Examining the Vulva: The Relationship between Female Genital Aesthetic Perceptions and Gynecological Care

By Vanessa R. Schick

B.A. May 2004, University of Massachusetts, Amherst

A Dissertation Submitted to

The Faculty of

Columbian College of Arts and Sciences of The George Washington University in Partial Satisfaction of the Requirements for the Degree of Doctor of Philosophy

January 31, 2010

Dissertation directed by

Alyssa N. Zucker Associate Professor of Psychology and Women’s Studies

The Columbian College of Arts and Sciences of The George Washington University

certifies that Vanessa R. Schick has passed the Final Examination for the degree of

Doctor of Philosophy as of August 19, 2009. This is the final and approved form of the

dissertation.

Examining the Vulva: The Relationship between Female Genital Aesthetic Perceptions and Gynecological Care

Vanessa R. Schick

Dissertation Research Committee:

Alyssa N. Zucker, Associate Professor of Psychology & Women's Studies,

Dissertation Director

Laina Bay-Cheng, Assistant Professor of Social Work, University at

Buffalo, Committee Member

Maria-Cecilia Zea, Professor of Psychology, Committee Member

ii

© Copyright 2009 by Vanessa R. Schick All rights reserved

iii

Acknowledgments

The past five years have changed me and my research path in ways that I could have never imagined. I feel incredibly fortunate for my mentors, colleagues, friends and family who have supported me throughout this journey.

First, I would like to start by expressing my sincere appreciation to my phenomenal dissertation committee and all those who made this dissertation possible:

Without Alyssa Zucker, my advisor, my journey would have been an entirely different one. Few advisors would allow their students to forge their own research path. However, she let me follow my passion, even when it led me into unchartered waters. I would not be where I am today without her support and guidance. I am forever thankful to her for taking a chance on me.

I feel incredibly fortunate to have had the opportunity to work with Laina Bay-Cheng over the past five years. Her thoughtful revisions never ceased to amaze me. She continuously challenged me to think about things in ways that I would have never considered. I am a better researcher because of her.

I never realized how influential a single course could be before I took one with Maria-

Cecilia Zea. The space that she created for openness and acceptance allowed me and my research to flourish in ways that I had not thought possible. Her faith in me gave me the confidence to take the risks that have had made my research possible.

I am incredibly thankful to my outside dissertation committee members. I cannot thank

Rolf Peterson and Florence Haseltine enough for offering to be on my committee despite their busy schedules and my condensed timeline. It was truly an honor to have such

iv distinguished members on my committee. Their unique input on my dissertation was invaluable.

I would be remiss not to thank all of all of the RA’s who have helped me over the years.

In particular, I would like to send a special thank you to Katie Armstrong. I feel incredibly fortunate to have had her as both a student and an RA. I am deeply appreciative for her enthusiastic and careful work.

Finally, I would like to thank everyone at the Center for Sexual Health Promotion for providing me with a motive to finish my dissertation. I could not have imagined a more perfect opportunity.

Most importantly, this dissertation would not have been possible without the women that took the time to share their personal thoughts and feelings with me. I am thankful to each and every one of them.

I would like to thank all of the mentors, colleagues and friends who helped me to grow both personally and academically over the years:

First, I would like to thank everyone that I worked with at the Society for Women’s

Health Research including Florence Haseltine, Stephanie Pincus, and Suzanne Stone. The skills that I learned while there will likely apply in my future in ways that I can only imagine.

I would not have gotten through the past five years without the support of colleagues and friends. Annette Kaufman, I will be forever grateful that I came into this program with someone as supportive and thoughtful as you. Laura Landry and Andrea Mercurio, thank

v you for taking me under your wing. Brandi Rima, I feel fortunate to have had the opportunity to work with you over the past several years. I cherish you as both a co- worker and a friend. Thaddeus Russell Sullivan, I cannot thank you enough for your unwavering support over the past several months. Tini Town, although we have had some ups and downs over the past several years, your consistent use of the litter box over the past few months has helped me to maintain my sanity in ways that you cannot even imagine.

Above all, I would like to express my gratitude to Sarah Calabrese. Words cannot express how meaningful she has been to me over the past five years. She is undeniably one of the most remarkable people I have ever known personally or professionally. I do not know what I am going to without my better half.

I would like to thank the family members who influenced the person that I am today:

Grandma and Aunt Bobbie, you showed me that one can be both elegant and refined without being either passive or submissive. I have always admired your seemingly smooth social graces. Frank, you made me recognize that I was stronger than I realized.

Thank you to Jordan, Max, Jenna, Jason and the many other family members who have touched my life in various ways.

At risk of writing an acknowledgment section that surpasses the length of my dissertation, I would like to thank all of my brothers and sisters individually. Maleese, thank you for always wearing such big shoes. I have had to run in circles trying to fill them. Jared, you have always been wise beyond your years. I envy your tenacity. Ezra, the good in you is absolutely undeniable. Rosalind, your pure kindness is an inspiration.

Sophie, I hope to be as versatile as you when I grow-up. Sam, my munchkin, I knew how

vi special you would be to me before you could even speak. You are truly my Okapi. Thank you all for helping me keep it all in perspective.

Finally, I would like to thank my parents whose love and support made this possible.

Dad, many people have told me that I work harder than anyone they have ever met. I often respond by telling them that they have never met my father. I am in awe of your ability to manage a business and raise a family. Your strength and resilience inspires me everyday. I would also like to thank my mother, who has always encouraged me to take the road less traveled. She has never suppressed my creativity, even when it meant letting me walk out of the house in a jacket made of bubble wrap and pants sewn together with

Astroturf. I have never had to question her faith in me.

Lastly, I would like to dedicate the dissertation to my stepmother Ellen. She was an incredibly humble person who, if alive today, would find this gesture uncomfortable and embarrassing. However, her role in this dissertation was undeniable. Her battle with gynecological cancer was at the root of the topic of the dissertation. Additionally, although Ellen never had the opportunity to finish her dissertation, I was recently surprised to find out that her topic (speaking about the unspeakable) parallels my own research (exposing taboos/ opening closed discourses), illustrating her enduring influence on me. Although she never got to see where my graduate path ended, I can only hope that the direction was one that made her proud. She was truly one of the most wonderful people that I have ever had the opportunity to know. Oddly, she always told me that she envisioned me being the happiest in Bloomington, IN. I sure hope that she was right.

vii Abstract of Dissertation

Examining the Vulva: The Relationship between Female Genital Aesthetic Perceptions and Gynecological Care

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.

viii 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

ix 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

x Pap smear embarrassment survey……………………………………… 67

Netherlands Comparison Orientation Measure (Social Comparison

Scale)…………………………………………………………………… 68

xi 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

.

xii 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

Intercorrelations for Measures of Vulva Perceptions and Pap 5. Smears. ……………………………………………………………. 73

xiii

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

1 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

2 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.

3 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

4 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).

5 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.

6 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).

7 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).

8 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

9 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).

10 An ABC Path from Genital Discontent to Pap smears Intentions

Activating Genital Perceptions via Female Genital Images

According to social comparison theory, when people are motivated to evaluate themselves and nonsocial comparisons (e.g., objective measurements) are unavailable, they will turn to social comparisons to evaluate themselves on a respective dimension

(Festinger, 1954). Consequently, a woman seeking information about genital aesthetics will turn to social comparisons in order to evaluate the appearance of her vulva.

However, social norms may limit the number of relevant others with whom women can compare their vulvas, forcing women to seek comparisons with images in the media.

Vulva imagery is largely absent within the mainstream media (Bramwell, 2002), limiting the availability of vulva images to sexually explicit materials (e.g., pornographic magazines). Past research suggests that women see Playboy and Penthouse models as reasonable referents and compare their own (Boynton, 1999) and others’ (Kenrick,

Gutierres, & Goldberg, 1989) attractiveness levels to those of these models.

However, unlike other body ideals, women may be unaware that the vulvas of many of the models have been airbrushed or reconstructed through plastic surgery in order to embody a social ideal that does not represent the normal range of sizes and colors of female genitalia (Braun, 2005). The social sanctioning of women’s genital exposure restricts women’s access to other visual depictions of female genitalia, making it difficult for women to make accurate comparative assessments (Blank, 1993). Thus, for those women who do not have more realistic vulva representations available, viewers of these pictures may see them as a reasonable referent, forming a distorted basis for comparison.

In the same way that using pictures of idealized genitalia as a comparison baseline may distort women’s perceptions about the size of their genitals, women presented with a realistic range of genital pictures will form a more accurate genital baseline with which

11 they can compare in order to assess the normality of their genitalia. Providing women with reasonable referents with which to compare their bodies (i.e., norm misperception education) has been demonstrated to be an effective tool in increasing women’s actual and ideal body weight over time (Mutterperl & Sanderson, 2002). Norm misperception education may prove to be similarly effective in expanding women’s perceptions of the range of attractive vulvas and increasing their satisfaction with their own genitalia.

The assumption that norm misperception education may decrease women’s concerns about the appearance of their genitalia is consistent with previous research that demonstrates that a woman’s perceptions of her vulva may be altered based upon her exposure to realistic vulva images. In an experiment, Schick, Calabrese, and Rima (2008) exposed undergraduate women to one of several sets of pictures. The participants were assigned to one of three conditions in which they were asked to rate the attractiveness of realistic genital images, idealized depictions of genitalia or a control condition (no picture). Participants were also asked about their about their previous exposure to their own and other women’s genitalia and their past viewing experience with pornographic magazines in order to control for experiences that would impact women’s intentions to use the genital images as a reference point. Many young women report having never looked at their own genitalia (Oscarsson et al., 2007) and, therefore, would not have a reference for comparison when presented with the pictures within the manipulations.

