Table Of ContentChapter Female Genital Cosmetic Surgery
1
Solution in Pursuit of Problem
Lih-Mei Liao and Sarah M. Creighton
Background complainingaboutsorenessfromthechaffingandrub-
bingofhervulva,especiallywhenshewearsherjeans.
Sociallymotivatedfemalegenitalcuttinghasalonghis-
“Itgetscaughtcozitsticksouttoomuch,”shesays.She
toryinEurope.Accordingtosocialhistorians,inancient
has recently cancelled a beach holiday with friends
Rome,metalringswerepassedthroughthelabiaminora
because,shesays,herclitorisgetserectinhotweather
of female slaves to prevent procreation. In medieval
andcanbeseeninsideherswimwear.Farfromfeeling
England, women in certain social strata were made to relieved by the gynaecologist’s reassurance that her
wear chastity belts to prevent them from engaging in genitalsarenormalandhealthy,Madisonismiserable.
sexual activities during their husbands’ long absences. Mother and daughter have spentmonths researching
In Tsarist Russia and nineteenth-century England, ontheinternetbeforeconcludingthatsurgicalremoval
France and the United States, clitoridectomy was per- of “the excess tissue” (in the clitoris) was the right
formedtocureepilepsy,hysteria,insanityandmastur- courseofactionforMadison.ToNicole,thepersistent
bation[1].Inmanycountriestoday,adiverserangeof despairofherdaughterissurelyevidenceenoughthat
lawfulproceduressubsumedunder‘femalegenitalcos- the problem is “not just in her head”. Having had
metic surgery’ (FGCS) overlap with a diverse range of a private neck lift herself a few years ago, Nicole is
unlawful procedures subsumed under ‘female genital aware of the high costs of private cosmetic surgery
and bemoans the fact that it would take Madison
mutilation’(FGM)(Chapter7).Thedoublestandardis
yearsofworkingatthehairsalon tosaveupenough
bewildering: moneyto“makethevaginarightagain”.
How can it be that extensive genital modifications,
Katelivesalone.Hersonanddaughterslivewith
including reduction of labial and clitoral tissue, are theirrespectivepartnersnotfaraway.Kate’shusband
considered acceptable and perfectly legal in many
moved out last year; their divorce has just come
European countries, while those same societies have
through.Afterseveralyearsofstressovertheuncer-
legislation making female genital cutting illegal, and taintyofher“rockymarriage”,Kateisenjoyinglife
theWorldHealthOrganizationbanseventhe‘pricking’
again. She feels ready for a new relationship. After
ofthefemalegenitals?[2]
aroutinesmeartest,sheasksthefriendlynurseabout
‘vaginallaxity’.IthasbeenatthebackofKate’smind
FGCSreferstolawfulprocedurestoalterthestructure
forawhiletodosomethingaboutit.Forafewyears
andappearanceoffemaleexternalandinternalgenitalia
beforethedivorce,herhusbandwasinitiatingsexless
in the absence of biomedical concerns. This definition
often.Whentheyhadintercourse,hedidnotalways
refers to a large and growing number of operations
orgasm.Katetookthistomeanthatsexwithherwas
including labiaplasty, clitoroplasty, introitoplasty, lessenjoyableforhim.Havinggivenbirththreetimes
hymenoplastyandvaginalrejuvenation,tighteningand andbeingpost-menopausal,shemuses,herbody“is
reconstruction(Chapters5and6).Theseoperationsare boundtofeelnotasnice”.Inpreparationforanew
said to ameliorate women’s worries about the appear- relationship,andasanactofdoingsomethingposi-
anceandfunctionoftheirgenitals,includingthekinds tiveforherself,Kateislookingtoseeadoctorexperi-
of concerns expressed by our three informants - enced in ‘vaginal tightening’. She wants to know
moreabouttheproceduresoastobeabletochoose
'Madison','Kate'and'Navaeh':
thebestprovider.
Madisonissobbing.NexttoherishermotherNicole.
Oppositethemisthegynaecologistwhohasjustexam- Afterasuccessfultermatschoolwheresheisahigh
ined Madison’s vulva. The twenty-year-old has been achiever,Nevaehisexcitedabouthersummertravels. 1
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Chapter1: SolutioninPursuitofProblem
Shebuysherfirstpotofhotwax.Atfourteenyearsof Doesthesharpriseinlabiaplasty[6]reflectsuccesses
age,sheisnotthefirstamongherfriendstoremove ofmarketingcampaigns?Havepricesfallenasaresult
theunwantedhairgrowthonherlegs.Nevaehtrieson of greater competition so that more women can pay
her new bikini and notices her pubic hair escaping for theoperation? Arebanks encouragingwomen to
throughthesidesofherbriefs.Sheinstinctivelypro-
takeoutpersonalloansforcosmeticsurgery?Isthere
ceedstotrimthehairoff.Anhourlater,sheiswaxing
anewsocialacceptanceoffemalegenitalcuttinginthe
herlabiamajora.It’sextremelypainfulandhervulva
Westand,ifso,whataretheimplicationsforwomen
islookingratherred.Theenlargedhairfolliclesgive
andforsociety?Hasfemalegenitaldissatisfactionand
the labial skin a pimpled appearance. Images of
distressincreased?Arethesefactorslinked,andifso,
chickenskincometomindandbringasenseofdis-
gust.Shedespisesher“purplyfleshy”innerlabiaeven how?
