Contraception 73 (2006) 493 500

Original research article

Attitudes, perceptions and knowledge about the vagina: the International

Vagina Dialogue Survey
Rossella E. Nappia,4, Goedele Liekensb, Ulrike Brandenburgc
a

Research Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, IRCCS Policlinico San Matteo,
University of Pavia, 27100 Pavia, Italy
b
St. Amandsstraat 2, 1853 Strombeek-Bever, Belgium
c
Klinik fqr Psychatrie und Psychotherapie, Pauwelstrage 30, D-52074 Aachen, Germany
Received 25 August 2005; revised 5 December 2005; accepted 15 December 2005

Abstract
Background: The International Vagina Dialogue Survey examined womens attitudes, perceptions and knowledge regarding the vagina.
Methods: In total, 9441 women (1844 years) from 13 countries underwent online interviews during April/May 2004.
Results: The majority of the women thought that vaginal health did not receive the attention it deserves (66%) and that society has too many
misconceptions about the vagina (65%); indeed, 78% agreed that societys taboos surrounding the vagina contribute to womens ignorance.
Only 39% of the women had ever read an informative article on the vagina, although 83% would like to read such an article. Although 79%
of the women relied on advice from healthcare professionals (HCPs) when choosing a contraceptive, b 50% were comfortable talking to
HCPs about vagina-related issues.
Conclusions: A more open and informative approach is needed with regard to the subject of the vagina in order to empower and educate
women about their bodies and in matters such as choice of contraception.
D 2006 Elsevier Inc. All rights reserved.
Keywords: Vagina; Attitudes; Society; Contraception

1. Introduction
In many countries, attitudes toward sexual matters have
become more relaxed since the sexual revolution of the 1960s.
However, there are some exceptions to this, and one topic that
still has inhibitions associated with it is the vagina. As
Catherine Blackledge [1] points out in the introduction to her
recent book bThe story of V,Q the vagina has been conceived
and misconceived over the centuries. The vagina represents
womens sexuality and fertility, but despite this, it is still
considered an intimate and private organ carrying a certain
degree of fear, mystery and shame. Indeed, the large number
of derogatory terms associated with the vagina means that
many women find it difficult to talk about this subject [2] and
still perceive an incredible distance between this important
part of their body and the emotional and cognitive aspects
related to female identity and power. This lack of openness is
a concern since the vagina is a central aspect of womens
4 Corresponding author. Tel.: +39 0382 503846/569; fax: +39 0382
520070.
E-mail address: renappi@tin.it (R.E. Nappi).
0010-7824/$ see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.contraception.2005.12.007

sexual, reproductive and general health, and increased

knowledge and ability to discuss the vagina will not only
aid womens self-confidence, sexual autonomy and satisfaction, but also help to ensure their overall physical well-being.
The general reluctance to discuss the vagina may also
imply that many women are unaware of related advances in
medicine. The anatomy and physiology of the vagina make
it an ideal route for drug administration [3]. Vaginal drug
delivery avoids the hepatic first-pass metabolism that can
affect orally delivered drugs. Several medications have been
administered via this route, including sodium salicylate,
quinine, insulin, misoprostol and hormonal compounds [4].
The vaginal route is also ideal for the delivery of contraceptive hormones, and this has led to the development of
NuvaRing, a vaginal ring contraceptive. NuvaRing delivers
very low doses of ethinyl estradiol (EE) directly to the
general circulation, thus, reducing the risk of estrogenrelated side effects.
One of the most important benefits of NuvaRing is ease
of dosing. Oral contraceptives (OCs) require daily dosing,
which apart from the inconvenience factor, carries with it

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Table 1
Number of women interviewed in each country who participated in the
International Vagina Dialogue Survey, together with the proportions who
had ever experienced a vaginal health problem
Country

Number of
interviews

Proportion that
had experienced a
vaginal health problem (%)

Austria
Belgium
Brazil
Canada
Finland
France
Germany
Italy
Netherlands
Portugal
Spain
Switzerland
UK
Total

