The Vagina Business E-Book

Marina Gerner

• Herausgeber: Icon Books
• Kategorie: Wissenschaft und neue Technologien
• Sprache: Englisch
• Veröffentlichungsjahr: 2024

Seitenzahl: 515

Beschreibung

This tech could change everything for women - here's how. From periods and childbirth to menopause, female pain has been normalized, as society shrugs and says 'welcome to being a woman' instead of coming up with better solutions. But it doesn't have to be this way. In The Vagina Business, award-winning journalist Marina Gerner takes an eye-opening look at the innovators challenging the status quo to deliver the healthcare solutions women need. With interviews from 100 entrepreneurs, researchers and investors across 15 countries, The Vagina Business explores the future of women's health, where female-focused companies are developing products to help women at every stage of life. From a life-saving bra to non-hormonal contraception and new takes on fertility and menopause, it shines a light on innovation that matters. Women should not be denied solutions to health issues just because people are embarrassed to talk about vaginas. We deserve much better.

Leseprobe

PRAISE FOR THE VAGINA BUSINESS

“In The Vagina Business, Marina Gerner takes you on a tour around the world to learn about the femtech products being designed and marketed today—from apps that track fertility and periods, to smart bras that tell women about their heart health, to new forms of contraception for women (and men). The Vagina Business is also an important story about the long-held taboos about women’s bodies that have hindered research, education, and investment in women’s health, and about the feminist innovators who are shattering these taboos to provide women what they want and deserve.”

—DEENA EMERA, PhD, author of A Brief History of the Female Body

“A smart, tech-savvy primer on not only the bottom-line business value of more inclusive research, but its whole-hearted worth for all humankind.”

—ABBY NORMAN, author of Ask Me About My Uterus

“Fascinating, infuriating, and exciting, The Vagina Business introduces some extraordinary female revolutionaries and the fantastic promise of tech to transform women’s lives. Some scenes will make you want to scream. But others will have you jumping up and down in delight at the extent to which women are supporting women to innovate—and the vast scale of the sisterhood’s imagination. Gerner renders complex science simple and makes venture capital thrilling. She is a strong writer with a gift for telling a story, and this is a great one. The Vagina Business is an important book, with significance for our understanding of the impact of structural discrimination on women’s health. I hope it is bought and read by many, many people who then advocate for, research and invest in the fairer future that femtech offers”.

—SOPHIE WALKER, activist and author of Five Rules for Rebellion

“The Vagina Business is an eye-opening book that everyone needs to read. It shines a light on how women’s needs have been routinely dismissed and ignored by science, medicine, and technology. Gerner offers us hope for the future, showing us how the world can be a better place for women when innovators in tech, science, and medicine begin to take our needs seriously.”

—SARAH E. HILL, PhD, author of This is Your Brain on Birth Control

“Marina Gerner’s brilliant book should be titled How to Make More Money Than You Ever Dreamed Possible because she is handing all venture capitalists, investors, and corporations that opportunity on a plate. She has done all the due diligence they could ever want in this deeply researched, wide-ranging and utterly riveting study of the entrepreneurs pioneering in the sector that business, finance and tech are massively missing out on through sheer squeamishness: women’s sexual and reproductive health. The Vagina Business is a must-read—and also, when you buy and read it, a must-display—to overcome the ridiculousness that is holding this sector back. Make sure you show the cover off when you’re reading it on the Tube, on the plane, by the pool, on the beach, in the office. There’s a huge amount of money to be made out of taking women seriously, and this book is the evidence. BUY IT NOW.”

—CINDY GALLOP, founder & CEO, MakeLoveNotPorn

“If you care about your health and the health of all the women in your life, you should read this book. After reading it, I finally felt heard. I finally felt seen. And it felt so good. The Vagina Business is one of those books every woman should read multiple times in her life—the lessons in it are invaluable.”

—MARIJA BUTKOVIC, entrepreneur, journalist, women’s health advisor and consultant

“Marina Gerner’s writing is electric, and The Vagina Business will leave you shocked and energized. It’s a terrific page-turner that will transform how every reader sees the worlds of business and technology.”

—JAKE KNAPP, author of the New York Times bestseller Sprint

“In a world where women’s health and pleasure have been sidelined, The Vagina Business is a rallying cry for change. This book will expand your mind, and make you rethink how you open your wallet.”

—RENA MARTINE, author of The Sex You Want: A Shameless Journey to Deep Intimacy, Honest Pleasure, and a Life You Love

Published in the UK in 2024 by

Icon Books Ltd, Omnibus Business Centre,

39–41 North Road, London N7 9DP

email: [email protected]

www.iconbooks.com

ISBN: 978-1-78578-984-7

ebook: 978-1-78578-985-4

Copyright © 2024 by Marina Gerner

The author has asserted his moral rights.

No part of this book may be reproduced in any form, or by any means, without prior permission in writing from the publisher.

Internal design © Sourcebooks

This book is not intended as a substitute for medical advice from a qualified physician. The intent of this book is to provide accurate general information in regard to the subject matter covered. If medical advice or other expert help is needed, the services of an appropriate medical professional should be sought.

References to internet websites (URLs) were accurate at the time of writing. Neither the author nor Icon Books is responsible for URLs that may have expired or changed since the manuscript was prepared.

Printed and bound in the UK

To my mother, obviously

CONTENTS

INTRODUCTION: SKIN IN THE GAME

PART I: Something New under the Sun

CHAPTER 1: LAUNCH

Who are we to interfere with Mother Nature?

CHAPTER 2: MONEY

We need to talk about investors’ problem with vaginas

CHAPTER 3: RESEARCH

Could a bra save your life?

CHAPTER 4: UNMET NEEDS

Why it pays to look for problems

PART II: Women-Centric Design

CHAPTER 5: PERIOD APPS, THE OG

What it takes to track an egg

CHAPTER 6: SEXTECH

Demystifying the female orgasm

CHAPTER 7: THE FUTURE OF CONTRACEPTION

I’ve seen this in sci-fi

CHAPTER 8: FERTILITYTECH

Alice in fertility clinic wonderland

CHAPTER 9: FAMILYTECH

Where’s your village now?