Additionally, the frequency with which the participants reported engaging in sexual acts that involved genital contact with other women was recorded under the presumption that participants who report previous exposure to realistic representations of women’s genitalia (e.g., a female partner with whom they have had genital contact), may already have a basis for genital comparisons, reducing the impact of the unrealistic images. For this reason, the frequency with which the participants reported having viewed previous pornographic images was also assessed. Finally, the participant’s propensity to engage in

12 upward social comparisons was measured in order to identify the participants who were

more likely to compare their genitalia to the genitals of the models. After controlling for

these four variables, Schick et al. found that woman’s perceptions of several components

of their vulva (e.g., labia size) varied according to the picture set to which they were

exposed. Consistent with other research which has incorporated norm misrepresentation

theory (e.g., Mutterperl & Sanderson, 2002), women who were asked to rate pictures of realistic vulvas rated individual components of their vulva appearance as closer to the social ideal (e.g., a smaller labia) than those exposed to pictures of idealized vulvas from men’s magazines. Thus, I hypothesize:

Hypothesis 1: After controlling for the frequency with which women view their

own vulva, the number of female sexual partners with whom they have had

genital contact, the frequency with which they reported viewing pornographic

materials and their tendency to engage in social comparison, women who are

exposed to idealized images of vulvas from men’s magazines will perceive the

external components of their own vulva (e.g., the labia minora) as more deviant

from the social ideal than those women who are exposed to realistic

representations of vulvas (see Figure 2, Path 1).

Genital Perceptions as an Antecedent to Generalized Genital Concerns

Higgins’ (1987) self-discrepancy theory contends that people have three social self domains including an actual (what they really have), an ideal (what they would like to have), and an ought (what they think they should have). According to self-discrepancy theory, if there is a discrepancy between the ideal (other) and the actual (self), the person will experience dejection-related emotions including shame and embarrassment about the relevant construct. Thus, if a woman’s perception of her actual labia minora and clitoris size deviates from her internalized ideals, she may be more likely to experience shame or embarrassment about her genitalia than a woman whose actual labia or clitoris size

13 matches her ideal. This assertion is consistent with research in which young women’s perceptions of the size of their labia minora predicted global genital discontent including perceptions that their genitals were offensive, embarrassing and unsatisfactory. The participants’ perceptions of their labia size also predicted sexual variables including genital self-consciousness during sex and future motivation to engage in sexual activities

(Schick et al., 2008). Therefore, I hypothesize the following relationship:

Hypothesis 2: The participant’s perception of the external components of her

genitalia (e.g., size of labia minora) will predict her overall rated satisfaction with

her genital appearance (see Figure 2, Path 2).

The Relationship between Genital Dissatisfaction and Exam Embarrassment

In a performance art show designed as a social critique of the objectification of women and their bodies, Annie Sprinkle invites audience members for an up-close look at her cervix through a speculum. During the show Sprinkle provides several reasons for conducting the show, titled the Public Cervix Announcement (Kapsalis, 1997). Included in her list of reasons is her belief that her cervix is beautiful, a statement which is meant as a mockery of the association between genital beauty and exposure. In accordance with

Sprinkle’s performance piece in which she critiques the relationship between attractive genitalia and genital exposure, Frueh (2003) writes about undergoing genital scrutiny during an endometrial biopsy:

…when I was in the lithotomy position and wanting to squeeze the nurse’s hand if

I hurt a lot during the procedure, she and the female gynecologist stared suddenly

at my cunt. Was it shrunken and dry like an old woman’s supposedly is? Was it

too colorful—more purple than pink? its inside unusually rugose, both

characteristics said to be indicative of a woman who enjoys sex and has had a lot

of it? Was mucky mucus or dried cum decorating my orifice or lips? Were the

14 latter, which are big [italics added], too conspicuous for the viewers’ taste

because I had trimmed off most of my pubic hair? (p. 144)

Frueh is concerned about her genital aesthetics, which differ markedly from the plasticized ideal presented in recent issues of Playboy magazine (Schick, Rima, &

Calabrese, in press). This discrepancy between the plasticized ideal and her actual vulva manifested into genital discontent, a feeling which she pointedly states had overshadowed fears of pain. The suddenness of Frueh’s concerns is consistent with Higgins’ (1987) self- discrepancy theory, which posits that people will experience shame and embarrassment about discrepant constructs in context-relevant situations. This is consistent with

Reinholtz and Muehlenhard’s (1995) finding that women reported the greatest genital concerns during sexual acts that focused on their genitalia. Outside of intimate encounters, the pelvic exam is one of the only occasions when women’s genitals are viewed by another person. Thus, if there is a discrepancy between a genital actual and a genital ideal, women may feel embarrassed about this discrepancy during a gynecological exam.

Although the relationship between genital perceptions and perceptions of embarrassment about gynecological care has yet to be investigated, research supports this relationship. For instance, Herbenick (2007) incorporated an item regarding gynecological care in her measure of genital perceptions. Additionally, women report perceiving a procedure in which they collect a vaginal specimen on their own to be significantly less embarrassing than a conventional Pap smear which requires that the sample be collected by a practitioner (Dzuba et al., 2002). This demonstrates that, when holding the act of undressing and body focus constant, it is the presence of the spectator that causes women embarrassment. Specifically, women rate the act of undressing for a stranger and allowing the practitioner to examine their bodies as especially embarrassing

(Oscarsson et al., 2007). The woman’s perception of embarrassment when the

15 practitioner gazes at her body is magnified if the woman has concerns about the

appearance of her body (McKinley & Billingham, 1998), including her genitalia.

Genital embarrassment may be especially poignant during a woman’s first pelvic

exam because it may be the first time that the woman exposes her genitalia for

observation and she may be concerned that her genitalia may not appear physiologically

normal to the practitioner (e.g., Hennigen & Kollar, 2000; Oscarsson et al., 2007;

Ricciardi, 2000). The magnitude of this barrier for patients was highlighted in a study in

which young women reported a limited recollection of exam details or physician

commentary other than comments related to the physiological normality of their genitalia,

indicating that genital concerns may take precedence for young women who may be

exposing their genitalia for the first time (Oscarsson et al., 2007). Both sexual experience

and number of gynecological exams are inversely related to age, limiting young women’s

opportunities for feedback regarding the ordinariness of their vulva. Consequently, in

order to make the Pap smear more comfortable for young women, researchers

recommend reassuring the women that their genitals are normal and healthy during the

exam (e.g., Leppert, 1985; Hennigen & Kollar, 2000; Ricciardi, 2000). This suggests that

women’s genital concerns may be an antecedent to the psychological distress of the

patient. Thus, I hypothesize the following relationship:

Hypothesis 3: The participant’s discontent with the appearance of her genitalia

will be positively related to the participant’s concerns that the Pap smear exam

will be embarrassing (see Path 3, Figure 2).

Exam Embarrassment and Anxiety as a Predictor of Pap smear Intentions

The direct relationship between Pap smear embarrassment and Pap smear intentions is a well established one (e.g., Moore, Gridley, Taylor & Johnson, 2000;

Murray, & McMillan, 1993). Burak and Meyer (1997) tested the applicability of the

Health Belief Model (HBM) variables in predicting Pap smear intentions with a college

16 population and found that the participants’ perception of embarrassment as a barrier to receiving the exam was high, with approximately two-thirds of the women reporting perceptions of the exam as embarrassing. The relation between embarrassment and gynecological care was further corroborated through a nationally-representative survey designed to assess the relationship between HBM variables and Pap smear behavior.

Researchers found that the removal of all the variables in HBM other than embarrassment failed to have a significant impact on the fit of the model (Sutton & Rutherford, 2005).

According to REBT, self-defeating thoughts about the exam (i.e., embarrassment) would not directly predict the consequence (i.e., Pap smear intentions) but are instead mediated by a negative affective reaction to the exam (Ellis, 1984). A review of past interventions found that while most interventions target women’s knowledge of Pap smears, the few interventions that have been designed to negate women’s Pap smear fears are more effective (Yabroff et al., 2003), suggesting that Pap smear fear is a significant impediment to women’s intentions to seek gynecological care. Women have reported that anxiety levels before receiving a Pap smear are similar to other anxiety-provoking procedures including colonoscopies, infertility treatments, dental exams and venepuncture (Frye, & Weisberg, 1994; Lee, Wetsrup, Ruzek, Keller & Weitlauf, 2007).

The anxiety that women experience in response to thoughts about obtaining a Pap smear may stem from a fear of pain, discovery of pathology, discomfort about discussions concerning sexual activity, embarrassment about being undressed, fear of genital abnormalities and/or concerns about personal hygiene. Although women’s anxiety may be a function of the aggregation of negative cognitions related to the exam, research suggests that women’s Pap smear anxiety will differentially predict exam intentions depending upon the specific source of anxiety that is being measured. For instance, certain types of anxiety (e.g., anxiety concerning pathology) may actually motivate participants to increase intentions to receive a Pap smear (Eaker, Adami, & Sparen,

17 2001). Other types of anxiety may affect Pap smear intentions differentially based upon the population that is being surveyed. While some of the fears that women have about

Pap smears may not decrease as a function of the number of Pap smears received

(Domar, 1985/6), other fears about the Pap smear experience may dissipate as women become more knowledgeable about the process. Thus, certain sources of fear related to the procedure may be unique to a population with limited Pap smear experience. For instance, a woman who has never experienced a Pap smear may be particularly apt to have procedural anxiety, including fear of pain, pathology and embarrassment (Burak &

Meyer, 1997). Thus, I hypothesize the following path:

Hypothesis 4 and 5: After controlling for the participant’s previous number of Pap

smears, the participant’s perception of procedural embarrassment will predict

future Pap smear intentions. Based upon an REBT framework, I propose that the

relationship between the self-defeating thoughts (embarrassment) and Pap smear

intentions will be mediated by an affective component (procedural anxiety) (See

Figure 2, Path 4 and 5).

