by Virginia Braun and Leonore Tiefer [*]
“[T]oday we have a whole society held in thrall to the drastic plastic of labial rejuvenation” (Elliott, 2008, p. 21)
Following a British Channel 4 documentary on the ‘designer vagina’, screened in 2008, Channel 4’s website for the show ran a poll which asked visitors ‘have you considered having a designer vagina?’ (see http://www.channel4.com/health/microsites/G/g-spot/perfect-vagina/vote.html). Of the 9216 respondents (on 13 Oct, 2008), 43% answered yes, they had considered having such surgery. [1]
While viewers of the site (and thus voters) are likely to have a particular interest in female genital cosmetic surgery (FGCS), the result still indicates an incredibly high proportion of women dislike their genitalia enough to have considered surgery as an option. However, it is not much lower than the proportion of women indicating, in both unscientific and scientific surveys, that they would have cosmetic surgery -- of any sort (e.g., Aitkenhead, 2005; Asthana, 2005; Most women 'want plastic surgery'," 2001; Sarwer et al., 2005). Cosmetic surgery has become a normalised practice within, and beyond, the west (see Blum, 2003; Brooks, 2004; Davis, 2003; Elliott, 2008; Fraser, 2003; Pitts-Taylor, 2007, for various analyses around normalisation), and now constitutes a viable solution to multiple forms of bodily distress for many women, and, increasingly, men.
Cosmetic surgery culture -- which is wrapped up in celebrity culture and fantasies of fame and beauty, as well as consumerism and economic factors (see Blum, 2003; Elliott, 2008) -- invites us into a regime of self-surveillance and technologically-mediated bodily self-improvement; it invites a focus on the minutiae of bodily imperfection. The body has become the starting point for radical self-transformation (Elliott, 2008); if we do not like something, and can afford it, a surgeon can change it (although not always successfully, and often at a [small] risk to life, e.g., Landman, 2004). Cosmetic surgery is material, a carving into flesh; it is also profoundly psychological -- a form of psychotherapy (Fraser, 2003; Gilman, 1998, 1999), aimed at providing an embodied solution to a psychological concern -- the person’s perception of a particular body part, and anxiety and distress that causes. [2] The idea that cosmetic surgery is ‘healthful’ and producing of inner wellbeing is now a common part of discourse around it (Pitts-Taylor, 2007).
Although genital distress is nothing new for women, women’s genitalia were, until recently, largely excluded from the intense self-surveillance and improvement imperatives that cosmetic surgery culture mandates. The ‘designer vagina’ phenomenon has changed that, with a wide range of female genital cosmetic surgery procedures targeting every part of women’s genital anatomy. These procedures aim to alter aesthetics (and/or function). They are performed in the absence of clear pathology, and without an evidence base (Cartwright and Cardozo, 2008; The American College of Obstetricians and Gynecologists, 2007; Tracy, 2007), and carry “real risks of potential complications” (The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2008). The most common procedures appear to be labiaplasty (reduction of labia minora), and vaginal ‘tightening’. Although still not vastly popular, limited statistics indicate these surgeries are increasing rapidly (Liao and Creighton, 2007, http://www.plasticsurgery.org/).
There is scant reliable information about these procedures. Some clinical case reports exist (e.g., Alter, 1998; Choi and Kim, 2000; Di Saia, 2008; Fliegner, 1997; Giraldo, González, and de Haro, 2004; Hodgkinson and Hait, 1984; Maas and Hage, 2000; Munhoz et al., 2006), mainly focused on technique, and some authors report more than a few cases (de Alencar Felicio, 2007; Pardo, Solà, Ricci, and Guilloff, 2006; Pardo, Solà, Ricci, Guilloff, and Freundlich, 2006; Rouzier, Louis-Sylvestre, Paniel, and Haddad, 2000), but there is not much beyond that. Some discussion about ethics is starting to appear, in limited form (e.g., Cartwright and Cardozo, 2008; Cosmetic Labiaplasty: The Great Ethical Debate," 2007; Goodman et al., 2007). [3] By far the most ‘extensive’ literature on the topic is critical (feminist) commentary and research (e.g., Adams, 1997; Braun, 2005, 2006, 2009a, 2009b; Davis, 2002; Green, 2005; Liao and Creighton, 2007; McNamara, 2006; Sullivan, 2007; Tiefer, 2008a).