CHAPTER 10: MENOPAUSETECH

When ageism meets sexism

CHAPTER 11: FINAL FRONTIER

The hardest taboos to break

PART III: Out into the World

CHAPTER 12: COMMUNITY

Social revolutions are fun

CHAPTER 13: BIG IN JAPAN

The world’s largest femtech expo

CHAPTER 14: THE INSIDIOUS SIDE

Monetizing insecurities

CHAPTER 15: VIGILANTES

Everybody deserves to be safe

CHAPTER 16: IMPRESSIONS

How to attract and repel

CHAPTER 17: BUSINESS & SOCIETY

What if femtech wins?

ACKNOWLEDGMENTS

NOTES

BIBLIOGRAPHY

ABOUT THE AUTHOR

INTRODUCTION

SKIN IN THE GAME

Did he actually just say that? For a moment, she thought she’d misheard him. Farah Kabir had come to an island in the English Channel to pitch her company to a group of investors. Flying in from London, she had gone straight to a conference center hotel, the kind you see all over the world, with cold gray floors and lukewarm coffee. She straightened her clothes and felt her hands shake as she reached for a glass of water. It had taken blood, sweat, latex, and her life savings to get to this point.

The idea for her company had come to her a few years earlier when Farah came off the contraceptive pill. There were too many side effects: weight gain, mood swings, and greasy skin. “Hormonal contraception just wasn’t working for me,” she says. Condoms became her preferred option.

One day, she went to a shop on her lunch break at work to buy condoms. “You walk down the condom aisle, and you see they’re garishly packaged, they promote a man’s conquest, and you don’t really know what the ingredients are,” she says. With other products you apply to your body, you can usually see what they’re made of, “But it’s not like that with condoms. Either way you don’t want to be down the condom aisle for too long.” Which is exactly what happened.

As Farah rummaged around the condom aisle looking for information on ingredients, she bumped into her boss. “I was absolutely mortified. He would’ve seen the bright red pack in my hands.” What was embarrassment at first turned into frustration. “Because internally I was thinking: why is it OK for me to take control of every other aspect of my health but not my sexual health?”

Over lunch, she told her friend Dr. Sarah Welsh, who is a gynecologist, about the awkward bump in with her boss, and asked: “Why isn’t it acceptable for women to carry contraception?” Sarah was not surprised. In her line of work, she had seen women come into her clinic with hard-to-treat STIs and women who said they didn’t carry protection because it was “a man’s job” or they didn’t want to be seen as promiscuous. “So, we had this light bulb moment there and then: why don’t we create a condom designed with women in mind?”

The two women decided to take a closer look at the industry to see whether there were any condoms that had been created considering the preferences of female customers. “We were so shocked that nobody had done this in Europe,” says Farah. Then, they surveyed two thousand women and discovered that when it comes to condoms, women care about the ingredients and sustainability. The women in their survey didn’t like the smell of latex or garish packaging, but equally they didn’t want something girly, pink, and floral. “We carved out a product from what our survey respondents wanted,” says Farah. “Our condoms are vegan and biodegradable. They have no nasty chemicals in them like anesthetics that make a man last longer but are irritating to the walls of a vagina.”

“We put all of our life savings into creating condoms,” she says. To take their company Hanx further, they needed to raise money from investors. At her pitch, Farah was the only female founder facing a group of predominantly male investors that day. That’s when she heard the question that threw her. One investor laughed and said: “Can you demonstrate how to put on a condom?”

She realized the question was meant to mock her. “They didn’t take me seriously as a woman trying to raise investment for a business that currently is in a male-dominated industry,” she says. It’s a throwback to the classrooms of decades-old sex education, where teenagers laugh while pulling condoms over bananas. Who would have thought this attitude would carry on into investor board meetings led by men with silver hair?

It’s my job to ask impertinent questions as a journalist. Over the last decade, I’ve been writing about business, technology, and culture. Stories like that of Farah drew my attention to a new field that’s at the cusp of a revolution: female technology—femtech, which is technology focused on female bodies around maternity, birth, periods, sex, menopause, fertility, and contraception and beyond. The question I wanted to answer became: What stands in the way of such innovation? And how can this new generation of entrepreneurs succeed?

I set out to interview a range of female entrepreneurs in the space for an article. Every entrepreneur I spoke to told me outrageous stories about reactions from investors, who tend to be predominantly male. It’s hard enough for female entrepreneurs in any industry to raise money, but for those with a vagina-centric innovation it’s even harder. Not only do investors not relate to the issue at hand, but they are too embarrassed to discuss it in a business setting. It isn’t proper, they think, twiddling their ties. It’s not polite conversation. As one well-known venture capital investor put it: “I don’t want to talk about vaginas in my Monday morning partner meeting.”

My article was published in Wired magazine and went viral. It was read and shared by tens of thousands of people. Messages came flooding into my inbox from female entrepreneurs: “I loved your article. I think it really captured how particularly difficult it is for women.” Perhaps more surprisingly, I received messages from younger, millennial male investors too. “Super cool article,” one wrote. “As an investor, I definitely had that problem initially. Now, I am way past it.” Like others who were squeamish at first, he was making a foray into femtech.

I realized this was just a flash of the ankle. The more founders I spoke to, the more I learned about the stigma they deal with, the censorship they face from mainstream media as well as social media platforms, and also, the tremendous potential they have in an industry that could capture 50 percent of the world’s population. This, I knew, has to become a global movement.

Society has mostly overlooked female health—from the detrimental side effects of the birth control pill to a lack of groundbreaking innovation in childbirth and menopause. Designing technology—largely by women, for women—is a novel approach. After all, most technology is still designed by men, for men. This bias starts with ever-growing smartphones, which don’t fit into our hands, and extends to bigger tech, like seat belts and the broad-shouldered, masculine car crash test dummies, as Caroline Criado-Perez has shown in her groundbreaking book on the gender data gap, Invisible Women. Prosthetics, voice recognition, and protective clothing for healthcare professionals have all been designed for male bodies. A world that was designed around a male default ultimately impacts our health and safety.

The more I immersed myself in the world of femtech, and its wider ecosystem, the more it puzzled me. Women make 80 percent of healthcare decisions in the United States, according to the U.S. Department of Labor, but are hardly involved in the design of the healthcare system. It was only in 1993 that women and people of color were officially included in U.S. clinical trials, and much of our current medical knowledge has been shaped by earlier research. Women were long excluded from research because of our cycles; even animal testing tends to exclude female mice, because of their hormones.

