Socially motivated female genital cutting has a long history in Europe. According to social historians, in ancient Rome, metal rings were passed through the labia minora of female slaves to prevent procreation. In medieval England, women in certain social strata were made to wear chastity belts to prevent them from engaging in sexual activities during their husbands’ long absences. In Tsarist Russia and nineteenth-century England, France and the United States, clitoridectomy was performed to cure epilepsy, hysteria, insanity and masturbation . In many countries today, a diverse range of lawful procedures subsumed under ‘female genital cosmetic surgery’ (FGCS) overlap with a diverse range of unlawful procedures subsumed under ‘female genital mutilation’ (FGM) (Chapter 7). The double standard is bewildering:
How can it be that extensive genital modifications, including reduction of labial and clitoral tissue, are considered acceptable and perfectly legal in many European countries, while those same societies have legislation making female genital cutting illegal, and the World Health Organization bans even the ‘pricking’ of the female genitals? 
FGCS refers to lawful procedures to alter the structure and appearance of female external and internal genitalia in the absence of biomedical concerns. This definition refers to a large and growing number of operations including labiaplasty, clitoroplasty, introitoplasty, hymenoplasty and vaginal rejuvenation, tightening and reconstruction (Chapters 5 and 6). These operations are said to ameliorate women’s worries about the appearance and function of their genitals, including the kinds of concerns expressed by our three informants – ‘Madison‘, ‘Kate‘ and ‘Navaeh‘:
Madison is sobbing. Next to her is her mother Nicole. Opposite them is the gynaecologist who has just examined Madison’s vulva. The twenty-year-old has been complaining about soreness from the chaffing and rubbing of her vulva, especially when she wears her jeans. “It gets caught coz it sticks out too much,” she says. She has recently cancelled a beach holiday with friends because, she says, her clitoris gets erect in hot weather and can be seen inside her swimwear. Far from feeling relieved by the gynaecologist’s reassurance that her genitals are normal and healthy, Madison is miserable. Mother and daughter have spent months researching on the internet before concluding that surgical removal of “the excess tissue” (in the clitoris) was the right course of action for Madison. To Nicole, the persistent despair of her daughter is surely evidence enough that the problem is “not just in her head”. Having had a private neck lift herself a few years ago, Nicole is aware of the high costs of private cosmetic surgery and bemoans the fact that it would take Madison years of working at the hair salon to save up enough money to “make the vagina right again”.
Kate lives alone. Her son and daughters live with their respective partners not far away. Kate’s husband moved out last year; their divorce has just come through. After several years of stress over the uncertainty of her “rocky marriage”, Kate is enjoying life again. She feels ready for a new relationship. After a routine smear test, she asks the friendly nurse about ‘vaginal laxity’. It has been at the back of Kate’s mind for a while to do something about it. For a few years before the divorce, her husband was initiating sex less often. When they had intercourse, he did not always orgasm. Kate took this to mean that sex with her was less enjoyable for him. Having given birth three times and being post-menopausal, she muses, her body “is bound to feel not as nice”. In preparation for a new relationship, and as an act of doing something positive for herself, Kate is looking to see a doctor experienced in ‘vaginal tightening’. She wants to know more about the procedure so as to be able to choose the best provider.
After a successful term at school where she is a high achiever, Nevaeh is excited about her summer travels. She buys her first pot of hot wax. At fourteen years of age, she is not the first among her friends to remove the unwanted hair growth on her legs. Nevaeh tries on her new bikini and notices her pubic hair escaping through the sides of her briefs. She instinctively proceeds to trim the hair off. An hour later, she is waxing her labia majora. It’s extremely painful and her vulva is looking rather red. The enlarged hair follicles give the labial skin a pimpled appearance. Images of chicken skin come to mind and bring a sense of disgust. She despises her “purply fleshy” inner labia even more. She experiences a longing for a firm, smooth-skinned and evenly coloured vulva “without all the bits”. Nevaeh shuts her eyes and imagines that different vulva and feels a sense of relief. She can’t remember where she may have seen such a “vagina” – perhaps as a drawing in a biology book? Nevaeh feels that she would be so happy if she did not have to deal with the body part that is “so not me”.