Predicting Pap Smears: The Present Study

The present study was designed to target young women within the 18-25 age range because even though this group is at risk for cervical cancer, their Pap smear attendance rates tend to be lower than women in older cohorts (e.g., Fletcher & Bryden,

2005; McKee, Fletcher, & Schechter, 2006). Although the present model may apply to women of all ages, the relevance of the model to young women may be more robust for several reasons. First, genital perceptions may be more malleable for younger women due to their relative sexual inexperience and limited anatomical knowledge. However, in contrast to their limited sexual experience, the hypersexualization of young women within this particular cohort (e.g., Levy, 2005) may pose risks and barriers that are unique to this generation of young women. Second, Pap smear apprehension may decrease as a

18 function of the number previous Pap smears (Burak & Meyer, 1997). The young women in the present study will be recruited from an undergraduate population as opposed to the patient sample commonly utilized in studies. The women who visit gynecology and obstetrics clinics and, specifically, the women who consent to participate in studies, may perceive the Pap smear to be less averse than women who do not attend these clinics

(Domar 1985/6). Thus, in order to avoid the sample bias typically incurred when patient samples are utilized, I recruited undergraduate college women for the current study.

In order to assess the activating impact that exposure to vulva imagery has on young female undergraduate students’ perceptions of their genital appearance, participants were randomly assigned to one of two experimental conditions in which the women viewed one of two sets of genital images. Similar to Schick et al.’s (2008) experiment in which female participants rated pictures of vulvas with relatively large and small labia minora, participants were asked to rate the attractiveness of vulvas of models from either a popular sexually explicit men’s magazine or an educational book.

Using rational-emotive behavioral therapy as a framework, I tested a hypothesized path through which exposure to pictures of vulvas activates a concatenation of cognitions and emotions that predict undergraduate women’s Pap smear intentions.

Specifically, I proposed that after controlling for female genital contact, the frequency with which the participant looks at her own genitalia, previous experience to pornographic images and the propensity to engage in social comparisons, exposure to pictures of female genitalia would trigger a woman’s rational belief that her genitalia may vary in appearance from the model’s such that women in the idealized vulva condition would perceive components of their genitalia to deviate further from the social ideal (e.g., a larger labia) and those in the realistic labia condition would perceive their labia to be closer to the social ideal (e.g., a smaller labia). Specifically, I predicted that:

19 Hypothesis 6: Exposure to these photographs will, in turn, indirectly instigate

generalized genital discontent, inflating concerns about embarrassment during a

Pap smear, perpetuating anxiety in anticipation of the Pap smear, thus decreasing

future Pap smear intentions (Figure 2). Although I proposed that the path from

genital perceptions to Pap smear intentions would be similar in both

manipulations, I hypothesized that the mean difference in the paths would vary

according to the impact of the activating event such that the agglomerative genital

concerns and negative pap smear perceptions of the participants that viewed the

men’s magazine would be significantly higher than those of the participants that

viewed the educational book.

Method

Participants

Four-hundred and eighty-five undergraduate women participated in the study in exchange for course credit. Approximately 65% of the participants ( n=313) reported that

they were in either their first or second year of college, with a mean age of 19.60 ( SD =

1.79). Sixty-eight percent of participants self-identified as white ( n=329); however, a minority of women reported that they were Asian (13%; n=63), Black (9%; n=42) or

Hispanic (6%; n=27). Participants were most likely to identify their religion as either

Jewish (24%; n=115) or Catholic (25%; n=120). A total of 50 participants (approximately

10%) reported that they were born in a country other than the U.S. (e.g., China, India,

Korea). Most participants (71.4%) reported a relatively high income bracket (i.e., over

$100,000). Sixty percent of the sample reported having engaged in heterosexual intercourse with a mean of 3.03 male partners ( SD = 4.23). Eleven participants (2%) reported having engaged in sex with other women and nine participants (2%) identified as homosexual. The majority of the participants reported having never seen a woman’s vulva outside of pornographic materials (67.68%), with 29% of the sample reporting

20 having viewed more than one woman’s vulva. Approximately 30% of the sample reported that they had never received a pap smear, with 55% of the participants reporting an exam within the previous year (M = 7.75 months, SD = 16.63 months).

Measures

Activating Event – Genital Image Manipulation. Participants were asked to rate the attractiveness of one of two picture sets on a Likert scale of 1 ( Very Unattractive ) to 5

(Very Attractive ). Both sets contained five 4” x 3” photographs set to 400 x 300 pixels

(see Appendix A and B for images). The pictures in the first set contained photographs of vulvas retrieved from a popular men’s magazine (i.e., Penthouse ) that were characterized by large labia majora, limited pubic hair and a small labia minora. The second set of pictures were retrieved from a book of images of female genitals (Blank, 1993) designed to encapsulate a range of vulvas of various shapes, sizes, and colors of women diverse in age, race and ethnicity. All vulva pictures depicted the full genital region and appeared to be shot from the lithotomy position (i.e., on the woman’s back with knees spread apart).

Perceptions of Genital Aesthetics. The measures used in Schick et al.’s (2008) experiment were replicated in the present study. Variations in the participants’ perceptions of the appearance of their genitals were assessed with the Vulva Rating Scale

(VRS; Schick et al., 2008). Participants were provided with a medical drawing of the vulva and asked to report the size of several components of their genitalia (e.g., labia minora and clitoris) on a 5-point Likert scale from Very Small to Very Large . Participants were also provided with an Unsure option, so as to ensure that only preexisting cognitions were measured. Schick et al. found that the inter-reliability for the scale was appropriate, α = .75. This was comparable to the alpha found in the current study (α =

.69).

Genital Aesthetic Discontent. The Vulva Appearance Satisfaction Scale (VASS;

Schick, Calabrese, Rima, & Zucker, 2009) was used to assess the participants’ discontent

21 with the appearance of their genitals. The scale was originally modified from the Body

Satisfaction Scale (Rapport, Clark, & Wardle, 2000) to include components of the

genitalia as opposed to components of the overall body. Participants were asked to rate

their perception of several components of their vulva (e.g., labia minora and clitoris) from

1 ( Very Dissatisfied ) to 5 ( Very Satisfied ). As with the VRS, they were also provided with an Unsure option. Participants were provided with a diagram of the vulva for reference during completion of the survey. The high Cronbach alpha from the present study (.89) is consistent with previous research (.91).

Pap smears Exam Anxiety. The participants’ perception of the Pap smear as an anxiety-provoking procedure was measured using a modified version of the Dental Fear

Survey (DFS; Kleinknecht, Klepac, & Alexander, 1973) because no pre-existing measures focused on procedural anxiety towards the Pap smear. The DFS was selected as a template for construction of the current measure used to assess Pap smear fear because, as opposed to most global measures of medical anxiety (e.g., The General Medical

Anxiety Index; van Balen & Verdurmen, 1999), it measures anxiety as related to a specific procedure (see Appendix E). Specifically, the DFS consists of 20 items that assess procedure avoidance (items 1-2), physiological symptoms typically associated with fear (items 3-7), anxiety as related to specific exam stimuli (8-19) and a global rating of exam fear (item 20). All items were measured using a 5-point Likert scale, with the first seven items ranging from 1 ( Never ) to 5 ( Nearly Every Time ) and the last 16 items ranging from 1 ( No Fear ) to 5 ( Extreme Fear ). Past reported psychometric properties for the DFS, including internal consistency ( α = .95) and test-retest reliability

(r = .88) were both high. Previous research has found that the DFS is strongly correlated with other self-report measures and is a good predictor of missed or canceled appointments (Antony, Orsillo, & Roemer, 2001).

22 The DFS was modified slightly for use in the present study as a measure of Pap smear anxiety (see Appendix F for modified version). Items designed to assess procedure avoidance, physiological anxiety symptoms and global anxiety (items 1-7; 20) were altered by changing the name of the procedure (i.e., ‘dental work’ to ‘Pap smear’). Items designed to measure anxiety about specific exam stimuli (8-19) were modified to include stimuli relevant to a Pap smear. For instance, item 15 on the DFS asked participants to rate the amount of fear that they felt when “feeling the needle injected.” In the present survey, the item was changed so that the amount of fear that the participant experienced when “feeling the speculum inserted” was assessed. All other wording was consistent between both versions of the surveys. The Cronbach alphas for the sub-scales (.82, procedural avoidance; .90, physiological anxiety symptoms; .97, exam stimuli anxiety) and the overall scale (.97) were all quite high.

Pap Smear Exam Embarrassment. The DFS was further modified in order to isolate the specific components of the exam that the participants perceived to be embarrassing (see Appendix G). In addition to the modifications made to the measure in order to make it appropriate to Pap smear use, several items were altered in order to assess embarrassment (i.e., the term ‘fear’ was replaced by the term ‘embarrassment’).

