Female genital cosmetic surgery: The modern practice of cutting in the West

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1 Female genital cosmetic surgery: The modern practice of cutting in the West Abstract Female circumcision, also known as female genital cutting (FGC) and female genital mutilation (FGM), is a practice concentrated mostly in parts of Sub Saharan Africa and the Middle East. It has been coined a barbaric and uncivilized practice by the international human rights community based largely in the Western world. Female genital cosmetic surgery (FGCS), contrastingly, is a growing medical practice in the West, as cosmetic surgeons continue to expand their services for women in countries such as the US and parts of the UK. This paper compares perceptions of female circumcision with the growth in FGCS procedures, highlighting points of similarities between the two practices that challenge the commonly held Western notion that genital cutting is symbolic of the foreign, third-world other. Through as analysis of the history of FGCS and the specific types of FGCS procedures undertaken by surgeons, this paper asserts that both female circumcision and FGCS reinforce heteronormative ideals of gender performativity, aesthetic femininity, and control of female sexuality through the modification of female external genitalia. Though FGCS may be medicalized, both practices are rooted in sociocultural phenomena regarding the normative roles, behaviors, and appearances of males and females. Five Key Words: Female circumcision, Cosmetic surgery, Genital cutting, Gender performativity, Aesthetic femininity Introduction By its better-known, viscerally repulsive title female genital mutilation, the practice of female circumcision is quick to evoke images of barbaric and uncivilized communities that subject young girls to unjust procedures in order to maintain deeply rooted tradition. The practice has largely become a symbol of the struggle between culture and human rights, and has been used to exemplify the regressive East by agents in the West. Female circumcision conjures strong sentiments amongst feminist and human rights activists, and has resultantly been labeled one of the most hotly contested human rights issues of our time. While Westerners are quick to label female circumcision as a backwards practice of the other, there has been a growth in female genital cosmetic surgery (FGCS) in the West, which, by definition, has many similarities to female circumcision. FGCS involves the modification of 1

2 the external female genitalia mainly for aesthetic or sexually functional purposes. It involves a subset of different procedures that include surgeries of the vaginal muscles, the G-spot, the clitoris, and even the hymen. Due to an increase in awareness of services, and frequent displays of genitalia in pornography and on the Internet, more and more women are seeking out these surgeries, despite a lack of regulation or long-term studies on the effects of the procedures. Nonetheless, surgeons market FGCS similarly to other popular forms of cosmetic surgery. Though female circumcision has been coined a backwards cultural practice by the international human rights community, and FGCS a growing medical practice as more surgeons expand their services, both reinforce heteronormative ideals of gender performativity, aesthetic femininity, and control of female sexuality through the modification of female external genitalia. Theoretical Framework Female circumcision, also referred to as female genital mutilation or female genital cutting, involves the partial or total removal of the external female genitalia primarily for cultural, religious, or other nonmedical reasons. The practice is largely concentrated amongst communities in Sub Saharan Africa and the Middle East. There are four basic types practiced today, ranging from partial or total removal of the clitoris, to excision of labia minora, to the most extreme form, infibulation. 80% of reported cases worldwide fall under type two, or the excision of the clitoris and labia minora. 1 In many communities, the procedure may mark a girl s transition into womanhood and preparation for marriage, while other communities circumcise girls when they are very young. It may be associated with enhancement of the female identity, as the visible part of the clitoris, which seems to protrude like a penis, is removed. 2 The practice has been controversial, as people, especially in the West, argue that it marks a woman s submission and negatively affects her ability to experience sexual pleasure; others consider it a symbol of female empowerment, and an important traditional practice. 2 Female circumcision entered into the international limelight in large part due to efforts by international organizations like the UN, which, since the 1970s, has facilitated conferences to prompt discussions surrounding the state of gender affairs. 1 During this period of time, genderbased violence, which female circumcision has been defined under, was incorporated into the agenda of international human rights; this led to a re-framing of practices like female circumcision that were previously not considered problematic, and further defined them as health issues to be addressed by organizations like the World Health Organization (WHO). 3 2

