Headache, a toothache, back pain, or even a hangover are acceptable topics to discuss at work or at a family dinner. But what about vaginal infections? Close your eyes and imagine an Easter gathering of grandparents, uncles, aunts, and cousins. Grandma reports on her successful melanoma operation, whereas her granddaughter gives a dispassionate speech on recurrent BV (bacterial vaginosis):

“Whether you have heard about BV or not, if you are a female, you are likely to experience it at some point,” she says. “As many as about 1 in 3 women have BV at some time in their lives.”

“B-what?” chips in Grandpa. “Binocular vision? Buena Vista? Best value?”

The granddaughter elaborates while peeling a colored egg: “Bacterial vaginosis is a common type of vaginal inflammation caused by the overgrowth of anaerobic bacteria. Microorganisms such as Gardnerella vaginalis replace the good vaginal lactobacilli and upset the balance of the vaginal flora.”

A caring aunt nonjudgmentally suggests the young woman to get tested for sexually transmitted diseases (STIs), to which our heroine responds: “Sure, but BV is not classified as a sexually transmitted disease. However, it has been reported that women who have sex with other women can pass each other the condition and that male partners can possibly reinfect their female partners. This sounds crazy, right?!”

A friendly intellectual conversation begins. Everyone sitting at a table has something to ask or to add. A cousin who went to a medical school shows off her knowledge: “STIs are passed from one person to another through unprotected sex. While BV can be passed via sexual contact, it is certainly not the only way that BV can be contracted. Infections classified as STIs such as chlamydia and gonorrhea can only be passed via sexual contact. However, even sexually inexperienced women can experience BV.”

An older brother shares his personal experience. A year ago, his ex-girlfriend had to take antibiotics to treat BV, while he did not: “There is little evidence that treating male partners with antibiotics decreases the rates of BV recurrence in women. As a matter of fact, BV may be viewed not as infection but as a complex microbial imbalance, with a key role played by the vaginal lactobacilli.”

Beyond COVID-19 restrictions on family gatherings, this scenario can be hard to picture. In societies permeated with religion and tradition, vaginas are not typically discussed at a dinner table. Too often, there is no suggestion that they even exist (e.g., Greek statues of women have enviable abs but no labia. Meanwhile, the male statues rock out with their cocks out).

Consequently, while 1 in 3 women will have BV, we rarely talk about it. To address this issue and learn about new technologies to handle vaginal infections, I shall dive into the oceans of knowledge on vaginal health with Giulia Tomasello, an interaction designer committed to the innovation of female intimate care.

Giulia teaches Soft Wearables at the Royal College of Art, London, and is the Winner of the Re-FREAM and STARTS Prize, both awarded by EU Horizon 2020 for her projects Alma and Future Flora that deal with women’s health. This interview has been edited for clarity.

Elena Lazutkaitė: In your newest project, called Alma, you are developing underwear to help women suffering from vaginal infections. I am holding these lovely lilac briefs in my hand. In front, I see a microchip and an embroidered antenna. Giulia, could you explain how this smart underwear works?

Giulia Tomasello: You are holding the prototype of Alma, underwear with a pocket for wearable biosensors, designed to prevent vaginal infection, especially bacterial vaginosis. The wearable biosensor detects pH, and pH is an indicator for bacterial vaginosis. The microprocessor you see is an open-source technology called Wisp. This microprocessor, which is like a tiny computer, does not have a battery, but it will recharge by sending data through radio waves.

So, the user will wear the underwear and use an app to receive notifications saying that everything is in check. Or perhaps one day a message might say “you need to see a doctor”?

Yes. Let us say you are a woman with a recurrent vaginal infection, which could occur once every month after some specific diet choices, significant stress, or change in sexual partner. And you cannot really understand what is happening and why, why the vagina feels itchy, why there is a bad smell. The biosensor gives you an indication of the pH in your vaginal fluid, which normally should be around 4.5, which is very acidic. If the pH is seven or eight, bacterial vaginosis is possible. The vaginal pH is becoming very alkaline and, therefore, it is time to see a doctor. Unfortunately, we are not there yet in diagnostics to fully prevent vaginal infections. But through technology women become more aware of their own bodies.

And if pH remains the same or decreases, then there is a chance that you will suffer from another common infection caused by an overgrowth of the yeast called Candida albicans. And both infections, bacterial vaginosis and candidiasis, result from an imbalance in vaginal flora.

Yes, if you have symptoms and the pH stays acidic, you could possibly have candidiasis. Our vaginal flora is one of the most diverse bacterial communities in our body. The first is the gut flora, which drives our instinct. The second one in terms of diversity is the microbiome in the vagina, which is made of more than simply lactobacilli; there are also other types of bacteria. Candida albicans naturally lives there. When the number of lactobacilli decreases, which could happen because of many reasons, for example, diet, a significant amount of stress, taking antibiotics, pregnancy, or a change in sexual partner, Candida can experience overgrowth. Normally, we always have Candida both in the vagina as well as in our skin microbiome, but when good bacteria are missing, the yeast starts to overgrow and causes problems.