In 2007, we drew attention to the fivefold increase in the number of labiaplasty operations performed in the United Kingdom’s National Health Service (NHS) in the preceding decade . The article was not the first commentary on the topic in a medical journal , and there had been important feminist scholarship on the subject . Since then, the FGCS industry has expanded considerably. According to a 2016 report by the International Society of Aesthetic Plastic Surgery (ISAPS), 138,033 labiaplasty operations were performed in the preceding year . These figures come from voluntary data submissions and are almost certainly to be underestimates. The overall increase in the number of cosmetic operations in the year was 9%, but the increase for labiaplasty, which had enjoyed the steepest rise, was 45%. The successful mainstreaming of FGCS in high-income countries is mirrored in low- and middle-income countries, as evidenced, for example, by the specialist sessions on Cosmetic Gynaecology and Vaginal Rejuvenation at the All India Congress of Obstetrics and Gynaecology in 2017 and 2018 . We know that there has not been a labial growth spurt worldwide. In any case, research shows that there is no difference in labial dimensions between women seeking and those not seeking labiaplasty . We also know that surgical techniques do not change that quickly. Hence some other factors must account for the growth of labiaplasty. Psychologist and sexologist Leonore Tiefer explained in 2008 that the infinite possibility of disease mongering in consumerist medicine fits comfortably with our free market and encourages the growth of FGCS . Does the sharp rise in labiaplasty  reflect successes of marketing campaigns? Have prices fallen as a result of greater competition so that more women can pay for the operation? Are banks encouraging women to take out personal loans for cosmetic surgery? Is there a new social acceptance of female genital cutting in the West and, if so, what are the implications for women and for society? Has female genital dissatisfaction and distress increased? Are these factors linked, and if so, how?
Female Genital Cosmetic Surgery: Solution to What Problem? is an interdisciplinary response to some of the questions asked. The volume combines historical and philosophical analyses and legal, pedagogic and clinical perspectives. Its aim is first to enable researchers to formulate questions about FGCS more strategically. An equally important aim is to enable education and health professionals to develop non-surgical alternatives to address genital dissatisfaction and the resulting distress (Chapters 11 to 15). The book was seeded by the experiences of women and girls who, like Madison, Kate and Nevaeh, experience doubt, concerns, worries, distress and disgust about the appearance and function of their genitals. It is hoped that some of the chapters will be of interest to the women and girls so affected. Although the volume is about FGCS, many of the discussions are relevant to cosmetic surgery more generally, so that some of the chapters may be of interest to wider audiences.
The contributions to the book by leading academic and clinical experts on the topic of FGCS combine to emphasise the critical importance of reframing the most frequently asked question about FGCS: “Why do women do it?” The question pre-locates the answers in the women and encourages the recycling of individualising discourses of free choice, self-improvement and female madness that exonerate FGCS (Chapter 8). These popularised discourses mask the powerful structural underpinnings of a cultural practice that is being promoted more or less unopposed.
In Power, Interest and Psychology, clinical psychologist David Smail proposed that to understand unhappiness, we should, rather than gain insight into ourselves, instead cultivate ‘outsight’ into the world around us, in particular in how social and economic factors mould our thoughts and feelings and organise our choices in ways that are often not obvious . Outsight into FGCS is the aim of this chapter, in which we highlight and problematise the interrelated systemic processes, including (1) binary notions of sex and gender, (2) the pressure of suspect norms, (3) the effects of medical framing, (4) the ambivalent professional responses, and (5) the barriers to establishing high-quality evidence to guide consumer choice and professional practice. We return to our three informants as the discussion progresses and offer suggestions at the end of the chapter on limiting damage.
Like other sex characteristics, the genitalia are culturally constructed as discrete and non-overlapping biological entities that confer femaleness and maleness, two forms of existence also constructed as discrete and non-overlapping. The concept of binary sex is not supported by science. Human embryos have the same reproductive and genital structures to start with. Sex differentiation typically begins at about eight weeks of gestation, and a sex-undifferentiated fetus gradually assumes the anatomical structures and appearance of what we think of as female or male. In other words, the tissues that develop into ovaries, womb, vagina, clitoris and labia are the same as those that develop into testes, penis and scrotum. The developmental processes often, but not always, result in a female- or male-typical combination of chromosomes, physiology and anatomy. Nature prefers diversity and delivers a spectrum of possibilities that makes binary sex a myth so hard to sustain that in modern times, surgical interventions have been developed to ‘correct’ the less differentiated genitals in many Western(ised) societies. Although the genital differences are medically benign, children may undergo a series of genital operations to satisfy adult expectations of normative genital appearance and function. These interventions are increasingly positioned as a violation of human rights .