3 In light of this new consideration, there arose a proliferation of studies and surveys conducted to gather data on the true health implications of female circumcision. Studies have cited complications to include hemorrhage, infection, painful sex, difficulty having sex, and psychological trauma. 1 However, other studies have complicated these findings by arguing that commonly-referenced consequences like painful sex, infection, and difficulty having kids may be concentrated amongst women who undergo the extreme form of infibulation, but not the more common forms of type one and two. Many women who have undergone these less severe types often report no negative effects on their sex lives, as well. 2 During the past couple of decades, rates of voluntary FGCS have been increasing worldwide, especially in parts of North America, Australia, New Zealand, and England. 4 Because FGCS involves modifications of the external female genitalia, it falls under the category of aesthetic surgery along with other procedures such as liposuction, breast augmentation, and facial rejuvenation, and is designed to not only improve appearance, but also to increase sexual pleasure and stimulation. 5 Surgeries of the external genitalia have long been performed to tighten muscles and support tissues during complications like urinary leakage and tears after childbirth, but the cosmetic industry has quietly grown behind the doors of surgeons in private clinics. 4 Procedures that fall under the category of FGCS include labiaplasty, vaginoplasty, G-spot augmentation, clitoral hood reduction, and hymenoplasty; each have their own specific purpose, which complicates the idea that these surgeries are performed solely to obtain designer vaginas. 4 Labiaplasty most commonly involves surgery of the labia minora, or the inner lips, to reduce size so that they do not protrude below the outer lips or to achieve asymmetry. 6 The procedure is motivated by a desire to change appearance rather than function, as women often report feeling self-conscious about their labia before choosing to undergo the surgery. Vaginoplasty, G-spot augmentation, and clitoral hood reduction are all marketed to enhance sexual pleasure and stimulation. Vaginoplasty, also referred to as vaginal rejuvenation, specifically involves tightening of the vaginal opening through the removal of excess tissue. 6 It has been reported that up to 76% of women experience a decrease in vaginal sensations through their lifespan, which becomes especially prominent after childbirth. 5 Schultz et al. concluded in a 1989 study that decreased vaginal sensation must come from a widened vagina, causing less friction. 7 A 2009 study found that 95% of participating women who were treated with lateral colporrhaphy, a specific surgical technique used during vaginoplasty, reported an improvement 3

4 in sexual sensitivity, as well as greater vaginal tightness at the 6 months follow-up. 8 G-spot augmentation involves the injection of a substance, commonly collagen, into the G-spot for size enhancement, ideally to increase the amount of pleasure a women may experience from sexual penetration and the resulting G-spot stimulation; the effects are known to last only 3-4 months after the procedure, however. 6 Clitoral hood reduction focuses on surgical alteration to the clitoris, aimed to increase the pleasure gained from clitoral rather than penetrative stimulation by reducing the skin around the clitoris to expose the head underneath. 6 Stimulation of the clitoris can be extremely pleasurable for a woman, as the clitoris is the embryonic equivalent of the male penis and is packed with 8000 nerve endings, twice the number of its male counterparts. 9 Studies have shown that many women require clitoral stimulation in order to orgasm during sex. 4 Hymenoplasty, lastly, does not fall within the category of aesthetic or sexual enhancement for women, but rather is performed predominantly for religious or cultural reasons as a means of revirginization. The procedure involves the reconstruction of the hymen, a thin membrane of skin that covers the vaginal entrance, in the hopes that during sex, the membrane will tear and bleed; many people believe that this bleeding signifies the loss of one s virginity. 6 Though this is a fairly common perception, the lack of the hymen is not a direct sign of loss of virginity, as many girls have ripped their hymen while partaking in athletic or other activities prior to ever having sex. Further, a recent study revealed that hymen was intact in as many as 52% of adolescent girls who admitted to have had sexual intercourse. 10 The hymen is known to serve no biological function, and many argue that hymenoplasty simply perpetuates the myth of an unbroken hymen as a sign of virginity, making it a potentially more problematic social procedure than other types of FGCS. 5 A cross-sectional study conducted by Goodman et al. in 2009 included a postprocedural analysis of patients of labiaplasties, clitoral hood reductions, and vaginoplasties; findings showed that close to 92% were satisfied with the results after a 6 to 42 month follow-up, with only minor complications and reported enhanced sexual functioning. 11 Though the effects of FGCS has been increasingly studied, sufficient evidence from long-term studies has not been reported on effectiveness of procedures like vaginoplasty years after the surgery. 5 Risks associated with FGCS have been found to include painful intercourse, loss of sensitivity, hemorrhage, scarring, and excessive bleeding. 5 The growth in prevalence of FGCS has been attributed to a rising awareness of the various procedures offered through the Internet, women s magazines, and publications by 4