more.Sheexperiencesalongingforafirm,smooth- FemaleGenitalCosmeticSurgery:SolutiontoWhat
skinned and evenly coloured vulva “without all the Problem? is an interdisciplinary response to some of
bits”.Nevaehshutshereyesandimaginesthatdiffer- thequestionsasked.Thevolumecombineshistorical
entvulvaandfeelsasenseofrelief.Shecan’tremem- and philosophical analyses and legal, pedagogic and
ber where she may have seen such a “vagina” – clinicalperspectives.Itsaimisfirsttoenableresearch-
perhapsasadrawinginabiologybook?Nevaehfeels
ers to formulate questions about FGCS more strate-
thatshewouldbesohappyifshedidnothavetodeal
gically. An equally important aim is to enable
withthebodypartthatis“sonotme”.
education and health professionals to develop non-
In2007,wedrewattentiontothefivefoldincrease surgicalalternativestoaddressgenitaldissatisfaction
inthenumberoflabiaplastyoperationsperformedin and the resulting distress (Chapters 11 to 15).
theUnitedKingdom’sNationalHealthService(NHS) The book was seeded by the experiences of women
in the preceding decade [3]. The article was not the andgirlswho,likeMadison,KateandNevaeh,experi-
firstcommentaryonthetopicinamedicaljournal[4], ence doubt, concerns, worries, distress and disgust
andtherehadbeenimportantfeministscholarshipon about the appearance and function of their genitals.
the subject [5]. Since then, the FGCS industry has Itishopedthatsomeofthechapterswillbeofinterest
expanded considerably. According to a 2016 report to the women and girls so affected. Although the
by the International Society of Aesthetic Plastic volume is about FGCS, many of the discussions are
Surgery(ISAPS),138,033labiaplastyoperationswere relevant to cosmetic surgery more generally, so that
performed in the preceding year [6]. These figures some of the chapters may be of interest to wider
comefromvoluntarydatasubmissionsandarealmost audiences.
certainlytobeunderestimates.Theoverallincreasein Thecontributionstothebookbyleadingacademic
thenumberofcosmeticoperationsintheyearwas9%, andclinicalexpertsonthetopicofFGCScombineto
buttheincreaseforlabiaplasty,whichhadenjoyedthe emphasise the critical importance of reframing the
steepestrise,was45%.Thesuccessfulmainstreaming most frequently asked question about FGCS: “Why
ofFGCSinhigh-incomecountriesismirroredinlow- dowomendoit?”Thequestionpre-locatestheanswers
and middle-income countries, as evidenced, for inthewomenandencouragestherecyclingofindivi-
example, by the specialist sessions on Cosmetic dualising discourses of free choice, self-improvement
Gynaecology and Vaginal Rejuvenation at the All andfemalemadnessthatexonerateFGCS(Chapter8).
India Congress of Obstetrics and Gynaecology in Thesepopulariseddiscoursesmaskthepowerfulstruc-
2017and2018[7].Weknowthattherehasnotbeen turalunderpinningsofaculturalpracticethatisbeing
alabialgrowthspurtworldwide.Inanycase,research promotedmoreorlessunopposed.
showsthatthereisnodifferenceinlabialdimensions InPower,InterestandPsychology,clinicalpsychol-
betweenwomenseekingandthosenotseekinglabia- ogistDavidSmailproposedthattounderstandunhap-
plasty [8]. We also know that surgical techniques do piness, we should, rather than gain insight into
not change that quickly. Hence some other factors ourselves, instead cultivate ‘outsight’ into the world
must account for the growth of labiaplasty. around us, in particular in how social and economic
PsychologistandsexologistLeonoreTieferexplained factorsmouldourthoughtsandfeelingsandorganise
in2008thattheinfinitepossibilityofdiseasemonger- our choices in ways that are often not obvious [10].
inginconsumeristmedicinefitscomfortablywithour Outsight into FGCS is the aim of this chapter, in
2 freemarketandencouragesthegrowthofFGCS[9]. which we highlight and problematise the interrelated
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Chapter1: SolutioninPursuitofProblem
systemic processes, including (1) binary notions of removal is unavailable or not practised indicate that
sex and gender, (2) the pressure of suspect norms, women have the potential to develop hair growth in
(3)theeffectsofmedicalframing,(4)theambivalent the same regions of the face and the body as men.
professionalresponses,and(5)thebarrierstoestab- The difference between men and women in the
lishing high-quality evidence to guide consumer amount of hair growth has never been quantified.
choice and professional practice. We return to our Nevertheless, clinicians have described women’s
three informants as the discussion progresses and extremereactionssuchasshameand‘morbidpreoc-
offersuggestions atthe endof the chapteron limit- cupation’ even with insignificant hair growth. [13].
ingdamage. Nevaehtakesforgrantedasatruththatfemaleshave
no body hair. It is a social norm that she has inter-
Binary Genitals nalisedanddoesnotquestion.Assheapplieshotwax
toremoveherleg,armpitandpubichair,sheismerely
Like other sex characteristics, the genitalia are cultu- actingonacommonsenseunderstanding–amatterof
rallyconstructedasdiscreteandnon-overlappingbio- fact,inherculturalcontext.
