Birth and the Bush: Untangling the Debate Around Women's Pubic Hair

When Andrew Kotaska asked Birth readers if they recalled “the days of physician-dictated obstetrical care” 1 that resulted in perineal shaves, he invited us to celebrate the end of dogma-driven medical practice and the dawning of a new era of evidence-based, patient-centered care. Diony Young, too, reminded us of the “unnecessary indignities of the day” that resulted in her “partial shave (with a very blunt razor)” 2 almost five decades ago as a way to mark just how far we have come in women-centered birth care. The practice of pre-labor perineal shaving has indeed become emblematic of all that was wrong with mid-20th-century birth, and its demise is a continued testament to the power of birth activism. With the right to pubic hair so ardently fought for just decades ago, how do we make sense of women's decisions to increasingly be shaved, waxed, or otherwise depilated when giving birth today? Pubic hair shaving during labor was common for several generations, part and parcel of preparing the perineum for an episiotomy and emblematic of modern obstetrics’ surgical approach to birth. By the 1920s, obstetrics had refigured the perineum as pathological 3, and the practice of pubic shaving became widespread 4. Joseph DeLee, celebrated 20th-century obstetrician, writes, “Labor has been called, and is believed by many to be, a normal function… and yet it is a decidedly pathologic process” 3. DeLee's sentiment exemplified a medical model of childbirth where “interventionist practices, such as forceps, episiotomies, general and conduction anesthesia, and induction have become commonplace” 5. As childbirth became a surgical endeavor, the perineum was increasingly seen as harmful to the baby, whose head was (according to another prominent obstetrician of the day R. H. Pomeroy) “a battering ram wherewith to shatter a resisting outlet. Why not open the gates and close them after the procession has passed?” 3. Through the discourse of medicalization, the perineum was cast as dangerous to both a woman and her baby and necessitated increasing levels of management and intervention. Such an approach intensified throughout the 20th century as knowledge about asepsis became more prevalent. The perineal shave, the episiotomy scissors, the chlorhexidine swabs, all suggested that women's bodies were unclean, dysfunctional, and dangerous. By the 1970s, women's “perineums were shaved, swabbed, and draped ready for the surgery that inevitably followed” 3, despite the growing evidence that leaving pubic hair intact did not increase rates of infection. Davis–Floyd argued that doctors were likely aware of the possibility that pre-labor pubic shaving hastened the spread of infection by the 1970s, but the practice persisted for several more years 6. Medical research throughout the 1970s–80s documented that the abrasions and small lacerations left by the razor served as vectors for infection, in fact, “No scientific study has shown that shaving reduces rate of infections” 6. But despite being contraindicated by evidence-based medicine, the pubic shave nonetheless remained standard maternity “prep” practice well through the 1980s. Synnott reminds us that, “hair is never just hair” and asks that we consider the social role that hair plays as “a symbol of the self and of group identity, and an important mode of self-expression and communication” 7. Scholars have suggested that the perineal shave maintained such prominence because of the socializing role it played in reinforcing the compliant patient status of birthing women 4, 6. Women reported feeling “dehumanized” after their pubic shave and Davis–Floyd proposed that such humiliation may have been the appeal of the procedure; the “ritual shaving of her pubic hair further intensifie[d] the institutional marking of the laboring woman as hospital property” 6. Submitting women to the shave, then, had the ancillary benefit of reinforcing their submission to hospital staff, to surgical instrument implementation, and to the larger project of medicalized birth. “To control the pubic hair, is to control the person and such control is even more powerful than the military control over men's head hair, precisely because it is so intimate” 7. Thus, perineal shaving became a powerful element of social control over birthing women, and reinforced the notion that women's bodies were inherently dysfunctional and unclean. The contempt directed at women's pubic hair aligned with a more general cultural sentiment that cast the female body as flawed. It was precisely this assumption that animated a growing feminist activism that sought to challenge gender conventions, and birth activism found itself aligned hand in glove with the larger feminist movement of the day. The arrival of popular birth texts 8-10 served to critique modern obstetrical practice. Childbirth became one of many fronts on which the struggle for women's control of their lives took place. As a result, the early 1980s saw the slow