9781784744915 by Smakprov Media AB

The Stitch-Up

How Medical Misogyny Harms Us All

e mma Szewczak and a ndrzej h arri S

Chatto & Windus LO nd O n

Chatto & Windus, an imprint of Vintage, is part of the Penguin Random House group of companies

Vintage, Penguin Random House UK , One Embassy Gardens, 8 Viaduct Gardens, London S w 11 7B w

penguin.co.uk/vintage global.penguinrandomhouse.com

First published in Great Britain by Chatto & Windus in 2025

The moral right of the authors has been asserted

This book is a work of non-fiction based on the life, experiences and recollections of the authors. In some cases names of people, places, dates, sequences and the detail of events have been changed to protect the privacy of others.

Epigraph taken from The Husband Stitch by Carmen Maria Machado, published by Serpent’s Tail. Used with permission. Extract from The Bluest Eye by Toni Morrison (Chatto & Windus, 1979) reproduced by kind permission of Penguin Random House, One Embassy Gardens, 8 Viaduct Gardens, Nine Elms, London S w 11 7B w , U k

No part of this book may be used or reproduced in any manner for the purpose of training artificial intelligence technologies or systems. In accordance with Article 4(3) of the DSM Directive 2019/790, Penguin Random House expressly reserves this work from the text and data mining exception.

Typeset in 12/14.75pt Bembo Book MT Pro by Jouve (UK), Milton Keynes Printed and bound in Great Britain by Clays Ltd, Elcograf S.p.A.

The authorised representative in the EEA is Penguin Random House Ireland, Morrison Chambers, 32 Nassau Street, Dublin d 02 Y h 68

A CIP catalogue record for this book is available from the British Library i SB n 9781784744915

Penguin Random House is committed to a sustainable future for our business, our readers and our planet. This book is made from Forest Stewardship Council® certified paper.

For our daughter, Orlando.

They take the baby so that they may fix me where they cut. They give me something that makes me sleepy, delivered through a mask pressed gently to my mouth and nose. My husband jokes around with the doctor as he holds my hand.

– How much to get that extra stitch? he asks. You offer that, right?

– Please, I say to him. But it comes out slurred and twisted and possibly no more than a small moan. Neither man turns his head toward me.

The doctor chuckles. You aren’t the first –

I slide down a long tunnel, and then surface again, but covered in something heavy and dark, like oil. I feel like I am going to vomit.

– the rumor is something like –

– like a vir–

And then I am awake, wide awake, and my husband is gone and the doctor is gone. And the baby, where is –

The nurse sticks her head in the door.

– Your husband just went to get a coffee, she says, and the baby is asleep in the bassinet.

The doctor walks in behind her, wiping his hands on a cloth.

– You’re all sewn up, don’t you worry, he said. Nice and tight, everyone’s happy. The nurse will speak with you about recovery. You’re going to need to rest for a while.

The baby wakes up. The nurse scoops him from his swaddle and places him in my arms again. He is so beautiful I have to remind myself to breathe.

From ‘The Husband Stitch’, by Carmen Maria Machado

Introduction

I Fell Out of My Vagina (And So Could You!)

There’s a short celebrity interview the Guardian runs at weekends called the Q&A. It’s a series of direct questions which tend to solicit profound or pithy replies. On the days when I’m confined to my bed, too frightened to walk or stand, I make Andrzej read it out to me. The questions in the Q&A vary from week to week, but they’re drawn from a common pool we’ve come to learn by rote. So we know that no one ever gives a straight answer to ‘How often do you have sex?’, and that ‘What is the trait you most deplore in others?’ – always something heinous like war crimes or usury – is funniest when followed up with ‘What is the trait you most deplore in yourself?’ (always something deeply incriminating like biting one’s nails or caring too much).

It doesn’t matter who’s being interviewed. That’s not the point. We only read it so that we can answer the questions ourselves, trying to make each other laugh with reference to this in-joke or that.

There’s a particular question – maybe the best one – that comes up only rarely. It’s a shame, because I have the best answer for it. When I get lucky and it does come up, Andrzej will hover over it, dragging the whole thing out. It’s a bit we do. Our way of processing things. ‘What is the worst thing anyone’s said to you?’ he’ll ask me, seeming interested, cultivating ignorance. But he knows the answer. He was there when she said it.