So, the technology you are creating can alert the user about the pH changes and potentially warn about infections. But are there any high-tech solutions to treat the infections?

I can tell you about the idea that I had before Alma. Before Alma, I developed another project called Future Flora. I designed a kit for women to grow their own healthy vaginal flora so that they could use the good bacteria every time their vaginal microbiome became a bit weak. By always having healthy lactobacilli present, you can reduce the risk of vaginal infections. But this kit is far from being commercialized. We are not there yet with the mentality of growing bacteria at home, because we still have this perception that we should just eliminate all bacteria.

At present, we can buy good bacteria in the form of a capsule or suppository from pharmacies, but they are typically not cheap and their cost is not compensated by health insurance. Given how many women are suffering from vaginal infections, this situation seems inadequate.

Our society is still quite patriarchal. Somehow the taboo is everywhere. People with a vulva grow up believing that we should not talk out loud about our vaginal issues, we should not pleasure ourselves, and so on and so on. We are not even able to talk with our peers about what is going on.

Indeed, there is an avoidance of these topics privately and publicly. The liquid presented in many ads of period products is blue rather than red – a clear effort to hide what menstruation is. But how does Alma talk about women’s intimate health?

We search for the language to talk about vaginal infections and intimate care. We develop our methodology through user experience and participatory co-design, which means we do workshops, surveys, and focus group sessions, where we invite people with vaginas to participate and share their feelings and thoughts. We talk about vaginal infection specifically as well as intimate care in general, including sexual health or the taboos around it. When you create this space of trust, you see the desire to talk. The beauty of our workshops, which we call Alma meets Flora, is that women meet up and create a magical, empowering, and lasting feeling. We have run this workshop in Brazil, Thailand, Malaysia, Italy, and Switzerland and understood that women need this space to have a community of peers. Alma has co-designed the underwear with the participants of the workshops.

You have spoken to women around the globe. Have you noticed significant differences in attitudes and openness?

The taboo is everywhere in Europe and Asia. But the way women open up is different because they are influenced by their cultural background and religious beliefs. For example, I was in Malaysia – Penang, which is an island populated by Chinese, Indian, and Malay people – and they all have different religions. Interestingly, even between themselves, the women did not know why they were doing certain things. Different traditions create taboos around revealing that you are having your period.

I realize that Alma is much more than just the technology of biosensors and wearables. Sexual health, contraception, abortion, childbirth, and menstruation remain highly politicized issues rather than simply medical or technological matters. I assume you need to be an activist to do what you are doing?

More than me being an activist, I let the user become an active participant. Alma has a team of scientists, and our approach is based on co-design. It is a type of citizen science combined with the do-it-yourself (DIY) philosophy. It is about a citizen who may not have a background in science but becomes a participant in the world of science and technology.

Technology that helps us to feel empowered is a huge step forward. However, I would like us to consider some dangers of technologies too. For instance, in 2019, The Guardian carried an investigation into fertility and menstrual tracking apps. The Femm app, which markets itself as a way to avoid or achieve pregnancy, was particularly criticized. The investigation revealed that the Femm app’s literature cast doubt on the safety and efficacy of hormonal birth control, asserting that the only safe way for women to avoid pregnancy is to learn their cycles. The Guardian’s investigation found out that the app was ideologically aligned, funded, and led by anti-abortion, anti-gay Catholic campaigners who oppose birth control. Other similar apps have also been criticized for monetizing intimate data, sharing data with third parties, and lack of privacy protections. How do we ensure that technology serves us rather than betrays us?

When we talk about privacy, it is not easy. There are many apps, especially for menstrual tracking, that unfortunately are not transparent with users. However, I know a few Berlin-based apps such as Clue, Drip, or Read Your Body, where users can choose whether to share their data. It is important to ensure that if you are going to share data, it is for research purposes and not for third parties to make money from it. We are doing this type of research because until now, there was not enough research invested to dive deep into female intimate health issues. That is why we have a low diversity in products and not enough communication. Unfortunately, we are full of uncertainties rather than real knowledge regarding intimate care.

I personally love the idea of smart underwear. I hope such technology enters the market soon. But will I be able to afford it? Are there ways to make it more accessible?

Yes, this is our ethics. We are developing a kind of hacking for the Alma system. We are trying to make a DIY version of Alma. Because for us, the main vision of Alma is bringing educational awareness to everyone through technology. We want to pass citizen science on to users. We will possibly do so in hackathons that explore how to hack our own technology.

And lastly, I know you have been involved in female intimate care for quite a while. Have you noticed a positive change in the way people react to the topic and participate, or a growing interest from companies, universities, or research institutes?

Yes, we are still in a wave of feminism that started in 2017. Even my project Future Flora was perceived as a provocateur in 2016, whereas in 2018, it received a European prize to start a conversation around social taboos, vaginal infection, and biohacking. Luckily, we are still riding this wave. Now in 2021, I see many investors in femtech. But my question is: is it hype? How can we continue this trend and make it a norm?