chronic vulvovaginal pain conditions. If they do, it’s likely after residency, as part of a highly specialized fellowship program. That’s what Dr. Maria Uloko did, as a urologist. And because of it, she went on to specialize in sexual medicine.
DR. MARIA ULOKO: my eyes were blown, like mind was blown as to, um, the content that I thought I knew that I learned in training, um, was markedly different.
NOA: Dr. Uloko was shocked at what she was hearing from her patients. They would say things like…
DR. MARIA ULOKO: this is like my fourth, fifth, sixth, 10th provider. I've had this condition for 15 years." Over and over and over and over again. And as a urologist, dealing with my patients with penises, whenever they have sexual health complaints, like once they get over the barrier of the shame piece, they can easily get care.
[ENTER MUSIC: “Bauxite”]
As soon as it started going down the realm of sex and sexual health for women, um, we would send them straight to gynecology.
NOA: So patients with vulvar pain aren’t getting the care they need from urologists or the supposedly appropriate counterpart - the gynecologists. According to Dr. Uloko, this is a larger problem with the institution of gynecology.
DR. MARIA ULOKO: So it's not necessarily a failure of the individual. It's a failure of the, the field of gynecology. And if you really look at the history of the field of gynecology, it's a history based in misogyny, racism and the exploitation of women's bodies.
[EXIT MUSIC: fade out]
NOA: Gynecology is a field that is still reckoning with informed consent. Until very recently, many med students and doctors were performing pelvic exams on unconscious patients who hadn't explicitly agreed to the procedure.
So maybe none of this should really be that surprising.
MARIA: As you're watching the progression of the field of gynecology, you're not seeing anything about sexual health. Actually, when it's addressed in historical context, it's actually a nuisance. sexual sexual health sexuality is seen as, uh, The woman is unclean. It is seen as hysteria. It is actually seen as a mental health condition.
NOA: Dr. Uloko says it’s also led to ideas that vulvas and vaginas are seen predominantly as things for reproduction - and that, in turn, gets reflected in the training, the curriculum, the textbooks.
MARIA ULOKO: if you look at the curriculum for gynecology and just doing a general exam, A lot of the structures that are so important to sexual health, all of our sexual health, aren't, weren't even officially labeled until 2005. Right? So that's like in gynecology textbooks, we didn't even have full structures labeled up until like path post Y2K, right? Like it's, that's wild.
NOA: It is wild. And what’s more infuriating is we know firsthand that this leads to so many patients not getting the care they deserve. There are real long-term consequences to this gap in training.
People who are dismissed by their medical provider might go years with pain, and their condition will likely be harder to treat by the time they are diagnosed. Many of us avoid getting our regular pap smears because we can’t tolerate the exams – and most of our gynecologists don’t know how to help us. There are patients who develop serious mental health conditions in the absence of a diagnosis and medical explanation for their condition.
[ENTER MUSIC: “Lemon and Melon”]
So how can we fix this? Who has the power to update curriculum? To change the diagrams in text-books, to require full vulvar exams in OBGYN training?
Well, we might have an idea. Right now, across the country, Tight Lipped is working with patients and providers who are trying to figure out a solution. But we’ll come back to that.
[EXIT MUSIC, fade on a post]
ACT III
Luckily, we’re not the only ones trying to change medical education. In Chicago, a group of medical students from 7 different schools are working on this. They founded the Medical Student Forum on Female Sexual Medicine. They host meetings for students to independently learn about sexual medicine, including vulvovaginal pain conditions.
Nicolette Codispoti and other leaders invite guest lecturers to come in and share knowledge.
NICOLETTE CODISPOTI: Does the need exist for us to do anything in medical education? And we knew the answer before starting the project. I mean, we've, most of us are now in our third year, so we've gone through all the preclinical years and we knew that we don't learn anything really about female sexual medicine, female sexual dysfunction.
NOA: To be clear, we know that this impacts patients' lives outside of their sexual health and function. It can be everything from urinary symptoms to chronic tailbone pain. But these conditions often fall under the umbrella of sexual medicine.
So, the student forum leaders are working to change what the schools themselves teach. They’re conducting original research and trying to quantify what is actually missing from the curriculum. They plan to make some big recommendations to the curriculum committees.
NICOLETTE: you know, what are the bare minimum things that we feel from like a sexual health perspective that need to be covered. I don't care where you put it, but like maybe find some room for it somewhere. Um, even if it's a lecture that you already have all this male sexual dysfunction. You should be including the female sexual dysfunction too.
NOA: There are also doctors, like Dr. Rachel Rubin, Dr. Sara McKinney, and Dr. Maria Uloko who are working around the clock to fill in the gaps themselves. They’re trying to educate their peers about these conditions.
[ENTER MUSIC: “Taoudella” after “gaps themselves”]
MARIA ULOKO: if I can teach people how to diagnose patients the first time they come into their office, validate them, diagnose them correctly, and then get them treatment, I will die happy. I am so tired of hearing stories of 20 years, 15 years, 30 years, I'm tired of people crying and I hold that pain that they have, and it's not crying because like, you know, it was painful. It's crying because finally someone believed them. Finally, someone gave them an answer.
[EXIT MUSIC, fade]
NOA: The doctors who are treating patients with these conditions know how important it is to train their colleagues. Like Dr. Uloko, they’re tired of seeing patient after patient who has been dismissed for years.
Hearing from these medical providers gives me hope for future patients. I know that the students who Dr. Uloko trains will believe their future patients and know the basics of vulvar, vaginal, and pelvic pain.
