For female cosmetic genital surgery (FCGS) to become a viable practice, major changes had to take place in women’s attitudes and practices. This chapter describes how the conditions emerged to make demand for FCGS possible among Anglo-American women and girls from the last third of the nineteenth century until the 2000s. Consideration is given to women’s sexual beliefs and practices; the role of hygiene; the basis for competition between girls and women; and the images of genitals that were available to them.
Women’s sexual response is complex and highly variable between individuals . The female organs involved in sexual pleasure, reproduction and excretion are packed tightly into a small area, with major bodily processes overlapping and impacting upon the others. In addition, there is a fundamental, strongly positive interaction between emotions and these organs or body parts, which is central to sexual arousal. Societal attitudes to female sexuality remain deeply contradictory. Questions about embodied sexual response raised in the 1920s, such as whether the cervix is involved in sexual arousal, remain unanswered [2, 3]. Women’s understanding of these processes has been shaped by the incorrect, or incomplete, existing knowledge, as well as by imposed ignorance and censorship.
Labiaplasty, or the cutting away of ‘excess’ tissue from the labia minora, has become an increasingly well-known operation since the late 1990s. Yet, the Kinsey Report on Sexual Behavior in the Human Female (1953) found that 84% of the 2,727 women interviewed who had ever masturbated did so using labial and/or clitoral techniques. Women reported stroking or rhythmically pulling their labia minora . Conversely, when performing clitorectomies to prevent masturbation in mid-nineteenth century London, the surgeon Issac Baker Brown brutally excised the labia [4, 5]. Why are women today, who say they want to improve their sexual experience, paying to have sexually responsive tissue removed? Surgeons who undertake labiaplasties argue that removal of labial tissue does not reduce sensitivity and, according to their research, women’s sexual response is improved following the operation. Once the tissue is sliced off, it has, obviously, no sensitivity, so their claim must be that labia do not contribute to sexual response . Kinsey et al. found that:
Both the outer and the inner surfaces of the labia minora … are highly sensitive to tactile stimulation … As sources of erotic arousal, the labia minora seem to be fully as important as the clitoris … During coitus, the entrance of the penis may provide considerable stimulation for the labia minora … [at the lower end,] the labia minora continue inward to form a broad, funnel-shaped vestibule which leads to the … introitus … of the vagina [and is] as important a source of erotic stimulation as the labia minora or the clitoris .
The labia minora also react strongly during sexual arousal. They are highly innervated along the edge and sexual arousal leads them to engorge and double or triple in thickness, then change colour from pink to intense red when orgasm is imminent [7,8]. Yet it appears some women feel slicing away the labia minora improves sexual satisfaction. These claims about positive outcomes indicate that even the mere awareness that her genitals may be seen at by an other can destroy a woman’s fragile, conscious connection with her embodied sexual response.
The availability of images depicting standardised genitals, combined with advertising and media coverage of cosmetic surgery from the late 1990s, is frequently offered as the cause of women’s rejection of their labia minora. Presentation of images cannot, however, in itself be held accountable for the acceptance of one look as ideal, or the rejection of another. The acceptance of pubic hair removal, also proposed as a causal influence, is subject to the same caveat. Why has a particular genital look lent itself at this particular moment to being broadcast to a wider audience? Why has that audience responded with such anxiety about their own genitals that they are willing to remove sexually responsive tissue? Readiness to accept new practices and aesthetic standards is socially and culturally constructed.
Having FCGS is often understood as simply a choice made by an individual, but the feelings and attitudes that result in such choices are created by powerful social forces. Social construction refers to the shaping of people from infancy by their environment, which includes available resources, such as housing and food, as well as patterns of nurture and all other behaviour by people around the child. By far the larger part of socialisation is non-verbal learning, involving embodied knowledge and practices. Bodies, as well as beliefs and attitudes, are socially constructed [3, 9]. For example, a child growing up in the 1890s sharing a bedroom, or even a bed, in a home with no bathroom or indoor toilet would have found using the toilet more of an effort . She might have been scared to go outside at night and discouraged from disturbing her siblings. Her capacity for sphincter control would probably have been greater than that of a child who grows up today sleeping in her own bedroom, possibly with an ensuite bathroom, and getting up to use the toilet whenever the urge strikes. As adults, however, both would have interpreted their feeling of a need to urinate as a response to a natural embodied demand which was/is independent of social or economic factors. Most people similarly experience their feelings of, and about, being sexually aroused as natural. This leaves a woman with no defence against the belief that there is something wrong with her if her genitals appear to look or respond differently to the way in which she believes those of other women look and respond.