5 surgeons. 6 Additionally, women are more likely today than in the past to be aware of the appearance of their genitalia, and to desire modifications. Brazilian waxing has become very common in the U.S., and the removal of pubic hair exposes genitals so that women are more aware of their appearance. 6 The growth of the pornography industry gives women models of what ideal genitalia look like, contributing to a rising self-consciousness amongst women who feel that their genitalia appears abnormal. In adult magazines and video pornography, female genitalia is often airbrushed so that the labia minora is not very visible, making the subject look like a pre-pubescent girl. 12 As Beverly Hills plastic surgeon Dr. Alter commented, pornography has influenced the aesthetic ideal of genitalia in a society that is becoming more and more sexualized and appearance focused women may seek out labiaplasty after seeing digitally altered pictures of women with minimalized genitalia. 4 Dr. Laura Berman, director of a female sexual dysfunction treatment clinic in Chicago, suggests, most women walk around with a feeling of anxiety about their genitals these surgeries kind of play into that. 4 Female genitalia vary from woman to woman in color, size, and shape, making the idea of an ideal norm in appearance a controversial aspect of FGCS. A study published by the British Journal of Gynaecology of 50 pre-menopausal women found that the labia minora ranged from mm longways and 7-50mm in width. 6 The color normally ranges from deep pick to brownish pink to purple, and the shape may be short or long, thick or thin, smooth or ruffled, and even asymmetrical; in other words, there is immense reported variation. 6 Genitalia is also known to change in color and shape as a woman ages in response to hormonal changes; during puberty and pregnancy it typically darkens and enlarges, and during menopause, the tissue may thin, shrink, and become paler in color. 6 An aging vagina loses tone and tightness as the pelvic flow and muscles slacken, giving a feeling of wideness. 6 Exact rates of FGCS are unknown, as procedures are performed in private clinics where there is no requirement to report the number of surgeries. Instead of peer-reviewed procedures that have undergone scrutiny and long-term study, most are unregulated and copy-written by renowned cosmetic surgeons in the industry who have expanded their services to cover FGCS. 5 LA-based plastic surgeon Dr. David Matlock credits himself for jump-starting the field; he announced at the 2010 International Society of Cosmetogynecology s Global Symposium on Cosmetic Vaginal Surgery, no one even considered performing these procedures until I popularized them 14 years ago, when a woman called his office requesting vaginal tightening to 5