In this paper, we critically examine FGCS in the west, locating the practice and process within broader structural, political, sociocultural and economic factors and practices. We argue that the practice and discourse of female genital cosmetic surgery works to promote one genital aesthetic as ‘right’, and simultaneously pathologise genital diversity in women. Rather than only discussing this surgery theoretically and academically, as previous critiques have done, we identify a range of factors and interventions to disrupt this trend and the concurrent pathologising of the genitalia. The broad framework we draw on is from critical health psychology (e.g., Murray, 2004; Stainton Rogers, 1996). Rather than the individualistic focus of mainstream health psychology (Campbell, 2004), critical health psychology instead adopts a more constructionist approach (Stainton Rogers, 1996), and theorises health and illness as intrinsically socially and politically located (Stam, 2004). This suggests an analysis of the role of economic, political and social factors, both locally and globally, is crucially important in understanding, theorising and analysing health (Murray and Campbell, 2003); it also locates a more diverse array of targets beyond the individual in interventions for change.
Bodies of Difference: Pathology and Perfection
To note that (western) women often have problematic relationships with their bodies is to state the obvious. A significant majority of women see their bodies as inadequate in some way (e.g., Harris and Carr, 2001), failing in the quest for feminine bodily perfection, or even ‘adequacy’. The cultural idealisation of a certain (typically unrealistic) bodily form is a key factor in making female embodiment problematic for many women. But within the range of diversity of female bodies, certain have been further marked as pathologically different -- for instance fat, non-white or ‘inappropriately’ sexual bodies (Gilman, 1985; Terry, 1990) -- and thus as inherently suspect, irredeemable in that particular embodiment.
Within consumer culture, women’s bodies occupy a location as commodity (Haiken, 1997; Negrin, 2002), but they are not singular commodity units; women’s bodies have long been “dissected into physical parts” (Duke and Kreshel, 1998, p. 49), and diversity and pathology extend to particular body parts as well as to whole bodies. The pathologisation of certain (non-white) facial features -- and surgical ‘correction’ thereof -- has a long but also changing and variable history (e.g., Gilman, 1999; Kaw, 1998; Pitts-Taylor, 2007; Preminger, 2001). A relatively recent example of this shift from bodily variation to ‘pathological’ difference can be illustrated with reference to breasts. In the 1950s, the small breast -- which at certain times in western history has been the most aesthetically desired -- became a ‘deformity’; women suffered the newly created medical condition of ‘hypomastia’ (Hausmann, 1992, cited in Adams, 1997), which persists to this day -- the solution: augmentation mammaplasty, the currently most popular form of cosmetic surgery (now typically for ‘inadequate’ rather than ‘absent’ breasts).
This same shift to pathologising diversity is now occurring for women’s genitalia. Here, we can identify a similar pathologisation through language, with the appearance of ‘hypertropic’ labia minora. Women’s genitals show broad diversity in all aspects (Lloyd, Crouch, Minto, Liao, and Creighton, 2005), and visible labia minora are statistically ‘normal’ and probably more common than invisible ones (Corinna, n.d.). Yet labia minora are identified as hypertrophic if they ‘protrude’ beyond the labia majora to a certain degree. How much is a matter of much debate, with definitions touted -- with no apparent evidence base --ranging from 2cm to 5cm (see de Alencar Felicio, 2007; Goodman et al., 2007; Maas and Hage, 2000; Pardo et al., 2006; Rouzier et al., 2000).
A description of ‘protrusion’ invokes abnormality, but the label/diagnosis of ‘hypertrophy’ locates certain genital appearance firmly within the realm of the medical and the pathological. The language is evident in medical discourse, but is also being used by women (and men) to identify particular morphologies: for instance, various girls on a recent online discussion board identified that “I have hypertrophic labia minora” (See http://www.steadyhealth.com/Is_hypertrophy_of_labia_minora_normal_thing__t53844.html).
In taking up such language, a certain (typically normal) bodily variation is medicalised and pathology ensured. And with the willing uptake of this condition, a surgical solution is implicitly rationalised and justified, over other possible ‘solutions’ -- because this becomes a real and authentic (material) problem, it needs to be resolved.
A pathological interpretation of women’s genitalia is, however, hardly new, and a continuation of a long history of western pathologising of women’s reproductive (and sexual) bodies more generally (e.g., see Ussher, 2006). Over the last few centuries, the genitalia of women deemed inherently suspect either by race (e.g., Black women) or by sexuality (e.g., lesbian women; prostitutes) have been subject to scientific scrutiny. From the 19th and 20th Century European public display of the genitalia of the Southern African Khoikhoi woman, Sartje Baartman, with her elongated labia (the so called ‘hottentot apron’), to the 19th and 20th Century measurements of the vulvas of prostitutes and lesbian women (Gilman, 1985; Somerville, 1997; Terry, 1990, 1995) to determine pathological difference, inappropriate feminine embodiment and (hyper) sexuality were read from genital ‘excess’. In this new ‘scientific’ diagnosis, it is still an excess of tissue that results in ‘hypertrophic’ labia minora -- the ‘too fleshy’ vulva (Davis, 2002) remains problematic. This troublesome real-life fleshiness fits with theorising of the (female sexual) body as abject (Kristeva, 1982), a deeply problematic, fluid, messy, seeping body that furnishes no clear boundary for the self, rendering subjectivity problematic. While the abject has often focused on fluidity -- Grosz (1994) argued, for instance, that “women’s corporeality is inscribed as a mode of seepage” (p. 203) --a similar analysis can apply here, where the offending article is tissue not ‘neatly’ contained with a seamless corporeal boundary. In Covino’s (2004) analysis of abjection and cosmetic surgery, cosmetic surgery is a practice that ‘amends’ the abject body; in FGCS, the ‘messy’ labial tissue is replaced with the ‘clean slit’ (Davis, 2002, p. 12).