revival of midwifery and women-centered birth care. Central to birth activism and the larger project of second wave feminism was a critique of the shame associated with the female body. As early as the 1950s, authors such as Simone de Beauvoir began calling attention to social norms that cast female bodies (and their attendant processes) as “repugnant” and “humiliating.” By the mid-1970s, beauty regimens (including shaving body hair) came to symbolize an oppressive social order. The growing feminist movement hoped to recast the female body in a positive light and challenge the common sentiment that a woman's body was inherently unclean, dysfunctional, and shameful. The perineal shave became a flashpoint; a manifestation of dominant social norms about the flawed female body. Birth activists married existing medical research showcasing the health risks of the perineal shave to a feminist critique of normative gender, and were successful in ending the practice in the early 1990s. While the perineal shave now serves as yet another footnote in the history of women's obstetrical mistreatment, the sentiment that motivated it has not similarly retreated. The notion that women's body hair is unhygienic or dirty continues to motivate women's pubic depilatory practices today. “It makes me feel cleaner,” reported Australian women in a national study, citing cleanliness as their primary reason for pubic hair removal 11. American women also selected “hygienic reasons” as the primary motivation for their pubic grooming 12. What was once a fringe endeavor has now become solidly mainstream. Indeed, by 32 years old, nearly all Canadian women surveyed (96%) reported performing some level of pubic hair removal 13. Similarly, 84 percent of American women report a lifetime of pubic hair grooming, and well over half (62%) reported regularly removing all of their pubic hair 12. While trying to explain this trend in hairlessness, scholars have pointed to the rising visibility of the practice in pop culture (evidenced by everything from Carrie Bradshaw loving her first wax on Sex in the City to Gwyneth Paltrow claiming that getting a Brazilian “changed her life”), and to ongoing media deregulation and the growing availability of online pornography. One thing is certain, as the perineal shave was fading from view; a new cultural milieu of hairlessness was gathering momentum. Of particular relevance to birth scholars and practitioners is likely the recent finding that nearly half (40%) of American women surveyed reported removing some or all pubic hair in preparation for a “health care professional visit” 12. For a growing number of women, a visit to the doctor's office now necessitates a pubic area that is highly groomed (or entirely bald) as a normative practice. Although national-level data on hairlessness during childbirth are not yet available, that women are considering hairlessness during delivery is certainly substantiated by the fervor with which this topic is discussed online. Discussion boards alight with women strategizing the details of their pre-birth Brazilian wax, and include discussion of how to manage pain, how to avoid bringing on labor, or how to negotiate waxing with pregnancy-induced hemorrhoids. “I so wanna get it [Brazilian wax] just so it's not a scary monster when I go to give birth and so that way you can see the babies [sic] head come out and not be confused if he's there or not lol any of you ladies do it before?” 14 asks one woman to an online community of new mothers. One woman answers, “Since we're more sensitive when pregnant, expect it to hurt real bad if its your first time. I go regularly and its been feeling more painful since pregnancy. Its totally worth it though” 14. This desire to be “clean” echoes the now-outdated medical notion that motivated a previous generation of doctors and nurses to take up the razor to begin with. This is significant when read against the growing amount of medical literature that refutes pubic baldness as a state of cleanliness and instead highlights the risks associated with pubic hairlessness 15. Maladies ranging from microabrasions and contact dermatitis to the transmission of viruses such as HIV and hepatitis are cited as potential risks associated with women's pubic depilatory practices 13. Waxing and shaving of the pubis has been found to cause “abnormalities of the skin barrier that allow the penetration of molluscum contagiosum and HPV virus,” along with other sexually transmitted infections 16. Researchers have warned about the risks of “genital burns from waxing, severe skin irritation leading to post inflammatory hyperpigmentation, vulvar and vaginal irritation and infection, and the spread or transmission of sexually transmitted infections” 17. More recent research has studied women's immune-inflammatory response, and posits that pubic hair removal “may contribute to inflammatory side effects” including vulvodynia, or chronic unexplained vulvar pain 18. Patients with immunosuppressive conditions (such as