The word culture refers to the systems of ideas existing and continually being developed in a society, which are evident in print media, including advertising, and in material objects. Cultural construction refers to shaping of beliefs and values. Subjectivity, a person’s perspective and understanding, are shaped by cultural beliefs that, for example, bodily processes just happen ‘naturally’; the person cannot not be aware of these beliefs and cannot not respond even if the response is to ignore, or reject, the accepted beliefs. As new circumstances emerge, people respond and, by doing so, create new ideas and practices from within the socio-economic relationships and culture they have inherited. When the object of concern is not openly discussed, as with genitals, the relationship between changing cultural beliefs and new emotional attitudes will often be obscure and confusing.
The concept of norms is central to understanding why women are vulnerable to the belief that their genitals require surgery to look acceptable and/or to improve their sexual response. Norms emerge in response to cultural beliefs about a given, regularly occurring action or state, such as frequency of urination, or sexual response. Individuals are sanctioned by society when they do not conform. Internalisation of norms causes individuals to conform by creating subjective beliefs in the necessity for the specified action, or persons may conform because they are avoiding sanctions. Norms evolve as practices are created based on existing values. Removal of body hair is an example of such development. Historically, the amount of hair on the face and easily visible body parts was subject to norms establishing whether a person was male or female. Those with too little or too little much hair in the correct places were vulnerable to taunting, such as a woman who grew a beard, or a man who could not. Once it became practical to remove face and body hair, the existence of those norms created a rationale supporting continuously increasing aspirations for a more female, that is, less hairy, body. The existence of alternatives, within subcultures or among other ethnic groups, may undermine norms, especially when the costs of compliance with the existing norms are increasing . Thus socialisation establishes people’s emotional and behavioural responses to their genitals; the individual’s culturally constructed beliefs provide explanations for these responses; and norms shape how the responses are expressed.
Feeling and Touching: Fertility Control, Sexuality and Hygiene in the Early to Mid-Twentieth Century
Around 1900, around three-quarters of the British and US population were working class. Most of these women never saw their own naked bodies. Even small mirrors were luxuries, and most lived in crowded homes, with no running water, indoor toilets or separate bathrooms. Growing respectability discouraged girls from activities such as communal swimming, which were, anyway, less usual in cities. They rarely undressed fully and they experienced their bodies by feeling, rather than by looking. Historians have described how the full range of the senses, feeling/touching, hearing, tasting and smelling, were replaced as modes of perception by visual modes of seeing and learning in the sixteenth and seventeenth centuries . Demands for female modesty and sexual reticence placed respectable female sexuality outside this trajectory. Despite the rise in literacy by the late nineteenth century, girls in all classes continued to learn about their genitals and sexuality/reproduction through feeling and touching [10, 13]. Mothers in this period were often too inhibited to talk about sexuality and reproductive processes [10, 14]. The distress ensuing from the resulting ignorance could be substantial : potential advantages to this culture of touch and feeling rather than seeing lay in the potential for the private discovery of personal sexual sensations and emotions .