Labia reduction appears to return the vulva to a pre-pubescent state (Fitzpatrick, 2007; Liao and Creighton, 2007; Manderson, 2004); arguably, to a pre-sexual body. This might appear an odd claim, as FGCS is often directly marketed around the improvement to one’s sexual life that will ensue (Braun, 2005). But perhaps here we are seeing a process not too dissimilar to the measurements of the labia of lesbian women, or even the western 19th and 20th Century clitoridectomies on young girls (Green, 2005; Rodriguez, 2008; Sheehan, 1997). Perhaps this, too, is about the policing or production of appropriate embodied (hetero)sexuality for women, but now appropriate sexuality is understood by women as accessed through particular genital morphology. Although Manderson (2004) suggests that ‘messy’ labia minora are associated with ‘promiscuous’ women, and these are stigmatised (see also Bramwell, Morland, and Garden, 2007), we wonder if something quite different is happening. It appears that ‘long’ labia (and indeed a ‘loose’ vagina) signal, to some women, a body ‘unfit’ for -- undeserving of -- sexual activity, and, even, of questionable womanhood (see Braun and Wilkinson, 2005, for discussion of links between genitals and gendered identity). In a context in which there is a “obsession with sexual gratification” (Hart and Wellings, 2002, p. 899) and sexual pleasure is framed almost as an individual’s right (see Braun, 2005, for more on this), this is a tenuous position to occupy, rendering surgery a legitimate avenue down which seek what is both entitlement and obligation (Hawkes, 1996) -- a sexual body.
While the too-present vulva -- hypertrophic labia -- and the absent breast discussed earlier -- hypomastia -- might appear different, a very similar logic is evident in the construction of both ‘deformities.’ Based on the premise of gendered dimorphism, each identifies as pathological a body that blurs the boundaries between distinctly ‘female’ or distinctly ‘male’: hypomastia renders the chest potentially ‘male’; ‘too long’ labia render the vulva open to a male reading (see also McNamara, 2006):
“My inner labial lips were long, messy and flappy and, worst of all, they hung down outside the outer lips. It looked like I had a small penis dangling down and I couldn’t stand to see myself naked” [Company Magazine, UK, 2003]
“I was so worried I thought I might not actually be fully female at one point, like the labia was actually meant to develop into balls but didn’t quite get there” [‘Flappyflaps, posted 03/09/2008 on http://answers.polldaddy.com/viewPoll.aspx?view=resultsandid=848800]
Similarly, ‘excess’ labia majora tissue is also viewed through such a lens:
“The outer layer can become almost scrotal, very wrinkly and lax,’ Dr. Romanzi said.” (Singer, 2008)
These accounts are not so far removed from Havelock Ellis’ identification of the labia majora of a lesbian woman as resembling “fleshy sacs” (Ellis, 1915, cited in Somerville, 1997, p. 42). Somerville notes that “the ‘fleshy sacs’ of this woman … invoked the anatomy of a phantom male body inhabiting the lesbian’s anatomical features” (1997, p. 42). In interpreting certain female genital morphology as ‘masculine’, these accounts reveal the societal importance of visible gender dimorphism. This is equally evident in the past -- and even current -- surgical alterations of the genitals of intersex infants. Ann Fausto-Sterling (2000), for instance, highlights the ‘unacceptable’ grey area between the acceptable size (<1cm) of a clitoris and the acceptable size (>2.5cm) of a penis in a newborn. The logic of dimorphism is evident also if you consider FGCS in comparison to male genital cosmetic surgery. In the former, reduction of tissue and ‘size’ is paramount; in the latter, the production of a larger penis is key (Cochrane, 2007).