logical entities that confer femaleness and maleness, Likewise, although many women in the general
two forms of existence also constructed as discrete populationhaverelativelylittlebreasttissueandmany
and non-overlapping. The concept of binary sex is men have more, ‘gynaecomastia’ is a medical term
not supported by science. Human embryos have the appliedonlytomen.NHSChoicesexplainsthatgynae-
samereproductiveandgenitalstructurestostartwith. comastiaisamedicalconditioninwhichboys’andmen’s
Sexdifferentiationtypicallybeginsatabouteightweeks breasts swell to become larger than normal [14].
ofgestation,andasex-undifferentiatedfetusgradually The definition of normal is left to the imagination of
assumes the anatomical structures and appearance of providers of ‘male breast sculpting’, which usually
whatwethinkofasfemaleormale.Inotherwords,the involves a combination of liposuction and removal of
tissuesthatdevelopintoovaries,womb,vagina,clitoris glanulartissue.Widelyadvertisedintheprivatesector,
andlabiaarethesameasthosethatdevelopintotestes, surgerysupposedlyhelpsmento“lookgoodinafitted
penisandscrotum.Thedevelopmentalprocessesoften, shirt when the meeting gets heated” [15]. Surgery is
but not always, result in a female- or male-typical intended not just to promote confidence in the board
combination of chromosomes, physiology and anat- room;itisalsosaidtoenablemento“lookforwardto
omy.Natureprefersdiversityanddeliversaspectrum holidays in the sunshine again”. [15]. The American
ofpossibilitiesthatmakesbinarysexamythsohardto Society of Plastic Surgeons (ASPS) reported a 30%
sustain that in modern times, surgical interventions increase between 2010 and 2016 in the number of
havebeendevelopedto‘correct’thelessdifferentiated malebreastreductionsperformed[16].
genitalsinmanyWestern(ised)societies.Althoughthe Asdiscussedabove,genitalsaresociallyconstructed
genitaldifferencesaremedicallybenign,childrenmay as mutually exclusively female or male. According to
undergo a series of genital operations to satisfy adult a medical report, a large penis in males “has always
expectations of normative genital appearance and symbolized strength, virility, power, and domination
function. These interventions are increasingly posi- inrelationships.”[17].Theclaimisnotonlysexistbut,
tionedasaviolationofhumanrights[11]. in erasing cultural differences, racist. The claim is also
Binaryunderstandingsalsoextendtonon-genital flawedin always. The amount of genital mass propor-
sex characteristics. Body hair, for example, is tionate to the overall body mass of the idealised male
a biological reality of all human beings, but ‘hirsut- body form in today’s pornographic images is different
ism’, defined as ‘an excess of body hair in the male fromthatinmanyclassicalEuropeanartisticdepictions.
distribution’ [12], is a medical term applied only to In ourcontemporary world,surgeryon thegenitalsof
women. Even if we were to accept that hirsutism is menincludespenilelengthening,penilegirthenhance-
a medical condition for women, the distinction ment, dual augmentation (length and girth enhance-
betweennormalandabnormalfemalehairgrowthis mentcombined),penileglanularenhancement,scrotal
farfromclear-cut.Women’scustomaryhairremoval webresectionandreconstruction.Accordingtoplastic
makesithardtodeterminetheactualdistributionof surgeons, many men want to know how phalloplasty
facial and body hair in the general population. can improve their self-confidence, sexual relationships
Anthropological studies of cultures in which hair and female partners’ sexual satisfaction. Despite these 3
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Chapter1: SolutioninPursuitofProblem
alluring suggestions, phalloplasty fell by 28% between shame and that which are steering some women and
2015 and 2016 and was the least popular form of cos- girlstowardsFGCS.
meticsurgerythatyear(8,434operations)[6]. Inaclassicalseriesofsocialpsychologyexperiments,
Just as male genitalia are constructed as present, researchersdemonstratedhowappearancenormsoper-
external and pendulous, female genitals are con- ate in social contexts [19]. The research participants
structed as absent and recessed. In other words, were randomly assigned to one of three conditions.
womenlackgenitals[18];theyhaveaninternalrecep- Theywereaskedtoimaginehavinganallergy,epilepsy
tacle instead. Some years ago, at a planning meeting or a physical scar. They then interacted with
foranacademiceventonFGCS,theorganisers,who aconversationalpartnerwhotheybelievedtobeaware
were familiar with the debates, requested that we oftheconditionbutwasinfactunawareofanyofthe
substitute another word for genitals in the title threeexperimentalconditions.Theresearchersdemon-
becauseitwas“ahorribleword”.Theyaskedthatwe stratedthatpeoplewhobelievedthattheyhadavisible
refer to “vagina” instead. The sensibility did not defect were more sensitive about the conversational
reflect ignorance on the part ofthe conference orga- partner’s behaviour and were more likely to interpret
nisers, rather a culturally shared sense of incompat- behaviourssuchasstaringasreactionstotheassumed
ibility between women and genitals. Madison and physical defect. They also expressed less favourable
Nevaeh refer to ‘vagina’ when they are talking about impressions of the conversational partner thought to
the clitoris and labia, which are part of the vulva behavingthereactions.