6 increase her pleasure during sex. 13 He quickly realized that there were many other women who would be interested in similar services, and began to publicize the procedures using advertisements. 13 Atlanta-based surgeon Dr. John Miklos similarly describes himself as a medical tailor, suggesting, women come to me and say they don t have the urge to have sex anymore because they don t feel anything I guarantee that if a man didn t feel anything, he wouldn t have sex either. 14 This discourse is prevalent amongst surgeons, who stress that they are aiding patients in their desire for sexual well-being. As the field of FGCS continues to grow in the U.S. and other parts of the Western world, there has been controversy over the role that surgeons play in perpetuating notions of the ideal genitalia. Since it involves voluntary modifications made to one s body out of dissatisfaction, FGCS can be considered an example of body distress. 12 There have been reports of strong correlations between body distress and the tendency to pursue cosmetic surgery, and as body distress is known to be higher in women, they constitute a significantly higher proportion of the cosmetic surgery market. 12 One of the critiques to the approach that FGCS practitioners have taken is their lack of understanding of the complexity of body distress and the extent to which their procedure is potentially helpful or harmful to a woman's long-term wellbeing [the practitioners are] unlikely to have the skills for carrying out a psychological assessment. 12 If FGCS involves a significant element of psychological intervention as it addresses deeply-rooted sentiments about appearance and sexuality, then it seems problematic that practitioners are not trained in this respect. There has also been significant controversy concerning the surgeries themselves, as voiced by Dr. Cheryl Iglesia, a member of American College of Obstetricians and Gynecologists, none of these procedures have proven effectiveness, and there is potential for harm. 14 Many worry that women are being misled into believing that their dissatisfactions are equivalent to conditions in need of treatment, especially because of the lack of evidence-based known outcomes and little standardization in training, methods, or standards of care. 8 Analysis Female circumcision and FGCS are both complex, socially driven practices that involve cutting of the female external genitalia. The WHO defines female genital cutting as all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or non-therapeutic reasons. 5 Interestingly, this definition does not seem to distinguish between traditional forms of genital 6

7 cutting that have been performed for thousands of years primarily in the East, and cosmetic forms of genital cutting that are rising in West. Both female circumcision and FGCS involve the excision of external genitalia for cultural reasons, including perceptions of how female genitalia should look, the sexual role they should play for women, and the need to conform to certain respected ideals. 12 In regards to the amount of genitalia tissue that is removed, most FGCS procedures compare to type one or two female circumcision, involving excisions of the clitoris and/or the labia minora. 12 Yet while female circumcision is ethically condemned and criminalized in most countries around the world, FGCS is left largely unregulated in the hands of private clinicians. 12 The major difference between the two practices, people argue, lies in the element of consent, as women voluntarily choose to undergo FGCS while many girls around the world seem to be forcefully circumcised. But there are deep social factors, assumptions, and misguided perceptions that inform and influence a woman s decision to undergo FGCS, when she might otherwise not desire to. 16 Further, it is inaccurate to assume that in all cases of female circumcision, girls are forced against their will; girls often do give consent, and many view the procedure as an aesthetic enhancement to the genitals rather than a mutilation. 2 Genital cutting in the West has not always been performed for cosmetic reasons. In parts of the US and UK between the 1800s and mid-1950s, hysterectomy (removal of the uterus) and clitoridectomy (removal of the clitoris) were used to treat disorders such as masturbation, lesbianism, and nymphomania. 5 These practices were all assumed to threaten the purity of women, and were resultantly labeled as abnormal behaviors that required intervention. In many cultures, female sexual enjoyment is perceived to be the most corrupt pleasure, justifying interventions like clitoridectomy that protect women from their own rampant sexuality or irresistible drive towards promiscuity. 4 As discussed in Genital cutting and transnational sisterhood: Disputing US polemics, while cleanliness, aesthetics, hygiene, birth control, and fear of the untrimmed clitoris are among the expressed reasons for practicing female circumcision, the general rationale that crosses geographical and cultural boundaries is the need to control women, especially their sexuality. 17 Control of female sexuality is not only the principle behind female circumcision in the East, but was also the reason for original uses of procedures like clitoridectomy in the West. While practices like clitoridectomy are no longer advertised in the U.S. to control promiscuous behaviors of women, deep-rooted perceptions of gender difference dictate much of 7

