A young teenager, Amanda D (not her real name), aged 13, comes with her mother to see her family doctor (GP), Dr Frances C. She looks embarrassed and avoids eye contact with the doctor. Her mother speaks on her behalf: “We think there is something wrong with her vulva – would you mind checking?” Frances endeavours to set Amanda at ease, and asks if her if she is happy to be examined. Amanda agrees. On the examination couch, Frances sees that Amanda has mildly protuberant, but healthy, normal inner labia (labia minora). She is perplexed:
“Amanda’s vulva is completely normal – why is she here?” she asks.
“Well”, says the mother defensively, “she doesn’t look like me.”
Meanwhile, Amanda, looking relieved, is hastily getting dressed.
Frances is appalled – imagine the damage one can do by suggesting to an adolescent that she has an ‘abnormality’ at the very time when bodily concerns and self-consciousness are at their height! Frances tells both of them in no uncertain terms that there is nothing wrong at all and that Amanda’s body is like that of many other girls and women. In any case the vulva will change in appearance as Amanda develops.
Frances thinks this is a one-off, but other consultations follow over the next two years. For example, an eleven-year-old girl comes with her mother. She tells the doctor she is worried about her appearance ‘down there‘. Her mother says that she has tried to reassure her daughter without success. On the examination couch, the girl points to her vulva, and, her nose wrinkling with disgust, says “what’s that?” Like Amanda, she has mildly protuberant inner labia and incomplete pudendal hair growth.
Later, a young woman, in her mid twenties comes to see Frances. She is agitated, her cheeks flushed. She says that she has had ‘this problem’ for seven years but has been too embarrassed to discuss it with anyone. She bursts into tears. She is so ashamed – she does not go swimming as she cannot wear a bikini, she cannot wear jeans, and she cannot allow her new boyfriend to see her naked. Her previous boyfriend taunted her. She is convinced she is abnormal, and is requesting a referral for labiaplasty. She mentions seeing the TV programme Embarrassing Bodies, which confirmed her fear that she is indeed abnormal. When Frances examines the woman, she finds she has totally shaved her pubic hair and has visible protruding inner labia of normal appearance. Frances attempts to reassure her that she is normal, but fails to convince. She then agrees to send her to a female NHS gynaecologist, a vulval expert, with the aim of reinforcing the ‘normality message’. She crafts a carefully worded letter to this effect. Unfortunately the gynaecologist refers the woman to a surgical colleague who corroborates with the patient, stating that the labia are ‘rather long’ and agrees to undertake the procedure.
I am a GP, not a gynaecologist or plastic surgeon, but over thirty years of practice, I have seen and examined thousands of women’s and girls’ genitalia. I have a pretty good idea of the range of normality. Until the last seven years or so, I never saw women or girls worrying about the size or appearance of their labia minora, but this has changed. Labiaplasty (or labioplasty) is a procedure that involves removal of all or part of the labia minora (occasionally it may also involve reduction of the labia majora), and sometimes part of the clitoral hood. It was very rare in the UK in the 1990s but since then it has risen exponentially. For example, the number of labiaplasty procedures performed within the NHS increased five-fold from less than 400 in 1998-9 to close to 2000 procedures in 2010.From that time there has been a clampdown, with NHS England in 2013 labelling the procedure as a low clinical priority and only to be performed in very limited circumstances. But the majority of labiaplasty operations take place in the private sector, and as private clinics are not obliged to give their procedure data we do not know the number of labiaplasty operations although it is undoubtedly considerably greater than in the NHS. There are also no large-scale prospective trials, so we do not know the incidence of short or long-term consequences, although we do know that surgical complications such as bleeding, infection, pain, numbness, scarring and deformity, can be quite high (up to 30%).