Binary understandings also extend to non-genital sex characteristics. Body hair, for example, is a biological reality of all human beings, but ‘hirsutism’, defined as ‘an excess of body hair in the male distribution’ , is a medical term applied only to women. Even if we were to accept that hirsutism is a medical condition for women, the distinction between normal and abnormal female hair growth is far from clear-cut. Women’s customary hair removal makes it hard to determine the actual distribution of facial and body hair in the general population. Anthropological studies of cultures in which hair removal is unavailable or not practised indicate that women have the potential to develop hair growth in the same regions of the face and the body as men. The difference between men and women in the amount of hair growth has never been quantified. Nevertheless, clinicians have described women’s extreme reactions such as shame and ‘morbid preoccupation’ even with insignificant hair growth. . Nevaeh takes for granted as a truth that females have no body hair. It is a social norm that she has internalised and does not question. As she applies hot wax to remove her leg, armpit and pubic hair, she is merely acting on a commonsense understanding – a matter of fact, in her cultural context.
Likewise, although many women in the general population have relatively little breast tissue and many men have more, ‘gynaecomastia’ is a medical term applied only to men. NHS Choices explains that gynaecomastia is a medical condition in which boys’ and men’s breasts swell to become larger than normal . The definition of normal is left to the imagination of providers of ‘male breast sculpting’, which usually involves a combination of liposuction and removal of glanular tissue. Widely advertised in the private sector, surgery supposedly helps men to “look good in a fitted shirt when the meeting gets heated” . Surgery is intended not just to promote confidence in the board room; it is also said to enable men to “look forward to holidays in the sunshine again”. . The American Society of Plastic Surgeons (ASPS) reported a 30% increase between 2010 and 2016 in the number of male breast reductions performed .
As discussed above, genitals are socially constructed as mutually exclusively female or male. According to a medical report, a large penis in males “has always symbolized strength, virility, power, and domination in relationships.” . The claim is not only sexist but, in erasing cultural differences, racist. The claim is also flawed in always. The amount of genital mass proportionate to the overall body mass of the idealised male body form in today’s pornographic images is different from that in many classical European artistic depictions. In our contemporary world, surgery on the genitals of men includes penile lengthening, penile girth enhancement, dual augmentation (length and girth enhancement combined), penile glanular enhancement, scrotal web resection and reconstruction. According to plastic surgeons, many men want to know how phalloplasty can improve their self-confidence, sexual relationships and female partners’ sexual satisfaction. Despite these alluring suggestions, phalloplasty fell by 28% between 2015 and 2016 and was the least popular form of cosmetic surgery that year (8,434 operations) .
Just as male genitalia are constructed as present, external and pendulous, female genitals are constructed as absent and recessed. In other words, women lack genitals ; they have an internal receptacle instead. Some years ago, at a planning meeting for an academic event on FGCS, the organisers, who were familiar with the debates, requested that we substitute another word for genitals in the title because it was “a horrible word”. They asked that we refer to “vagina” instead. The sensibility did not reflect ignorance on the part of the conference organisers, rather a culturally shared sense of incompatibility between women and genitals. Madison and Nevaeh refer to ‘vagina’ when they are talking about the clitoris and labia, which are part of the vulva (Chapter 2). In 1995, artist Joani Blank had the foresight to create Femalia, a book of photographs of the vulva. Blank wanted to counter the “unfortunate habit that most people have of calling a woman’s vulva her vagina”. She reasoned, “by teaching our little girls to call their genitals vaginas, we practice a sort of psychic genital mutilation”. Blank forewarned that language could be “as powerful and swift as the surgeon’s knife”. In her words: “What is not named, does not exist.”