(Chapter2).In1995,artistJoaniBlankhadthefore- Fewpeoplecanescapethepressureofappearance
sighttocreateFemalia,abookofphotographsofthe norms,butsurveysconsistentlyshowthatthemajor-
vulva.Blankwantedtocounterthe“unfortunatehabit ity of women are dissatisfied with or distressed by
thatmostpeoplehaveofcallingawoman’svulvaher aspectsoftheirphysicalappearance,somuchsothat
vagina”.Shereasoned,“byteachingourlittlegirlsto bodydissatisfactionanddistressaresynonymouswith
calltheirgenitalsvaginas,wepracticeasortofpsychic being female [20]. Furthermore, the majority ofcos-
genital mutilation”. Blank forewarned that language meticoperationsareperformedonwomen[6].
could be “as powerful and swift as the surgeon’s In the foregoing example, Madison’s sense of
knife”. In her words: “What is not named, does not threat comes from three facts: (1) women have flat
exist.” vulvas;(2)hervulvaisnotflatenough;and(3)shewill
Binarynotionsofgenitalsexplain whymen,who be shamed and humiliated if found out. Madison
on average have a greater share of the burden of avoids exposure by withdrawing from certain activ-
genitalmass,tendnottocomplainaboutthekindof ities until her sense of threat is removed. If she goes
rubbing and chaffing of the genitals that bother aheadwiththebeachholidayasplanned,Madisonis,
women, nor are men known to have their genital according to the aforementioned psychological
mass surgically reduced to accommodate sporting research, likely to feel self-conscious and interpret
activitiessuchascyclingandhorsebackriding. people’s behaviours as intrusive. She is likely to
think that her genitals have given rise to the unwel-
Suspect Norms comeattention.Shemaydisengagefromsocialinter-
action. Convinced by her interpretation of the
Historian Hera Cook (Chapter 9) explains that norms situation,sheisnotreassuredbyherfriends’alterna-
emerge in response to cultural beliefs about a given, tive explanations. Madison may decide to wear
regularlyoccurringactionorstate,andthatindividuals asarongtothebeachtocoverupherpresumeddefect.
who do not conform are sanctioned. Social norms are In this case, her self-judgement is untested. Either
notexperiencedasnormsbuttakenforgrantedasreality way,hernorm-basedbeliefsaremaintained.
andcommonsenseandarenotquestioned.Individuals Gradualchangestosexualexperiencesandprefer-
consciously or non-consciously scrutinise themselves ences in response to ageing and other life circum-
(and others) and steer towards alignment with the stances are not diseases, unless people choose to
taken-for-grantedreality.Normsarethereforeaneffec- view them as such. In Kate’s (sub)culture, a reduced
tiveformofsocialregulation,andnotalwaysinnegative capacity for orgasm in men contradicts the social
ways.Thekindofsocialnormsbeinginterrogatedhere norm of undiminished lustful urges in men.
4 are the appearance norms that contribute to genital To Kate, her observation of the changes in her then
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Chapter1: SolutioninPursuitofProblem
husbandneedsexplaining.Asanolderwoman,‘vagi- products too. Certain toothpastes are claimed to be
nal laxity’, not a recognisable condition, medical or preferredby dentists.Foodsupplementsare oftensaid
otherwise, is culturally available as an explanation. to contain nutrients more ‘bioavailable’ than those
Kate may be sexually experienced enough to know foundinfood.Advertisementsforcleaningcompounds
that enjoyable sex does not require a perfect body. mayclaimacapabilityforinfectioncontrolinordinary
She may remember the days when she and her then households.Productdevelopersunderstandthecultural
husband enjoyed coitus not long after she had given currencyenjoyedbymedicineandscienceandhowto
birth, sothat ‘vaginallaxity’ is not a logical explana- appropriatethevocabulary.
tion.Katemayalsorememberthattheirrelationship Medicalframingofcertainbodilyattributesasnor-
was not going well and that this was affecting their malandothersasabnormalcanhavepowerfuleffects
overall pattern of physical affection, not just their on how people think and feel about (their) bodies.
sexual experiences. Nevertheless, ‘vaginal tightening’ Words such as hirsutism and gynaecomastia trump
somehow sounds like a credible solution for some- the reality of diverse combinations of female-typical
thing,albeitKatehasnotquitethoughtthroughwhat and male-typical sex characteristics in human beings
kindofdifferencetheinterventionwouldmaketoher and put pressure on people for self-surveillance, self-
lifeandhow.Katemaygoaheadandbenefitfromthe judgementandself-regulationofappearanceandcom-
intervention.Alternatively,shemaynoticenodiffer- portment to fit with cultural norms. The naming of
enceafterawhileandregretwastingthemoney.Itis bigger labia as ‘labial hypertrophy’ or ‘luscious lips’
alsopossiblethatKateisharmedbytheprocedureto constructs two realities that shape different actions
the extent that she never enjoys vaginal sex again. and reactions. Even so, not all women who seek
No one may hear of such an outcome, perhaps not FGCS are duped into believing that they have
even Kate’s surgeon, because she may blame herself a genital defect such as labial hypertrophy. On the
and just want to forget the entire episode. In the contrary,manywomenknowthattheyhaveordinary
absenceofindependentresearch,noonecanbesure genitals that are not especially flawed. Some even say
whathappenstothemanywomenwhoundergoinva- explicitlythattheirdesire tohave the interventionsis
siveinterventionsontheirgenitals. shapedbynormativepressures.However,suchaware-
It would be inaccurate to claim that the denigra- nessisnotalwaysenoughtodefendagainsttheunre-
tion of female genitals is caused by FGCS. In their lentingfeelingsofbeingnotgoodenough.