FGM vs FGCS
At the same time there has been a mounting campaign in the UK to prevent Female Genital Mutilation (FGM) and the FGM Act was introduced in 2003. Under this Act, a person commits a criminal offence, liable for up to 14 years imprisonment, if he or she “excises, infibulates or otherwise mutilates the whole or any part of a girl’s labia majora, labia minora or clitoris.” But there is no offence – and here is the loophole – if carrying out “a surgical operation [by a qualified practitioner] on a girl which is necessary for her physical or mental health”, or for reasons connected with labour or birth. Although the Act says ‘girl’, it refers to a female of any age. Furthermore it makes no difference if the ‘girl’ is fully autonomous and capable of giving consent. It is also an offence to aid, abet, counsel or procure a girl to undertake FGM. If one compares milder forms of FGM to female genital cosmetic surgery (FGCS) and labiaplasty in particular, the difference between the two becomes indistinct. Indeed, I would argue that FGCS is a ‘Western’ form of FGM. Yes, it is sanitised and professionalised, and generally carried out on adult women or adolescents, not children (although one finds cases in the literature of girls aged only 10 years having the procedure for so-called “labial hypertrophy”), but essentially we end up with the same outcome; the amputation of healthy, normal, erogenous tissue in a cultural context that debases female genitalia and imposes artificial restrictions on normal variation. One can imagine a scenario whereby an adult woman whose parents’ country of origin is from a country where FGM is common, but who has been born and brought up in the UK, requests a partial removal of her clitoral hood (defined as type 1 FGM) as she is planning to get married and believes that her ‘uncut’ state would be unacceptable to her husband and to the more traditional community she is going to live in. Besides, she wants it for herself to be “clean”. Is this FGM? And if so, what is the legal and ethical distinction from a woman requesting labiaplasty? Does this not smack of bias?
So what is going on?
What I find so disturbing is how young girls and women are becoming more and more preoccupied and insecure regarding their bodies. Well-conducted surveys reflect this. One study in 2016 (https://www.girlguiding.org.uk/globalassets/docs-and-resources/research-and-campaigns/girls-attitudes-survey-2016.pdf) showed that around half of girls in the UK aged 11 to 16 years are unhappy with their bodies, and this rises to two-thirds of 17 to 21 year-olds. In this age group half are ashamed or embarrassed about how they look. This bodily dissatisfaction and striving for (unobtainable) ‘perfection’ is rising at an alarming rate and prevents girls from engaging in everyday activities such as socialising, wearing certain clothes, or doing sport. This pervasive and pernicious lack of body confidence (also a feature of older women and others) leads people to ‘reconstruct’ their bodies with the aid of surgery and other cosmetic ‘solutions’. In the lucrative and booming world of plastic surgery, we have moved from reconstruction of faces, to breasts, tummies, thighs, buttocks, and now, the last frontier, the female genitalia.
There are a number of theories regarding this latest trend:
- The rise in ‘extreme’ pudendal shaving exposes the labia to greater scrutiny and also removes a layer of protection of the vulva from friction and chafing. Interestingly, until recently I only used to see Muslim women completely depilated, as this is a traditional custom and linked to notions of purity.
- The wearing of tight clothing, such as skinny jeans, ‘thongs’ and minimal beachwear where friction and/or visibility of the labia is enhanced.
- The widespread availability of pornography on the internet showing air-brushed photos of models with ‘invisible’ inner labia (either by nature or following surgery), which provide an ersatz model of ‘normality’. Another trend, relevant to young people, is of ‘sexting’ (although it is technically illegal under the age of 18), focusing the attention on genitalia. But TV programmes such as Embarrassing Bodies, and women’s magazines, also promote the image of the smooth, flat genitalia as the desirable and only acceptable norm. Meanwhile it is difficult for girls to know what is normal as they cannot readily access real-life examples and so inevitably they rely on the internet.
- There is no doubt that the medical profession (and I refer specifically to gynaecologists and plastic surgeons) play an important role. Using their powerful high-status authority, they endorse the notion that ‘there is something wrong’, because if there wasn’t a clear clinical indication, why on earth would they be cutting up women’s healthy genitalia? The lines between aesthetics and treatment become blurred, as does the ethics. If a woman does have doubts and consults medical websites, she will be met with subtle and not so subtle messages that it would be desirable to be refashioned. Many of these contain ‘before and after’ pictures, with the ‘before’ pictures stretching out the labia to make them seem larger than they are. They also rarely mention the risks and complications of the procedure. A fascinating study showed that plastic surgeons, when compared with GP’s and gynaecologists, were significantly more likely to regard pictures of large (but normal) labia minora as ‘distasteful and unnatural’, and they were much more likely to consider the women as candidates for surgery. Unsurprisingly, male surgeons were also more likely to opt for surgery (Reitsma et al., 2011).