Binary notions of genitals explain why men, who on average have a greater share of the burden of genital mass, tend not to complain about the kind of rubbing and chaffing of the genitals that bother women, nor are men known to have their genital mass surgically reduced to accommodate sporting activities such as cycling and horseback riding.
Historian Hera Cook (Chapter 9) explains that norms emerge in response to cultural beliefs about a given, regularly occurring action or state, and that individuals who do not conform are sanctioned. Social norms are not experienced as norms but taken for granted as reality and common sense and are not questioned. Individuals consciously or non-consciously scrutinise themselves (and others) and steer towards alignment with the taken-for-granted reality. Norms are therefore an effective form of social regulation, and not always in negative ways. The kind of social norms being interrogated here are the appearance norms that contribute to genital shame and that which are steering some women and girls towards FGCS.
In a classical series of social psychology experiments, researchers demonstrated how appearance norms operate in social contexts . The research participants were randomly assigned to one of three conditions. They were asked to imagine having an allergy, epilepsy or a physical scar. They then interacted with a conversational partner who they believed to be aware of the condition but was in fact unaware of any of the three experimental conditions. The researchers demonstrated that people who believed that they had a visible defect were more sensitive about the conversational partner’s behaviour and were more likely to interpret behaviours such as staring as reactions to the assumed physical defect. They also expressed less favourable impressions of the conversational partner thought to be having the reactions.
Few people can escape the pressure of appearance norms, but surveys consistently show that the majority of women are dissatisfied with or distressed by aspects of their physical appearance, so much so that body dissatisfaction and distress are synonymous with being female . Furthermore, the majority of cosmetic operations are performed on women .
In the foregoing example, Madison’s sense of threat comes from three facts: (1) women have flat vulvas; (2) her vulva is not flat enough; and (3) she will be shamed and humiliated if found out. Madison avoids exposure by withdrawing from certain activities until her sense of threat is removed. If she goes ahead with the beach holiday as planned, Madison is, according to the aforementioned psychological research, likely to feel self-conscious and interpret people’s behaviours as intrusive. She is likely to think that her genitals have given rise to the unwelcome attention. She may disengage from social interaction. Convinced by her interpretation of the situation, she is not reassured by her friends’ alternative explanations. Madison may decide to wear a sarong to the beach to cover up her presumed defect. In this case, her self-judgement is untested. Either way, her norm-based beliefs are maintained.
Gradual changes to sexual experiences and preferences in response to ageing and other life circumstances are not diseases, unless people choose to view them as such. In Kate’s (sub)culture, a reduced capacity for orgasm in men contradicts the social norm of undiminished lustful urges in men. To Kate, her observation of the changes in her then husband needs explaining. As an older woman, ‘vaginal laxity’, not a recognisable condition, medical or otherwise, is culturally available as an explanation. Kate may be sexually experienced enough to know that enjoyable sex does not require a perfect body. She may remember the days when she and her then husband enjoyed coitus not long after she had given birth, so that ‘vaginal laxity’ is not a logical explanation. Kate may also remember that their relationship was not going well and that this was affecting their overall pattern of physical affection, not just their sexual experiences. Nevertheless, ‘vaginal tightening’ somehow sounds like a credible solution for something, albeit Kate has not quite thought through what kind of difference the intervention would make to her life and how. Kate may go ahead and benefit from the intervention. Alternatively, she may notice no difference after a while and regret wasting the money. It is also possible that Kate is harmed by the procedure to the extent that she never enjoys vaginal sex again. No one may hear of such an outcome, perhaps not even Kate’s surgeon, because she may blame herself and just want to forget the entire episode. In the absence of independent research, no one can be sure what happens to the many women who undergo invasive interventions on their genitals.
It would be inaccurate to claim that the denigration of female genitals is caused by FGCS. In their 2001 research report, psychologists Virginia Braun and Sue Wilkinson identified seven persistent negative representations of the vagina . The authors discussed how these representations had become culturally available resources for how the vagina and its functions were thought of, talked about and acted on. As the denigrating ideas become everyday understandings, they are no longer questioned and shut down other ways of thinking and talking about the vagina. Cultural devaluing of ordinary female genitals contributes to the fertile ground for FGCS to flourish.