2001 research report, psychologists Virginia Braun Invasiveandirrevocablegenitalsurgerycanbejus-
and Sue Wilkinson identified seven persistent nega- tifiedonlyifthegenitalsareconsideredoutofrangeand
tive representations of the vagina [21]. The authors medicalinterventionsasnormalising(Chapters7to9).
discussedhowtheserepresentationshadbecomecul- Normalhastoberedefinedifmoreoutofrangevulvas
turallyavailableresourcesforhowthevaginaandits weretobecreatedtogrowtheFGCSindustry.Historian
functionswerethoughtof,talkedaboutandactedon. Sarah Rodriguez (Chapter 4) accounts for how larger
As the denigrating ideas become everyday under- labiahavebecomerarerthroughthechangingconversa-
standings, they are no longer questioned and shut tions in medicine. Women used to be sold the dream
down other ways of thinking and talking about the vulva that was aspired to but known to be a statistical
vagina.Culturaldevaluingofordinaryfemalegenitals rarity. Today, they are being sold ‘the new normal’
contributestothefertilegroundforFGCStoflourish. (Chapter 3). Rhetorical sculpting both precedes and
followssurgicalsculptingoffemalegenitalia.
Medical Framing The power of framing on medical decision-
makingwasdemonstratedexperimentallybyagroup
Citing advertisements of beauty products in popular ofresearchersinZurich[23].Theseresearcherswere
magazines that target women, philosopher Luna interested in how parents decide to allow cosmetic
Dolezal drew attention to the routine use of medical genital surgery on their children with medically
and scientific jargon in marketing [22]. Moisturising benign genital differences. The researchers asked
creams are said to be ‘clinically tested’ to be able to medical students to imagine that they were parents
‘fight free radicals’, having been developed through of a child born with ‘ambiguous genitalia’ – genitals
‘years of groundbreaking DNA research’. Scientific not obviously female- or male-typical and with ele-
vocabularies are deployed to validate other types of ments of both. Participants were randomly assigned 5
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Chapter1: SolutioninPursuitofProblem
to one of two scenarios which involved watching unsafe practices [25]. The report was especially critical
a video presenting either medicalised information of the lack of regulation with regards to non-surgical
about ambiguous genitalia by an actor claiming to cosmetic interventions, stating that “a person having
be a physician or de-medicalised information by the anon-surgicalcosmeticinterventionhasnomorepro-
sameactorclaimingtobeapsychologist.Participants tectionandredressthansomeonebuyingaballpointpen
werethenaskedwhetherornottheywouldconsentto or a toothbrush.” The purchasing of FGCS and other
correctivesurgeryfortheirimaginedchild.Research cosmeticoperationshopefullycomeswithsomeprotec-
participants in the first scenario were three times tion,althoughtheactualamountofaccessibleprotection
more likely as those in the second one to choose ishardtoquantify.WhileUKsurgicalprovidershaveto
surgeryfortheirimaginedchild.Bothgroupsbelieved beregisteredwiththeCareQualityCommission,thelack
that they had decided independently of any undue ofclearstandardsfortheprovisionofcosmeticsurgery
influence. servicesmeansthatregulatorybodiesareunabletoper-
Medical framing sanctions norm-induced genital formeffectivereviews.
insecuritiesandsimultaneouslyclaimstoresolvethem. WithreferencetoFGCS,theKeoghReportacknowl-
These transactions operate freely in neoliberal consu- edgedtheincreaseddemandinrecentyearsandempha-
meristsocietiesthatvilifyFGMasviolenceagainstgirls sised the need for providers to have a clear
and women. The rhetorical manoeuvre to separate understandingofthelegislationonFGM,aswellasthe
FGCS from FGM by positioning the former as a cure importance of managing patient expectations. Like
forpsychologicaldistress(andthereforeaclinicalrather otherreports,italludedtotheimportanceofpsycholo-
than cultural practice) is flimsy and losing credibility gical assessment. The idea of psychological assessment
increasingly (Chapter 7). As Clare Chambers aptly and ‘education and counselling’ [26] is an interesting
observes, although supposedly it is legal to operate on one. Although body distress and a decision to have
healthygenitalsonlyifprovennecessaryfortheperson’s cosmetic surgery are psychological processes, the indi-
mentalhealth,FGCSproviderstypicallydonotreferto vidualseeking surgery can be saidtobe accessingpsy-
mentalhealthintheiradvertisementsorstatethatthey chology with a scalpel. This makes actual psychological
operate only on patients mentally troubled by their interventions, the kind provided by people with real
genitals(Chapter8). psychological expertise, rather redundant. Madison
may admit to intense preoccupations that are familiar
Professional Ambivalence to psychological practitioners, but she may also insist
thatthestrongemotionswilldisappearwithsurgery.