She was a midwife called Chris. She had just delivered my second child and was in the middle of sewing me back up. Mercifully, I was still numb from the waist down after the epidural. Andrzej was sitting beside me in the wipe-clean plastic armchair holding our new baby in his arms, the two of them lost in a world of their own, as another midwife, whose name I hadn’t caught, toiled over a standing

desk in the corner of the room, typing up my notes. So it was really just Chris and me, huddled together over a mound of paper towels covering my knees, my two limp legs propped up in metal stirrups.

I don’t know if it was the adrenaline from the delivery, or the simple surprise at somehow still being alive, but while she snipped and snapped – every so often dropping the bloodied scissors into the metal bowl with a clang to get a better purchase on a stitch with her fingertips, pulling it taut like the women in films fixing corsets – I couldn’t stop talking. I asked her things like, ‘Why did you want to be a midwife?’, ‘Do you have any children?’, ‘What are you doing on the weekend?’, and she answered it all with patient humour. She used to be a lorry driver, but one day she realised – with urgency – that she needed to be a midwife. Her own traumatic childbirth had prompted it – a common strand among the midwives I’ve met – and she was determined that other women should fare better than she had. While she had a busy home life with two young children, and the drive to work was a long one, she loved the job and felt completely fulfilled by it. It was her vocation. She had only just started in Cambridge after relocating from a hospital closer to home, and she was frustrated to find that the ward here wasn’t as well equipped as her old one, and that the staff were far more overworked, under-resourced, and generally struggling. At the weekend she was taking her son to his cousin’s birthday party. It was a nerf gun party and she was under no illusions as to where he was going to shoot her (in the face). I asked her what her children were called. ‘Normal names,’ she answered, eliciting laughs all round.

When I’d first told her, in the heavy moment just after our baby girl was born, what she was going to be called, Chris had pulled a face, the memory of which still to this day makes me laugh. ‘We want it to confuse people,’ I’d explained. ‘As good a reason as any,’ she’d replied, unconvinced.

I was now making her work past the end of her shift. She looked exhausted. I had to be sewn up because my daughter’s head had torn my perineum in half. At some point Chris’s colleague finished the notes and came over to watch, marvelling at her skill. She told him that she’d taken special courses in the technique in London. They

had left her out of pocket, but she was hell-bent on learning how to do it properly. Andrzej’s interest was piqued at that. Clutching the small sleeping form of our daughter to his chest, he dipped his head beneath the paper-towel canopy to take a look at Chris’s handiwork.

‘It looks better than the first time,’ he said approvingly, referring to when I’d been sewn up last time. It hadn’t been my son’s skull that had split me then, but the head of the vacuum they had used to try and extract him, and the blade of the forceps, and then finally the scissors they’d used to open me up, making two doors of me. Afterwards the obstetrician, not a midwife, had been in a rush, and had left me with a thick scar that still aches when the seasons change.

Instead of a reply, I gestured for the sick bowl. I needed to throw up again. For some reason I’d started vomiting, violently and inconveniently, straight after giving birth. Chris’s face now creased in concern.

‘Why are you sick?’ she wondered aloud, not for the first time. ‘If it carries on, I’ll have to go and get someone.’

‘Could it have been the epidural?’ asked the other midwife. ‘It was a heavy dose,’ Chris nodded. ‘Maybe it’s that.’

I started to tell her: no, I always throw up, it’s just a thing my body does; it’s not the epidural, please don’t blame the epidural, everyone always blames the epidurals – I had so many thoughts on the politics of epidurals – but Chris interrupted me, her voice heavy like stone.

‘Hang on a second,’ she said, her eyes fixed on a point somewhere in the distance between my legs.

There was a pause. A Pinter pause. Just long enough for me to think: Oh God, what now?

Then she looked up at me with her dark hair tumbling out of its bun and all over her face, she looked straight through its veil and into my eyes, and she said the worst thing anyone has ever said to me.

‘Your vagina’s fallen out.’

