Can “comprehensive sex education” [1, p. 475] tackle the dissatisfaction and distress that underpin female genital cosmetic surgery (FGCS)? A literature search has not identified any research that can directly answer the question, nor has it turned up resources that sex educators can immediately put to use. Nevertheless, theories developed within sex education (sex ed) can have useful applications for addressing female genital concerns and FGCS.
My understanding of sex ed is framed by my position as a norm-critical clinical psychologist with a specialist focus in sexology. A Swedish-speaking Finlander, I completed my clinical psychology training in Sweden and doctoral research training in Norway and now live and work in Sweden near the border with Denmark. I draw on my understanding of sex ed in Sweden to explore the topic in question.
Despite a relatively liberal attitude to sex ed in Sweden, several reports have concluded that provision is patchy and that the quality is inconsistent between schools and between teachers . Many programmes aim at fostering well-being and equal (sexual) relationships but end up mainly giving information on fertility and sexually transmitted infections (STIs) . Further development is undoubtedly required in Sweden and the rest of Scandinavia to meet new and emergent challenges, such as the issues that steer women towards FGCS. Nevertheless, useful lessons can be drawn from the Swedish sex ed context.
The chapter begins with a brief introduction to sex ed and discusses how programmes could be expanded to become more comprehensive. The discussion progresses to more specific deliberations to situate pedagogic responses to female genital distress within a feminist and norm-critical framework. Whereas women are steered by normative pressures to ask what they can do for their genitals, effective norm-critical sex ed could help more women to reverse the question by asking what their genitals can do for them.
A Brief Introduction of Sex Education
Sex ed is mandatory in many post-industrial nations where school attendance is compulsory for children. That said, it is contested in most countries, if not conflicted to the point of stagnation. Suffice to say that there are strong ideological drivers behind the questions as to whether sex ed does more harm than good, what the content should be, how should it be taught, who should teach it, and how old the children or adolescents should be when they participate in it. The prevailing ideas, influenced by strong social values, can be thought of as falling into conservative, liberal and feminist/postmodern perspectives . Conservative approaches typically focus on fostering abstinence from sexual activities before marriage. Liberal approaches are oriented towards promoting a shame-free attitude to sex and sexuality and emphasizing sexual rights and sexual health. Feminist critics, however, argue that in reality, such liberal approaches usually fail to foster positive and agentic sexualities . In practice, most sex ed programmes probably reflect shades of grey in between these three broad orientations.
Traditional sex ed programmes use didactic methods to teach young people to evade the negative consequences of sexual activities such as pregnancies and/or STIs. Critics suggest that such a negative focus fails to engage young people as sexual agents  and homogenises them . Such limitations have particular ramifications for young women and gender and sexual minorities. For example, the conflation of sex and coitus and reproduction is based on cis- and hetero-normative assumptions and leaves little room for other possibilities. Advocates argue that feminist and LGBTQI perspectives should not be applied to mainstream sex ed as add-ons but transform it altogether by addressing complex psychosocial aspects of bodies, identities, relationships, desires and norms.
Evidence-based sex ed programmes require the collaborative involvement of interdisciplinary stakeholders to develop clear aims and content [5–7]. Research also suggests that programmes should include theoretical information about social influence, delivered in group-based methods informed by cognitive and developmental theories. Such group exercises can enable participants to reflect on what the information might mean to them personally but also to access each other’s perspectives. Young people also have opportunities to reflect on how best to counter the effect of unhelpful social influences and acquire social interaction skills to navigate sexual situations. As such the processing of information and its translation in lived realities might qualify such sex ed approaches as comprehensive. Although the programmes that have been evaluated have targeted specific behaviours, such as preventing transmission of HIV/AIDS, the insights gained from delivery of these programmes are relevant for distressed and dissatisfied girls and women seeking FGCS.