In the early nineteenth century, fertility rates were historically high and the existing methods of birth control and abortion were either not effective or posed risks to health . Effective approaches to preventing births severely limited sexual activity; delaying marriage (including sexual intercourse), followed by marital restraint or even abstinence from sexual intercourse once married [3, 15, 16]. The burden of embodied reproductive labour that high fertility imposed on women gave them a stronger motivation to forgo sexual pleasure than the solely economic pressure men shared with their wives . In achieving the required control, women and some men developed an almost abstract fear of embodied sexual desire, producing a culture of prudish respectability that peaked around 1900 (not during the so-called Victorian era of the mid-nineteenth century) and was probably stronger in Britain than in other European cultures or in the United States [3, 17]. For many, if not most, women in the late nineteenth century, particularly in Britain, disgust was more prominent than pleasure as the normal response to evidence of embodied sexuality, including the genitals of both sexes. This emotion serves to defend the self against psychological and physical contamination and reflected the belief that sexuality was powerfully polluting. The belief that masturbation caused a wide variety of diseases emerged in the eighteenth century and, though this fear peaked around 1900, these anxieties continued to strongly reinforce negative feelings about the genitals, dwindling into strong embarrassment, or defiant promotion, only in the last third of the twentieth century [3, 18].
Research into British pornography found that around 1880, ‘eroticism in some fundamental way became equivalent with dirtiness’ . In the United States sexual repression seems to have been less extreme and dominant than in Britain, but anxieties about hygiene appear to have been greater. Scientific discoveries emphasised the association of ‘dirt’ with disease and this fused with anxieties about sexuality, reinforced by high rates of syphilis . For most women their genitals were a dirty part of the body to avoid and think about as little as possible. Being seen to be dirty was increasingly shameful, lower class and might expose a person to taunts and to being seen as ugly. Engaging in more demanding and not yet fully established hygiene practices was, on the other hand, innovative and modern. It established status, gave righteousness and was seen as more beautiful. Even when aspirations are new, congruence with such associations and beliefs built up over decades and centuries makes pressure for conformity to norms very difficult to resist.
In the late nineteenth century, the majority of women were ignorant even of the existing knowledge about their sexual and reproductive organs and processes. Cultural radicals believed that provision of sexual knowledge, which came to be termed sex education, would improve women’s well-being. The response of Marie Bonaparte, a wealthy French psychoanalyst, reveals that the emerging ‘knowledge’ about women’s sexual response failed to provide simple answers. Sigmund Freud’s developmental theory shaped cultural beliefs about female sexual response in the first two-thirds of the twentieth century; he argued a girl’s sexual feeling began in infancy with clitoral (masturbatory) sensations which were independent and masculine. Maturity involved the transfer of her erotic response to the vagina and the achievement of feminine orgasms in coitus. Freud’s belief that female sexual response should be confined to vaginal intercourse was widely shared but the importance he placed on infantile masturbation and the child’s sexual feelings was extremely challenging.
Bonaparte was tormented by her frigidity, defined as the failure to have mature vaginal orgasms in coitus [21, 22]. She collected data on other women and concluded this failure could be caused by too great a distance between the clitoris and the vagina. An Austrian surgeon, Josef Halban, created a procedure in which the suspensory ligament of the clitoris was transected and the clitoral glans was moved downward, closer to the vaginal entrance . To achieve this, the surgery had to slice the clitoris away from the underlying and surrounding structures. Anatomical knowledge of clitoral anatomy revealing the destruction the operation would cause was available . Bonaparte did not value clitoral sensation because she was convinced neuroses and unhappiness were produced by women’s reliance on masculine clitoral sensation. Halban performed the operation on Bonaparte three times, in 1927, 1930 and 1931, before they decided surgical approach was misconceived. That such an intelligent woman should have gone down this route illustrates the distress that feelings of sexual inadequacy and unfulfilled desire produced in response to sexual and gender norms.
Ignorance and anxiety could cause very different problems. Vaginismus, which is the unconscious clamping of the vaginal muscles such that the penis cannot enter (without force) and intercourse take place, was an extreme response of some women to fears about sexuality and giving birth. In 1958, a three-year training seminar was held in London on treatment of non-consummated marriages, during which the participating doctors saw around 700 cases, in many of which the woman experienced vaginismus . Treatment involved talking with the patient and then insertion of glass dilators into her vagina to encourage acceptance that the penis would not cause damage; feelings of disgust led to worse outcomes than fear and anxiety. These women’s unconscious use of their vaginal muscles highlights the extent to which their socialisation had resulted in an absence of capacity for conscious use of their genital musculature.