diabetes, HIV infection, and transplantation) face higher risks of contracting a more serious life-threatening infection such as streptococcus pyogenes or herpes simplex from pubic hair removal 19. Despite this growing medical concern about the risks associated with women's pubic hair removal, the practice continues to gain popularity. Between the years 2002 and 2010, Glass et al. found a nearly sixfold increase in women requiring emergency department care for injuries related to pubic hair removal 20. A previous generation of birth activists were successful in removing the razor from the delivery room, though they were less successful in addressing the cultural negativity surrounding women's body hair. The legacy of seeing women's bodies as unclean persists 21. Feminist scholars have suggested that the “removal of body hair reflects society's discomfort with the adult female body” 22 and argued that a Western esthetic, with its celebration of the pre-pubescent body, “little or no body fat, narrow hips, and unusually long legs” 22, prevents a healthy bodily experience for the vast majority of women. Women do not relate to their adult bodies as powerful, desirable, or even as functional. Body hair, then, is just another reminder of the “definition of ‘acceptable’ feminine embodiment, which maintains—at the most ‘mundane,’ and, hence, insidious level—the message that a woman's body is unacceptable if left unaltered” 21. Hairlessness, then, signals more than just the cultural fascination with girls’ and young women's pubescent bodies; it is a proxy for a more general bodily naiveté and sense of bodily awkwardness that comes with female youth. A sense of bodily capacity or physical strength continues to elude women: women and girls do not know their bodies as proficient, competent, or capable 23, 24. As such, women do not bring a sense of body confidence and physical mastery into the delivery room; instead they bring a lifetime of gender socialization that not only celebrates their body frailty but also casts their body hair as unhygienic. This aspect has very real consequences for the ways that women experience childbirth: labor and delivery require a level of physicality that runs counter to normative femininity 25. That women might see pain, work, and the indignities of vaginal birth as distasteful and unfeminine should be of little surprise in a culture of femininity that inoculates women against a sense of body- and self-confidence 26. Hairlessness, then, is emblematic of a cultural moment where women's bodies are seen as dysfunctional and impure, and creates an environment where women are primed to see intervention into their bodily processes as essential. Increasingly, women see their bodies requiring intervention in all aspects of their reproductive life–not just to remove their pubic hair, but to medically manage their menstruation, labor, and menopause as well. Certainly the growing rate of pubic hairlessness, of medically mediated menstruation and menopause, and of medicalized (and increasingly surgical) delivery suggests that intervention is a central component of women's embodied experience. Reading the current trend in pubic hairlessness during childbirth as a personal choice that women are making overlooks the fact that the individual decisions women make are governed by dominant ideas about the female body that appear to be extremely durable. Although women have escaped the indignities of the perineal shave, they have not escaped the cultural sentiment that has cast their bodies as flawed. More pernicious still, perhaps, is our cultural fixation on the pubescent body and the bodily naiveté and inexperience it celebrates. The physical exertion and body confidence that vaginal labor necessitates is antithetical to the body passivity implicit in this new version of femininity: one that is intricately bound up with a pervasive and persistent bodily fear. Equally problematic is the underlying assumption that how a woman's body looks is more important than what it can do. So while nurses may no longer brandish the razor, women themselves are taking up a modern version of the pubic shave in the misguided assumption that female hairlessness is equated with cleanliness. Little discussion about this practice exists, and it is my hope that the recent survey data on rates of hairlessness will create a platform for nurses, midwives, physicians, and birth health care workers to both qualitatively and quantitatively explore the motivations for and consequences of women's hairlessness. Those who work directly with women are well-positioned to offer insight into how this more general phenomenon manifests in the specific moment of pregnancy, labor, and delivery. The aim here is not to romanticize pubic hair, but to instead surface the underlying social and cultural features that have created an environment where the physical appearance of a woman's body may have become more important than its physical accomplishment.

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