A surgeon says women are getting designer vagina surgery to look better in leggings

Such opening sentences to an article (about labiaplasty) would have been unimaginable not that long ago. Not anymore. For almost 20 years, the ‘designer vagina’ – genital cosmetic surgery for the vagina and vulva – has been part of public discourse and material practice. We now have a generation of young adults who have developed body and genital awareness, genital aesthetic preferences and indeed ideas and expectations about genito-sexuality, in a context in which surgical and non-surgical interventions to alter form and function of the vulva/vagina just are. This creates a different set of potentials, and alongside this, a different set of obligations, around the genitalia. Today, just ‘taking what you are given’, genitally, is not the only option available to you – it is a ‘choice’ that you make. Engaging in some level of aesthetic genital labour [2, 3] is now required, in Global North/Westernised nations, as well as many others globally [4].¹

Ellen Scott’s article, which includes a critical or questioning voice, starts with a caveat: “There’s nothing wrong with getting labiaplasty” [1]. This logic seems dominant, yet many critics would question the logic of a sentence like that. Many of us have been critical of these genital procedures (commonly referred to as female genital cosmetic surgery [FGCS]), in the academy [5–8], in popular culture [9] and through activism [10]. I have examined representation and discourse around genital cosmetic surgery, and implications of these, since the early days of the practice [2, 4, 11–17]. In contrast to the opening quote, I have argued that there is much that is wrong with (getting) labiaplasty. The aim of my argument is not to blame the individuals who have labiaplasty, for bad choices or some kind of false consciousness. Instead, it is to suggest that not every option of ‘choice’ provided is positive, and that choosing per se is not the same as liberation or bodily empowerment.

I will summarise some of the key issues in critiques of FGCS, and provide some new analysis about genital aesthetic desire. I emphasise the implications of these procedures for people with vulvo-vaginal genitalia. Even if we see the surgeries and non-surgical interventions as problematic, it is tempting to see them as solutions that arose in relation to a real existing problem. I will argue that offers an easy, but inadequate, analysis of the issue. These procedures do not simply respond to a problem; instead, representation and practice of these procedures are part of creating our socio-cultural – and thus individual – ideas about what a vulva/vagina should be like – and, indeed, of bigger questions about how we make sense of bodily distress, and the appropriate responses to them.

But Isn’t There a Real Problem?

The short answer is yes. Women have a long history of experiencing genital distress, a history that preceded these procedures [18, 19], and has continued since they appeared. Before I discuss genital distress, however, I need to address the terms at stake: women and female genitalia. In the context of some fairly rapid shifts in understandings and categorisations of gendered identity, both terms are now understood as potentially exclusionary – people who identify as women may not have a vulva and/or a vagina; people who identify as men may have a vulva and/or a vagina. Language is problematic. The concept of ‘female’ genitalia cuts across a messy intersection between understandings of (biological) sex and (personal/social) gender. There is no easy definition here. Most research around ‘FGCS’ has focused on cisgendered women (the genital experiences and surgeries of trans [or non-binary], as well as intersex people, tends to be treated separately); the literature of genital distress I discuss focuses almost entirely on cisgendered (non-intersex) women. This reflects the scope and focus of ‘FGCS’: they are aimed at women, conceptualised within a sex/gender binary, women whose genitalia trouble them, but whose sex and gendered identities do not. My use of terms such as women throughout this chapter, then, reflects the scholarship, but is imperfect.

Women whose gendered bodies or identities are not outside binary norms experience considerable levels of genital distress, anxiety or ‘dislike’ [18–22]. Distress can be mild or significantly interfere with women’s potential for living their lives. Anxiety and/or distress have clustered around appearance and hygiene-oriented concerns. Related to hygiene, women express concerns that their genitalia are somehow unclean, and in particular smelly or dirty. Any discharge – a natural physiological part of vaginal function – is sometimes treated as problematic. A multi-billion dollar industry of ‘feminine hygiene products’ has supported and perpetuated this perception. This industry persists despite various critiques [23], and use of the products has been associated with cleanliness and freshness [24]. In relation to appearance, women report concerns about ‘messiness’ and ‘ugliness’, and (perceived to be) large(r) labia minora, uneven labia minora, more wrinkly labia or significant colour variation can be seen as problematic. The idea that hygiene and appearance should be concerns – that the vulva is legitimately ugly, dirty, smelly – is reinforced through a plethora of sometimes humorous, sometimes hateful, slang terms which construct the vulva in these ways [25].