It took them months to tell me that it was a prolapse. Which prolapse, exactly, is still in dispute, as is the gradation, whether or not it will heal, or whether or not it has already done so. People tell me

different contradictory things, so I don’t really know what to believe. And when you don’t know what’s wrong with you, you haven’t got a hope in hell of putting it right.

Around half of all women will experience some degree of prolapse in their lifetime.1 It is a major medical concern. In the United Kingdom alone, a fifth of all of those awaiting major gynaecological surgery suffer from prolapse.2

I use the term ‘prolapse’ as if the condition is singular, but it isn’t. Prolapse is rather an umbrella term for a host of complex issues covering a number of regions: vaginal, uterine, bladder, rectal. Within each region of prolapse are several other layers of complication and gradation. Formally, prolapse is understood as a descent of certain organs, or the tissues and muscles that surround them. These many potential descents are so varied, their effects so multiform, however, that to group them under a common name is meaningless, if not actively counterproductive. Many common, and many not- so- common, vaginal health issues are impossible to prise apart from prolapse when using the limiting language of contemporary medicine. The Prolapse loiters always at the edge of diagnosis, a pervasive presence in discussions of other, proximate conditions, such as endometriosis, pelvic inflammatory disease, recurrent cystitis, recurrent thrush, bacterial vaginosis, vaginal bleeding, vaginal dryness, vaginal discharge, vaginal numbness, vaginal pain, while being generally under- diagnosed in and of itself. Prolapse can somehow be both anything and nothing. In that sense, it is the mother of all vaginal health problems. Existing in this paradoxical state, it is the primary cause of all problems pertaining to the vagina, while also being invisible, indefinable, unavoidable. And untreatable.

To illustrate this point, the UK health service found that one in twelve women in the UK report experiencing symptoms of pelvic organ prolapse.3 However, when a random sample of women was taken across the population, it found that a far higher number – almost 50 per cent of the sample – suffered from some degree of it.4 Sufferers themselves, therefore, are vastly under-reporting. That is not to say that they do not suffer from prolapse. But, rather,

they do not know what it is that they are suffering from. Perhaps they have been led to believe that they aren’t suffering from anything at all.

Immediately after my vagina fell out, the midwife – Chris – asked for something to push it back in with.

‘I need a vaginal pack,’ she told her assisting colleague. He shook his head and replied with a tight smile, ‘We’ve run out.’

Thinking on her feet, Chris cut a length of surgical gauze and rolled it into an over-large tampon. Then she ducked beneath the sheets that were now covering my stirrupped legs and got to work on reassembling me. Thankfully I was still under the influence of the epidural. While it was a relief not to feel anything, it was also unnerving. All the attention in the room had converged on a space between my legs that I could neither see nor feel, a space that felt, all of a sudden, as alien to me as Mars. After a few long minutes of absolute silence, Chris straightened up – coming back into my view – and said simply, ‘It’s back in,’ before dashing out of the room to find a surgeon. Her assistant followed quickly after – there were other babies to be born, other women waiting their turn to fall apart – and Andrzej and I were left alone, our questions clamouring for answers. Andrzej began fumbling for his phone but as he moved to fish it out of his back pocket, the baby in his arms started to fuss, threateningly, so he gave up trying. Unable to make a sound so as not to disturb her, we instead communicated with our eyes while we waited for the surgeon to come. This can’t be happening, said his. Of course this is happening, said mine.

Since giving birth, which had been followed by my immediate bout of nausea, I’d barely had a chance to look at my daughter. Now I dared not look for fear of disturbing her with my heavy stare, exposing her to my confusion and disquiet. As though she was still inside of me and we were still one. ‘Don’t get stressed!’, the books on pregnancy scream, stressfully. ‘It can harm the baby!’

I wasn’t in pain. I wasn’t even tired. I was suddenly more awake than I had been in days, if not weeks or months. The room was glaringly bright. Outside, the sun was rising over south Cambridge,

lighting up the first day of our daughter’s life. Today was her birthday, the worst day of my life.

As the surgeon examined me, he spoke to Chris in muted tones that I couldn’t make out. I watched their faces closely. Many frowns – frowns I’ve later come to know too well – accompanied by shrugs that could only mean that I was either very lucky or the very opposite.