In both puberty and perimenopause, hormone levels are chaotic.

Perimenopause Lost, Professor Jerilynn C. Prior.

The consequences have been catastrophic. Women are 50 percent more likely than men to be given a wrong diagnosis after a heart attack. Across 770 types of diseases, women are diagnosed an average four years later than men. And a delayed diagnosis means women are more likely to suffer pain and complications.

Female-specific diseases are met with a raised eyebrow, as polycystic ovary syndrome (PCOS) is routinely misdiagnosed. It can take close to a decade to get a diagnosis for endometriosis. Even Oprah was repeatedly misdiagnosed when she had heart palpitations as part of menopause.

The dosage of most drugs is calculated based on studies overwhelmingly conducted on male participants, even though in women, drugs tend to linger longer, as our liver and kidneys process them differently.

Only 4 percent of all healthcare research and development is focused on women’s health issues, according to PitchBook data. In the UK, less than 2.5 percent of publicly funded research is dedicated to reproductive health and childbirth. Women’s health is both underfunded and underresearched.

This disparity has existed for millennia. In ancient Greece, people believed women’s health problems were caused by our uterus wandering around our body; say if it got stuck in the chest, we’d have chest pain. In the nineteenth century, doctors blamed “hysteria,” which comes from the Greek word hystera for “uterus,” as a cause for female health issues. Today, women continue to be brushed off for “complaining.”

Female pain has been normalized, from childbirth to menopause, as society shrugs and says “Welcome to being a woman” instead of coming up with better solutions. The terms we use are revealing. There’s nothing quite like “morning sickness” to trivialize what can be a debilitating experience in pregnancy, confined not only to the morning. Another contender for outdated terms is “geriatric pregnancy,” which sounds bleak and is also oxymoronic, as you can’t be ancient and fecund. We don’t say, “Here’s your geriatric pack of Viagra.”

Female bodies have long been shrouded in mystery, and those who work in related fields continue to face stigma. In a speech Virginia Woolf gave in 1931, she said it would still be decades before women could tell the truth about our bodies. To this day, our culture and the attitudes—of both men and women—stand in the way of innovation and of how we as women relate to our own bodies. As data is slowly catching up with reality, could a burgeoning group of innovators help to plug the gap?

Vagina innovation

Let’s not forget that the business world is a reflection of our culture. Think about the way we use language. Calling somebody “a dick” is commonplace, but try shouting “vagina” in a pub. A figurative fear of vaginas can be traced back to folktales of the toothed vagina, the vagina dentata, throughout history. This fear was central to Freud’s idea that men suffer from castration anxiety. Today, many femtech entrepreneurs I’ve spoken to encounter what they describe as “a fear of vaginas.”

We can find “vagina ghosts” haunting ancient Japanese woodblock prints. But there’s no direct Japanese word for “sexual wellness,” notes Amina Sugimoto, the founder of Fermata, an online marketplace for femtech products in Japan and Asia. While dick doodles grace public bathroom walls around the world, most people can’t draw a clitoris.

To begin with, words like “vagina” are tricky for many people. Just by reading the word “vagina,” you may feel awkward, excited—or both. Many of the entrepreneurs echo the words of Tracy MacNeal, CEO of Materna, a company that has developed a dilator that pre-stretches the vaginal canal to make vaginal birth easier and faster: “When I first saw the product, I thought, ‘Don’t be ridiculous. Do I want to be the CEO of Vagina?’ But then my sister said, ‘You just feel this way because society has not valued vaginas.’ So, I realized I have to start with myself.”

Despite my liberal upbringing, I’m not immune to societal norms either and catch myself participating in them. Why do I whisper the word “period”? When asked for a period pad at work in the past, I have passed it on surreptitiously in an envelope, as if I’m dealing drugs. Gloria Steinem imagined that if men had periods, “menstruation would become an enviable, boast-worthy, masculine event,” but we still have some way to go. Businesses thrive when people recommend products to each other, when we tell our friends about this new meditation app or that massage hammer we enjoy. Of course, somebody’s period is a private matter, but how can a business thrive in an area most people talk about in whispers, if at all?

Our prejudice runs deep. In an experiment, researchers at a university in Colorado recruited a group of participants aged seventeen to thirty-six, who were told they were part of a study on “group productivity.” They were instructed that they would be solving a problem together with another person. What they didn’t know was that this other person, a woman, was part of the experiment. At one point during the task, she reached into her handbag to get some lip balm and instead fumbled out one of two things onto the table: either a wrapped tampon or a hair clip. After the task, researchers asked participants to evaluate their partner. The women who dropped the tampon as opposed to the hairclip were rated to be less competent and less likable by participants.

Privacy is one thing; shame is another. Lift one strand of shame, and you’ll be pulling up a whole web of it. In a survey, Dr. Ingrid Johnston-Robledo, a researcher on body shame, has found that women who agree with the statement “I am embarrassed when I have to purchase menstrual products” were also more likely to say, “I think pictures of women breastfeeding are obscene.” Sadly, they were also less likely to have the ability to advocate for their own sexual pleasure. In other words, shame about the female body inhibits sexual agency. Entrepreneurs in the sextech space face a complicated web of shame that entraps potential customers, and this, in turn, influences how they conceive of and promote their products.

At the same time, there is a huge opportunity for companies to reach people who are looking for quality information and innovative products. Two-thirds of women between the ages of eighteen and twenty-four are too embarrassed to use the word “vagina” at a doctor’s office, according to a survey by Ovarian Cancer Action, a British charity. It’s likely that these same women would feel more comfortable if they could seek answers through an app or a community of like-minded people.

The other issue is that there is no legacy of knowledge. Information about pelvic floors, for instance, is not typically passed down the generations together with the family heirlooms. Instead of talking openly about pelvic floor issues like incontinence, people use euphemisms. “After I gave birth, my mum would say ‘Lie down,’ and she wouldn’t tell me why,” says Gloria Kolb, the founder of Elidah, which provides a noninvasive therapeutic device for stress urinary incontinence. “It wasn’t until after I started my company that I found out she had two pelvic floor surgeries herself. I asked: ‘How could you not have told me any of this?’ She was just like, ‘Eh, you don’t talk about it.’”