8 the discourse surrounding FGCS, similarly to female circumcision, and resultantly form the basis of much of the associated controversies. Hymenoplasty, which involves the reconstruction of the hymen to simulate re-virginization, is considered controversial for [perpetuating] discrimination against women in the expectation of virginity in unmarried women not expected or required of unmarried men. 18 The control of the female virginity is a well-known principle behind female circumcision, to preserve the purity of a young girl before she finds a suitable husband. Hymenoplasty serves as a related procedure, allowing women to feel like virgins once again, and give the gift of virginity to their significant others. 4 There also lies the underlying emphasis on appearance, with FGCS procedures aimed to distinguish between the male and female genitalia. As the clitoris is the female embryonic equivalent of the male penis, there has been sufficient talk of its masculinity; the clitoris, given a chance, may grow too long through maturity making a woman too masculine, and thus (hetero)sexually strange and unattractive. 5 Sigmund Freud argued that the elimination of clitoral sexuality is a necessary precondition for the development of femininity. 5 Talk of the clitoris as being too masculine is an example of heteronormativity, suggesting that females should not let themselves appear masculine. Where clitoridectomy is still prevalent, excision of the clitoris serves as a tool to remove this masculine mark on the female genitalia. Clitoral hood reduction serves a similar purpose, allowing for the reduction of the protruding clitoris in length and hood size so as to increase femininity. 5 Female sexuality is further regulated by the heterosexual tendency to devalue clitoral stimulation and emphasize the importance of penetrative sex; clitoral stimulation [has generally been] seen as something ancillary to penetrative heterosexual intercourse, which was defined as a central conjugal act. 4 Around the 18 th century, knowledge of the benefits of clitoral stimulation for women was progressively more concealed by European medical and religious authorities. 4 Feminists have argued that this spread of misinformation worked to strengthen patriarchal control of women, suggesting that a male counterpart was necessary for women to have pleasurable sex, and inherently defining sex as between a man and woman. 4 Vaginoplasty aims to tighten the vaginal muscles so as to increase pleasure from penetrative sex, but feminists have argued that there lies little value to these operations that continue to reinforce the outdated belief that a tighter vagina equals more pleasure for a women. 4 The vagina has long been represented as an absence in psychoanalysis, namely resulting from a lack of penis that has allowed scholars to represent 8

9 women as castrated men, their bodies marked by a lack, and what is hidden is just a hole. 16 This depiction further emphasizes the importance of penile penetration, not solely for pleasure, but as a method to fill the absence of the female vagina; if the purpose of a vagina, devoid of agency, is to receive the penis, as was popular thought during the Freudian era, then this suggests the passive nature of women as basic receptacles for male desire, emphasizing the heteronormative nature of sex. 16 FGCS is embedded within social constructs of gender difference that dictate how a woman must behave, appear, and present herself, a larger example of how essential becoming a gender is to one s very personhood. 19 Since gender relations have the power to influence the interpretation of biological traits, the ways that people perceive males and females influence the expectations they have about the genitalia. 20 Further, through the iteration of what is normal and abnormal, certain identifications become valued at the expense of others; in the case of female genitalia, this devaluing operates from a heteronormative standpoint. Women are expected to have bodies that differ from men, and genitalia serve as distinct markers of this identity difference, based on assumptions that there should only be two sexes. 4 Gender implications are deeply rooted within society, as the social and political functions a subject will perform are significantly determined by the sex-gender system of the social web into which one is born. 21 A woman s concern with her own appearance, therefore, results from an understanding of hierarchical gender structures. These structures create socio-cultural representations of female genitalia as inadequate and in need of improvement, with an ideal appearance and function obtainable if women are willing to make the required changes. 16 In this respect, women who do undergo cosmetic procedures simply comply with larger structures that define their own limitations, and in the process, construct the inherent constraints of femininity. 4 To be a true woman, with respected feminine characteristics, requires a culturally prescribed and approved form of genitalia, a notion that is further supported by medical rationale through the medicalization of FGCS. 4 In Bodies That Matter: On the discursive limits of "sex", Judith Butler stresses a need to [recast] the matter of bodies as the effect of a dynamic of power. 22 By defining the ways that female genitalia should appear and function, and prescribing procedures that allow the body to meet these standards, female bodies are cast into a dynamic of power, one that Foucault calls biopower, to control the behaviors of women. 23 9