‘Your vaginal wall caved in,’ the surgeon said finally, bracingly. ‘But it’s back in now.’

My many questions – too many questions – came tumbling out, rendering me incoherent. What does that mean? Is it normal? What will happen next? What do I do next?

‘It can happen,’ he said vaguely. ‘It could be fine but it’s impossible to say. Go home. Don’t overexert yourself! See how it goes.’

It is not just those who have undergone childbirth or pregnancy who suffer from prolapse. It can often occur ‘for no reason’ in otherwise healthy bodies. It can happen to those who have had a vaginoplasty, and those who have had a hysterectomy – a procedure that, ironically, is sometimes prescribed to treat prolapse. The research into the causes of it is scant. But nature abhors a vacuum, and where there is no confirmed explanation you will instead find hypotheses, guesswork, theories – all of which are laden with attitudes. Perhaps unsurprising in the area of women’s health, those attitudes tend to circle the same drain: that having a prolapse is ultimately your own fault. Sufferers might be told that they simply have a predisposition for the condition on account of weak and deficient tissues. Or that it was brought on by lifestyle factors such as weight, age, constipation, or even a chronic cough.

When I first started writing this book, I was inundated with stories from people who wanted to share with me their own experiences of medical misogyny and gender violence in healthcare. I soon noticed that most if not all these accounts had a unifying theme: the sufferers had been explicitly or otherwise blamed for their conditions, the length of time it took them to heal (if ever at all), and their very place and standing in the healthcare system. I saw my own medical journey reflected in theirs and vice versa, all through the prism of blame.

There was the intersex woman who was told that she should expect painful examinations because of her ‘odd genitalia’. The trans woman who complained of vaginismus only to have a doctor snap back at her ‘you wanted a vagina’. A cis woman who had suffered multiple miscarriages was told that her depression may have been the cause; another was told that her active sex life may have caused her stillbirth. One person told me that their elderly mother had had a hard, plastic ring pessary implanted deep inside her vagina to treat bladder incontinence. They are supposed to be removed by a doctor every five years, but hers wasn’t until she noticed, when defecating, that faeces was leaking out of her vagina. The pessary had corroded through her tissue into her rectum, causing an inoperable fistula. Multiple healthcare workers admonished the woman for forgetting to book an appointment to get the pessary removed. She had dementia.

It all begins to feel a lot like a stitch-up, as though the whole game’s fixed and we can never win, only lose. And lose we do. Worldwide, around 800 people die every day in childbirth of a treatable illness. Thirteen per cent of those deaths are caused by unsafe abortion.5 You can expect to wait nearly a decade to be diagnosed with endometriosis, a common – and excruciating – condition of the lining of the uterus that is also a leading cause of infertility in women. Women are 50 per cent more likely to receive an incorrect diagnosis for lifethreatening coronary heart disease than men.6 And, even though they are less likely to have a heart attack than men, they are more likely to die of it if they do.7

It is incontrovertible: women get a raw deal when it comes to healthcare. But not all women experience that with equal violence. Where I can lament my own poor treatment when it comes to my prolapse, so too can I admit that if I was of an ethnic minority group it would’ve likely been a whole lot worse: in 2022, in the UK , Asian women were twice as likely, and Black women four times more likely, to die in childbirth than white women.

And it’s not only women who experience medical violence on account of their gender either. Think of the Black men who most disproportionately suffer from untreated heart disease; men with breast cancer who ‘aren’t supposed to get’ breast cancer; men with

ovaries who ‘aren’t supposed to get’ ovarian cancer; intersex people who are subjected to invasive procedures that aren’t medically indicated, sometimes leaving them in chronic pain, infertile, with lifelong disabilities, or worse.

The different forms of medical abuse do not count each other out, and when we speak about medical misogyny, it is always of how it exists as part of a bigger picture. Medical misogyny, misogynoir, racial bias and gender violence make all too common bedfellows in healthcare settings across the world.