“Nobody tells you, right? Nobody tells you about these phases in life until you’re there and you don’t even know what you don’t know,” said Dr. Mridula Pore, CEO and cofounder of the healthcare app Peppy, at a Women of Wearables event.

“People are realizing the same things over and over in each generation, but they’re not putting it somewhere in black and white,” says Rob Perkins, cofounder of OMGYes. This means companies in the space have an opportunity to provide access to trusted information, at a time when people turn to Google with mixed results.

If we continue to avoid talking about female bodies, by shrouding them in mystery, we rob women of pleasure and inflict them with pain. Juliana Garaizar of angel fund Portfolia was presenting Materna’s birthing device to a group of investors in Houston. Shortly before the meeting, a colleague warned her, “There is no way we can put this slide on.” But Garaizar insisted. “If there is one slide we should be showing—it is this one!”

As expected, the slide caused a ripple of giggles to run through the crowd. What they were shown was a photo of a vagina torn after childbirth compared to a healthy vagina. For too long, women’s pain has been ignored, from endometriosis to childbirth and breastfeeding. We can no longer let giggles get in the way of female health. It’s time for Eve’s curse to become a blessing.

First-person power

It was Sigmund Freud who said that clitoral orgasms are infantile, while vaginal orgasms are mature. But Freud didn’t have any skin in the game. He had no firsthand experience. Over the last decades, researchers have made great strides in discovering the origins and functioning of the female orgasm, and unsurprisingly, many of these researchers are women. Just like research and art, businesses and innovation often arise out of a problem the founder has experienced and wants to solve. Whenever I speak to founders, they talk about what it is that inspired their idea. Their personal stories, the risks they take, and their motivations are what the business world refers to as “skin in the game.”

Dr. Lyndsey Harper sits in front of her bed, framed by two brass lamps, as I speak to her on Zoom. “My background is that I am an obstetrician gynecologist, and so I’m treating patients for women’s health issues, contraception, pregnancy, pap smears, breast exams, all things from fertility to menopause,” she tells me with a bright smile and the kind of upbeat voice that always endears me to American entrepreneurs.

“When I was in private practice, a lot of my patients would share with me—especially once we had gotten to know one another, you know, maybe after a couple of babies together—like, ‘Hey, I love my partner, but I don’t care if we ever have sex again.’”

“And I would hear that over and over every day,” she says. “I literally had no idea what to do to help my patients. and I do not like feeling that way. I asked my partners in the practice, ‘Hey, do y’all patients have these problems?’ They said, ‘We hear this all the time’. Unfortunately, in ob-gyn training and our wider culture, we’re taught to think ‘Oh, join the club, drink a glass of wine, or go on vacation’—it can be very dismissive. But for me, I know these women, right, I’ve taken care of their pregnancies, we’ve been through a lot together. So, for me these answers felt like a bad idea.”

Harper realized that there was hardly any research on women’s sexual dysfunction. “There are urologists who spend half of their time on men’s sexual dysfunction. We know all about erectile dysfunction, premature ejaculation—these things are discussed at medical conferences, and we have medications for them. The same is not true for women, unfortunately. So, once I became aware of this disparity and learned that 43 percent of women have sexual problems, I became very interested and excited about learning as much as I could about women’s sexual health.” It inspired her to found Rosy, a platform offering women advice on sexual health and wellness.

For Lora DiCarlo, it all began with an orgasm. DiCarlo, who has a shock of curly black hair and the eyes of a leopard, experienced what she describes as a mind-blowing orgasm. “The convulsions made me roll off the side of the bed, and I was lying on the floor just thinking, ‘Okay—how do I do that again?’ and I’m looking at this person and I’m like, how do I do it again by myself? I want this power!” She tried to find a sex toy that would re-create the experience but soon realized that what she was looking for didn’t exist. She would have to invent it herself.

Many founders describe realizing that technology is out of step with their needs. “I had this moment: I was sitting at my desk, I had my laptop, my Kindle, Apple Watch, iPhone—I had all these gadgets, everything was perfect and functional,” says Eirini Rapti, the CEO of Inne. But these gadgets contrasted with the internal thermometer she used to chart her menstrual cycle—it was clunky and beeped through the night. “I was like, this is just bullshit,” she says. “It needs to be on par with what the rest of technology offers us.” A decade later, her company launched a cycle tracking device that can read progesterone levels through a daily spit test connected to an app.

It was when Colette Courtion, the CEO of Joylux, had her first child that she “learned firsthand what women truly go through when it comes to their vaginal health and wellness. No one—not even my doctor—shared with me that every time you sneeze or jump up and down, you would pee your pants, and I was mortified to learn of this.” She discovered there were very few treatment options. “And I said to myself, there’s got to be a better way.”

A lot of what has held female technology back in the past is stigma. It was easier for obstetricians to think “just stitch her up” instead of developing a tool that would help with vaginal tearing. It was easier to release a mere contraceptive pill for women than to get men to accept the same side effects for themselves. It was easier to ban images of female pleasure in advertising than it was to counteract the damage done by exploitative porn. And without the first-person perspectives of women who innovate in the space, there’s a risk it continues to be so.

Entrepreneurs of female well-being

How can a bra save lives? Could birth ever be painless? What’s the future of contraception? In an age where female bodies are still the most sexualized and the least understood, I embark on a one-woman journey to answer these questions and to uncover the most revolutionary femtech innovation.

Some people take umbrage at the word “vagina,” noting that “vulva” would be more anatomically accurate. The reason I call it “vagina-centric” rather than “vulva-centric” innovation is that I would like to continue the conversation that began with the Vagina Monologues and carries on with books like Dr. Jen Gunter’s The Vagina Bible and Rachel E. Gross’s Vagina Obscura—I believe there is value in creating a unified, go-to term, rather than getting lost in labia.

I’m interested in what I think of as “entrepreneurs of female well-being.” To me, this encapsulates everything to do with vaginas, but it also goes beyond the ovaries. It includes innovation that helps us recognize the symptoms of heart attacks in women, which is the number one killer of women in the UK and United States. It includes companies that playfully educate people about female sexual pleasure. It includes not only apps that support new parents but also tech that alleviates the symptoms of menopause.