In Sweden, sex ed has been a mandatory part of the school curriculum since 1955 . The guidelines issued by the Swedish National Agency for Education recommend that sex ed is introduced from age 6 and an integrated part of most subjects . From age 6 to 9, for example, biology lessons should focus on not just how the body appears and functions but also the importance of relationships on overall well-being. From age 10 and onwards, questions concerning puberty, sexuality, reproduction, identity, relationships, love, equality and responsibility should be introduced and integrated in a range of subjects . In addition to integrating sex ed in all subjects, teachers are encouraged to have specific hours devoted to sex ed and address questions related to sexuality whenever they are raised in class – regardless of subject. Having moved from social non-inclusiveness to a tolerance-based perspective on LGBT sexualities, Swedish sex ed is, according to some authors, embracing a norm-critical approach as articulated in the guidelines provided by the Swedish National Agency for Education . Despite these guidelines, however, reports suggest that the principles do not always translate consistently into practice .
Although sex ed is typically delivered to pupils in schools as part of a broader public health agenda, aspects of sex ed can be adapted to other settings [5, 10]. Health care providers, for example, can usefully deploy aspects of socially inclusive sex ed to meet patient needs in various clinical specialties. For example, sexual difficulties are associated with progressed diabetes; therefore a discussion of non-coital/penetrative sexual activities can be a useful aspect of diabetes care and counselling delivered by nurse specialists (see Chapter 14, this volume). However, research shows that health care providers are in general poorly trained to talk about sex and sexuality with patients in a helpful and confident manner . Building on these insights, the World Health Organization etc. The World Health Organization (WHO) argues that sex ed should be integrated into the professional education of health care providers .
Despite conceptual shifts in sex ed to focus more on well-being rather than risks and diseases, many sex ed programmes are still focused on providing information that focus on the latter . Workers continue to argue for information to become much more comprehensive to help young people to make choices about their bodies and lives in the social sphere . Several commentators have also suggested that such comprehensive provision of information would constitute an important response to the problems that underpin the seeking of FGCS . In the text that follows, I outline how sex ed could include information to address the rising problem of FGCS but also discuss the limits of information giving, however well put together.
In traditional sex ed materials, the female genitalia are usually discussed within a narrative of threat. The vagina, represented as a desensitised, inanimate recess, is typically emphasised over and above the rest of the genital anatomy . Images are usually clinical and factual, often with an internal rather than an external view. If the external genitalia are represented at all they are seldom erect and present. Outside sex ed, in some mass media and mainstream pornography, the female genital anatomy is portrayed as a flat and smooth surface with a vertical slit that gives the two sides perfect symmetry . Within medicine, there is a lack of descriptions of genital appearance diversity . In the context of increased exposure of the female genitalia via modern genital grooming techniques and revealing clothing, many girls and women not surprisingly find themselves feeling anxious and confused as to how their genitals (should) look (to others). In a social context where female body image distress is already rife and where intense marketing of unproven medical interventions is permitted, if not encouraged, it is unsurprising that many girls and women judge themselves against the homogenised aesthetic being sold [15, 16].
In health and social care, where dilemmatic issues appear, people typically call for more information. However, information on the diversity of female genital appearance and structure to counter the above is not exactly lacking. Rather, materials are not utilized or even subjugated. Since the 1970s, feminists have encouraged women to do self-examinations in order to get to know and appreciate their vulvas . Newer resources such as the Labia Library and The Great Wall of Vagina are easily accessible to enhance sex ed programmes. However, some information and materials are easily absorbed while others have very little currency, depending on the prevailing narratives and norms, and it is the unhelpful narratives and norms that should be the focus of interventions .
Pedagogic theorists have been at stake at emphasising the limits of instructing people via information alone . Many sex educators and health professionals have experienced the limits of teaching as instruction that ignores the contextually dependent and interactional aspects of learning . Early on, pedagogic experts have pointed out that learning is a matter not of instruction but construction . Factual information targets cognitions, not emotions. In an interview study, the authors highlighted that several of their participants reported that they knew that female genitals came in a variety of shapes and sizes but that such knowledge did not affect the negative feelings that they had about their genitalia . Telling girls and women about diversity may modify their knowledge but usually fails to shift the negative, albeit false and socially constructed, meaning of genital protrusion in females. It is the meaning that distresses the individuals . Psychosocial interventions can be useful precisely because they centralise emotions and work to transform meaning . Overall, it is the social construction of the female genital anatomy as an invisible recess (hence it is typically called a vagina) that needs to be challenged collectively. Finally, focusing on information on appearance diversity could even reify the importance of genital appearance. As long as appearance matters, feelings, including shame and pride, will be highly invested in it (see Chapter 3 by Braun, this volume).