These accounts also, importantly, reveal the limits of knowledge of women’s genital diversity, and of imagination around what women’s genital diversity can (or should) be. In our sociocultural imaginary, it seems that female genitalia occupy a morphology far more limited that their physiological reality (as demonstrated by Blank, 1993; Lloyd et al., 2005). And this discrepancy, between material flesh and imaginary morphology, can produce considerable psychological distress for some women (e.g., see numerous entries on http://answers.polldaddy.com/viewPoll.aspx?view=resultsandid=848800). The website Scarleteen reports ‘what’s wrong with my labia?’ has become one of the most asked questions in recent years, and that they’ve “been seeing more and more -- often unfounded -- worries about labia as the years have gone by” (Corinna, n.d., para 1). A key point to make is that how we ‘come to know’, ‘see’ and indeed read body parts as flesh, and beyond that, how these are personally and socially meaningful, depends on culture, on the discursive contexts which render visible and invisible various different objects and meanings (Pitts-Taylor, 2007).
Given the normalisation of cosmetic surgery, one concern we have is that for women who already have significant genital concerns, surgery will come to occupy a position in which it is seen as the only solution to the distress. Any other potential approach to treat this psychologically (let alone socio-politically) is taken out of the equation. What this does is not only undermine other non-surgical ‘treatments’ and promote FGCS -- a general feature of medicalisation processes (Doyle, 2007). It also naturalises, normalises and individualises the experience of genital distress for women, locating the problems she perceives as an almost inevitable response to unappealing physiology. What is unappealing becomes almost as given (e.g., who could possibly like ‘long’ labia minora?) and her response is located legitimately within herself/psychology because of this. Any social influence on her aesthetics and desires disappear. Aesthetics become a matter of (almost) the obvious, rather than the socially constructed. With the numerous before-and-after photos on surgeon websites or occasional clinical case reports of labiaplasty, for instance, we are expected to naturally agree that the ‘after’ shot is an improvement on the ‘before’. This undermines the possibility of ‘undoing’ such aesthetics or perceptions through other levels of interventions, be they psychologically or socially oriented.
A second important concern is that with the (re)pathologisation of genital diversity for women, through the promotion of certain ‘desirable’ vulval and vaginal states, any partially formed or vague anxieties that women might already have could be enhanced, and develop into more significant ‘distress’ about their vulva. Another possibility is that women who had no concern about their vulval appearance might suddenly pay attention to, and dislike, their vulvas if they differ from the ideal “clean slit” (Davis, 2002, p. 12) of FGCS discourse and imagery. It could be that “a brand-new worry is being created” (Davis, 2002, p. 8), and that things like advertising and media coverage produce a demand for FGCS (Liao and Creighton, 2007). This is in line with Elliott’s (2008) argument that “cosmetic surgery culture promotes the very anxieties it seeks to quell” (p. 90). The consumer system relies, of course, on a perpetual cycle involving the (personal) identification of deficiencies, and the consumption of offered up (temporary) solutions (Bordo, 1997).
But FGCS did not emerge in isolation, and likewise women’s (potentially increasing) genital concerns have not appeared in isolation. In line with a critical health psychology approach, which moves beyond the individual to consider contextual influences on women’s perceptions and desires around their sexual and reproductive bodies (e.g., see Bordo, 1993; Martin, 1987; Ussher, 2006), numerous (gendered) contexts need to be considered if we are fully to understand this practice, and even the desire for it in the first place. We now briefly discuss various continuities between these concerns and FGCS practices, from a range of different perspectives, before considering interventions and activism to disrupt the pathologisation of female genital diversity.
Continuities for Genital Distress and Female Genital Cosmetic Surgery
Women’s perceptions and experiences of their genitalia are far from straightforward, positive, or even neutral (e.g., see Berman, Berman, Miles, Pollets, and Powell, 2003; Bramwell and Morland, 2008; Braun and Wilkinson, 2003, 2005; Ellis, 2006; Ensler, 1998; Green, 2005; Morrison, Bearden, Ellis, and Harriman, 2005; Reinholtz and Muehlenhard, 1995). Numerous concerns, often related to appearance, are expressed by women, and “many women nurture fearful fantasies about the abnormality of their genitals” (Laws, 1987, p. 9). This reflects the wider sociocultural context (Braun and Wilkinson, 2001), in which “pudendal disgust is a social reality” (Tiefer, 2008a, p. 475). A diverse range of negative sociocultural genital meanings persist in women’s everyday contexts -- for instance in slang, in which visible labia minora are pathologised through crude slang such as “beef curtains” and “fishy fanny flaps” (Braun and Kitzinger, 2001). In such contexts, it is not surprising that women experience genital ‘concern’.