My intention is to focus on solutions that are pertinent to vast numbers of women. When we address female well-being, we better the well-being of all—of families, of workplaces, and of nations.

The term “femtech” was popularized by Ida Tin, the founder of Clue, a period tracking app, and it has been gaining traction ever since. People who have never encountered the term femtech before tend to mishear it as “fintech.” Others yet assume that the “fem” excludes those who don’t identify as women, but that’s not reflective of the companies in this space.

This innovation is not just valuable to women; it can also help gender minorities including trans men, intersex people, and non-binary people, who have vaginas; some of these products can be used by everyone. Whatever your gender identity may be, I welcome you.

Equally, no woman is the same. Some menstruate, some don’t. Some want children, some don’t. Some women had their uterus or ovaries removed in medical interventions. Some women have high testosterone levels. None of this makes you more or less of a woman.

Another common misconception is that femtech refers to companies led by female founders. It’s estimated that 80 percent of femtech companies are led by women, according to FemHealth Insights. Most entrepreneurs in this book are women, but it’s not like we’re Amazonian warriors who are surrounded only by women—I believe we get nowhere without getting everybody on board.

Many femtech innovations come out of first-person perspectives, but just as it’s possible to be an excellent addiction therapist without being an addict, lived experience should not be a prerequisite for working in this industry. It’s about compassion, which, as Martha Nussbaum puts it, is “a central bridge between the individual and the community.”

The term “femtech” does have downsides: some products are more medical than tech, like contraceptives. Others hardly feel like tech at all, such as period underwear. That’s why some prefer to use “women’s health innovation” as an umbrella term.

In any case, terms like “femtech” evolve and new ones arise, but female well-being will always require innovation. What began in the period tracking world has since expanded to encompass aspects of health that impact women not only solely, like periods, but also differently, like heart health, or disproportionately, like bone health.

Some areas of female health receive far more attention than others if we look at the number of femtech companies.

FemHealth Insights.

The diverse range of femtech entrepreneurs face stigma and censorship. They have seen it all: from being asked to demonstrate how to put on a condom to pitching panels of men whose faces turn the color of beetroot to being disinvited from conferences and banned on social media. At the same time, their ventures are far from niche, and femtech could have a market potential of $1 trillion.

In some countries, the innovation I write about is provided through public organizations, like the NHS or Medicaid, employers, or non-profits. Others are bought by consumers directly. The most powerful innovation needs to be accessible and affordable.

Many of the innovations in the space are subjective. Just like you might say, “I’d never wear an oversize lemon-yellow jacket” while I say, “I’ve always wanted one!” Just like some women want a delivery in a birthing pool, while others want an elective cesarean. Just as some like to meditate with an app, while others prefer to not meditate at all. At the end of the day, it’s about having greater choice.

In many cases you’ll have to decide for yourself: Is this empowering to me? Or is it useless? Either answer is fine, and let’s not judge those women who make different choices.

I am, however, drawing some lines: I’m calling out any products that are damaging and unnecessary by design. The prime example of this is vagina cleaning and steaming products. Vaginas are self-cleaning, and unlike asparagus, they need no steaming.

There have always been, and there continue to be, companies that perpetuate and cash in on insecurities. Let’s separate the “empowerment talk” from what a product actually is or does.

Technology is a tool. It can serve and it can exploit us. If societal values don’t keep up with the pace of technology, the result is likely to be insidious. There’s a huge difference between innovation that genuinely improves female well-being and products that reinforce and monetize women’s vulnerabilities. There is, unfortunately, a long history of such products. And there is a large number of vendors who sell snake oil.

We need to be wary of anything that falls into the “pink tax” category—the classic examples are razors in pink packaging—that are sold to women at a markup price. My mother always told me to buy men’s razors, which cost less and fulfill the same function. The pink tax permeates healthcare too when the painkiller ibuprofen is repackaged and sold at a higher price as “Feminax” for period pain.

For me, the definition of femtech is innovation that moves women’s health forward. It’s often consumer focused and digitally enabled. But I have seen people use femtech to encompass anything aimed at women, including beauty, hair removal, or even weight loss products. None of these fit my definition of femtech.

It’s not that I dislike lipstick. Please. My bathroom shelf holds a pile of lipsticks as much as anyone else’s. But I’m focused on health for a reason, rather than what to wear this season. What’s hair removal got to do with health? Nothing. And I’m tired of having the thought “Wouldn’t it be nice to lose a bit of weight?” live rent-free in my head—beauty takes on all shapes, sizes, and skin tones. The test to figure out whether something qualifies as femtech is simple: Does it advance female health?

Femtech products are as varied as their innovators. Whether they leave us feeling curious or laughing with embarrassment, they share a crucial goal: to better our understanding of female health. This goal is unusual in a business world that is still a male-dominated one. Until recently, there were more CEOs called John than female CEOs at big companies in the United States and UK. Executive boards are still populated with male names like Paul and George (but I have yet to see Ringo).

The femtech community is a powerful example of how women thrive when we support each other in business. In the femtech industry, the sisterhood is alive and ovulating. It’s diverse and inclusive. It’s time to draw a new portrait of the archetype of female entrepreneurship, one that does not require a deep voice or black turtleneck.

While interviewing female investors and entrepreneurs in other fields, they sometimes ask me: Why do you focus on femtech? Their first reaction is to think that focusing on femtech is another way of “keeping women in their place,” of confining women to launching vagina-centric companies.

The reality is, as one interviewee put it, “If it’s too vagina-related, investors clench up, but if it’s too far removed from vaginas, clothes, and makeup, they’re not interested either.” That’s because women are more likely to raise funding in “gender-congruent” fields like fashion and beauty while facing a “lack of fit” bias and less funding in male-dominated engineering and tech. Society wants women to look good; it’s less interested in whether we feel well.

What’s telling is that male-led ventures escape the “lack of fit” bias, as men are not pigeonholed in the same way. Consumers replicate this one-sided perception: craft beer made by women is evaluated less favorably, while cupcakes made by men are welcomed with open arms. Femtech founders therefore face two kinds of hurdles: they often operate in male-dominated fields, like condoms, or areas that are shrouded in taboos, like miscarriage.