In the United Kingdom in 2012, the silicone breast Thevalueofnuancedpsychologicalinterventions
implant scandal exposed woeful lapses in product could be explored (Chapters 12 to 14). However,
quality, aftercare and record keeping [24]. About psychological experts may have to negotiate how
300,000 women in 65 countries were believed to their input is positioned, to ensure that they can
have received implants made by a French company, bring tangible psychological benefits for the women
the Poly Implant Prothèse (PIP). The PIP implants and are not mobilised to salvage respectability for
were filled with industrial grade silicone rather than consumerist medicine or, worse still, be an alibi for
medical grade material suitable for use in a human maverick medicine. When surgery is clearly on offer
body. The implants were twice as likely to burst and and there is no decision to be made, psychological
had been associated with toxicity. About 47,000 inputisno morethana rubberstampingexercisefor
British women were thought to have had PIP FGCS.Thiswouldbeunproductiveandundermining
implants. Attention was also drawn to the potential forbothpsychologistandclient.
costsincurredbytheNHSindealingwiththehealth A number of opinions from professional bodies
problemscausedbytheimplantsinsertedintowomen express reservations about FGCS, but none of them
mostlybyprivatepractitioners. canclaimtohavehadasignificantimpactonpractice.
Professor Sir Bruce Keogh was asked to chair Itisunderstandablychallengingforprofessionalbodies
acommitteetoreviewtheregulationofcosmeticinter- tomanagetheconflictedinterestsoftheirmemberships.
ventions intheUnitedKingdom.Thereportwaspub- Afewyearsago,theRoyalCollegeofObstetriciansand
lished in 2013 and drew attention to widespread Gynaecologists (RCOG) establisheda new ethics com-
6 misleading advertising, inappropriate marketing and mitteeundertheimpeccablestewardshipofDameSuzi
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Chapter1: SolutioninPursuitofProblem
Leather.Itwasourprivilegetoworkalongsideleading distressratherthanrecognisablediseases,agoodwork-
academicsandpractitionersandhighlyexperiencedlay ing knowledge of relevant psychosocial research and
representatives,toserveadistinguishedinstitutionand methodsshouldalsobealearningoutcome.
the general public. The committee’s first task was to
develop an ethical opinion paper on FGCS, Barriers to Research
a process that took two years from inception to
eventual publication in 2013 [27]. The document Researchthatyieldsreplicableandgeneralisablefind-
had to accommodate multiple revisions. According ings to help women make an informed choice is as
to the eventual published opinion, labiaplasty per- badlyneededasitisunlikelytohappen.IntheUnited
formed for ‘medical or functional reasons’ is ethi- Kingdom, cosmetic surgery in the private sector was
cally unproblematic (despite an absence of medical worth£720millionin2005.Tenyearslater,theindus-
indications), as opposed to the same operations try was worth an estimated £3.6 billion [25]. At this
carried out for ‘aesthetic reasons’. Despite the leveloffinancialreward,itisdifficulttoimaginehow
dedicated input of a highly able multidisciplinary practitionerscouldaffordtospendtimeincollaborat-
committee, the opinion has had no discernable ing on complex research studies. However, there are
impact. UK providers blatantly advertise for ‘aes- otherobstacles.
thetic’ FGCS and make no mention of medical Post-FGCS, the consumer’s subjective appraisal
indications. fallsalongaspectrumofsatisfactionanddissatisfac-
The challenge of managing conflicted interests is tion. For the satisfied customer, the modified geni-
unlikely to be unique to any one institution. talia are no longer ‘not me’. The idea is not for her
The influence of partisan interests may well have toexperiencehergenitaliaasartificiallyconstructed
worked their way into all professional documents on but as an assimilated and naturalised part of her.
FGCS. Professional opinions are not legally binding. She is not likely to want to participate in longer-
A confident and unambiguous message can guide term research and be repeatedly reminded of the
meaningful reflections and encourage practice surgery. The women who are dissatisfied or not
improvements without prohibiting FGCS. At the wholly satisfied are unlikely to re-engage with their
same time that the RCOG paper was launched, the surgeons for additional reasons. Many research
British Society for Paediatric and Adolescent reports do not specify attrition rates and those that
Gynaecology(BritSPAG)releasedapositionstatement do suggest that many patients are lost to follow-up
that expressed a much clearer collective view against (Chapter 6). These shortcomings vastly limit the
performinglabiaplastyongirlsyoungerthantheageof generalisability of any conclusion. Dissatisfied
18years[28].Itisadutyofpublicbodiestocentralise women are the people whom FGCS providers have
the interests of women and girls in the context of the most to learn from. Their scarcity in research
contentiouspracticessuchasFGCS. deprives practitioners of the opportunities to hear
IntheUnitedKingdom,asinmanyothercountries, about the limitations of what they do, so that they
cosmetic surgery is not a medical specialty in its own can adjust their claims and manage their own and
right.Thereisnorecognisedtrainingandaccreditation their clients’ expectations more effectively.
pathway, a fact that may not be known to many con- FGCS represents a loose assemblage of contro-
sumers, who may believe that their surgeons have versial procedures that are continually being added
undergone extensive training and supervised practice to and rebranded to attract new customers, so that
before being allowed to operate on them. The Keogh any negative research findings can be said to be
Reportrecommendedthe introductionofproperstan- out of date. That is, providers can argue that
dardsfortrainingandaccreditation.Theprinciplesand techniques have changed and that the problems
implementationofbioethicsshouldbethreadedthrough identified are no longer relevant. These conditions
any training programme and continuing professional justify the classification of some FGCS procedures
development. Demonstration of diligence in the appli- as experimental. The design of future research
cation of bioethics principles should be a requirement and data handling should therefore involve
forrenewalofregistration.Becausecosmeticsurgeryis researchers who operate independently of the ser-
justified on the grounds of ill-defined psychological vice providers and proprietors. If techniques keep
7
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Chapter1: SolutioninPursuitofProblem
changing and the evidence cannot catch up, it is and perhaps cosmetic surgery more generally [32].