Several further modifications were made to items designed to assess physiological arousal associated with fear (items 3-7.) The items were replaced with affective and physiological reactions associated with embarrassment including feelings of embarrassment, self-consciousness and blushing (Mosher & White, 1981). As with the previous measure, the Cronbach alphas for sub-scales were good (.76, procedural avoidance; .91, physiological anxiety symptoms; .96, exam stimuli anxiety); however, the overall scale was very high (.96) indicating possible redundancy between items.

Pap Smear Exam Behavior. The measure used to evaluate Pap smear behavioral intentions was designed for use in the present study. The participants’ intentions to seek a

23 Pap smear were assessed by providing them with a hypothetical scenario in which they

will be asked to rate the likelihood that they would seek a free Pap smear (including an

external exam of their genitalia, a speculum exam of their vagina and a bimanual exam of

their ovaries) within the upcoming year if the Pap smear was provided at a local,

convenient facility with a doctor of their choosing. Participants were asked to rate the

likelihood that they would schedule an appointment, cancel a scheduled appointment

(reverse-coded) and attend the appointment on a 7-point Likert scale from Very Unlikely to Very Likely . Higher numbers indicated increased intentions to seek gynecological care within the upcoming year. The Cronbach alpha for the scale was within the acceptable range, α = 76.

Control Variables. In addition to the primary variables of interest, the participants were asked to report on five control variables. First, the participant’s propensity to compare herself with others was assessed using the Iowa-Netherlands Comparison

Orientation Measure (Gibbons & Buunk, 1999). The measure has 17 items on a 5-point

Likert scale (α = 77), with higher scores indicating an increased tendency towards social comparisons (Appendix H). Participants were asked to record the number of women’s vulvas that they had physically seen (i.e., not in sexually explicit materials) from a distance no further than their current distance from their computer (e.g., while performing cunnilingus). This distance was used both to provide the participants with a simple gauge and because it was assumed that the distance was close enough for her to view genital detail. Next, the participants were asked about the frequency with which they looked at their own genitalia on scale from 1 ( Never ) to 4 ( Frequently ). Following this, participants were asked to report their previous experience with pornographic materials including both movies and magazines. Participants that reported viewing pornographic materials rated the frequency of exposure on a scale ranging from 1 ( Viewed at Least Once in the

Past ) to 5 ( Currently Own ). The participants were also asked to report how many times

24 they had received a Pap smear in the past and the length of time since their last Pap smear. Finally, participants were asked for demographic information including race, ethnicity, religion, age, year in school, economic status, sexual orientation and country of origin.

Procedure

After each participant signed-up for the study through the subject pool recruitment website, the experimenter automatically received a verification e-mail that included the participant’s contact information. In response to this e-mail, the experimenter sent the participant the study URL for one of two randomly assigned conditions. Aside from the experimental manipulation, all other elements of the survey were consistent in all versions. After indicating informed consent, the participant was asked to complete the anonymous web-based survey at a computer of her choosing. To receive credit, the participants were told to send the experimenter a password assigned at the end of the survey. Participants were fully debriefed about the true purpose of the experiment following the completion of all measures.

Results

Preliminary Analyses

Descriptive statistics including the means, standard deviations and frequencies of participants that endorsed individual items are reported in Tables 1, 2, 3 and 4.

Participants’ perception of their vulva size was within the mid-range; however, reported vulva satisfaction was toward the high end of the scale. Pap smear embarrassment and anxiety were relatively low relative to reported intentions, which were relatively high.

A multiple analysis of covariance (MANCOVA) was used to test for mean differences in participants’ perceptions of their vulva appearance among those assigned to each genital image condition, controlling for previous vulva exposure (own and others), frequency with which they viewed pornographic materials and propensity to

25 socially compare (Hypothesis 1). Participants did not significantly vary in reported

genitalia size, F (1, 244) = .57, p > .05, or appearance satisfaction, F (1, 244) = .95, p >

.05. Similarly, after controlling for the participant’s previous Pap smear experience, familiarity with her own and other’s women’s genitalia, experience with pornographic materials and tendency to socially compare, a multiple analysis of covariance

(MANCOVA) failed to detect significant differences between the participants’ reported

Pap smear exam embarrassment F (1, 245) = .92, p > .05, anxiety F (1, 244) = .74, p >.05 and intentions F (1, 244) = .60, p >.05 based on experimental condition.

The bivariate relationships proposed in Hypotheses 2 and 3 were tested with

Pearson Product Moment Correlations. External vulva size perceptions was negatively correlated with vulva appearance satisfaction, r (461) = -.29, p < .001, such that larger perceived genitalia was significantly related to decreased reported genital satisfaction.

Genital satisfaction was, in turn, negatively correlated to perceptions of Pap smear embarrassment, r (460) = -.15, p = .001, indicating that reports of genital appearance satisfaction was related to perceptions that the gynecological exam was increasingly embarrassing. In addition to both these relationships, the significance of bivariate relationships were assessed among all continuous variables, including genital size perceptions, self vulva viewing, other vulva viewing, social comparison tendencies, porn exposure history genital appearance discontent, pap smear history, pap smear embarrassment, pap smear anxiety and pap smear behavioral intentions (see Table 5).

In accordance with the fourth hypothesis, Pap smear anxiety was tested as a mediator between Pap smear embarrassment and Pap smear intentions using Baron and

Kenny’s (1986) 4-step test of mediation. As stipulated by Baron and Kenny’s four steps,

Pap smear embarrassment was related to both Pap smear anxiety and Pap smear intentions (β= -.85, t(448) =-.6.89, p <.001) at the bivariate level. When all three variables were entered into a multivariate model, the relationship between Pap smear

26 embarrassment and Pap smear intentions remained significant (β= .30, t(448) =-4.41, p

<.001) and the relationship between Pap smear anxiety and intentions became non- significant (β= .30, t(447) =1.18, p >.05). This indicates that Pap smear embarrassment fully mediated the relationship between Pap smear anxiety and Pap smear intentions.

Path Analysis

The full path presented in Figure 2 was tested to assess whether the variables related to one another in the predicted pattern (Hypothesis 5) and whether the means of the model varied significantly based upon experimental condition (Hypothesis 6). Both experimental groups (idealized vulva images vs. realistic vulva images) were tested independently with their respective path. Although the structure of the path was not hypothesized to vary between the groups, experimental groups were assessed separately due to the hypothesized difference in the mean structure of the models. Thus, the fit of

Figure 2 was assessed separately for participants in the magazine and educational book conditions.

Structural equation modeling was conducted using Amos 5.0 (Arbuckle, 2003) in order to evaluate the fit of the data to the model presented in Figure 2. All variables in the model were tested as manifest variables due to the large number of variables and correspondingly small N. Paths were only included in the final model if they were significant (p<.05) for both groups. Using this criterion, all control variables other than the participants’ Pap smear history (i.e., self and other genital exposure, pornographic material viewing frequency and propensity to socially compare) were eliminated. In addition to eliminating paths, the modification indices were investigated for additional paths (e.g., correlated error terms). Thus, the best fit of the path for the group exposed to the magazine condition, χ 2 (18, 227) = 16.35, p =.59, was compared to the best fit for the

group exposed to the educational book condition, χ 2 (7, 229) = 4.61, p = .71, in order to

ensure that the two groups did not vary significantly. The difference between the χ 2

27 values for the two models was 11.74 with 11 degrees of freedom (a reflection of the

difference between models in the number of paths deleted due to non-significant fit). The

critical value of χ2 with eleven degree of freedom at p = .05 is 19.68, indicating that the model fit for the two groups were not significantly different from one another.

Following the analysis of invariance in model fit between groups, structural equation modeling was used to assess whether the mean structure of the model significantly differed between the groups (Hypothesis 6). Using structural equation modeling to assess whether there is a mean difference between the models of the two groups takes into account both the covariance and the mean structure of the model and can be conceived of as an extension of an analysis of covariance. Although analysis for variances in path means between groups is a rare statistical procedure (Byrne, 2001), it is recommended for use when testing for mean differences in the path of several variables.

An assessment of the critical ratios for the individual paths indicated that none of the paths were significantly different from one another at p>.05, signifying that the mean structure of the path for the groups did not vary significantly.

The non-significant difference between the paths of the groups justified the assessment of an aggregated model. Consequently, the fifth hypothesis was tested again after the two groups were combined. Previously identified non-significant paths were eliminated and the investigation of the modification indices for additional paths (e.g., correlated error terms) shared across both groups led to the addition of one path. The model fit of the modified path (Figure 3) was tested using structural equation modeling.

Accordingly, all subsequent paths were significant within the model (see Figure 4). The fit of the model was established by comparing several goodness-of-fit measures to pre-set criteria. A model with a comparative fit index (CFI) or incremental fit index (IFI) over

.90 was considered an adequate fit for the data and a model with fit indexes over .95 was considered to be a good fit (Byrne, 2001). Additionally, a root mean square error of

28 approximation (RMSEA) measure below .05 indicated a good fit of the model (Kenny,

2003). The goodness-of-fit measures met the pre-set criteria for the CFI and IFI

(CFI=.99, IFI=.99), indicating that the model was a good fit of the data. However, the

RMSEA (.05) and significant chi-square χ 2 (9, 461) = 18.04, p <.05, indicated that the model was not the best fit of the data. The investigation of the modification indices suggested that the addition of one additional path from the error terms for Pap smear history and Pap smear intentions would improve the overall fit of the model. Therefore, the additional path was added and the fit of the modified model was reassessed (see

Figure 5). As opposed to the hypothesized path, the non-significant chi-square,

χ 2 (8, 461) = 10.18, p >.05, indicated that the alternative path was a good fit of the data.