Of course, women create and innovate across all fields. I’m very proud of the fact that my mother is an artist, that my grandmother is an engineer, that my great-grandmother was a doctor, and that my great-great-grandmother ran a small business. Of course, I believe that we should blaze trails and succeed in all parts of society. The reason I’m writing about femtech is that we urgently need more vagina innovation. One day, I hope that femtech will just be tech, but for now, we’re not there yet.

A journey through the world of femtech

I am based in London. Together with New York, it’s the city with the highest number of femtech companies, according to FemHealth Insights. There are about two thousand femtech companies globally. Over 50 percent of them are in the United States.

I have seen several maps that capture the geographical spread of femtech companies, and though definitions vary, the main hubs outside of the United States are the UK, Switzerland, France, Germany, India, Australia, Israel, Singapore, and Japan. My research reflects this global and diverse set.

The global distribution of femtech companies.

FemTech Analytics report, 2021.

Every place has its own needs and characteristics. Laws, such as whether abortion is legal, vary by country. What is covered by the healthcare system, once again, varies by country. Regulatory approval varies by country. There’s the CE Mark in Europe and FDA regulation in the United States. Some innovation is closely tied to its local context, while others swim the currents of globalization.

In the course of my research, I’ve come across many hundreds of entrepreneurs, researchers, medical professionals, and investors at conferences, webinars, pitches, and other industry events. In this book, I include about one hundred of them in over fifteen countries.

I am an experienced journalist, which means I chase experts with endless questions, hear what goes unnoticed, report, investigate, and dig deep to unearth stories. I am also a trained social scientist, having done a PhD on a scholarship in my early twenties, so I can interpret and evaluate scientific studies to turn them into accessible insights.

For each study or data point I write about, you can find a source in the endnotes, if you would like to delve further into a topic. Bear in mind that new evidence always continues to emerge on our health: that is the nature of scientific evidence.

My focus is on tech that connects us to ourselves and each other, rather than disconnecting us. In low-risk pregnancies, human continuity of care is just as important as good tech. In the contraceptive space, I believe we need more nonhormonal choices. When it comes to sexual pleasure, I have no interest in sex robots.

The rise of femtech is accompanied by large seismic shifts. In the medical world, there is a reconfiguration of who holds power in the examination room between the patient and doctor, as more people than ever can access information—and misinformation—about health online. With increased information and opportunities for patients to get involved, it’s more important than ever that we learn about our bodies, so that we can advocate for ourselves.

We are at an unusual juncture, as people’s trust in businesses is at an all-time high, while trust in governments continues to spiral, according to the Edelman Trust Barometer. Businesses are seen as competent, and business leaders are seen as unifiers in a polarized world. Almost seven in ten employees chose their workplace based on shared values and expect their CEO to take a stand on societal issues. What we buy and where we work are conscious decisions, and businesses play a role, for better or worse. Technology can be a great force for good, but in the wrong hands, and without ethics and regulatory oversight, it can be a tool of exploitation.

In the business world, there’s a shift from “shareholder capitalism” to “stakeholder capitalism.” This means moving on from Milton Friedman’s doctrine that the utmost priority of companies is to return money to their shareholders by maximizing profits while ignoring wealth inequalities. Instead, businesses need to consider all stakeholders—employees, customers, and the well-being of society and the planet at large. We have an opportunity to create new types of businesses.

As I work on this book, it often feels like the universe rearranges itself. At the pub, strangers tell me about their contraceptive preferences. Meetings turn into conversations about UTIs. The minute I sit down at a café on a Sunday to finally relax, two women start to loudly talk about their period migraines. At first, I think it’s confirmation bias. But over time, it becomes clear to me that the conversations around women’s health are getting louder. As I listen intently to understand the experiences of friends and acquaintances, I think of Maya Angelou, who said, “I come as one, but I stand as ten thousand.”

PART I

SOMETHING NEW UNDER THE SUN

1

LAUNCH

WHO ARE WE TO INTERFERE WITH MOTHER NATURE?

Any day could be the day now. My friend Daniella usually races down the roads of London like a bullet train, but over the last three months she’s had to slow down. The final trimester of her pregnancy has made her feel much heavier. As we sit down for tea and banana bread on a sunny spring day, she airlifts herself into the seat.

She tells me she has prepared a birth plan, but she’s keeping an open mind about how the day might go, because it’s impossible to predict what happens during labor. What she knows for sure is that her priority is for the baby to be born alive and safely and that she wants her own experience to be as painless as possible.

In the prenatal classes she attended with her husband, she has noticed a preference among the group for everything natural. “It’s an overcorrection,” says Daniella. Birth has long been medicalized at the expense of women’s own preferences, and now some people feel suspicious about any form of intervention. “Despite the fact that everything you do up to that point is enabled by technology, all of the tests and scans,” she adds.

Commenting on her birth plan, she says, “It’s a pretty medical affair.” It includes a TENS machine, medication, and an epidural—in other words, electric currents, drugs, and anesthetics.

A bit later, I talk to my friend Emma, who is also about to give birth. She can barely keep her eyes open, says she is eating like a horse, and has five naps a day. “I am very excited about meeting my baby,” she says. To prepare for the birth, she has been watching hypnobirthing videos by the Positive Birth Company. The message is that “birth doesn’t have to be painful. It is a natural process, and if you understand the process and keep calm, your body will do what it’s designed to do.” One of her affirmations is “I can do anything for one minute,” as that’s how long a contraction tends to last before there’s a break.

For the time she will be in labor, she plans to inhale gas and air, ideally in a birthing pool at the hospital. She wants the birth to be “as natural as possible, with minimal medical intervention, using hypnobirthing techniques.” She wants to experience what birth feels like.

From where I stand, each friend’s choice is fully valid for her. As I explore the world of femtech, I keep that in mind. It’s always her choice.

Something new under the sun

I have been keeping an eye on a medical device developed by the California-based start-up Materna Medical. For any new medical device or drug to be sold on the U.S. market, it first has to pass several rounds of regulatory approval by the Food and Drug Administration, a federal agency of the Department of Health and Human Services—and rightly so. In this case, the device is classified as being on “de novo” pathway—in Latin that means “of new.” It’s the first of its kind.