The next time my vagina fell out, it decided to hang around for a while. It happened on the day before my six-week check. I was walking back from a shop – probably Boots; it was always Boots back then – on my own, looking at but still not really taking in the autumn that had rolled around here without me noticing. The students were back in Cambridge after the long summer break and the tourists had all disappeared, back to their real lives, out of this pretend city as I’ve always thought of it, as I might’ve been thinking of it then, when I lifted my leg to step up onto a curb and, in that fatal shifting of weight, something fell out of me. Or rather slid, wet and bulbous, into the door of my vagina, pressing itself against the cotton of my underwear. Immediately surprising, completely predictable. Oddly painless and, like the very first time it happened in the hospital when I was numbed with the epidural drug, all the more frightening for it. I stood completely still, hovering on the edge of the curb, one foot up and one foot down, wondering whether if I followed through with the action, more of myself would come out. I contemplated plunging a hand down there and shoving the mass back in, but the thought of touching it made my innards churn. People about me were beginning to look, in that sly, hoping-not-to-be-caughtlooking sort of way, and I realised that I was going to have to move or risk having someone ask if I was okay, because how could I possibly explain this ?

I leaned forward and began to hitch my lower leg up onto the curb, dreadfully slow, like folding eggs into batter: softly, softly, add the heavy to the light. Sickeningly, the gelatinous mass moved to fill

up the space that had just been cleared for it, and pressed firm and damp against the inside of my crotch. Like Silly Putty warmed in the hands and slick with sweat, it adhered only slightly to my lips while slipping them apart with its bulge. There came a nefarious tugging sensation deep in my gut, somewhere below the belly button. I forced myself to keep my breathing light and shallow, convinced that any internal movement would have a domino effect on my organs and thrust it further out. And then, and I don’t know how I managed it, but I started to walk home. Every step came with the mental assessment: Has it got bigger? Is it moving downwards? What is it? What is it taking with it? I imagined comically unspooling entrails, like Punch and Judy sausages, like handkerchiefs unfurling out of a magician’s sleeve – first the cervix then the uterus, then the bladder then the intestines, all tumbling out on top of one another in a gruesome chain.

When I entered the doctor’s office the next morning, the thing had retreated inside of me. There was a sensation in my vagina of heaviness, and fullness, but that clearly perceptible object had gone, retreated into my depths. I think it must have done so at some point in the night when I was lying awake, or so I thought, barely daring to breathe. Like waiting up for Father Christmas, one eye fixed on the bedroom door, though he always manages to slip in and fill your stocking when you’re not looking. One moment I was in bed with something warm between my legs, and the next it was gone.

Most of the doctor’s appointment was spent discussing my daughter because the ‘six-week check’ is shared between mother and newborn, but I was itching to talk about me. I lingered guiltily on things I knew didn’t really matter, as though to prove to myself and the GP that I didn’t care about my own health, only that of my child. ‘She has this mark on her neck,’ I said, knowing it was an innocuous birthmark. ‘There’s some dry skin on her thigh’ that was just that: dry skin.

When it finally came to talk about me, we only had a few minutes left. The GP ordered me up on the bed after I told her what had happened. She was frowning.

‘You should’ve mentioned this first . . .’

She didn’t know what it was that she could feel. I still hadn’t dared touch or look at it, so her findings were new to the both of us.

‘I don’t know . . .’ she said uncertainly. ‘Maybe it’s just swelling?’

‘But would swelling . . fall out of me, like that?’

‘It could feel like it, I suppose.’

I wasn’t convinced. I still had the memory of the pressure of an object, not a swelling, etched on my inner thigh. I felt nauseated. How could that thing, that terrible thing, be indefinable, unknown, nameless to the very person, the only person, who could name it for me?

‘It’s a prolapse,’ she finally concluded. I sighed with relief. ‘What can we do about it?’ I asked, relieved to have a diagnosis.

‘Not much,’ she replied, before changing her tone almost imperceptibly and simultaneously asking and telling me: ‘You overexerted yourself, didn’t you ?’

I want to show how, when it comes to women’s healthcare, we find ourselves in a position of Damned if you do, damned if you don’t at practically every turn. We are blamed for everything from our lifestyles to our bodies; womanhood itself is treated like an illness, and really, there’s nothing we can do to cure ourselves of it.