499
793
888
750
793
779
774
761
748
691
826
197
942
9441

78
80
80
78
86
74
76
67
60
73
64
85
76
75

the threat of poor compliance and unplanned pregnancies

[5,6]. In contrast, in each cycle of NuvaRing use, a single
ring is inserted and provides effective contraceptive
protection for 1 month. Another major benefit offered by
NuvaRing is excellent menstrual cycle control. Bleeding
irregularities can affect compliance and are a commonly
reported reason for discontinuation of OCs [79]. NuvaRing
has been shown to produce excellent cycle control, with low
levels of irregular bleeding [10,11]. Furthermore, when
compared directly with an OC containing 30 Ag of EE and
150 Ag of levonorgestrel in a large-scale clinical study,
NuvaRing produced statistically significantly superior cycle
control compared with the OC [12]. In clinical trials, the
overall acceptance of the ring was very high, and N 95% of
the women reported that the ring was easy to insert and
remove, and 94% of their partners never or rarely minded

that the woman was using the ring. Moreover, 85% of the
women said that they never or rarely felt the ring during
intercourse, more than 81% said that they preferred
NuvaRing to their previous method of contraception within
three cycles of use and 97% said that they would
recommend the ring to others [13,14].
Despite the potential benefits of vaginal contraception,
feelings of embarrassment and difficulties in discussing the
vagina and related issues may mean that awareness,
knowledge and understanding of this alternative contraceptive option among the wider population are generally low.
The International Vagina Dialogue Survey was therefore
conducted to determine womens attitudes, perceptions and
knowledge with regard to such matters.
2. Methods
This international survey was designed with the objective
of improving the understanding of knowledge and perceptions of the vagina in a large group of reproductive age
women from 13 countries. Levels of comfort in discussing
vagina-related issues and perceptions of societal attitudes
were also assessed. The interview was designed by a panel
of experts, and a pilot sample of 10 subjects from each
country underwent the survey to support validity. The
institutional review board of the first author at the
University of Pavia, Italy, approved the use of this survey.
Women who participated in the survey were aged
1844 years and came from 13 countries: Austria, Belgium,
Brazil, Canada, Finland, France, Germany, Italy, the Netherlands, Portugal, Spain, Switzerland and UK. The consumer
research organization HI Europe (London, UK) conducted
the survey on behalf of Organon, the manufacturer of
NuvaRing. A volunteer sample was extracted from a
validated web database and the survey was conducted
during April and May of 2004 using online interviews that

Fig. 1. Proportion of women who agreed that it is important to be well informed about the vagina.

R.E. Nappi et al. / Contraception 73 (2006) 493500

495

Fig. 2. Proportion of women who agreed that vaginal health does not receive the proper attention that it deserves.

lasted approximately 25 min. A multiple choice answer

format was used: some sections assessed responders levels
of agreement or disagreement with statements such as
bdiscussions about the vagina should not be held in public.Q
Other sections allowed responders to choose from a
selection of responses to a question or statement. Data were
weighted to adjust for attitudinal differences that might arise
from using an online panel sample. Responses are expressed
as the overall average for all 13 countries in the survey and
per country as the proportion of responses given for each
statement/question in each section.
3. Results
During April and May 2004, a total of 9441 women were
interviewed, and the number of women by country is shown
in Table 1.

3.1. Attitudes toward the vagina

3.1.1. Personal attitudes
Overall, the great majority of women (95%) felt that it
was important to be well informed about the vagina (Fig. 1).
This high level of feeling was apparent in all countries
(z 90%), although there was slightly less agreement in
Finland (81%). This result is corroborated by the finding
that, overall, just under half (47%) of the subjects felt that
the vagina is the part of the body that women know least
about. Moreover, a very high proportion of women (87%)
agreed that understanding their vagina will help to improve
sexual satisfaction. The responses to this question about
sexual satisfaction were reasonably similar across all the
countries, with only a relatively small difference between
the country with the highest proportion of women in

Fig. 3. Proportion of women who agreed that society has too many misconceptions relating to the vagina.

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R.E. Nappi et al. / Contraception 73 (2006) 493 500

Fig. 4. Proportion of women who have read or would like to read an informative article about the vagina.

agreement (Portugal, 95%) and the country with the lowest

(the Netherlands, 79%).
When asked if they felt that vaginal health does not
receive the attention that it deserves, 66% of the women
overall agreed. The responses on this issue were quite
uniform (Fig. 2), with more than 50% of the women in all
countries, except Finland, agreeing that the attention to
vaginal health was less than it should be. The importance of
vaginal health is also highlighted by the number of women
who had experienced vagina-related health problems.
Overall, 75% of the women stated that they had experienced
a vaginal health problem (Table 1). The proportion of
women who had experienced such problems was generally
high, with the largest proportion being 86% (Finland) and
the smallest being 60% (the Netherlands and Spain, Table 1).
When asked about childhood experiences, just under
30% of the women overall agreed that they had been told as
children that touching their vagina was dirty, nasty or
unclean. More than 30% of the women in Spain, UK,
Canada and Belgium agreed with this, with Brazil (34%)
being the country where the greatest proportion of women
were in agreement. Germany and the Netherlands (17%
each) were the countries where women were least likely to
agree with this.
3.1.2. Societys attitudes
Women were also asked how they felt about societys
attitudes to and perceptions of the vagina. Overall, the
majority of women (65%) felt that society has too many
misconceptions about the vagina (Fig. 3). There was some
variation between countries in regard to this issue, with very
high levels of agreement seen in some countries such as
Brazil (82%) and Portugal (80%), whereas in the Netherlands, the proportion of women who agreed was half this
amount (38%, Fig. 3). Moreover, an even larger proportion
of women overall (78%) agreed that societys taboos
surrounding the vagina contribute to womens ignorance.