The goodness-of-fit measures corroborated this finding (CFI=1.00, IFI=1.00,

RMSEA=.02). The fit of the alternative path was compared to the fit of the hypothesized path to see if the groups differed significantly different from one another. The difference between the χ 2 values for the two paths was 7.86 with one degree of freedom. The critical value of χ 2 with one degree of freedom at p = .05 is 3.84, indicating that the adjusted model was a significantly better fit of the data than the hypothesized model.

Discussion

Findings

Hypotheses 1 and 6: The Experimental Manipulation.

The data failed to support the first hypothesis that a participant’s perceived genital size would vary significantly based upon her exposure to one of two picture sets (i.e., images with a limited aesthetic range from Penthouse vs. pictures with a realistic aesthetic range from an educational book). Correspondingly, because the sixth hypothesis was contingent upon assumptions made in the first hypothesis, the overall path for the participants in each condition did not significantly differ from one another.

The non-significant difference between conditions was unexpected because the

29 experimental manipulation was modeled after Schick et al.’s (2008) successful experimental manipulation. In contrast to the present study, Schick et al. found that female participants’ post-experiment vulva size perceptions significantly varied from one another based upon their exposure to a set of vulva pictures (i.e., men’s magazine, pre- labiaplasty, post-labiaplasty). However, although Schick et al.’s experimental manipulation was used as the foundation for the experiment; minor modifications to their design in the present study may be accountable for the discrepancy in findings. The mainstream magazine utilized in the idealistic genitalia condition in the present study differed from Schick et al.’s idealistic condition in that all the pictures were taken from a lithotomy position, a shot that is only included in more explicit magazines (e.g.,

Penthouse , Hustler ). The graphic positioning of the models in the more explicit men’s magazines provides the audience with an unobstructed view of the model’s vulva, making the photographs of the labia minora of the models in the current study appear more prominent. Therefore, the pictures from mainstream men’s magazines included in the present study (i.e., Penthouse ) tended to depict visible labia minora, as compared to invisible labia minora presented in the experimental manipulation by Schick et al. Thus, women may have viewed the explicit pictures in the current study as a more realistic referent than those who viewed the pictures with invisible labia minora in Schick et al.’s study. Alternatively, it is possible that the sliver of visible thigh and/or the differences in the positioning of the models (i.e., standing vs. lithotomy in this condition) may have triggered an objectifying gaze in only one of these manipulations. Thus, the differences between these two groups may not only beg questions about relative body assessments but also about the tipping point for the objectification of the women’s bodies.

In addition to the difference in the idealistic vulva image condition discussed above, the realistic vulva image condition was modified slightly for this study. In contrast to Schick et al.’s realistic condition which included a restricted range of exclusively large

30 labia minora ‘before’ pictures from a labiaplasty website, the present study presented women in the parallel condition with vulvas that ranged in size, shape and color. If a participant were to assess the size of her labia minora relative to the array of labia minora images in the present study, her assessment of her labia minora size should be fairly accurate. Therefore, theoretically, participants who viewed vulva pictures that ranged in labia minora size in the present study may have reported a wider range of perceived genital sizes than women who compared their genitalia with pictures of large labia minora only, as in Schick et al.’s study. Thus, the average vulva size ratings for both groups in Schick et al.’s study may have been at the extremes, as opposed to the less divergent conditions in the present study. Future research should investigate this question further by utilizing several conditions which provide women with pictures that include both a limited and an extended range of labia minora to determine whether constraining the genital range differentially distorts women’s genital perceptions.

The lack of a relationship between groups may also be due to the fact that both the experimental manipulation and subsequent model were theorized based upon the assumption that the majority of the participants would have limited exposure to female genital imagery, and thus, the participants would use the images in the experimental manipulation to establish a normative genital appearance baseline, as in norm misperception education (Mutterperl & Sanderson, 2002). However, in contrast to the theory, a surprisingly high number of women reported having viewed another woman’s genitalia. Unfortunately, there is no information regarding the context in which the participant viewed another woman’s genitalia (e.g., the vulva of a friend, during a sexual encounter). This is an important differentiation because the context of the encounter(s) during which the participants viewed another woman’s genitals may influence their relative assessment of the genitalia. For instance, the experience of a woman who views an older woman’s genitals in a medical context (e.g., while bathing her) may be

31 qualitatively different from the experience of a woman who views a younger woman’s

genitals in a sexualized context (e.g., while in a strip club). The theoretical importance of

accounting for the context in which women report previous exposure to genitalia points

to the importance of context in the construction of women’s genital aesthetic perceptions.

In the present experiment, participants were exposed to the genital pictures within

an artificial social vacuum (e.g., without context about the models or the picture source).

This is problematic because in the same way that the context of the encounter is

important, the context of the images may be used to guide a woman’s assessment about

the aesthetic desirability of her genitalia. For instance, the source of the pictures may

influence women’s perceptions because men’s magazines market the models as the

sexual/social body ideal. Additionally, the models within the magazines have become

younger, thinner and larger breasted over time, following (or defining) social perceptions

of female body ideals (e.g., Schick et al., in press). Thus, even without information

regarding the source of the images, when a woman assesses the appearance of the model,

certain socially idealized characteristics (e.g., age, weight, breast size) may function as

heuristics that cue her relative appraisal of other components of the model’s body (e.g.,

her genitalia). Accordingly, women may perceive models in Playboy and Penthouse as an

automatic referent for an appearance ideal and use them (and their individual body parts)

as a referent for an upward appearance comparison (Boynton, 1999; Kenrick et al., 1989).

Braun (in press) emphasizes the role of context in her analysis of the construction of

genital aesthetic concerns. In discussing the impact of ‘before’ and ‘after’ labiaplasty

images on plastic surgery websites, she states: “Any woman can look at these ‘before’

photographs and, if perceiving any vulva resemblance, potentially (re) define and

(re) experience [italics added by the author] her vulva as undesirable and wrong. She can identify ‘desirable’ vulval morphology: the ‘neat’, ‘tidy’, contained, almost pre-pubescent vulva, ‘the clean slit’” (p. 6). In other words, it is not necessarily the images themselves

32 but instead the labels attached to the images that women use to guide their genital assessments. The ‘before’ pictures define genitals that are pathological/undesirable, while the ‘after’ pictures represent the normal/ideal. Consequently, future research should investigate the role of social context in women’s evaluation/ satisfaction with the appearance of their genitalia.

Hypotheses 2 and 3: Vulva Perceptions and Gynecological Care.

In contrast to the hypotheses regarding the experimental manipulation, the second hypothesis was confirmed. The participants’ genital size perceptions were significantly negatively related to their overall satisfaction with the appearance of their external genitalia. The relationship between perceived genital size and satisfaction in the present study is consistent with Schick et al.’s (2008) study in which they noted that the participants’ reported labia size predicted several sexual variables including genital self- consciousness during sex and future motivation to engage in sexual activities. Together, these findings suggest that participants may be concerned about their divergence from a universal genital aesthetic ideal. The negative relationship between genital size and satisfaction may be explained using Higgin’s (1987) self-discrepancy theory, which posits that a participant’s perceived discrepancy between her actual and her ideal external genitalia will lead to dejection-related emotions (e.g., decreased satisfaction). The increase in female genital cosmetic surgeries (FGCS) designed to match the appearance of the vulva to a genital ideal (Braun, in press, 2005; Tiefer, 2008) supports this supposition.

As with the second hypothesis, the third hypothesis was confirmed. Accordingly, higher genital appearance satisfaction was significantly related to lower perceived embarrassment during a gynecological exam. Although this relationship has been suggested by feminist scholars/activists in performance pieces (e.g., Annie Sprinkle’s

Public Cervix Announcement) and experiential accounts (Frueh, 2003; Kapsalis, 1997),

33 this is the first empirical study of which I am aware to document the relationship between vulva appearance concerns and gynecological care perceptions. This finding supports previous recommendations made to practitioners regarding the importance of reassuring women that their genitals are normal and healthy during their initial gynecological exam

(e.g., Leppert, 1985; Hennigen & Kollar, 2000; Ricciardi, 2000).

Hypothesis 4: Pap smear anxiety, embarrassment and intentions.

In addition to identifying a significant relationship between genital perceptions and gynecological care, a significant relationship was also detected between Pap smear anxiety, Pap smear embarrassment, and intentions. However, in contrast to the fourth hypothesis, Pap smear embarrassment mediated the relationship between Pap smear anxiety and intentions, as opposed to the hypothesis that Pap smear anxiety would function as the mediator. This path was hypothesized based upon an REBT framework, in which the relationship between cognitions and behavior is mediated by an affective component (e.g., Ellis & Barnard, 1985). In the present model, embarrassment was conceptualized as the self-defeating thought with consequent anxiety (affect) and decreased Pap smear intentions (behavior). While it is possible that an REBT framework is not applicable to gynecological care, REBT has been effective in predicting and intervening in a host of behaviors (Freeman, Felgoise, Nezu, Nezu, Reineke, 2005), including Pap smears (Park, Chang, & Chung, 2005). Thus, it is likely that REBT was not properly theorized in the present study. Although I conceptualized perceptions of embarrassment as a self-defeating thought, it is quite possible that assessing embarrassment as an affective reaction would have been a more accurate representation of the construct. If this is the case, REBT does not make any predictions about the order of affective reactions to behavior. Consequently, REBT is best tested by investigating the relationship amongst all variables along the path, as opposed to these variables in particular.