imperative for women and girls like Madison, Kate The decision to undergo FGCS is to a greater or less
and Nevaeh to know about the experimental nat- extent driven by emotions. The more emotive the
ure of the procedures and make an informed situation,themorelikelyareconsumerstoselectively
choice. attendtothedesiredoutcomeandminimisetherisks
or filter out the potential for disappointment.
Limiting Damage The chance of a mismatch in understanding between
The rise in the number of websites offering FGCS is provider and recipient is high. A rigorous protocol
should elaborate on risk information and include
being shadowed by a rise in the number of websites
adiscussionofpotentialproblemsthathavenotbeen
advertising repeat operations to overcome the pro-
properly investigated. If during the consultation the
blems of botched labiaplasty [29], referred to by
some providers as “avoidable unintentional female patient is presented with the perfect ‘after’ images,
genital mutilation” [30]. The same providers who she should also be shown the imperfect ones.
offer repeat operations also provide primary labia- Theprovidershouldofferagenuinespaceforwomen
todiscussnosurgeryasavalidoption,atleastforthe
plasty[29].Alloftheservicesimplythatitisproviders
otherthanthemselveswhobotchwomen’slabia,exhi- timebeing.Thewomanshouldbeabletorepeatback
tothe providerthe risks, benefitsand limitations dis-
bitingapatternofself-servingignorance.Areviewof
the content of the advertisements has identified cussed, to ensure that the information is processed.
Furtherquestionsshouldofcoursealwaysbeencour-
a lamentable lack of quality information on safety
and effectiveness. The same women whose expecta- aged. However, many women may not know what
questions to ask, so that the onus is on the provider
tions are not met by their primary surgery are now
toensurethatallthebasesarecovered[32].
being targeted for more of the same, with no more
TheFGCSindustryexistsatwomen’sexpense,phy-
assurance than verbal claims. For women who
sically,emotionallyandfinancially.Bydefinitionitcan
undergo repeat genital operations, it is debatable
growonlywithmorewomenfeelingworseabouttheir
howmuchmoreprotectionandredresstheycanread-
genitals.ThemoreFGCSisnormalised,thegreaterthe
ily access, compared to those available when buying
industry’scapacitytoharmwomenandgirls.Structural
aballpointpenoratoothbrush.
changes to the genitals do not materialise by magic,
ThereisnoquestionthatFGCSprovidersneedto
however strong the desire. Sensitive flesh without dis-
be made much more accountable. The question is
ease is subjected to invasive cutting and manipulating
how.High-quality researchmayneverbepossiblein
thefield,andtheneedforresearchshouldnolonger withunknownlong-termeffects.GiventhelawonFGM
inmanycountries,legalchangesarerequiredtoaddress
bedeployedtostalltheimplementationofmuchmore
the inconsistencies in genital cutting (Chapter 7).
rigorousregulatorymeasures.Therefore,submission
However, the relevant public bodies should not wait
of clinical data to a system designed by an indepen-
passively for these changes. Rather, they should take
dent,multidisciplinaryresearchgroupshouldbecome
mandatory.Thefindingsshouldbefreelyaccessibleto seriouslytheconcernsraisedbywomen’shealthadvo-
cates andcampaigners about the socialharm ofFGCS
the public. These activities should be funded by the
profit-makingservices. (Chapter10)andactdecisivelytolimitthepotentialfor
harm. They could (1) introduce an ethically and psy-
As well as training in bioethics for providers,
chosocially informed process of accountability that is
a much tighter decision-making protocol for patients
mandatory for all registered providers; (2) stipulate
shouldbeformulatednationally,toensureconsistency
strictadvertisingstandards;(3)debunkratherthansub-
in implementation. Informed consent is an ethical
mit to the myths of choice and self-improvement in
imperative that transcends legal requirements.
policyandguidancedocuments;and(4)facilitatecritical
The principles are outlined by the General Medical
conversations between relevant academic and profes-
Council,whichrecommendsatwo-stageprocess[31].
Theperiodof reflection between stages gives patients sionaldisciplines,andmaketheseconversationsacces-
sible to lay audiences. These are the least changes that
the opportunity to consider the full implications of
womenandgirlslikeMadison,KateandNevaehshould
surgery.Therecan,however,beagulfbetweenethical
beabletocounton.
principlesandethicalbehavioursinthisservicecontext
8
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Chapter1: SolutioninPursuitofProblem
References 17. KrakovskyAA.Stateoftheartinphalloplasty.Am
JCosmeticSurg.2005;22(3):172–8.
1. ParekhB.Rethinkingmulticulturalism:Cultural
18. BramwellR.Invisiblelabia:Therepresentationof
diversityandpoliticaltheory.Cambridge,MA:Harvard
femaleexternalgenitalsinwomen’smagazines.Sex
UniversityPress;2000,p.275.