Most women (77%) feel that while society is bmore

comfortableQ about vagina discussions, it is still not a
common subject. Moreover, only 10% feel there is no
shame attached to discussing the vagina today. Also, just
under a third of women overall felt that discussions about
the vagina should not be held in public. When asked about
the ideal situation relating to discussions involving the
vagina, 51% of the women overall said that they wanted
societys attitude to be enlightened and without shame.
3.2. Perceptions of the vagina
To gain an insight into perceptions of the vagina, women
were given a selection of descriptive words and asked to
select the word that best suited their perception. The
Table 2
Proportion of women (%) who agreed with various statements about aspects
of vaginal physiology and health
Country

The vagina
has a
vertical
orientation
in standing
womena

The vagina
folds
around
and holds
inserted
objects

The
vagina
is a route
of drug
administration

Feminine
hygiene
products
contribute
to vaginal
healtha

A tampon
could
get lost
or trapped
inside the
vaginaa

Austria
Belgium
Brazil
Canada
Finland
France
Germany
Italy
Netherlands
Portugal
Spain
Switzerland
UK
Overall

71
52
40
68
67
50
71
49
62
46
41
61
64
52

94
67
71
68
61
72
93
76
72
85
81
81
60
75

66
19
33
31
23
19
68
27
34
27
28
37
32
35

73
27
30
64
16
30
72
20
40
26
22
45
40
38

81
68
71
73
83
69
78
67
67
74
84
74
53
71

a
The statement is false; therefore, agreeing with the statement
is incorrect.

R.E. Nappi et al. / Contraception 73 (2006) 493500

Table 3
The proportion of women (%) who have looked at and who regularly look
at their vaginas
Country

Have ever looked

Regularly look

Austria
Belgium
Brazil
Canada
Finland
France
Germany
Italy
Netherlands
Portugal
Spain
Switzerland
UK
Overall

84
71
84
80
87
59
81
63
81
70
69
83
76
76

52
18
64
31
32
9
38
27
36
62
37
28
30
41

majority of women (72%) chose positive words to describe

their vagina. The most popular terms that were selected by
women were intimate (51%), sexy (11%) and mysterious
(10%). In contrast, only a small proportion (4%) chose
negative terms such as troublesome, ugly or unattractive to
describe their vagina. Women were also asked about their
partners perceptions of their vaginas. Here, an even greater
proportion of women (93%) selected positive terms, and
only 5% selected negative terms. Again, the most popular
descriptive terms chosen were sexy (41%), intimate (17%)
and mysterious (8%).
To investigate whether women had any worries about
their vagina, they were asked whether they had confidence
in its size and appearance. When asked about the size of
their vagina, 53% of the women overall were confident that
their vagina was the right size. However, the proportion of
women who were not sure about its size was also fairly large
(39%). In regard to appearance, 39% of the women overall
had no concerns, but 13% had major concerns.
3.3. Vagina facts
The survey also asked questions about written materials
as a source of information on the vagina. The replies to
these revealed that, overall, only 39% of the women had
ever read an informative article on the vagina (Fig. 4). In
some countries, such as Belgium and France, only a quarter
of the women surveyed had ever read such an article. In
contrast, 83% of the women said that they would like to read
an informative article about the vagina (Fig. 4), with a high
level of interest evident in all countries. The lowest level of
interest in such articles was 63% (the Netherlands) and the
highest was 94% (Brazil).
The survey included questions about the physical
characteristics of the vagina. The majority of women
(75%) answered correctly when asked if the walls of the
vagina were able to spread and fold around inserted objects
like tampons (Table 2). However, when asked if the vagina
has a vertical orientation when a woman is standing, 52% of