Still, thousands of patients will continue to be left behind if we don’t push for broader change from the institutions and governing bodies that could require all OBGYN residents to learn about vulvovaginal pain.
MARIA: ACOG, gynecology should be putting more of this in a, to a focus because it's not a niche. It should never be a niche. Sexual health is health, and it should not be a niche anymore.
NOA: While curriculum and training can vary from program to program, there are a handful of institutions that have the authority to set standards nation-wide. For example, there’s ACGME, the accreditation body for OB/GYN programs. And there’s ACOG - the American College of Obstetricians and Gynecologists. They can influence what OBGYN residents are learning – and they’re often the go-to resource for gynecological care.
MARIA ULOKO: that's the only way that's going to happen is by administrators, hospitals, ACOG, medical centers, knowing that this is a problem. Um, because they can only listen to you know, a handful of doctors screaming at the top of their lungs, doctors, physical therapists, sex therapists, screaming at the top of their lungs, but they have to listen to patients because why we exist is for patients.
NOA: That pressure also needs to come from us, the patients. Starting now .
[ENTER MUSIC: “Um Pepino”]
Tight Lipped has launched our first grassroots campaign. We’re advocating for OBGYN residency programs to teach about vulvovaginal and pelvic pain. Every single OBGYN should be learning how to diagnose and manage these conditions.
This is really basic information. It’s knowing what questions to ask when a patient presents with pain – how to do a vulvar exam and assess the pelvic floor muscles. It’s learning about trauma-informed care and what to say to a patient. It’s understanding the range of conditions that could cause someone to have persistent pain, itching, burning, and stinging.
[EXIT MUSIC: fade on a post]
You’ve heard me say this a million times, but I’ll say it again. Chronic vulvovaginal pain is so common, no OBGYN resident should be graduating and practicing medicine without this knowledge. Here’s Dr. Rachel Rubin again.
RACHEL RUBIN: there have been some incredible advocates, patient advocates who have gotten textbooks changed.
NOA: Historically, patients have joined together to fight for the treatment they need. We’ve seen this with Breast Cancer patients, HIV and AIDS activists…and today with people in every state working day and night to help each other access reproductive care .
RACHEL RUBIN: Right where, uh, roadblock, roadblock, roadblock, but you just keep, um, you know, plowing down those roadblocks / We can, we will and can, and are forming an army to fix this problem because we will not rest until these problems are fixed.
[ENTER MUSIC: “Matamoscas” at “forming an army”]
NOA: Tight Lipped is calling on OBGYN residency programs – and the institutions that govern them – to teach about pain.
We’re building on decades of powerful patient activism – like Dr. Rubin said, we’re building an army of patients demanding change. I’m thrilled that what started as a storytelling project, with this podcast, has grown into a grassroots movement of patients, doctors, OBGYN residents, med students, and so many friends and supporters.
We’re fighting for a future where every patient with chronic pelvic pain can go to the gynecologist and get a diagnosis. Where patients are screened for these conditions at annual check-ups to prevent them from going years suffering in silence. Where every gynecologist knows how to help a patient in pain through an exam, and where to refer them for resources.
Here’s the future our community members envision and are working towards.
[Enter Voice Montage]
[MUSIC CHANGE: “Calmion”]
I walk into the doctor's office, into the waiting room. It feels like I'm going to actually be cared for.
The provider greeting me and asking what I would like them to know about me and what is most important from my perspective to discuss at today's session.
It would've been really amazing if the doctor asked me about how this was affecting my life beyond the physical pain.
…understanding my life and my sexuality. And they do so in a respectful tone. There's no judgment.
I want to be asked for consent before every step of the process. So I like my nurse and doctor to tell me about each thing they're going to do before they do it.
…making it really well known that I can say no at any time.
My doctor doesn't need me to educate her on vaginismus or what an overactive pelvic floor is. She already knows about these things.
I leave my doctor's appointment feeling empowered and informed, and I feel like my medical team knows me, cares about me.
The first provider is gonna be the appropriate provider. You know, instead of them seeing five to seven providers before getting the appropriate treatment.
I just want to know that I will be taken care of, that my time matters, um, and that my body matters.
And if you know, we're able to prevent the next person from. You know, being held down during a pelvic exam or being told that their pain isn't real, or to just drink a glass of wine to relax during sex, That that working for one person is enough for me.
Noa: Our community is transforming this vision into a reality every day. We hope you’ll join us! You can sign up to get involved in our campaign, on our website at www.tightlipped.org!
[MUSIC CHANGE: “Home Home At Last”]
CREDITS:
Thanks for listening! To join our community, sign up for our newsletter at tightlipped.org or find us on instagram. Check out the episode page on our website to find articles and info that we referenced in this story.
This episode was written by Angela Johnston and edited by Ava Ahmadbeiji. It was executive produced by Hannah Barg with the help of Delilah Righter, Sararosa Davies, and Kalaisha Totty. We received additional support from Judah Kauffman and Sela Waisblum . Our fact checkers are Rachel Gross and Sara McKinney.
Special thank you to Roshni Babal, Shannon Boerner, Kaitlin Bonfiglio, Hannah Haas , Allison Landry, Shea O’Donnell, Hips and Pelvis Advocate, and to all of the folks at the Medical Student forum.
Our episode art this season was designed by Sami Aryal. The music you heard was from Blue Dot Sessions.
If you’d like to contribute to our work, you can make a donation on our website. We’re building a grassroots movement by and for people with chronic vulvovaginal pain and we hope you’ll join us.