If approved, this device could drastically change both the immediate experience and the long-term effects of giving birth. It can take medical devices over a decade to go from being invented to being available on the market. For femtech products, it can take even longer because the fundraising path is more likely to be rocky.

“Raising money in women’s health has been hard,” says Tracy MacNeal, the CEO of Materna, at the beginning of our conversation. Why is that the case? “I think the primary issue is that investors are pattern seekers,” she says. Investors who analyze a company will look for examples of previous companies that have made money in the same space.

But in this case, identifying a pattern is not straightforward for a reason that is truly mind-boggling. “The last real innovation in the fundamental standard of care in childbirth was the epidural in the 1950s,” says MacNeal.

The first videotape recorder was invented in the 1950s. The first commercial computer was released then too—it was the size of a room and weighed 29,000 lb. The first floppy disk would only be invented two decades later. We don’t think of these inventions from the 1950s as state-of-the-art anymore—but when it comes to childbirth, we do. And by the way, the speculum with its duck beak, which is used for pap smears, hasn’t changed much since the 1870s. If this was the automotive industry, we’d still be riding in a horse-drawn carriage, wearing a fetching bonnet.

Welcome to being a woman

With her flowing red hair and silver earrings made of intricate circles, I can’t help thinking that MacNeal would have been considered a witch in medieval Europe, where women were persecuted for acting as midwives, for teaching the secrets of sex, birth control, and abortion. Trying to improve birth has always been a dangerous business. In the sixteenth century, a Scottish woman called Eufame Macalyne was burned at the stake for asking a witch-midwife for pain relief during labor. But I digress.

MacNeal specializes in the commercialization of medical devices. Her previous companies have focused on orthopedics and endoscopy. “Somewhat more polite conversation,” she says laughing. This is her first role focused on women’s health. “And it’s interesting, because previously, I was never asked, ‘Who are we to interfere with Mother Nature?’ When people get an artificial hip, nobody’s asking that!”

An engineer by training, MacNeal worked in the pharma industry before setting up her own company, “because I wanted to have children on my own terms and not have to work a big corporate job and pretend I wasn’t a mom.” After selling her start-up, she worked for midsize companies before rejoining the world of start-ups as CEO of Materna. “Start-ups are a hassle,” she laughs. “The highs are high; the lows are low. They’re relatively high risk.”

At first, she was taken aback by the shape of Materna’s device: it looks like a dildo. Throughout my research, I have observed that this is a common reaction. People will look at a femtech device and exclaim, “It looks like a sex toy!” when in fact, that’s just the internal shape of a vagina. As MacNeal points out, “They look like sex toys because our society thinks anything going into the vagina must be for sex.”

Becoming the CEO of Materna was a breakaway moment for MacNeal. “I had been worried about what my network would think if I took this job.” Would she dare to become the CEO of Vagina? “I had spent my entire career pretending I wasn’t a woman,” she says. “And then, all of a sudden, there was just no way to keep doing that. On the contrary, I had to embrace being a woman as a strength and bring other women along.”

Seeing the early results of their initial clinical trials convinced her to take on the role. “We’re all on the edge of our seats,” she says. “What if we could totally transform one of the highest volume procedures in healthcare? And one of the biggest transitions in most families’ lives? And to think that I might have blocked myself from the opportunity to make that kind of contribution simply because I was embarrassed? That would have been awful.”

Childbirth is the number one reason for hospitalization worldwide. Most hospitals have a building just for births. “I do think that women are conditioned to be a bit fatalistic about it,” she says. “Well, you know, ‘Welcome to being a woman! This is going to hurt.’”

I admit that growing up, I assumed that by the time I was ready to give birth, all the world’s technology would stand by to support me. Instead, I listen to my friends with some astonishment as they recount giving birth with the help of technology best described as “salad forks” and “toilet plungers,” also known as forceps and vacuum delivery. The forceps, by the way, were invented in the late seventeenth century.

Why is now the time to bring more innovation to childbirth? “First of all, women are having babies later,” says MacNeal. What’s more, babies are born larger thanks to improved prenatal nutrition. “Babies could routinely be eight to ten pounds, but mums are not getting bigger. On the contrary, our pelvises are getting smaller.” The combination of these factors means it’s time to reimagine vaginal delivery.

Reimagining birth

The vagina is a muscular tunnel that stretches from the vulva—which you can see externally—to the cervix, which is the bottom of the uterus, like the knot of a balloon. The cervix looks like a tiny pink doughnut, and it mainly opens to let in sperm, or let out menstrual blood, mucus, or a baby. In a relaxed state, a vagina is like a deflated parachute with the ability to stretch.

So how exactly does the device called Materna Prep work? MacNeal shows me an illustration of a baby in a uterus. “A lot of people don’t know what the cervix is or where it is, but it’s the bottom of the uterus,” she says.

In the early and first stage of labor, the cervix dilates and effaces. “For some women it’s an hour, and for some women it’s three days,” she says. The device does not touch the cervix, which dilates to about 10 centimeters in its own time. What the device does is it pre-stretches the birth canal while the cervix dilates. “Muscles are viscoelastic—if you stretched them suddenly, they tear, right?

“For decades, we’ve known stretching before and after exercise is better for them,” she says. “What we’re doing is that rather than having those muscles go from zero to baby, we’re slowly stretching those muscles before the baby comes through the birth canal.”

The device looks like a mini purple flashlight with four arms on its sides, and that’s the company’s intellectual property. “It’s super boring to watch, because it dilates a millimeter at a time,” says MacNeal. A nurse applies the device, and it dilates automatically as its arms stretch slowly to about 8 centimeters. That’s not as big as the baby’s head, but almost. “You need to get pretty close to the baby’s head size for efficacy is what we learned.”

Materna Prep

The speed at which it dilates, and the final diameter, is still being tested. Once it has dilated, the device is taken out, and the muscles in the birth canal stay stretchy for up to three hours. Once the cervix is fully dilated and the baby enters the birth canal, the second stage begins.

If approved, the Materna Prep device could shorten the time of pushing a baby through the birth canal. It could also protect the pelvic floor muscles, which support the vagina, bladder, and rectum. These muscles contract during orgasm, and they control the bladder and bowel. If these muscles weaken, it can lead to stress urinary incontinence or, worse, pelvic organ prolapse, which causes pain and discomfort and can require surgery.