More specific, and newer, shifts in cultural norms also help make sense of the ‘rise’ of the designer vagina. Two central factors in western cultures relate to pubic hair removal and pornography -- evident in this woman’s comment related to an online labiaplasty poll: “I blame porn for this. And Brazilian waxes. Nobody was comparing lips when they were nicely hidden in the bush” (ClatieK, posted 30 October 2008, http://www.thefrisky.com/post/246-poll-would-you-ever-snip-down-below/). The emphasis on removal of most or all pubic hair for women has become widespread in the last 5-10 years (e.g., Fitzpatrick, 2007; Peixoto Labre, 2002; Tilley, 2007), to the point it has been claimed as “routine” (Trager, 2006, p. 117) and “entirely mainstream” (Cochrane, 2007, p. 30) in adults and adolescents -- so much so that some women are reportedly having ‘permanent Brazilians’ (McLean, 2007). The removal of most or all pubic hair makes the vulva more visible (Green, 2005), and more an object of attention (and also more prepubescent, Peixoto Labre, 2002). It is indicative of a shift from the vulva being a part of women’s ‘natural’ body where modification was not mandated, to being a part almost inherently inadequate without at least some minor modificatory (e.g., depilatory) practice. FGCS is part of this shift in status. Cochrane (2007) notes a link between this trend for pubic hair removal, and “the rise and rise of vaginal cosmetic surgery” (p. 30); and it is frequently noted in women’s narratives of FGCS presented in the media:
When it became all the rage to get heavy bikini waxes and have almost no pubic hair, my prominent labia really started to bother me (Marie Claire, UK, 2000)
This hairless norm has also been linked to pornography (Peixoto Labre, 2002), as has FGCS, and especially to magazines such as Playboy: “by 2001, pubic hair seems to almost have disappeared from the pages of [Playboy]” (Peixoto Labre, 2002, p. 120). In recent years, ‘mainstream’ pornography has come to occupy a more normalised position within western heterosexual relationships (Häggström-Nordin, Sandberg, Hanson, and Tydén, 2006), so that heterosexual women may well be exposed to a range of (depilated) supposedly particularly desirable vulvas, to which they can compare their own. In media accounts, women locate these vulvas as desirable:
I really wanted my genitals to have the tight, tucked-in look that I’d seen in men’s magazines (Cosmopolitan, Aus/NZ, 2001)
Numerous sources indicate women or take porn images to surgeons to demonstrate the vulva they want (Green, 2005; Liao and Creighton, 2007):
Women sometimes come armed, says [surgeon] Martin Rees, with a porn magazine, a variant on taking a picture of some celeb to the hairdressers” (Metro, NZ, 2005)
[Lisa’s] deciding exactly what looks she’s going to plump for. But she’s not looking at beautiful bodies and faces in a fashion magazine; she’s looking at full-frontal shots of vaginas in Playboy. (Shine, AUS/NZ, 2001)
Broader contemporary cultural influences related to women’s genital perceptions, desires and practices include marketing by surgeons and medicalisation. Medicalisation is a process whereby ‘problems’ -- which might already ‘exist’ or be newly created -- are located within the biological, and the influence of the social or psychological are ignored or downplayed. Solutions to these problems similarly prioritise the biomedical at the expense of the psychological or social (Conrad, 2007). In the final section of the paper, where we discuss action and activism against FGCS, we situate our analysis within broader processes like medicalisation and disease-mongering, as well as advertising and media representation.
Action and Activism against Female Genital Cosmetic Surgery: A New View Perspective
FGCS is clearly a problematic group of practices, and the practice and discourse around them (re)pathologises women’s genital diversity, potentially creating a self-referential cycle in which surgery becomes more and more popular and diverse genital morphology less and less acceptable. While academic critique of this nature is vital, it is simply not enough; public and political level action is needed to intervene to challenge this process. One area of female genital cutting where this has occurred is in relation to practices commonly referred to female genital mutilation (‘FGM’) (which tend to be distinguished from (western) FGCS by a rhetoric of choice, Braun, 2009a). [4] In contrast, challenging the practice and growth of FGCS is a new area for feminist activism. Before discussing activism against FGCS, we briefly survey some activism against ‘FGM’, as well as activism aimed at intervening in other practices which promote one bodily singular ideal or norm and problematise embodied diversity and difference.