497

the women thought that this was correct, and this proportion
rose to around 70% in some countries (Germany and
Austria). The proportion of women who knew that the
vagina can be used as a route of drug administration was
low at 35% overall (Table 2). The majority of women (71%)
believed that a tampon could not get lost or trapped within
the vagina, and results for this question were broadly similar
for most countries.
Vaginal defenses include mucus production and the
presence of lactobacillus species that produce hydrogen
peroxide and result in an acidic pH, specialized elements of
the immune system [15,16]. Because the vagina is a selfcleaning organ, it has no need for vaginal hygiene products,
and the use of these has been associated with adverse health
effects, including pelvic inflammatory disease and bacterial
vaginosis [17,18]. However, the survey revealed that a
surprisingly large proportion of women (62%) believed that
these products do contribute to vaginal health. In some
countries such as Spain, Italy and Finland, more than 75%
of the women believed this, although in some other
countries, such as Austria and Germany, the proportion of
women who believed this was much lower (27% and 28%,
respectively). When asked about knowledge of the appearance of their vagina, 27% of the women overall said that
they knew exactly what its appearance was, 48% said that
they had a reasonable idea and 24% had only a partial or no
idea at all.
3.4. Behavior
In general, women appeared to be comfortable with
looking at their vagina. Overall, the majority of women
(76%) had looked at their vagina (Table 3). In contrast, the
proportion of women who looked at their vagina regularly
was generally lower, at 41% overall and particularly low in
France (9%) and Belgium (18%).
When asked about inserting something into their vagina,
such as a tampon, most women (62%) were comfortable
with this. During their periods, overall, the majority of
women (73%) used tampons either regularly or sometimes.
Table 4
Proportion of women (%) who never used tampons or feminine hygiene
products
Country

Tampons

Feminine hygiene products

Austria
Belgium
Brazil
Canada
Finland
France
Germany
Italy
Netherlands
Portugal
Spain
Switzerland
UK
Overall

9
22
35
25
25
24
15
38
25
22
16
14
31
27

75
43
83
85
66
64
85
39
79
53
61
51
78
73

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Fig. 5. Womens levels of comfort in talking to HCPs about vagina-related issues.

The proportion of women who used tampons was highest in

Austria (91%) and lowest in Italy (62%) (Table 4). Feminine
hygiene products were used by a relatively small proportion
of women overall (27%). The lowest levels of use of these
products was seen in Germany and Brazil (15% and 17%,
respectively), and the highest levels of use were seen in
Belgium (56%) and Italy (49%, Table 4).
3.5. Dialogue
Overall, most women (77%) were comfortable discussing their vaginas with female friends, although women in
France (56%) and Belgium (68%) were less likely to feel
this way. When asked about discussing the vagina with
their partners, the great majority of women (88%) said that
they were comfortable with this. A high level of comfort in
talking to partners was observed consistently in all
countries, with the highest level seen in Portugal (95%)
and the lowest in the Netherlands (84%). In contrast,
womens level of comfort in talking to healthcare

professionals (HCPs) was markedly lower. Overall, fewer

than 50% of the women were comfortable talking to a
HCP about vagina-related issues, and 25% were uncomfortable (Fig. 5). The proportion of women who were
uncomfortable talking to an HCP about vagina-related
issues was particularly high in the Netherlands (49%) and
UK (41%). When asked about their preference for talking
to a male or female HCP, most women (60%) said that
they preferred a female. This proportion was highest in UK
(79%) and Finland (80%) but was considerably lower in
other countries, most notably, Belgium (41%).
A significant proportion of women relied on HCPs for
advice on contraceptive choice. Overall, 79% of the
women relied on advice from HCPs, either completely or
somewhat, when deciding on contraceptive choice (Fig. 6).
The degree of reliance varied considerably between
countries with the greatest proportion of women relying
on the advice of HCPs seen in Brazil (99%) and the lowest
seen in Spain (45%).

Fig. 6. Degree of reliance of women on HCPs for advice on contraceptive choice.