What makes this device unusual is that it is preventative. The pelvic floor is “like a seat belt,” explains MacNeal. The pelvic bone and muscles “form a seat belt where the urethra and the vagina and the rectum all go through.” When those muscles separate from the bone, the organs they hold up can fall out of place. “I had never heard of prolapse before I joined Materna, if you can imagine; I didn’t even know what it was.”

The company has already created a dilator called Milli to help with vaginismus, the involuntary tightening of the vaginal muscles. It remains to be seen whether Materna’s new dilator can help with birth. “The main reason I joined the company was that in our pilot study, we reduced pelvic floor injury by 60 percent, not to mention the potential to reduce C-section rates and potentially reduce the incidence of forceps and instrumental birth,” says MacNeal.

What about vaginal tearing? It’s estimated that nine in ten first-time mothers who have a vaginal birth experience tearing or a graze or an episiotomy. “We are collecting data on perineal lacerations,” she says, using the medical term for tearing of the perineum. “Those are classified in four degrees, and we’re collecting that as a secondary endpoint. Our primary endpoint is the pelvic musculature measured by ultrasound.”

It has been shown that perineal massage, which aims to stretch the tissue between the vagina and anus in preparation for birth, can reduce the risk of tearing in birth.

It also decreases the need for episiotomies, which are cuts made at the vaginal opening by healthcare professionals to create more room as the baby’s head appears. Episiotomies are a largely outdated medical practice. The American College of Obstetricians and Gynecologists (ACOG) issued a recommendation against the routine use of episiotomies. The persistent thought behind these cuts is that they’re precise, but research suggests that natural tearing is preferable in most cases. When episiotomies are done as routine procedures, they do more harm than good: they can lead to postsurgical infection, deeper tears, long-term discomfort, and slower healing. It’s an example of over-medicalization.

Not only new technology and new insights are needed but also greater education on what we already know: a supine birth position in the second stage of labor may be more convenient for healthcare professionals, but it increases the risk of birth injuries for mothers.

MacNeal has two children, who are teenagers now. “I was very much aligned to the idea that my body knew what to do. And I did not know that 50 percent of us will end up with incontinence or prolapse. And we’re almost six times more likely to have those symptoms if we’ve had a vaginal delivery.”

Women may feel too embarrassed to talk to their doctors about what’s going on below the waist, “because we’re taught from the time we are little girls that it doesn’t even have a polite name,” says the CEO of Vagina. “Part of what we’re trying to do is normalize the conversation,” she says and goes on to praise two other femtech companies, Elvie and Joylux, which are covered in this book.

“I think the media has been incredibly important in women’s health, continuing to publish on issues of maternal mortality, racial disparities, and gender disparities, and not letting it go.” As a result, investors are increasingly taking notice.

MacNeal says investors are beginning to wonder “Are we still on the bleeding edge? Are we on the leading edge of something? Am I going to get ten times my investment because I’m an early mover who sees an important trend? Will I be brilliant? Or will I be foolish?” She adds, “They’re all trying to figure that out right now.”

A challenging topic in a challenging place

From the beginning of life itself to near-death situations, femtech entrepreneurs blaze trails to help other women. Maria is a twenty-four-year-old Venezuelan mother of three struggling to make ends meet. Over the last three years, the price of a loaf of bread has gone up by 260 percent, as the country is engulfed in an economic and humanitarian crisis. Condoms cost half her daily wage. In her local area, hospitals are failing, and now, she needs an abortion.

In desperation, she consults someone, anyone. She is given a drink, and someone performs an abortion on her by using a hook. That night she wakes up in a pool of blood and wonders if this is how she’s going to die. A story like this is not dissimilar from the stories of the women Dr. Roopan Gill has taken care of in northern Nigeria and Yemen, where she has worked as a field gynecologist. She is the cofounder of Toronto-based Vitala Global.

In Venezuela, abortions are illegal in almost all circumstances. In the absence of safe options, women turn to dangerous methods. “They go and do it with herbs or with coat hangers,” Gill tells me, and I am speechless. “People are still dying from unsafe abortions, and the vast majority of the unsafe abortions happen in countries that are facing humanitarian crises,” she says with both urgency and a sense of calm. Gill has the strong presence of one who is good at emergency situations, a woman who gets things done.

One in three women has an abortion in her lifetime worldwide. Each year, 111 million unintended pregnancies occur in low-and middle-income countries. They result in 35 million unsafe abortions, which can lead to complications and injuries, and an estimated 22,000 women and girls die from unsafe abortions.

There’s a prevalent assumption that creating restrictive laws around abortions reduces their number, but that’s a fallacy. Banning abortion only bans safe abortions.

“What ends up happening is that it increases the number of unsafe abortions,” says Gill. Vitala’s internal research shows that one in three women have an abortion in Venezuela, which is in line with places where abortions are legal. In other words, reducing access to abortion does not decrease the demand for abortions—it only makes them dangerous.

According to the Guttmacher Institute, unintended pregnancy rates are the highest in countries that ban abortions and lowest in countries where abortion is legal. In countries with bans, the number of unintended pregnancies ending in abortion has increased from 36 percent in 1990–1994 to 50 percent in 2015–2019.

Making abortion illegal drives up abortion rates. Note: Rates are shown without China and India because the countries have a large effect on the average due to the size of their populations.

The Lancet.

Gill, who earns a living as a gynecologist in Canada, first learned about the self-managed abortion movement when she was working at the World Health Organization’s unit dedicated to preventing unsafe abortion. The introduction of safe and effective abortion medication—rather than only surgical abortion—was a revolution in the space of abortion care. It was approved by the FDA in 2000.

In 2019, Gill won a grant for innovators at the Grand Challenges Canada, to fund abortion-related work in low- and middle-income countries. “That was my opportunity,” she says. “I looked at it as seed funding.”

The first app she designed, myPostCare, provided information on postsurgical abortion care for Canadian women in remote settings, focusing on diverse populations. Gill realized how powerful an app could be. “And I said, I want to do this in a humanitarian setting.” This time around, her friend Dr. Genevieve Tam, also a trained obstetrician gynecologist, came on board as a cofounder. Together they set up Vitala Global as a nonprofit, “with the mindset that down the road, we want it to be more of a social business.”