34 Regardless, as two of the primary predictors of Pap smear uptake, increased knowledge about the mechanisms through which perceptions of both anxiety and embarrassment impede gynecological care may be valuable in designing future interventions. A review of interventions found that those that targeted women’s Pap smear anxiety were the most effective (Yabroff et al., 2003). Although women may experience Pap smear anxiety for a variety of reasons (e.g., fear of pain, pathology), this study suggests that concerns about embarrassment may be one of the primary reasons why women with anxiety fail to seek gynecological care. Thus, although the variables were not related to one another in the hypothesized pattern, the interrelationship amongst these variables continues to have implications for women’s health.

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

Finally, taken together, the bivariate relationships along with the significant fit of the path suggest that young women’s satisfaction with their genitalia is related to their

Pap smear embarrassment, fear and intentions to seek care (Hypothesis 5). This finding is consistent with Rheinholtz and Muehlenhard’s study (1995) in which they found a relationship between young women’s genital perceptions and context-relevant activities.

However, while numerous other studies have identified a relationship between genital perceptions and sexual health (e.g., Berman, Berman, Miles, Pollets, & Powell, 2003;

Morrison, Bearden, Ellis, & Harriman, 2005; Reinholtz & Meuhlenhard, 1995), this is the first study of which I am aware to document a predictive relationship between women’s genital aesthetic perceptions and gynecological care intentions. This finding speaks to the utility of the continued investigation of this underdeveloped construct.

Although the model was a good fit of the data, contradictory to prediction, all of the control variables, with the exception of Pap screening history (i.e., porn viewing history, reported history of viewing own and other women’s genitalia and social comparison tendencies), were excluded from the model. While it is surprising that these

35 components did not increase the fit of the model, it is not entirely inconsistent with the

previous research (Schick et al., 2009). Whereas the present study investigated the

relationship of the control variables on the other outcome variables, Schick et al. (2009)

simply used the variables as controls when testing for mean differences. Additionally,

they did not assess the inclusion of the variables for model fit. Thus, although their

research suggested the inclusion of these variables, the fact that the variables were not

significantly related in the present study is not entirely contradictory, particularly when

taking into consideration that some of the relationships were significant at the bivariate

level. Future researchers should continue to investigate other variables that may

contribute to our understanding of the variation in women’s genital aesthetic perceptions.

In addition to the original hypotheses, the unexpected addition of a correlated

error term from genital appearance satisfaction to Pap smear intent significantly increased

the overall fit of the model. Although not originally hypothesized, this relationship is

theoretically justifiable. There are several reasons why error terms may need to be

correlated, including that they are measuring the same construct or that they are both

failing to measure a construct not included in the model (Byrne, Shavelson, & Muthen,

1989). According to Herbenick’s (2007) measure of genital dissatisfaction, both concerns about genital appearance and items related to gynecological care are interrelated . Thus,

both constructs may be measuring a component of global genital dissatisfaction,

amplifying the importance of measuring genital perceptions in order to predict

gynecological care.

Limitations

As with all studies, there are several limitations to the present study, including

those concerning the participants, methodology and theory. First, future research should

examine the present model with a sample that differs in several important ways. The

relatively small N did not meet ideal standards (10 participants per path- e.g., Bentler,

36 1995) for the large size of the tested model. This may have increased the likelihood of a

Type II error; failing to identify a significant relationship when one actually existed. This may be one possible reason for the non-significant fit of control variables paths in the model. The likelihood of this possibility is heightened by the fact that Pap smear frequency became significant when the N increased after both groups were aggregated. In addition to the limited size of the sample, the sample was limited in terms of its relatively homogenous demographics. Thus, the findings only represent a small snapshot of the population and should not be generalized to the general population. The sample was not only limited in its relative homogeneity but by the social privilege experienced by most of the participants based upon their demographic composition (i.e., young, white, heterosexual, upper-class). The heightened sense of social power experienced by these women may have boosted their sense of agency over their bodies and their health, increasing both their bodily perceptions and gynecological care intentions. Additionally, as with body ideals, genital ideals are constructed to typify those in socially privileged positions and, therefore, epitomize whiteness and youth. Consequently, some of the participants in the present study may have harbored decreased concerns about their genitalia if they perceived their genitalia to be closer to the ideal genital prototype.

In addition to the limitations of the study based upon the homogeneity of the sample, the sample may have also confounded the study because of the pool from which the participants were drawn. In the previous year, similar studies at the same university were conducted utilizing a theoretically similar subject pool. Therefore, it is possible that some of participants in the present study participated and/or viewed images/findings from one of the previous studies. If so, the participants would have been biased if the impact of the previous experiments were long withstanding.

The research methodology was also limited in its design. Other than the experimental manipulation, the data was purely correlational and, therefore, a causal

37 relationship cannot be determined. Previous research found that women reported feelings of relief following a Pap smear, often reporting that it was not as bad as they had anticipated (Larsen, Oldeide, & Malterude, 1997). So, it is quite possible that after receiving a Pap smear, a woman’s perceptions of the Pap smear as anxiety-provoking and embarrassing are reduced. Additionally, a woman’s concerns about the appearance of her genitalia may be reduced if she receives a positive or neutral comment about the appearance of her genital appearance from her gynecologist (e.g., Leppert, 1985;

Hennigen & Kollar, 2000; Ricciardi, 2000). However, because gynecological care intentions were measured as opposed to behavior, these situations may not be applicable.

Still, it is possible that when women intend to seek a Pap smear, they prepare by consciously reducing their anxiety, embarrassment and/or concerns about their genital appearance. In addition to the temporal precedence of the variables, assertions about the translation of gynecological care intentions into actual behavior should be made with caution because there are many potential barriers which may have stopped the women from actually making/attending their appointment. Finally, the size of the model precluded the inclusion of additional conditions due to the large sample size ( n=250 per condition) that would be needed in order to test any additional models. Consequently, the design of the study was limited in that it failed to include a control condition (e.g., exposure to pictures of a ‘neutral’ body part). Without the inclusion of a control condition, it remains unclear whether exposing the participants to vulva pictures activated a series of similar cognitions or whether viewing vulva pictures were unrelated to women’s gynecological care affect/intentions. It is quite possible that the simple act of viewing vulva pictures, regardless of their labia size, may have an impact on women.

Thus, these methodological flaws should be taken into consideration when making assertions about the findings in the present study.

38 The theory was also limited in several important ways. Researchers found that both women’s body size (Ferrante, Chen, Crabtree, & Wartenberg, 2007; Wee,

McCarthy, Davis, & Phillips, 2000) and physique anxiety (McKinley & Billingham,

1998) predicted women’s Pap smear intentions, indicating that women’s negative view of their body may be a barrier to attaining regular Pap smears. Bodily discontent was not measured in the present study, so it remains unclear how much of the variance predicted by genital perceptions in gynecological care intentions/affect would be accounted for by women’s global body perceptions. However, when investigating this relationship in a similar context-relevant situation, Schick and Calabrese (2009) found that genital image self-consciousness fully mediated the relationship between body image self consciousness and enjoyment of cunnilingus. This suggests that although genital image satisfaction may correlate with global body satisfaction, the precise measurement of genital image perceptions may better predict context-relevant outcomes.

Implications and Future Research

In light of the limited tools that have successfully predicted gynecological care

(e.g., Yabroff et al., 2003), the utility of a path that is related to increased gynecological care may have grave importance for women’s health and wellbeing. As the number of young women who receive the HPV vaccine increases, the perceived importance of gynecological exams may decrease. This is problematic because the vaccine may not protect women against all strains of HPV, leaving many women at risk for cervical cancer. Even if cervical cancer risk rates are diminished, a Pap smear remains an integral part of a woman’s physical health routine. In addition to a Pap smear, women frequently benefit from several other exams (e.g., breast, blood pressure, etc.) during their gynecological exam. In fact, for many women, their gynecologist is their primary care physician, highlighting the importance of the continued investigation into the possible predictors of gynecological care. Continued investigation into social

39 predictors/interventions for gynecological care is especially important because the infrastructure of the gynecological care unit may affect ability to effectively perform complex interventions. While gynecological care practices have limited resources and over-burdened staff, the large and corporate nature of hospitals can make it similarly difficult to negotiate greater institutional change. Thus, the continued investigations into simple interventions that can be conducted without the provider remain exceedingly important (Backer, Geske, McIlvain, Dodendorf, & Minier, 2005).

Although the present study identified a relationship between one group of women and gynecological care intentions, this finding may not transcend to other groups of women. Cultural/racial contexts may impact women’s relationships to the Pap smear, both directly and indirectly. Cultural or religious conventions may increase women’s concerns about exposing their genitalia to a stranger. For instance, certain groups of women (e.g., Latina and Vietnamese) have a markedly lower rate of Pap smear adherence, which may be due to concerns about the conflict of the nature of the exam with cultural perceptions of modesty (Boyer et al., 2006; Taylor et al., 2004). A historical analysis of the exam may also provide insight into cultural/racial perceptions of the Pap smear. The speculum was originally designed in order to mend painful vaginal/anal fistulas. These exams were conducted without anesthetics, and were considered too painful for most privileged women. Therefore, the earliest experimental Pap smears were conducted on Black women who did not have the sufficient rights to protest the examination (Kapsalis, 1997). Thus, although the exam is now designed to increase women’s health and agency over their bodies, the exam historically jeopardized the health and wellness of Black women. Thus, contemporary differences in the perceptions of the exam may be worthy of further consideration.