In all of these, the concern is as much – sometimes more – about how another person will perceive and judge the genitalia, than about how the individual herself feels. For instance, concern about smell or, particularly, taste, relates typically to an imagined sexual partner; visual aspects also have an element of this (which also informs pubic hair practice [26]). However, much of the framing around FGCS, through public media stories and marketing by surgeons, is almost exclusively in terms of the self – your own aesthetic preferences; your own sexual response and experience [16]. The rhetoric frames it as a practice for the self – an act you can choose as part of a general project of improvement of body/self. In this, FGCS aligns with the general shift towards individualised understandings of, and investment in, the self, that has been characterised as a neoliberal self-improving agent [11, 27].

What Do Women Say?

To explore labial concerns expressed ‘naturalistically’, I, along with Chloe Rigg and Dr Helen Madden,² analysed commentary from women in online sexual/health forums regarding labial appearance concerns and considerations of labiaplasty. Using Google and Yahoo (US, UK, NZ sites), we searched using “I want labiaplasty”, “I hate my vagina”, “I hate my labia” and “Are my labia normal?” and compiled the first 10 hits from each search. After excluding surgeon sites, professional-opinion sites and videos, the dataset comprised mostly ‘naturally occurring’ discussions – such as discussion forums. These offer a valuable source of ‘everyday sense-making’ outside the realm of researcher influence [28]. Following ethical considerations, we chose only to access open/public forum data, but do not report usernames in the analysis [28, 29]. A thematic analysis [30] identified two coexisting but contradictory patterns of meaning: the first, “the ideal vulva,” captured the way an ‘ideal’ vulva was articulated; the second, “we can’t all be Barbie,” captured an acknowledged and sometimes idealised opposition between this ‘ideal’ and ‘real life’.

The ideal vulva was expressed by people who contrasted their own vulva with public imagery:

This meaning contained two distinct ideas. First, the ideal vulva (often expressed as ‘vagina’) should be ‘small’ and ‘neat’ [31, 32]. Personally assessed anatomical difference from this ideal produced challenges for embodied self-acceptance: “I want to feel like it’s normal but it’s hard because I know that others are smaller and definitely not like mine” (A; I hate my labia; Google UK #6). This connects to Moran and Lee’s analysis of Australian women’s discursive shifts from a ‘natural’ to a ‘normal’ vulva [20]. Labiaplasty was constructed not only as a viable, but as an empowering, method to achieve this ideal:

In line with neoliberal self-improvement mandates, labiaplasty was constructed as a way to increase self-confidence – even, dramatically, to change your life. In this way, public discourse on forums echoes the empowering-psychologising discourse deployed by surgeons and the media [16, 17], constructing FGCS as a tool through which psychology operates.

Our analysis identified two ways a vulval ideal was evident: through a normalisation of a neat ‘vulva’ – this as the ‘norm’ is conceptual; it does not map onto material, fleshy reality, where vulval appearance is diverse [33] – and through the construction of ‘protruding’ labial tissue as both ‘excessive’ and ‘freakish’. Larger labia minora, sometimes simply visible labia minora, were referred to using negative constructions such as ‘worn-out’, ‘old-looking’, ‘overused’, ‘masculine’, ‘unattractive’, ‘disgusting’ and ‘sexually unappealing’: “it looked like a watermelon which had been hit with an axe” (U; I hate my vagina; Yahoo UK #2). Men’s voices appeared as reported truths, or actual commentary, to validate the desirability of ‘neatness’: “I’m currently dating the love of my life, and I was so terribly devastated to discover that she doesn’t have a neat little box … it’s SUCH a turn off for me” (J; I hate my vagina; Google UK #3).

Throughout the online discussions, a small and ‘neat’ vulva was held to represent femininity, youthfulness and desirability. And with the appearance, marketing and increased popularisation, and thus normalisation, of labiaplasty (discussed further later), it was (potentially) achievable even if your vulva did not meet the standard. It was indeed a logical course of action:

For many, recounted embodied affect was deep and thorough, usually centred on disgust: “they disgust me, when I look in the mirror I just see ugliness … ” (C; I hate my vagina; Yahoo USA #3). Disgust is a powerful emotion, and one not unfamiliar to the experience of embodied womanhood [34, 35]. Some described the extreme lengths to which they had gone to resolve their labial concerns:

The second patterned meaning “we can’t all be Barbie” captured resistance to an idealised (small, neat, contained) vulval norm, constructing ‘perfection’ as non-existent and positioning the appropriate response as psychological reframing – ‘learning to love yourself’ – rather than surgical intervention. A diverse vulval reality was often contrasted with a (false) ideal or idea of normal, created by pornography:

Genital diversity was named, and desirability of all genital formations stated by some: “all are different, and all are beautiful” (T; are my labia normal? Google UK #3). Some evoked an individualising ‘personal preference’ discourse, but flipped what was valued: “small labia are just ‘eh’ to me. Gorgeous, sexy long labia are beautiful” (T; I hate my vagina; Yahoo UK #2). Lack of (sexuality) education, or miseducation in reference to pornography, was often situated as the problem [32], and information as the answer, which could have powerful impacts. For instance, in response to a Hungry Beast story about censorship of labia minora in media [36], R commented:

For R and S, information was revelatory, constructed as transformative to their selves. The data contained a sense of camaraderie, in a collectivised (lack of) understanding and knowledge – bearing contemporary echoes of the value of ‘consciousness raising’, a core activity for women’s health movements [37]. Other accounts, however, highlighted that gaining information did not necessarily provide an easy solution:

This ‘love your body’ idea, that A challenges, was evident in various ways, articulating a neoliberal self-improving subject through a different mode, through claims that changing psychology was preferential to surgery:

Here, the correct response is to love your body – a surgical decision is ‘allowed’, but is pathologised at the same time. To shift from disgust to love is a potentially big ask. Recent critiques of the ‘body positivity’ movement [38] are relevant here. Some kind of ‘neutrality’ is perhaps not only a more realistic goal, but a mandate to ‘love’ can be part of unrealistic neoliberal and healthist perpetual body optimisation discourse, co-opted by, and perpetuated through, ‘empowerment advertising’ to women that penetrates deep into women’s psyches [39]. This discourse is one that surgeon advertising directly evokes and reinforces, with claims of empowerment, amazing sex and psychological transformation [16, 17].

Threaded throughout the dataset were the voices of real (or claiming to be real) men, as well as reference to men as a general category. Men’s voices expressed certain aesthetic preferences; claims of ‘what men like/dislike’ (see also [21, 40, 41]) appeared in various guises, positioned within a heteronormative framing as a relevant consideration. Men’s voices provided reassurance that smaller isn’t ‘better’; men’s voices expressed preference for ‘the Barbie’ vulva. In Alex Li’s and my analysis of pubic hair practice, sexual partner preference was a key theme influencing women’s pubic hair practice [26]. Often, a partner’s preference was assumed or imagined – echoing the idea of ‘the male in the head’ explicated in Holland and colleagues’ analysis of British youths’ (hetero)sexual encounters [42]. The use of men’s voices is troubling in two ways. First, men’s tastes are often somehow treated as unchangeable, even if they are recognised as socio-culturally influenced (for instance, by pornography – an influence that has been questioned by some [43]). Second, it positions men as final arbiters of genital appearance. Combined, this gives more validity to what men might think than to what women might think about vulval appearance. It constructs a position of hetero-relational embodied aesthetics, but in a way in which power is not equally shared.

Selling the Vulva

How people make sense of vulval appearance does not occur outside of socio-cultural influence; nor do the options they perceive as available to them and/or desire to engage with [44]. Much of the early public narrative around genital cosmetic procedures came from surgeons [16], speaking into a context (noted earlier) of pre-existing strong negative vulval associations. I analysed the websites of a selection of surgeons from English-speaking countries who were offering FGCS [17]. I had systematically compiled a dataset of information from 20 websites (10 from US surgeons; 10 from UK, Australia, Canada and New Zealand surgeons) in 2005, a time when the surgery was still framed as fairly new and outside the typical offerings of gynaecologists or plastic surgeons. I focused on the way ‘right’ and ‘wrong’ genitalia were demarcated on the sites discursively, through the language used and visually, through before-and-after photos (see also [7]). The premise of my analysis is that reality is constructed [45], so language matters. Larger/visible labia minora were regularly discussed with language which suggested at best, redundancy, and at worst, pathology. The opposite – a vulva that is ‘small’ or ‘neat’, a vagina that is ‘tight’ – was explicitly and implicitly positioned as ideal. Through vague language, readers could exist in a state of comparative aesthetic uncertainty. Imagery worked alongside such uncertainty, to tell a transformational tale, and reveal a ‘right’ state. One small experimental study has suggested exposure to modified genital imagery can influence perceptions of normality and desirability [46].