Vaginismus still occurs today, though these feelings are far less usual. Fear about the impact of giving birth may, however, have grown. Birth may result in some changes to the vagina ranging from imperceptible to significant; only a small proportion of women require surgical repair. In some Asian cultures, strippers perform a show that consists of women using their pelvic muscles to hold in, or eject over a distance from their vagina objects such as ping pong balls. Leaving aside the exploitation involved, this act reveals a radically different cultural awareness of the vagina. The strippers’ act would have been inconceivable to Western women, who overwhelmingly were unaware their vaginas had any muscles, or that these muscles could play a role in protecting their vagina during childbirth and in increasing sexual pleasure. Kinsey et al. found that deep insertion of objects into the vagina by early to mid-twentieth century US women during masturbation was almost unheard of and even shallow insertion of fingers was rare, showing their socialisation resulted in a lack of awareness of potential pleasure . Embodied experience produced through socialisation contributes in such instances to poorer outcomes for women.
Advertisers Appropriating Feminism to Sell New Products, Including Birth Control
US advertisers appropriated feminist rhetoric in the 1920s, representing modern emancipated women as exercising their new agency by choosing between alternative products. Following World War I, there had been a huge growth in women’s confidence. In 1918, English women aged over thirty were given the vote, and all US women were guaranteed the right to vote in 1920 by the Nineteenth Amendment. Even at the peak of the struggle for women’s suffrage, relatively few women were active feminists; but, following World War I, what had been radical ideas about women’s capacity and their right to make choices about their lives became commonsense for the younger generation. Young American women in the 1920s connected female heterosexual expression with defiance and pleasure, while feminism was, largely correctly, associated with the sexually repressive Victorian sensibilities of older women. The radical feminists of the 1910s, or the earlier free lovers, radicals and sex hygienists, had been few in number and their ideas received little attention . Young women rejected female submissiveness and sacrifice to duty but few aspired to higher education or careers, most had little education or political awareness and minimal exposure to feminist ideas. The consumption of attractive new products, often purporting to be supported by medical or scientific authorities, was compatible with their aspirations . Many of these products required considerable further development or were expensive, including toothpastes, deodorants, sanitary pads, shampoo and safety razors. Nonetheless, in this period, young women began to interpret their body as a project, which they could use products to improve and develop [26, 27].
Rising product consumption and feminism created the context in which Anglo-American women began to use products in their vaginas. US advertisers spent very heavily promoting Lysol® and other douches as ‘feminine hygiene’ products, a covert means of referring to birth control . By 1930, 60% of white married US couples were limiting their fertility but most were doing so with male-controlled methods such as condoms and, especially, withdrawal, which involved no commercial products. By 1940, antiseptic vaginal douches were the most widely used method by US women in all classes . In the 1950s, more than two-thirds of US women (68%) used methods that required them to insert items, including diaphragms and douches, into their vaginas, compared to under a quarter of British women (24.5%) [28, 29]. British women were less willing to touch their genitals and both British men and women were uncomfortable with women being seen to initiate sex by inserting birth control devices before intercourse . In this context, their reticence had advantages; commercial douches such as Lysol® were caustic disinfectants, also used for cleaning the home, which caused injury, and even deaths, when not properly diluted .
Existing beliefs primed women to accept that strong disinfectants were required to make the vagina ‘clean’. There has been considerable historical research on such advertising [14, 24, 25, 27] in the United States but little on the topic in the United Kingdom. It is probable there was less advertising of intimate products, as the British were less affluent, more sexually reticent and more resistant to intrusive internal practices . Even so, a British medical textbook gave an example of a ‘young woman in her twenties [who] presented with a severe vaginal and vulval condition as the result of douching four times daily with Lysol, in an excess of zeal for cleanliness’ . In this period, desire for control of fertility encouraged US women to accept the authority of advertisers and to disregard discomfort caused by the products, while for many British women, control over fertility continued to be achieved by male domination of sexual practice and comparatively less experience of sexual pleasure .