RelatTher.2002;17:187–90.
2. JohnsdotterS,EssénB.Genitalsandethnicity:
Thepoliticsofgenitalmodifications.ReprodHealth 19. KleckRE,Strenta,A.Perceptionsoftheimpactof
Matters.2010May;18(35):29–37.doi:10.1016/S0968- negativelyvaluedphysicalcharacteristicsonsocial
8080(10)35495–4. interaction.JPersonalitySocialPsychol.1980;39(5):
861–73.
3. LiaoLM,CreightonSM.Requestsforcosmetic
20. SmolakL.BodyImage.In:WorellJ,Goodheart,CD
genitoplasty:Howshouldhealthcareproviders
respond?BMJ.2007;334:1090–2. (eds),Handbookofgirls’andwomen’spsychological
health:Genderandwell-beingacrossthelifespan.
4. ConroyRM.Femalegenitalmutilation:Whose
OxfordSeriesinClinicalPsychology.NewYork:
problem,whosesolution?BMJ.2006;333:106–7. OxfordUniversityPress;2006,pp.69–76.
5. BraunV.Insearchof(better)sexualpleasure:Female
21. BraunV,WilkinsonS.Socio-culturalrepresentations
genital‘cosmetic’surgery.Sexualities.2005;8:407–24. ofthevagina.JReprodInfPsychol.2001;9(1):17–32.
6. InternationalSocietyofAestheticPlasticSurgery
22. DolezalL.Thebodyandshame:Phenomenology,
(ISAPS).GlobalStatistics2016.Availablefrom:www
feminismandthesociallyshapedbody.Lanham,MD:
.isaps.org/medical-professionals/isaps-global-statistics/
Lexington;2015,p.132.
7. AllIndiaCongressofObstetricsandGynaecology2018.
23. StreuliJC,VayenaE,Cavicchia-BalmerY,HuberJ.
Availablefrom:www.aicog2018.org/image/Pro_Aesthe
Shapingparents:Impactofcontrastingprofessional
tic%20Gynaecology.pdf counsellingonparents’decisionmakingforchildren
8. CrouchNS,DeanR,MichalaL,LiaoL-M, withdisordersofsexdevelopment.JSexMed.2013;10
CreightonSM.Clinicalcharacteristicsofwomenand (8):1953–60.
girlsseekinglabiareductionsurgery.BJOG.2011;118:
24. BBCNews.PIPbreastimplantshealthscare.Available
1507–10.doi:10.1111/j1471-0528.2011.03088.
from:www.bbc.co.uk/news/health-16391522
9. TieferL.Femalecosmeticgenitalsurgery:Freakishor
25. DepartmentofHealth.Reviewoftheregulationof
inevitable?Analysisfrommedicalmarketing,bioethics
cosmeticinterventions.2013.Availablefrom:www
andfeministtheory.FeminismPsychol.2008;18:
.gov.uk/government/uploads/system/uploads/attach
466–79. ment_data/file/192028/Review_of_the_Regulation_o
10. Smail,D.Power,interestandpsychology:Elementsof f_Cosmetic_Interventions.pdf
asocialmaterialistunderstandingofdistress.
26. SocietyofObstetriciansandGynaecologistsofCanada.
Monmouth,UK:PCCSBooks;2010.
Femalegenitalcosmeticsurgery.JObstetGynaecolCan
11. LiaoLM,WoodD,CreightonSM.Betweenarockand 2013;35(12):e1–e5.
ahardplace:Parentschoosingnormalisingcosmetic
27. RoyalCollegeofObstetriciansandGynaecologists.
genitalsurgeryfortheirchildren.BMJ.2015;351:
Ethicalconsiderationsinrelationtofemalegenital
h5124.
cosmeticsurgery(FGCS).2013.Availablefrom:www
12. ConnJJ,JacobsHS.Managinghirsuitismin .rcog.org.uk/globalassets/documents/guidelines/eth
gynaecologicalpractice.BJOG.1998;105:687–96. ics-issues-and-resources/rcog-fgcs-ethical-opinion-pa
per.pdf
13. KeeganA,LiaoLM,BoyleM.Hirsuitism:Apsychological
analysis.JHealthPsychol.2003;8(3):327–45. 28. BritishSocietyforPaediatricandAdolescent
Gynaecology.Labialreductionsurgery(labiaplasty)on
14. NHSChoices.Whatisgynaecomastia?Availablefrom:
adolescents.2013.Availablefrom:www.britspag.org/
www.nhs.uk/chq/Pages/885.aspx?CategoryID=61
sites/default/files/downloads/Labiaplasty%20%20final
15. JainR.Muscleorman-boobs?Availablefrom:http:// %20Position%20Statement.pdf
riverbanksclinic.co.uk/cosmetic-surgery/gynecomas
29. LearnerH,RundellC,LiaoLM,CreightonSM.
tia/muscle-or-man-boobs/
Botchedlabiaplasty:Onlinepromotionofrevision
16. AmericanSocietyofPlasticSurgeons.2017Plastic labiaplasty.AbstractattheBritishSocietyfor
surgerystatistics.Availablefrom:www PaediatricandAdolescentGynaecologyAnnual
.plasticsurgery.org/news/plastic-surgery-statistics Meeting,LondonUK,March2018.
9
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