The demographics of the population may also have a direct impact on the participants’ perception of their genitalia. Some research suggests that the idealization of

40 more realistic/ more diverse body type(s) within select subcultures (e.g., Black Women,

Lesbian/ Bisexual Women) may buffer some women’s bodily discontent (e.g., Polimeni,

Austin, & Kavanagh, 2009). Genital perceptions and ideals may also vary culturally. For

instance, Asian cultures often describe protruding labia minora as a ‘sexual delicacy’

(Green, 2005). Other cultures may be more accepting of all women’s genitalia,

regardless of the appearance. For instance, in India, the vagina (which is affectionately

titled ‘the Yoni’) is often revered (Frueh, 2003). Yet, the research on the impact of global

body perceptions within subcultures remains divided and research on culture and genital appearance perceptions is extremely limited, making conclusions about the beneficial/detrimental impact of select subcultural ideals challenging.

Lesbian and bisexual identified women’s genital perceptions may not simply benefit from their group identity/inclusion; they may also benefit from the increased access to realistic vulva referents if the women engage in genital contact with other women (e.g., cunnilingus). However, as with sexual identity, the impact of sexual behavior on women’s genital perceptions may be mixed in that sexual behavior may also impede a woman’s genital appearance satisfaction if her partner has a vulva that she perceives to be more aesthetically desirable than her own. This may be especially problematic if the participant has a high propensity towards social comparison. Thus, future research should investigate the impact of subcultural identities/behavior on women’s genital perceptions.

While the findings of this study suggest that genital appearance perceptions may be an important predictor of gynecological care intentions, women report a variety of concerns about their genitals including concerns about the smell, pubic hair, tightness and

several other features (e.g., Braun & Wilkinson, 2001; Morrison et al., 2005; Stewart,

2006). The magnitude of women’s hygienic concerns is best exemplified through the

success of products marketed to cover the odor of women’s genitalia. Products designed

41 to promote ‘feminine hygiene’ have a $2.3 billion dollar annual revenue ( Packaged

Facts , 2006), with a significant portion of the total sales attributable to either douches or feminine deodorants, both products advertised to reduce the natural odor associated with female genitalia. The translation of these concerns to gynecological care intentions is evident in two sets of interviews with women, one about their perceptions of their vulva and the other about their Pap smear experiences. During an interview about her vulva,

Penny, a woman who had never visited a gynecologist, stated that she would have to

“spend about five hours scrubbing her fanny” before her initial visit (Braun & Wilkinson,

2003, p. 32). Penny’s concerns about her genital hygiene were corroborated by several women who spontaneously emphasized the importance of having the opportunity to care for their hygiene prior to the exam during interviews about their Pap smear experiences.

If denied this opportunity, the women reported heightened feelings of vulnerability during the exam (Oscarsson & Benzein, 2002). Taken together, these accounts suggest that hygienic concerns may be an additional impediment to women’s gynecological care intentions. Future research should continue to explore the multifaceted ways in which women’s genital perceptions may impact their physical and psychological wellbeing.

Promoting understanding of women’s genital perceptions, particularly within the context of women’s healthcare, is becoming increasingly relevant as the demand for female genital cosmetic surgery (FGCS) continues to rise (e.g., Braun, 2005, in press;

Braun & Tiefer, in press; Davis, 2002; Tiefer, 2008). This rise is concerning because the surgeries have been described as “like the Wild, Wild West: wide open and unregulated”

(Goodman, 2009, p. 156). The relationship between FGCS, women’s genital perceptions and gynecological care is complex because a woman may use the gynecological visit to assess the normality of her vulva appearance. Yet, many of these surgeries are done in gynecologist offices, endorsing the notion that there is either a normal or ideal genital

42 aesthetic. Thus, the role of the gynecologist in the increase in FGCS is yet another area ripe for further research.

In its entirety, the present study provided important and timely information regarding the role of women’s genital aesthetic perceptions on their intentions to seek gynecological care. Although continued empirical research remains important, the critical analysis of women’s genital perceptions and gynecological care remains equally essential. If, as Kapsalis (1997) suggests, the “critical examination of gynecology is simultaneously a consideration of what it means to be female” and the vagina is the anchor used to define femaleness, the continued exploration of these variables is an essential component, not only to increasing women’s health, but also to the critical understanding of women.

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52 Appendix A

Genital Images from a Popular Men’s Magazine

You will be presented with several pictures of women’s

external genitalia that will range in shapes and sizes. Compared to other vulvas, how would you rate the attractiveness of this vulva?

Very Somewhat Neither Somewhat Very Unsure, I Unattractive Unattractive Unattractive Attractive Attractive have no or Attractive comparison

Relative 1 2 3 4 5 to other vulvas I have seen, this Vulva Is…

53

Very Somewhat Neither Somewhat Very Unsure, I Unattractive Unattractive Unattractive Attractive Attractive have no or Attractive comparison

Relative 1 2 3 4 5 to other vulvas I have seen, this Vulva Is…

54

Very Somewhat Neither Somewhat Very Unsure, I Unattractive Unattractive Unattractive Attractive Attractive have no or Attractive comparison

Relative to 1 2 3 4 5 other vulvas I have seen, this Vulva Is…

55

Very Somewhat Neither Somewhat Very Unsure, I Unattractive Unattractive Unattractive Attractive Attractive have no or Attractive comparison

Relative 1 2 3 4 5 to other vulvas I have seen, this Vulva Is…

56

Very Somewhat Neither Somewhat Very Unsure, I Unattractive Unattractive Unattractive Attractive Attractive have no or Attractive comparison

Relative 1 2 3 4 5 to other vulvas I have seen, this Vulva Is…

57 Appendix B

Genital Images from an Educational Book

You will be presented with several pictures of women’s external genitalia that will range in shapes and sizes. Compared to other vulvas, how would you rate the attractiveness of this vulva?

Very Somewhat Neither Somewhat Very Unsure, I Unattractive Unattractive Unattractive Attractive Attractive have no or Attractive comparison

Relative 1 2 3 4 5 to other vulvas I have seen, this Vulva Is…

58

Very Somewhat Neither Somewhat Very Unsure, I Unattractive Unattractive Unattractive Attractive Attractive have no or Attractive comparison

Relative 1 2 3 4 5 to other vulvas I have seen, this Vulva Is…

59

Very Somewhat Neither Somewhat Very Unsure, I Unattractive Unattractive Unattractive Attractive Attractive have no or Attractive comparison

Relative 1 2 3 4 5 to other vulvas I have seen, this Vulva Is…

60

Very Somewhat Neither Somewhat Very Unsure, I Unattractive Unattractive Unattractive Attractive Attractive have no or Attractive comparison

Relative 1 2 3 4 5 to other vulvas I have seen, this Vulva Is…

61

Very Somewhat Neither Somewhat Very Unsure, I Unattractive Unattractive Unattractive Attractive Attractive have no or Attractive comparison

Relative 1 2 3 4 5 to other vulvas I have seen, this Vulva Is…

62 Appendix C

Vulva Rating Scale (VRS)

Listed below are several aesthetic features of vulvas (female’s external genital area). Please answer the questions below about several aesthetic features of your vulva. Please use the following diagram as a reference.

I would describe the following components of my vulva as:

Very Small Small Neither Large Very Large Large nor Small Labia Minora

Very Small Small Neither Large Very Large nor Large Small Clitoris

Very Small Small Neither Large Very Large nor Large Small Vaginal Canal (see vestibule)

63 Appendix D

Vulva Appearance Satisfaction Scale

Listed below are several aesthetic features of vulvas (female’s external genital area). Please answer the questions below about several aesthetic features of your vulva. Please use the following diagram as a reference.

I would describe the following components of my vulva as:

Very Somewhat Neither Somewhat Very Dissatisfied Dissatisfied Satisfied nor Satisfied Satisfied Dissatisfied Labia Minora

Very Somewhat Neither Satisfied Somewhat Very Dissatisfied Dissatisfied nor Dissatisfied Satisfied Satisfied Clitoris

Very Somewhat Neither Somewhat Very Dissatisfied Dissatisfied Satisfied nor Satisfied Satisfied Dissatisfied Vaginal Vestibule

64 Appendix E

Dental Fear Survey

The items in this questionnaire refer to various situations, feelings, and reactions related to dental work. Please rate your feeling or reaction on these items by circling the number (1, 2, 3, 4, or 5) or the category which most closely corresponds to your reaction.

1. Has fear of dental work ever caused you to put off making an appointment? 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 2. Has fear of dental work caused you to cancel or not appear for an appointment? 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time

When having dental work done:

3. My muscles become tense… 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 4. My breath rate increases… 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 5. I perspire… 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 6. I feel nauseated and sick to my stomach 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 7. My heart beats faster 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time

Part 2: Following is a list of things and situations that many people mention as being somewhat anxiety or fear producing. Please rate how much fear or anxiety each of them causes you. Use the numbers 1-5 from the following scale (1= no fear; 5=extreme embarrassment). Click on the appropriate item. (If it helps, try to imagine yourself in each of these situations and describe what your common reaction is).