R.E. Nappi et al. / Contraception 73 (2006) 493500

4. Discussion
This survey gathered information on knowledge, attitudes and behavior toward the vagina in more than 9000
women from around the world. Women from 13 different
countries were interviewed using a standardized online
survey. This has provided us with a large body of data that
can be used to identify global trends and to compare and
contrast individual countries. Before considering the results
in detail, one of the main points that should be mentioned is
that it is clear that in contrast to the situation with other
sexual matters, or with other areas of the body, there is still a
considerable degree of stigmatization and taboo attached to
the vagina.
The survey shows that in regard to the vagina, the
attitude of society is still far from being open and
enlightened, and most women would like to see more
progress in this regard. A total of 51% of the women want
an attitude of enlightenment and no shame, which contrasts
with the 10% of the women who think society is already at
that point. The country with the highest perceived level of
enlightenment without shame was Spain, but even here,
only 18% of the women felt that societys attitude was
enlightened. Overall, the majority of women also felt that
society has a high level of misconceptions about the vagina,
and in some countries such as Brazil and Portugal, as many
as 80% or more of women felt this way. This lack of
openness was also reflected by the feeling of the great
majority of women (78%) that societys taboos surrounding
the vagina contribute to womens ignorance.
Our results show that, in general, societal attitudes
regarding the vagina are far from ideal. It is reassuring that
the overall majority of women used positive terms to
describe their vagina, but it was also worrying to see that
around a third of women had received negative vaginarelated messages during their childhood. It was also clear
that womens knowledge of the vagina could be improved.
Nearly half of the women regard the vagina as the part of
their body they know least about. Although the majority of
women know that a tampon cannot get lost or trapped in the
vagina, a staggering 29% of the women either believe that it
can, or are not sure, and in UK, almost half of the women
interviewed believed this. Another aspect of the general lack
of knowledge of the vagina was highlighted by the large
proportion of women (just under two thirds overall) who
agreed that vaginal hygiene products contribute to vaginal
health. In some countries, such as Italy and Finland, 80% or
more of women were in agreement with this. Apart from the
lack of knowledge demonstrated by the responses to these
questions, there was also an obvious need and desire for
knowledge about the vagina. Overall, less than 40% of the
women had ever read an informative article about the
vagina, whereas the proportion that said that they would like
to read such an article was more than twice as great (83%).
This would indicate that there may be some form of barrier
that prevents women from increasing their knowledge,

499

possibly a lack of available material or difficulties in

seeking such material through embarrassment.
In the introduction to her book, Blackledge [1] points out
that the word bvaginaQ is generally avoided in conversation.
Our results highlight the extent to which this is true: N75%
of the responders agreed that although society is more
comfortable with vagina-related discussions, it is not a
common subject. Moreover, around 30% of the women felt
that discussions about the vagina should not be held in
public. In contrast, the majority of women felt able to
discuss vagina-related matters with either female friends
(77%) or their partners (88%). Although it is positive to see
that women are comfortable talking about the vagina with
friends and partners, this is further evidence that women do
not perceive society as being open and are not comfortable
with discussing vagina-related matters in public.
One of the most striking results was the finding that
only 50% of the women feel comfortable in talking to
HCPs about vagina-related issues and 25% said that they
felt uncomfortable in this situation. Several factors increase
the significance of these results. One is the high proportion
of women in the survey who had experienced a vaginal
health problem. Better education and a higher level of
knowledge in this area may help to reduce the frequency of
such health problems. Another factor is the finding that the
majority of women (79%) relied on the advice of HCPs
when making decisions on contraception. This means that
for many women, HCPs would be a major source of
information on forms of contraception. As discussed earlier,
women appear to have difficulty in finding informative
articles on the vagina. Since women find vagina-related
matters difficult to discuss with HCPs, this means that they
would be relatively unaware of a vaginal contraceptive
method such as NuvaRing. On the other hand, the
availability of a vaginal contraceptive method may facilitate
HCPs to counsel women on this important part of their own
body, and it may effectively contribute to genital and
general health.
Womens lack of knowledge relating to vaginal contraception restricts their contraception choices and implies an
overreliance on other methods, such as OCs. This is a
significant disadvantage because OCs have a requirement
for daily dosing, which is clearly an issue for many women.
When the contraceptive practices of 3316 French women
were followed for 6 months by their gynecologists, it was
found that 23% of the women missed a pill at least once a
month, and that of these, almost one third took no specific
measures in response to the missed pill [19]. A survey of
943 women in the United States found that the frequency of
missed pills was even higher: 47% of the OC users had
missed one or more pill per month and 22% had missed 2 or
more pills [5]. For OC users, noncompliance is a serious
issue since it leaves women at risk of unplanned
pregnancies. In 2003, a survey of 2863 French women
showed that 33% of pregnancies were unplanned, of which
50% were terminated; furthermore, of the unplanned

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pregnancies, 21% had occurred in pill users [20]. The risks

associated with forgetting to take pills mean that many
women may be interested in contraceptive methods that do
not require daily dosing.
5. Conclusion
The current survey shows that despite apparent improvements in recent decades, societys attitude toward the vagina
is not very open and not as open as women would like it to
be. Although most women are comfortable talking about the
vagina with friends or partners, there is still a significant
degree of discomfort when talking about it in public,
including with HCPs. Women desire more openness and
information and want to be comfortable when discussing the
vagina and learning about it. Improved communication will
empower women to educate themselves about their bodies
to become aware of their vagina as an active and powerful
female organ and will also increase their freedom of choice
in self-managing matters such as contraceptives.
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