I argued that the “sites work in multiple ways to sell both vulval distress and transformation. Certain morphologies are pathologized, implicitly and explicitly; certain morphologies are valorized. Women are invited into a medicalized regime of self-assessment and intervention to achieve the perfect vulva” ([17], p. 133). Psychology and affect were a key mode through which FGCS was legitimised, and promoted, on these sites. The genitalia were positioned as having the capacity to produce great psychological and emotional distress; the surgery, to resolve it. It offered a physical and psychological transformation, resulting in an empowered, bodily and sexually confident, sexually fulfilled woman. Of course the claims were not, necessarily, always explicitly stated in these terms. The material on surgeons’ websites is increasingly recognised as partial and problematic [47]. A systematic review around impacts of online information identified similar themes, but highlighted a need for more research into the impact of the internet on the promotion and normalisation of these procedures [48]; others have urged caution in the public language around these procedures [49].

What Has Changed, and Why Should We Be Worried?

When I conducted that analysis, labiaplasty and related procedures could still be characterised as not-yet-normative, although situated within a trajectory of growth. Now, labiaplasty is everywhere: offered by many doctors as one of a plethora of genital interventions, as well as part of a complex cosmetic tourism industry that sees people travel to ‘exotic’ locations in search of cheaper procedures combined with some kind of ‘holiday’ [50]. Virtually daily, I receive Google alerts for ‘labiaplasty’ or ‘designer vagina’, mostly media stories or surgeon press releases. Genital procedures are now ubiquitous, but paradoxically they are still newsworthy; they are also still being questioned. I finish this chapter by briefly reflecting on the contemporary context (in the Global North), discussing mainstreaming and legitimisation, ongoing critique and the construction of the vulva as contemporary (economic) commodity.

Labiaplasty and other genital cosmetic procedures for the vulva/vagina have become (somewhat) mainstreamed and legitimised. This has occurred despite critique of both cultural hypocrisy and legal dubious standing when genital ‘cosmetic’ procedures are considered alongside laws banning ‘female genital mutilation’ (e.g., [51]). By mainstreaming, I am referring to a shift in socio-cultural positioning – from something fringe or extreme, something shocking, to something more ‘everyday’, more mundane, more ‘normal’. Although extensive media stories in one way construct labiaplasty and their ilk as newsworthy and by definition unusual, the constant presence of the topic normalises the idea through keeping it in everyday discourse, normalises genital modification as something that people do. And stories which tell of (massive) increases in numbers having labiaplasty (etc.), or expressing interest [52–54], similarly work to make such procedures a ‘happening thing’ – even if they contain content that is (also) critical of it.

A mainstreaming also occurs as more and more surgeons offer labiaplasty and other genital procedures through private practice (as well as within public health systems). Google labiaplasty, and if you live in a city in the Anglo-West, you will probably find a clinic near you. It appears to have become a necessary procedure to offer, like rhinoplasty or breast enlargement. Various studies continue to(claim to) demonstrate ‘positive outcomes’ (e.g., [55]) and point to the procedure as ‘safe’ and carrying ‘a high satisfaction rate’ [56, 57]. This does not mean it will be successful – there is now an industry in labiaplasty repair [58], sometimes with the same surgeons who pioneered labiaplasty [59] – but it adds to visibility and therefore normalises. Surgeons continue to publish around their techniques (e.g., [60]), and the establishment of a professional body in 2004 – the International Society of Cosmetogynecology [61] – does legitimising work, aligned to mainstreaming, as well as offering training and promotional activities. From the outside, labiaplasty now appears as a normalised and legitimate form of cosmetic alteration. But it remains contested, within, as well as outside, the medical profession [62]. The UK’s Nuffield Council on Bioethics, in their major 2017 report on the ethics of cosmetic procedures [63], highlighted many concerns related to FGCS (see also [64]), and noted the way dissatisfaction with body parts is promoted throughout the entire cosmetic surgery industry.

Professional critique has continued – from initial cautions issued in a 2007 opinion statement by the American College of Obstetricians and Gynecologists (ACOG) [65] and the corresponding Australasian body in 2008 [66]. For instance, the Society of Obstetricians and Gynaecologists of Canada (SOGC) evaluated evidence in 2013 and concluded that

The weight of evidence currently available does not support female genital cosmetic surgery, and the proliferation of non-medically indicated surgery to the genital area is of great concern. … The SOGC’s position does not support non-medically indicated female genital cosmetic surgery procedures considering the available evidence of efficacy and safety.

([67], p. 1112)

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Related posts:

Chapter 2 – Female Genital Anatomy Chapter 11 – Can Better Sex Education Tackle the Rise in Female Genital Cosmetic Surgery? Chapter 4 – The History of Female Genital Cosmetic Surgery in the United States Chapter 14 – Addressing Female Genital Dissatisfaction and Distress Chapter 11 – Can Better Sex Education Tackle the Rise in Female Genital Cosmetic Surgery? Chapter 2 – Female Genital Anatomy

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