Various feminists from around the globe have campaigned against ‘FGM’ on every continent and in every medium and venue for many years. As a consequence, many countries have banned it (see Rahman and Toubia, 2000). A widespread international coalition of activists as well as institutional agents such as the UN, WHO, and the European Parliament work to bring the issues before the public in a variety of forms (see http://www.un.org/News/Press/docs/2008/dsgsm377.doc.htm). The goal of anti-‘FGM’ activism is to reduce the practices both through legal prohibitions and via raising the level of public disapproval (e.g., Olembo, 2007). The key discursive moves in the global anti-‘FGM’ campaign were, first, to include FGM within the rubric of “violence against women” and, second, to reframe violence against women as a human rights issue , as one of a number of ‘harmful cultural practices’ (Jeffreys, 2005). These shifts, which occurred over a period of years towards the end of the twentieth century, expanded the discussion of FGM beyond the frame of “gender and health,” allowing large and well-funded human rights organizations such as Amnesty International to become involved (e.g., http://www.amnesty.org/en/library/asset/ACT77/002/2000/en/dom-ACT770022000en.pdf). [5]
Another area of much more limited activism in the west, but one which has resulted in some success, is around the medical/surgical practices for intersex infants. Arguing for diversity and against pseudobiological binaries, feminists have challenged the involvement of genital surgery in the management of intersex individuals since the 1970s (Kessler and McKenna, 1978). Intersex individuals themselves began to advocate in an organised fashion against genital surgeries in the US in 1993, with the founding of The Intersex Society of North America (ISNA) (http://isna.org; see also Hegarty and Chase, 2000). Partly as a result of activists' research, education, and advocacy, a new standard of care was published in the medical literature in 2006 representing negotiations among many stakeholders in this debate (Lee et al., 2006). [6] However, medical authority that stresses the reality of a two sex model with surgical "correction" for "deviations" is still dominant in this area (Karkazis, 2008).
Another related area of feminist activism can be seen around what we might call western ‘body politics.’ For example, there have been numerous challenges to the narrow range of media portrayals of women’s bodies in advertising and other media (e.g., Bordo, 1993; Gill, 2008; Kilbourne, 1999). Many public health campaigners have raised awareness of commercialized “beauty practices” as a source of danger and oppression (e.g., http://phsj.org/?page_id=10), and this has also been the focus of feminist academic/activist critique (Jeffreys, 2005). Finally, although space precludes a detailed focus, there has been a long feminist history of activism related to women’s health issues, including extensive activism around breast implant surgery (for a timeline and links, see http://www.commandtrust.com/implants.html).
Although critical feminist commentary about FGCS has appeared in scholarly, print media and online articles, as well as in more informal online blogs and commentaries (e.g., Anna, 2007; Corinna, n.d.), there are as yet only a few indications of feminist activism. This absence of activism perhaps reflects the dominance of choice rhetoric related to western bodily practices (see Braun, 2009a), and possibly a reduction in activism more generally. Thus far activism seems to be against the invisibility of women’s genital diversity, rather than against surgical interventions, per se. For example, the ‘Everyday Bodies Project,’ started in 2004, posts self-photographed images of women’s genitals to a signed-up online community, to combat ignorance and concerns about ‘abnormality,’ and to challenge the typically uniform (edited) genital imagery most available to women (Parker, 2007). Similarly, the author of the pro-vulva website Vagina Vérité is planning to produce a book of vulval images to “make it clear that diversity is the norm” (http://www.vaginaverite.com/book.html). And sex educators who focus their attention on adolescents have been especially vocal about the need for positive attitudes towards their genitalia, especially as teens can be influenced by TV surgery “makeover” shows and pro-surgery articles and imagery in magazines (Corinna, n.d.; Redd, 2008), and increasingly express concerns about vulval normality, as discussed above.
Our work has focused on FGCS as part of a wider critique of the medicalisation of women’s bodies and sexualities and the creation of new homogeneities and new norms for sexual function and experience. It is situated within The New View Campaign (see http://www.newviewcampaign.org/), convened in 1999 by a group of feminist social scientists, academics and health care providers in reaction to the escalated medicalisation of women’s sexual ‘problems’ that followed the blockbuster success of Viagra (Tiefer, 2008b). Most of The New View’s work to date has focused on analyzing and publicizing the harms to women, and to the understanding of sexuality, from the new sexuality medications and medical framings of sexual life (see http://newviewcampaign.org/). The Campaign based our analysis of harm on similar feminist critiques arising from scandals about sex hormones (HRT, National Women’s Health Network, 2002 ), dangerous contraceptives (Dalkon shield, Hicks, 1994 ), and birthing practices (unnecessary hysterectomies, Morgen, 2002 ).
Ten years on, The New View Campaign’s perspective on the medicalisation of sexuality has expanded greatly. In our discussions of “the hunt for the pink Viagra,” for example, instead of focusing attention solely on urologists and other physicians as usurpers of sex research and women’s sexual health care, we now see them as overt or disguised agents who promote the profit-seeking agenda of a global pharmaceutical industry. We now understand that the influence of the pharmaceutical industry grows because it benefits from favourable governmental and professional organization regulations regarding advertising, education and drug approval (Tiefer, 2008b). Over these 10 years, our understanding of medicalisation and sexuopharmaceuticalisation has moved beyond simply targeting doctors and drug company representatives to include wider networks of influence including political, media, corporate, educational, and professional interests. Doctors and drug companies alone would be unable to accomplish hegemony over research and professional education practices without the active collusion of these wider networks (Tiefer, 2008b).