It’s crucial that we don’t realise we’re being played, though, because then we’d demand what’s fairly ours: truly equitable access to health systems that actually work for us.

You may have experienced something similar to the stories recounted in the following chapters. Or not. In any case, I hope through engaging with them that you will begin to see how the systems we currently put up with are not working for many – if any – of us at all.

Bringing together these threads has only been possible by cowriting this with my husband Andrzej. As a biomedical researcher, he has been able to wade into depths that would’ve drowned me. On my more cynical days, I might think that it is useful for practitioners and healthcare providers that most of us don’t know the fundamental science behind the diagnostics on offer and can’t make sense of the

collected raw data. I might think that it makes us more pliant customers, and less likely to complain, and ask for more. Generally, though, I think the problem is more one of a lack of adequate translators – of people who can understand multiple languages, and then bring different ideas together (about science, say, or women’s health; or policy matters, or even the personal experience of knowing what a smear test feels like). To tackle the problems at hand – and overcome the fundamental matter of a deeply entrenched medical misogyny – we will need to involve a great number of different people, all with their own languages, voices and experiences.

In the following pages, I hope you gain an insight into the lives – and languages – of just a few of those people. Some of them I have met, and some I am intimately connected with. Others, I have perhaps spoken to briefly once or twice, and others still, never at all. But this is, equally, their story – as much as it is yours.

1. You Didn’t Do Your Kegels

Over women’s healthcare towers a behemoth: Kegels.

Otherwise known as pelvic-floor exercises, these involve strengthening the muscles around your bladder, vagina and rectum through daily exercises of, well, squeezing.

The pelvic floor is like a hammock stretched between the pelvic bones. It’s made up of muscles and ligaments that support the weight of the organs above it, in the abdomen. Two main muscles dominate the space. They don’t form one continuous layer, but have openings for the urethra, anus and – in the case of the female pelvis – the vagina. Pelvic-floor exercises are meant to improve the strength, power and endurance of these muscles, which is said to be helpful in cases where they have been damaged or weakened by physical trauma, childbirth, chronic disease or age.

They were supposedly invented by American gynaecologist Alfred Kegel in the mid twentieth century, hence the name. Supposedly, because pelvic-floor exercises were already a well-known technique among women and midwives around the world, and Kegel merely sought to ‘medicalise’ a relatively common practice. In his first major paper introducing the technique to the academe, published in 1948, he cited the observations of his colleague Van Skolkvik who’d been working with South African tribeswomen.1 When examining the women’s perinea, Skolkvik found them to be ‘unusually firm’ and attributed this to the intense regimen of vaginal exercises prescribed by the women’s midwives – usually their mothers or mothers-inlaw – whereby the women would contract their vaginal muscles around the midwives’ distended fingers starting from immediately after childbirth.

Nowadays, these exercises are almost universally recommended as a first line of treatment for prolapse2 and stress urinary incontinence.3 They are also widely used for a host of other pelvic problems,

including vulvodynia,4 vaginismus,5 chronic pelvic pain,6 pain caused by endometriosis,7 ovarian cysts, and period pain.8 In fact, they are advised for just about anything – and nothing. As they’re considered the cornerstone of good vaginal upkeep, you don’t even have to present with particular symptoms or conditions to be bracingly reminded to ‘do your Kegels’. Everyone with a vagina is expected to undertake a daily regime of intimate clenching to fight the signs of wear and tear, time, and childbirth. There are many different training plans that are described in medical literature, and every women’s health resource, maternity unit, mother and baby group, website or magazine dedicated to women’s health and well-being is guaranteed to recommend their own regimen of pelvic exercises.

I came across Kegels long before my first pregnancy. In fact it was my granny who first told me, in the mock-serious tone she always employed to convey serious subjects, to ‘Make sure you do your pelvic-floor exercises – I certainly wish I had.’ It wasn’t until after my prolapse that this really hit home.