10 Conclusion Female genital cutting is quickly labeled as a practice of the other, but the growing prevalence of female genital cosmetic surgery in Western countries complicates this notion, as women desire modifications to their genitalia for social reasons that stem from gender performativity, control of sexual behavior and function, and aesthetic conformity; these reasons, though in different contexts, also drive the practice of female circumcision. FGCS may be considered simply another subset of plastic surgery, but the vulnerability of female genitalia, and the many associated connotations that deeply affect perceptions of a female, make it a potentially more problematic practice than other cosmetic surgery procedures. Women may give consent to undergo the procedure, but the encouragement they receive to alter their female genitalia can be considered a form of heteronormative social control, dictating the ways that women view themselves in relation to men. In this light, under the guise of a rights-based discourse, age-old perceptions of the inherent social and biological differences between men and women are brought to life by medicalized practices like FGCS in the West. References 1. Alston, Philip, Ryan Goodman, and Henry J. Steiner. International Human Rights in Context: Law, Politics, Morals. 3rd ed. NY: Oxford University Press, "Seven Things to Know about Female Genital Surgeries in Africa." The Public Policy Advisory Network on Female Genital Surgeries in Africa. Hastings Center Report, Nov Hodzic, Saida. "Ascertaining Deadly Harms: Aesthetics and Politics of Global Evidence." Cultural Anthropology 28.1 (2013): Green, Fiona J. From clitoridectomies to 'designer vaginas': The medical construction of heteronormative female bodies and sexuality through female genital cutting. Sexualities, Evolution and Gender 7.2 (2005): Dobbeleir, Julie, Koenraad V. Landuyt, and Stan J. Monstrey. "Aesthetic Surgery of the Female Genitalia." Seminars in Plastic Surgery 25.2 (2011): Braun, Kirsten. "Genital Cosmetic Surgery." Health Journey. Women s Health Queensland Wide Inc. (2013):

11 7. Weijmar Schultz, W., Wiel, H.; Klatter, J, et al. Vaginal sensitivity to electric stimuli: theoretical and practical implications. Archives of Sexual Behavior 18.2 (1989): Goodman, Michael P. Female cosmetic genital surgery. Obstetrics and Gynecology (2009): Gravina, Giovanni L., Fulvia, Brandetti, Paolo Martini, Carosa, Eleonara, et al. "Measurement of the thickness of the urethrovaginal space in women with or without vaginal orgasm." The Journal of Sexual Medicine 5.3 (2008): Raveenthiran, V. Surgery of the hymen: from myth to modernization. Indian Journal of Surgery 71 (2009): Goodman, Michael P., Placik, Otto J., Benson R H., III, et al. A large multicenter outcome study of female genital plastic surgery. The Journal of Sexual Medicine 7.4 (2010): Michala, Lina, Lih-Mei Liao, and Sarah M. Creighton. "Female genital cosmetic surgery: how can clinicians act in women's best interests?" The Obstetrician & Gynaecologist 14.3 (2012): Triffin, M. Warning: Some doctors may be dangerous to your vagina. Cosmopolitan. (July 2010): Beasley, Deena. "Gynecologists alarmed by plastic surgery trend." Chicago Tribune. 25 Aug Derrick, L. (1998). Dr Tight New York Times Los Angeles Online. Jenda: A Journal of Culture and African Women Studies. Retrieved July 12, 2005, from Braun, Virginia, and Sue Wilkinson. "Socio-cultural representations of the vagina."journal of Reproductive and Infant Psychology 19.1 (2001): James, Stanlie, and Claire C. Robertson. "Introduction: Reimaging transnational sisterhood." Genital cutting and transnational sisterhood: Disputing US polemics. Illinois: University of Illinois Press, Prakash, Vishwa. Hymenoplasty how to do? Indian Journal of Surgery. 71 (2009): Butler, Judith. Undoing Gender. NY: Routledge, Krieger, Nancy. Genders, sexes, and health: what are the connections- and why does it matter? International Journal of Epidemiology 32 (2003):

12 21. Holmes, Morgan. Rethinking the meaning and management of intersexuality. Sexualities, 5 (2002): Butler, Judith. Bodies That Matter: On the discursive limits of "sex". NY: Routledge, Foucault, Michael. The History of Sexuality: An Introduction. Vol. I. Trans. Robert Hurley. NY: Vintage Books, 1990[1978]. 12