- But I believe there is something deeper going on. We are witnessing the wholesale commodification of the body – although we are embodied beings, we behave and act as if the body is a ‘thing’ that needs to be trimmed, refashioned and reshaped according to some artificial benchmark. When it comes to female genitalia, the ‘standard’ is Barbie, a plastic doll with no genitalia, a tiny waist and large, stuck-on breasts. In fact some surgeons in the USA promote “the Barbie” – a drastic removal of all the labia minora and part of the clitoral hood. Everything has to be smooth, no wrinkles or crinkles – doll-like, or maybe childlike. But our brains are unable to distinguish the real from the virtual, so when we look at artificial images we develop a deep sense of insecurity, of guilt even, based on what “we should look like”. This frightening trend of implacable conformity is both powerful and widespread.
So what are the justifications for labiaplasty?
The reasons women express in requesting labiaplasty are aesthetic (looks ugly), functional – it interferes with sport, or sexual activity – or psychological distress. But this baffles me. Men have ‘dangly bits’ and yet do not request removal or trimming of parts of their genitalia even though they cycle, ride horses etc. with great gusto. One can, after all, get special underwear to provide protection or use emollient creams to prevent chafing, but these are rarely suggested. Besides, removal of the inner labia exposes the highly sensitive clitoris and the vestibule (the entrance to the vagina) to more friction and pain. The ‘functional’ reasons in my mind just don’t add up and yet they are universally accepted. Regarding sex, the labia minora are full of nerve endings and are part of the erogenous system. With sexual arousal they become engorged and lubricated. In this state, it is very unlikely that they interfere with intercourse, and if anything they are likely to increase sexual pleasure. If there is an issue with them ‘getting in the way’, surely one can deal with this without too much difficulty? Regarding the clothing issue, again I find it bizarre – women wear very tight, pointed footwear and high heels, cramming their toes and causing pain and chafing (more so as one ages and the feet ‘spread’) and yet very rarely do women ask to have their toes amputated so that they better can fit into their shoes. I don’t think (hope!) that many surgeons would agree to this drastic ‘solution’? As to the psychological distress, who created it in the first place? We end up with professionals treating a condition that was in part created by their own prejudices and their (at times aggressive) marketing techniques. Finally, we know from psychology, that once we are made aware of a part of our body, that part becomes much more the focus of our attention, more sensitive and more likely to give rise to symptoms.
Another much vaunted reason is ‘choice’. In this age of neoliberalism, individual autonomy is sacrosanct and has to somehow remain steadfast and unaffected by the many and powerful societal influences that bear down on it. But it is a moot point how much ‘choice’ a woman has when she is unaware of the range of genital normality, when she is not fully appraised of the risks and consequences of surgery, but above all when she is encouraged to believe that her genitalia are ugly or deformed, such that nothaving surgery is a highly distressing option, or even an irresponsible one.
What are the solutions?
Finding solutions is not easy, but the first thing I would suggest is sex education in primary and secondary schools which includes educating young people on what normal male and female genitalia look like in puberty and maturity and directing them to websites such as the Great Wall of Vagina (http://www.greatwallofvagina.co.uk/home). The aim would be for young people to accept diversity and to cherish and respect their bodies as they are. I would also suggest that labiaplasty is not offered in the NHS or the private sector except for very rare cases, and certainly not on girls under eighteen (unless, for example, they suffer from rare endocrine conditions leading to true hypertrophy). Women who are determined to have the procedure will probably go to other countries, but with the profession refusing to normalise it, this would give the clear message that labiaplasty is a harmful and unnecessary operation. There has to be a recognition that as the law stands, criminalising FGM but not FGCS does not really stand up to close scrutiny and leads one to believe that this is an example of ‘ethical imperialism’, or, dare I say it, vested interests.
As a Post Script it is interesting to note that Desmond Morris, author of The Naked Ape, believes that our facial lips are surrogates for our genital ‘lips’. It is ironic that women’s facial lips nowadays are plumped up with injections and ‘fillers’ and yet those ‘down below’ are cut away, obliterated even. One can conjecture that there may be a connection…..
Paquita de Zulueta is a part-time sessional GP in North West London and Honorary Senior Clinical Lecturer at Imperial College. She is also a qualified coach and cognitive behavioural therapist (CBT). She holds a wide-ranging portfolio of lectures, workshops, articles and book chapters in clinical ethics and currently teaches undergraduates, postgraduates and established practitioners at Imperial College and elsewhere. Her current interest is developing and sustaining compassion in healthcare and healthcare professionals’ wellbeing.
Reitsma, W., Mourits, M.J.E., Koning, M., Pascal, A., & van der Lei, B. (2011). No (wo)man is an island – the influence of physicians’ personal predisposition to labia minora appearance on their clinical decision making: a cross sectional study. Journal of Sexual Medicine, 8, 2377-2385