After I was first diagnosed by my GP at the six-week check and told that there wasn’t much that could be done for it, I was referred to a gynaecologist. I arrived at our initial meeting, a few months later, full of hope. This was the first person I had encountered since it had happened who was expressly tasked with making it better. I was also overwrought and exhausted. ‘Taking it easy’ simply hadn’t been an option. I had a newborn baby and a two-year-old child to look after. Living with an unidentified mass that would slump out of me – the degree to which depended on how far that day I had walked, or how many times I had picked up my children – played havoc with my mental health. Merely standing came with the instinct to constantly clench. My entire pelvic region hovered in a state somewhere between discomfort and pain: tired, aching muscles, odd twinges, concerning pulls. Some days I couldn’t get out of bed, gripped with the terror of what gravity might do to me next. Andrzej took extended periods of time off work – leave that he wasn’t, legally, entitled to, and we were thrown into a perilous position. Would his boss lose patience with him? What if he was forced to go back in; worse, what happened if he was sacked? Would I, myself, ever work again?

Big problems need big solutions. I expected to hear that I would need highly specialised, complex surgery; or, failing that, I would at least be offered some kind of living aid – a pessary, perhaps – to tide me over until my pelvic floor could heal or while the next steps were being assessed.

It was disconcerting, then, to be asked by the gynaecologist – two fingers inside me, face level with my breasts – ‘Have you ever heard of Kegels?’

Of course I’d heard of Kegels: I had been doing them three times a day for months. I had an alarm set on my phone for 10 a.m., 2 p.m. and 6 p.m., at which point I’d squeeze my vagina as hard as I could ten times in a row. It was difficult at first, as my muscles were still numb from childbirth and nothing seemed to be happening at all. As the feeling returned it seemed to get easier – and less like I was taking a rough stab in the dark – but the symptoms of my prolapse hadn’t been alleviated and, if anything, I suspected that my bladder weakness was worse than before I started.

As I scraped the surgical gel from between my lips with a sharp paper towel, and the gynaecologist retreated behind the vinyl curtain he’d drawn to protect my privacy, even though he’d been eye-to-eye with my clitoris moments before, he asked me whether I had considered using a Kegel ‘aid’.

My ears pricked up at this. Aid implied an object. Object implied a prescription. Now this is what I wanted to hear.

He didn’t answer me straight away. A new tapping sound joined the ambient machine beeps and whirrs coming from deeper within the clinic; he was typing on his computer. In a brief pause between clicks, he repeated what he’d already told me, with only minor elucidation.

‘A Kegel aid. That makes sure you’re doing them right.’

Ah, I thought to myself. That’s my problem – I haven’t been doing them right. Of course, it’s my fault! I only ever had myself to blame.

I walked away from that appointment not with a prescription, because such items aren’t available on the NHS , but with the name of a ‘Kegel aid’ scribbled on the back of my hand. Elvie.

The Elvie Trainer is a small, smart, egg-shaped device that’s

inserted into your vagina. It informs you, via your phone, of your pelvic-floor strength, and if it’s improving over time. On the website, it’s described as follows:

The small pebble-shaped pod is inserted like a tampon and connects to an app that visualises, guides, and corrects your technique in response to your muscle movements. Elvie Trainer enables you to get the most out of your pelvic floor exercises, providing motivation, expertly designed workouts and personalised training programmes. Use 3 times a week for just 5 minutes a day for better pelvic floor strength, control and confidence. [. . .] Elvie Trainer has won more than 12 awards and is recommended by over 800 health professionals worldwide. Loved by women and celebrities alike, Elvie Trainer was featured in the 2017 Oscar nominee goody bag.9

The high price- point – then £ 169 – was off- putting, but having access to concrete information about my pelvic- floor health was appealing, to say the least. My desperation won out, and I ordered one – pushing from my mind thoughts of Isabelle Huppert returning to Paris not with an Oscar but a luxury incontinence aid instead.

Something that neither the website nor the gynaecologist had quite conveyed to me was the fact that the Elvie programme is designed to emulate a video game. After inserting the egg into my vagina and connecting to my phone, I was guided through a series of challenges to help determine and collate my ‘score’ (pelvic-floor health). It had a sleek and pared-back interface, admittedly, but even so: the exercises consisted of repeatedly trying to get a ball through a hoop on the screen, or up and over an ever-rising bar, by squeezing my vagina. A jaunty tune accompanied this charade.