It has been suggested that interventions could promote ‘vulvar literacy’ [27, p. 145] among women. Research suggests that genital dissatisfaction is a driver in FGCS [16, 23] and that this is not easily accounted for. For example, mainstream pornography is associated with an openness to labiaplasty, but the relationship is not usually a linear one . Studies show that women seeking labiaplasty have internalised representations of the genitalia from the internet and advertisements . Watching images of modified vulvas seems to affect what general young women perceive as normal and desirable . If women’s internal representations of normal and desirable vulvas are modifiable by watching media images, might not these representations shift via counter-exposures [15, 26]?
The Swedish Association for Sexuality Education (RFSU) encourages sex educators to draw external and erect genitals and allow different genitals to be represented in drawings, for example, genitals of different sizes that may be symmetrical and less symmetrical and sometimes with and sometimes without hair. Furthermore, norm-critical pedagogical exercises are recommended whereby participants are asked to articulate all kinds of “genital language” that they know . Participants are then asked to critically discuss the connotations of different words as well as the limitations and possibilities of each term. They are also encouraged to explore language that could be useful in different contexts in order to develop a bank of possible terms to use in sexual and non-sexual situations. In relation to FGCS, some commentators have suggested that health professionals also need to develop different ways of talking about genitals. One important issue is to develop language that avoids making sense of appearance in dichotomies (e.g., normal versus abnormal, small versus large) .
In summary, although information on genital diversity is an important response to the distress that underpins FGCS, insights from sex ed also point to the risks of becoming over-invested in informational resources. These concerns are supportive of two conceptual shifts already occurring in sex ed in some quarters. First of all, the focus is being redirected from needs to rights and from disease to pleasure . Second, the ideological underpinning of sex ed is increasingly debated. Commentators argue, for example, that a focus on information often implies a neo-liberal understanding of individual agency , and some raise the question if this is the kind of agent that sex educators should foster. Critical scholars suggest that we move from a focus on information to an exploration of the kinds of agency we should promote .
Refocusing from information to agency does not mean discarding the works discussed earlier. Rather, we need to interrogate the ideological and theoretical underpinnings of sex ed and evaluate the consequences of sex ed programmes. For example, on reviewing a sex ed programme, we can ask: what opportunities for personal agency does this programme open up and close down? This kind of critical engagement with personal agency has been demonstrated in sex ed  and in interventions that specifically target the problem of FGCS . In this section, I explore alternative ways of thinking about agency in sex ed but also discuss the limitations of focusing on agency.
Feminist scholars argue that the intention to provide young people with information to make choices is grounded in a liberal ideology but reflects a simplistic understanding of individuals as rational agents and negates the importance of social structures and power relations. Such an understanding of choice is stripped of our gendered social context (see Chapter 8 by Chambers, this volume). It is problematic to talk about an autonomous individual freely choosing a potentially harmful intervention in a context where social and media pressure to live up to certain ideals is inescapable and experienced daily . Critical commentators suggest that we focus on the available discursive resources within our social, cultural and economic contexts within which ‘choice’ is freely made.
How then, could sex ed help to promote agency that would enable people to become sexual and embodied agents in new ways? In feminist and critical education, such agency is fostered not by information on what people do and are, but by exploring what people can do and can become . This move from a descriptive to a transformative stance is similar to the goals of norm-critical approaches. Norm-critical sex ed examines “different societal norms and how they affect people on an individual, group and societal level. The aim is to notice and challenge the norms that frame what is considered ‘normal’ and thus what is, unconsciously, understood as desirable” [29, p. 23]. Norm-critical sex ed therefore aims at creating spaces of becoming , where young people are encouraged to move from questions such as what they can do for their genitals to fit with normative understandings of sex and sexuality, to a focus on what their genitals can do for them. Some ways of providing such spaces of becoming are explored next.