A new social movement has grown to challenge the public health impact of various corporate practices (Freudenberg, 2005). Academics and non-profit reform groups have revealed how, in their pursuit of profits, corporations use advertising, public relations, and lobbying to defeat or water down progressive regulations that would protect the health of the public. For example, instead of banning cigarette ads entirely, laws only ban them in newspapers, some magazines and television, while permitting ads on billboards and other magazines. In addition to academic and theoretical critique, activism for change has involved these ‘reformers’ challenging the unhealthy policies and practices of corporations by using the very same tactics: media advertising, public relations and lobbying to influence regulation, legislation, and research.
The concept of disease-mongering [7] emerged as an important tool for analyzing how the sexual medicine industry (which is larger than just the pharmaceutical industry) was manipulating the media and public opinion to create markets for a medicalised view of sexual problems (Moynihan and Cassels, 2005). The New View Campaign has examined how the ‘research’ and ‘educational’ activities of the pharmaceutical industry have themselves become disease-mongering tactics used to market drug products (cf Payer, 1992). This involves practices such as: taking a normal function and implying that there is something wrong with it, and it should be treated; assuming suffering that isn’t necessarily there; defining as large a proportion of the population as possible as suffering from the ‘disease’; using an end point in clinical research that advantages the pharmaceutical company rather than being important to the public; promoting technology as risk-free magic (Tiefer, 2006). Most of these are easily applicable to FGCS.
The New View Campaign’s activism over these years to challenge Big Pharma’s disease-mongering tactics has consisted of many journalism interviews, public lectures, debates at medical congresses, public testimony at government hearings, academic publications, self-published brochures and teaching manuals, a website and listserv, letters to government agencies and professional continuing education courses (Tiefer, 2008b). This multi-pronged approach has been a key strength of the Campaign, which has been successful, for instance in helping defeat the first sex drug for women that came to the US Food and Drug Administration in 2004.
The Campaign’s interest in FGCS came about because of a sudden escalation in promotion of this new group of genital surgery procedures through internet videos and television “makeover” shows. The largest impetus seemed to come from one particular Los Angeles gynaecologist who has developed a franchise-like arrangement for training doctors in trademarked procedures using patented equipment and licensed media ad campaigns. The combination of medicalisation for a new ‘condition‘ (distress over clitoral, labial and vaginal appearance), and the flagrant use of business practices which cross the boundaries of ethical advertising practice (see The American College of Obstetricians and Gynecologists, 2006), provoked a strong reaction from the New View group. We came to believe that, despite claims that they are about empowering women and improving women’s sexual pleasure (see Braun, 2005), these surgeries were being recommended out of a misogynist disregard for women’s genital diversity and a willingness to exploit women’s lack of knowledge and confidence about their genitals. This called for action.
A small New York-based feminist group studied the journalism about FGCS, the websites of the FGCS providers, the complex and extensive feminist literature on cosmetic surgery, writings about ‘FGM’, and the New View pro-diversity and anti-medicalisation philosophy, and developed a campaign to challenge FGCS.
The goals of the campaign are:
To create public concern about the unchecked expansion of the FGCS industry and its lack of scientific research support;
To pressure professional OB-GYN and plastic surgeons’ associations to collect data on these procedures, and to censure or sanction FGCS surgeons who offer services without publishing research outcomes;
To expand the idea of ’informed consent‘ for FGCS to include genital education about anatomical diversity through showing independent illustrative and scientific materials;
To shed light on the growth of a new set of medical business practices that uses franchise models, public relations, multiple advertising avenues, and all the bells and whistles of contemporary marketing to medicalise everyday bodies, lives, and functioning.
To achieve these goals, we designed an activist campaign consisting of:
Development of a website with resources for press and public (http://www.newviewcampaign.org/fgcs.asp);
Letters to medical and governmental agencies and organizations calling for increased consumer protection, and increased professional standards;
A 2-hour sidewalk rally in front of a NYC FGCS surgeon’s office (including guerrilla theater);
Distribution of a press release announcing the sidewalk rally;
Collection of a list of individual and organizational endorsers of the rally;
Sharing of resources with feminist university organizations to educate their members about the issues;
Collaboration with documentarians interested in FGCS.
The public rally was attended by about 30 feminists and photos can be seen on http://www.newviewcampaign.org/fgcs.asp. Major press coverage included an excellent article in the largest American newsweekly, Time magazine (Fitzpatrick, 2008). The resources will remain online indefinitely. In upcoming conference presentations we plan to use this activist event as a model for feminists planning public actions to challenge the continuing pathologisation of women’s bodies and sexualities.