8. Making an appointment for dentistry 9. Approaching the dentist’s office 10. Sitting in the waiting room 11. Being seated in the dental chair 12. The smell of the dentist’s office 13. Seeing the dentist walk in 14. Feeling the anesthetic needle 15. Feeling the needle injected 16. Seeing the drill 17. Hearing the drill 18. Feeling the vibrations of the drill 19. Having your teeth cleaned 20. All things considered, how fearful are you of having dental work done?

65 Appendix F

Pap Smear Fear Survey

The items in this questionnaire refer to various situations, feelings, and reactions related to pelvic exams. Please rate your feeling or reaction on these items by clicking the item (1, 2, 3, 4, or 5) for the category which most closely corresponds to your reaction.

1. Has fear of a Pap smear ever caused you to put off making an appointment? 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 2. Has fear of a Pap smear caused you to cancel or not appear for an appointment? 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time

When having a pelvic exam done:

3. My muscles become tense… 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 4. My breath rate increases… 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 5. I perspire… 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 6. I feel nauseated and sick to my stomach 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 7. My heart beats faster 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time

Part 2: Following is a list of things and situations that many people mention as being somewhat anxiety or fear producing. Please rate how much fear or anxiety each of them causes you. Use the numbers 1-5 from the following scale (1= no fear; 5=extreme fear). Click on the appropriate item. (If it helps, try to imagine yourself in each of these situations and describe what your common reaction is).

8. Making an appointment for the gynecologist 9. Approaching the gynecologist’s office 10. Sitting in the waiting room 11. Being seated in the stirrups 12. The smell of the gynecologist’s office 13. Seeing the gynecologist walk in 14. Seeing the speculum 15. Feeling the speculum inserted 16. Feeling the speculum opened 17. Seeing the cotton swab 18. Feeling the cotton swab inserted 19. Having your genitals examined 20. All things considered, how fearful are you of having a Pap smear

66 Appendix G

Pap smear Embarrassment Survey

The next items in this questionnaire refer to feelings of embarrassment that may be related to pelvic exams. Please rate your level of embarrassment on these items by clicking the item (1, 2, 3, 4, or 5) for the category which most closely corresponds to your reaction.

1. Has embarrassment about having a Pap smear ever caused you to put off making an appointment? 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 2. Has embarrassment about having a Pap smear caused you to cancel or not appear for an appointment? 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time

When having a pelvic exam done:

3. I feel embarrassed… 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 4. I feel self-conscious… 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time 5. I blush… 1 = never 2=once or twice 3=a few times 4= often 5=nearly every time

Part 2: Following is a list of things and situations that many people mention as being somewhat embarrassing . Please rate how much embarrassment each of them causes you. Use the numbers 1-5 from the following scale (1= no embarrassment; 5=extreme embarrassment). Click on the appropriate item. (If it helps, try to imagine yourself in each of these situations and describe what your common reaction is).

6. Making an appointment for the gynecologist 7. Approaching the gynecologist’s office 8. Sitting in the waiting room 9. Being seated in the stirrups 10. The smell of the gynecologist’s office 11. Seeing the gynecologist walk in 12. Seeing the speculum 13. Feeling the speculum inserted 14. Feeling the speculum opened 15. Seeing the cotton swab 16. Feeling the cotton swab inserted 17. Having your genitals examined 18. All things considered, how embarrassed would you feel during a Pap smear?

67 Appendix H

Iowa-Netherlands Comparison Orientation Measure (Social Comparison Scale) Most people compare themselves from time to time with others. For example, they may compare the way they feel, their opinions, their abilities, and/or their situation with those of other people. There is nothing particularly “good” or “bad” about this type of comparison, and some people do it more than others. We would like to find out how often you compare yourself with other people. To do that we would like you to indicate how much you agree with each statement below, by using the following scale. A B C D E I disagree I agree strongly strongly 1. I often compare how my loved ones (boy or girlfriend, family members, etc.) are doing with how others are doing. 2. I always pay a lot of attention to how I do things compared with how others do things. 3. If I want to find out how well I have done something, I compare what I have done with how others have done. 4. I often compare how I am doing socially (e.g., social skills, popularity) with other people. 5. I am not the type of person who compares often with others. 6. I often compare myself with others with respect to what I have accomplished in life. 7. I often like to talk with others about mutual opinions and experiences. 8. I often try to find out what others think who face similar problems as I face. 9. I always like to know what others in a similar situation would do. 10. If I want to learn more about something, I try to find out what others think about it. 11. I never consider my situation in life relative to that of other people. Upward comparison subscale 1. When it comes to my personal life, I sometimes compare myself with others who have it better than I do. 2. When I consider how I am doing socially (e.g., social skills, popularity), I prefer to compare with others who are more socially skilled than I am. 3. When evaluating my current performance (e.g., how I am doing at home, work, school, or wherever), I often compare with others who are doing better than I am. 4. When I wonder how good I am at something, I sometimes compare myself with others who are better at it than I am. 5. When things are going poorly, I think of others who have it better than I do. 6. I sometimes compare myself with others who have accomplished more in life than I have

68 Table 1. Vulva Perceptions Means and Standard Deviations

Category Min. Max. M SD Size Labia Minora 1 5 2.78 .70 Clitoris 1 5 2.66 .67 Vagina 1 5 2.60 .71 Satisfaction Labia Minora 1 5 3.46 1.09 Clitoris 1 5 3.76 .99 Vagina 1 5 4.00 .99 Note. Higher numbers represent an increased endorsement of the construct. Vulva size perception 1 (very small ) and 5 ( very large ). Vulva appearance satisfaction 1 (very dissatisfied ) to 5 ( very satisfied ).

69 Table 2. Vulva Size and Satisfaction Perception Frequencies

Category Response n % Size Labia Minora 1 8 1.70 2 143 31.10 3 260 56.50 4 42 9.10 5 7 1.50 Clitoris 1 22 4.800 2 139 30.30 3 274 59.70 4 21 4.60 5 3 .07 Vagina 1 27 6.00 2 151 33.30 3 256 56.50 4 12 2.60 5 7 1.50 Satisfaction Labia Minora 1 19 4.10 2 55 11.90 3 190 41.10 4 92 19.90 5 106 22.90 Clitoris 1 8 1.70 2 19 4.10 3 189 40.90 4 106 22.90 5 140 30.30 Vagina 1 9 2.00 2 20 4.40 3 197 43.00 4 103 22.50 5 129 28.20

Note. Higher numbers represent an increased endorsement of the construct. Vulva size perception 1 (very small ) and 5 ( very large ). Vulva appearance satisfaction 1 ( very dissatisfied ) to 5 ( very satisfied ).

70 Table 3.

Pap Smear Means and Standard Deviations.

Category Min. Max. M SD Embarrassment Procedural Avoidance 1 5 1.38 .90 Physiological 1 5 2.25 1.31 Symptoms Stimuli Anxiety 1 5 2.13 .96 Global Assessment 1 5 2.61 1.24 Full Measure 1 5 2.35 .92 Anxiety Procedural Avoidance 1 5 1.42 .97 Physiological 1 5 2.01 .98 Symptoms Stimuli Anxiety 1 5 2.24 1.00 Global Assessment 1 5 2.60 1.25 Full Measure 1 5 2.44 .93 Intentions 1 7 5.09 1.64

Note. Higher numbers represent an increased endorsement of the construct.

71 Table 4. Pap Smear Frequencies.

Category Response n % Embarrassment 1 80 17.20 2 206 44.30 3 119 2.59 4 46 9.89 5 14 3.01 Anxiety 1 54 11.69 2 221 47.84 3 122 26.41 4 48 10.39 5 17 3.69 Intentions 1 19 4.09 2 8 1.72 3 67 14.41 4 69 14.84 5 80 17.20 6 23 22.15 7 119 25.59

Note. Higher numbers represent an increased endorsement of the construct.

72 Table 5.

Intercorrelations for Measures of Vulva Perceptions and Pap Smears. Measure 1 2 3 4 5 6 7 8 9 10

1. Self Vulva Viewing - .16*** .04 .11 -.06 .16*** .13** -.03 .00 .04

2. Other Vulva Viewing - - -.10 .11 -.10* .14** .12* -.04 .00 -.05

3. Social Comparisons - - - -.07 .13** -.08 -.03 .16*** .20*** -.05

4. Pornography Exposure - - - - .05 .07 .14* -.11 -.14* .14*

5. Vulva Size ------.29*** -.08 .08 .05 .01

6. Vulva Satisfaction ------.15* -.15** -.10* .21***

7. Pap Smear History ------.31*** -.24*** .24***

8. Pap Smear Embarrassment ------.87*** -.40***

9. Pap Smear Anxiety ------.44***

10. Pap Smear Intentions ------

Note . * p < .05 ** p < .001 *** p < .001.

73 Figure Captions

Fig 1. Rational-Emotive Behavior Therapy Model.

Fig 2. Theoretical model predicting women’s Pap smear intentions following exposure to female genitalia. The mean structure is hypothesized to vary per group such that the mean structure is the lowest in the idealistic picture group and highest in the realistic genital images condition.

Fig 3. Modified theoretical Pap smear intention model based an analysis of model fit for both experimental conditions. The mean structure is hypothesized to vary per group such that the mean structure is the lowest in the idealistic picture group and highest in the realistic genital images condition.

Fig 4. Standardized coefficients for Pap smear intention model. * p < .05.

Fig 5. Standardized coefficients for alternative Pap smear intention model. * p < .05.

74 Fig. 1

75 Fig 2.

76 Fig 3.

77

Fig 4.

78 Fig 5.

79