Now, I am no stranger to video games. I’m an only child: I practically grew up on them, and have an enduring – adult – love for my Nintendo Switch, which I get out periodically during times of overwhelming stress, or on long flights and car journeys. I am not someone who would immediately recoil from the idea of ‘gamifying’ healthcare for better engagement.

My problem was not one of engagement, however. I didn’t need to

play a game to try and fix my prolapse. In fact, this was the least fun I had ever had playing a game in my life. Something about (literally) jumping through hoops and collecting points so that I could pick up my baby and go for a walk again just didn’t sit right with me. To make matters worse, I would have to carve out surprisingly large portions of my day to leave the room and lie on the bed because, unlike the Kegels, I couldn’t do this in company, and playing a game on my phone in front of my toddler was like waving a red rag to a bull. Being technologically inept, it would take me longer than most to get set up, if I had even remembered to charge the device that seemed to drain energy like a sieve. This is when it wasn’t plagued with connectivity issues. I’d push the pebble into my vagina and squeeze, only for my phone to declare ‘Device not recognised’. Or, I would come to the end of a level, having been squeezing away like a pro for twenty seconds prior, only for the connection to drop, and my daily score to be lost. I found accurately measuring my progress impossible.

Then came the strict cleaning instructions in order to stave off infection, and having to leave it out on the drying rack in the kitchen overnight. A visitor thought it was a sex toy, something I found less embarrassing to run with than explaining what it really was. No, I would have to say, that is something that a real doctor recommended to prevent my organs from tumbling out of my vagina.

My suspicion that the exercises weren’t all they were cracked up to be had morphed into a deeper humiliation and horror at what I had been asked to do. To combat the fact of an organ falling out of me, I’d been prescribed . . . exercise. Every day I would squeeze my vagina, three times a day, tears in my eyes, in a desperate bid to hold in my bladder and cervix. Was this all they could offer me? One of my friends likened it to a man presenting with a hernia and being told that ab crunches would suffice as treatment. Laughable. And yet, here I was.

Maybe the Elvie works for some people. Maybe Kegels do, too. There is indeed clinical evidence to show that Kegels can improve the symptoms of stress urinary incontinence (SUI ). SUI is the most common type of incontinence in women.10 It happens when the bladder comes under pressure, causing urine to leak out. The source

of pressure can be coughing or laughing, or big, sudden shifts in body weight such as when jumping and running. It happens when the muscles surrounding the bladder and the urethra become weak or damaged, often as a result of pregnancy and vaginal birth, and also with age. There is likely an element of genetic predisposition too, seeing as some younger women can develop it who have not experienced damage or trauma to those muscles.11

Regardless of the cause, SUI is a common problem affecting around a quarter of all women. This number may be higher, given the stigma surrounding incontinence and the likelihood of underreporting. Aside from that caused by stress, there are three other types of urinary incontinence. The second most common is urge incontinence, which is also referred to as overactive bladder syndrome.12 In this condition, a group of muscles controlling the bladder can become overactive and spasm uncontrollably, causing a sudden urge to urinate, whether the bladder is full or not. Why these muscles spasm uncontrollably is unknown.

The two other types of incontinence are much less common. One is overflow incontinence, caused by a blockage in the bladder that prevents it from emptying fully.13 The bladder will subsequently overflow and leak. The final form of incontinence is known as ‘total incontinence’.14 Here, the bladder cannot store urine at all due to serious neurological injury (such as spinal injury), or a fistula: when a hole forms between the bladder and the surrounding area, most often as a result of trauma such as childbirth or extreme sexual violence.

Stress urinary incontinence, the most common form, is usually treated with Kegels. The rationale behind this is that the weakened muscles can be strengthened by repeated exercise. This is well supported by literature: a review of thirty-one published, controlled trials that involved 1,817 women from fourteen different countries shows an agreement in terms of effectivity.15

As urine leakage caused by SUI in those who are pregnant or have recently given birth is commonplace, pelvic-floor exercises are a common recommendation for patients. There are six published controlled trials that provide evidence indicating that exercise can help