Conclusion: The ‘Personal’ Remains Political
With this paper we have aimed to present both academic critique of the emergence of FGCS along with activism to challenge the practice. The case of FGCS demonstrates, once again, the feminist claim that ‘the personal is political,’ and that this concept is still as relevant as when it was first stated. We have outlined cultural factors which make it entirely understandable that women both experience anxiety and distress about their genitalia, and seek cosmetic surgery to change them. Women’s personal distress and desires around genitalia need, however, to be located within a wider socio-political context, which includes active practices of medicalisation as well as pathologisation of genital diversity through the promotion of one ideal vulval form. As a final point, it is important to realise that it is not just women who are influenced by culture, economics and practices such as medicalisation. Health and other related professionals are cultural members as well as professionals; their practices can reflect, and reinforce, negative cultural assumptions around women’s genitals, sometimes in quite subtle ways (e.g., Kapsalis, 1997; Lomax and Casey, 1998; Pliskin, 1995). For this reason, comprehensive critical education around genital diversity and normality remains essential.
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Footnotes:
[1] Different polls give different results. Of the 655 respondents to the current thefrisky.com poll on the same topic, 17% indicated they would consider labiaplasty, and 13% that they might (response categories were worded somewhat differently, see http://www.thefrisky.com/site/post/246-poll-would-you-ever-snip-down-below). Less enthusiasm was shown by 85% of respondents in Company Magazine's (UK) “biggest ever surgery survey” who reported that they would “never consider having surgery done down there” ("Can surgery better sex?," 2008, p. 102) - although 15% apparently would, and number of respondents was not indicated. Sound empirical research on interest and uptake is lacking.
[2] In a different way, it is also profoundly commercial, and tied into economic factors and imperatives as well (Elliott, 2008; Haiken, 1997; Sullivan, 2001), which we should not forget in our analyses, and deeply cultural.
[3] Critics (e.g., Allotey, Manderson, and Grover, 2001; Conroy, 2006; Essén and Johnsdotter, 2004; Manderson, 2004; Sullivan, 2007) have also raised questions about the practical, moral, ethical and legal aspects of the different ways western and non-western genital 'cuttings' are treated in the west, such that FGCS is not subject to legal contestations, although laws against 'female genital mutilation' technically prohibit some forms of labiaplasty, for instance (Sullivan, 2007).
[4] There is much controversy over terminology in this area, not least because the practices are diverse. This has seen the emergence of less 'judgmental' terms like 'female genital cutting,' which not all agree with. Our views on these issues are not uniform or singular. We use the term 'FGM' in this paper, but in scare quotes, although we recognize that some readers will find it problematic.
[5] We must acknowledge this account around FGM activism as singular and one which focuses on the positives of international efforts against it. However, much controversy exists in this area, and activism against FGM (by western feminists/organisations) has been subject to substantial critique, and there are ongoing debates about who should be involved in moves to eradicate FGM practices, and how these might be put into practice. Both insiders (women from countries where various 'traditional' forms of 'cutting' are practiced) and outsiders (women from countries where they are not) present a wide range of differing viewpoints in these debates. Critics have suggested that western activism continues long histories of cultural imperialism and colonisation, obliterates the complexities of meaning and practices around genital cutting, and situates African women as 'uncivilised' within a matrix of cultural influence that can only be challenged by outside perspectives (e.g., see Abusharaf, 2001; James and Robertson, 2002; Njambi, 2004).
[6] The Consensus Statement is not without its critics, not least in relation to the shift in terminology, from “intersex” to “disorders of sexual development” (e.g., http://aiclegal.org/yabb/YaBB.pl?num=1218845029/4; http://intersexpride.blogspot.com/)
[7] Where critical analysts identify that disease-mongering involves the creation of new 'diseases' to fit treatments (Moynihan and Cassels, 2005), those within the pharmaceutical industry refer more positively to 'condition branding' (Angelmar, Angelmar, and Kane, 2007).
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Biographical notes:
Virginia Braun is a Senior Lecturer in Psychology at The University of Auckland. Her research is located within feminist and critical psychology, and focuses on topics related to sex, sexual health, and female genital cosmetic surgery. She is Co-Editor, with Nicola Gavey (The University of Auckland), of the journal Feminism & Psychology.
Leonore Tiefer is a clinical psychologist in the Psychiatry Department at the NYU School of Medicine. She is author, educator, researcher, therapist and activist in sexology and has keynoted conferences around the world. In 2000 Dr. Tiefer initiated the Campaign for a New View of Women's Sexual Problems [http://newviewcampaign.org] to challenge the new medicalization and Big Pharma trends. She is the author of Sex Is Not a Natural Act (2nd edition, Westview, 2004) and other works.
