Labia reduction for non-therapeutic reasons vs. female genital mutilation: contradictions in law and practice in Britain

In the 26 May 2007 edition of the British Medical Journal (BMJ), two British psychologists reported that the numbers of requests from women for surgery to alter the appearance of their genitals, especially the labia, were increasing.¹ In examining this phenomenon, the authors asked: how should health care providers respond to requests for this surgery? From this and other literature on this subject, a picture emerges of a growing number of women, many of them very young, who have been led to believe something is wrong with their genitals. According to a recent French study for example:

“Demand for this procedure is becoming common amongst very young patients who appear to have nurtured a complex since their early adolescent years, disturbing their love life.”²

A Dutch study in 2007-2008 corroborates these concerns. Among 394 female medical students and female patients visiting an obstetrics & gynaecology clinic and another private clinic for a range of reasons, 95% of them had been aware of the possibility of genital cosmetic surgery to reduce the size of the labia for at least two years; 78% had heard about it through a media source. As many as 95% of them frequently examined their own labia, and 43% found the appearance of their labia important. As many as 14% thought the appearance of their labia was abnormal; 7% had considered labia reduction for this reason and 0.4% had undergone the procedure.³

This issue deserves more attention from feminist, psychological, clinical and ethical perspectives. Labia reduction surgery may of course make it easier for women to wear very scanty underwear and swimsuits, with less fear of their labia “showing” round the edges. However, it is difficult to understand why this should qualify as a valid reason for a surgical procedure, even if it is provided by the private sector, even in a so-called developed country, when access to essential health and medical care is still subject to serious restrictions due to cost and limited human and financial resources.

This paper focuses on labia reduction in relation to law and policy in Britain, where there is a law against female genital mutilation (FGM) which describes it in the very same terms as the procedure described by the Department of Health as labia reduction.

Female genital mutilation is a criminal offence in Britain

Female genital mutilation is a criminal offence in England and Wales under the Female Genital Mutilation Act 2003,⁴ and in Scotland under the Female Genital Mutilation (Scotland) Act 2005.⁵ In fact, it has been a criminal offence since the Prohibition of Female Circumcision Act 1985.

The 2005 Scottish Act defines female genital mutilation, in line with the World Health Organization definition,⁶ as follows:

“Female genital mutilation (FGM) involves procedures which include the partial or total removal of the external female genital organs for cultural or other nontherapeutic reasons.”⁵

The 2003 English/Welsh Act (which defines “girl” as also including women) says:

“A person is guilty of an offence if he excises, infibulates or otherwise mutilates the whole or any part of a girl's labia majora, labia minora or clitoris.”⁴

and:

“A person is guilty of an offence if he aids, abets, counsels or procures a girl to excise, infibulate or otherwise mutilate the whole or any part of her own labia majora, labia minora or clitoris.”⁴

Thus, under British law, even partial removal of the labia minora is defined as female genital mutilation.

Labia reduction as a form of cosmetic surgery

I first went looking for information about labia reduction surgery in 2007 and again in 2010 in order to write this article. On the Department of Health's website pages on cosmetic surgery in 2007 (unchanged in 2010)⁷⁸ and on the BUPA Hospitals (a large private health care company) website on cosmetic surgery in 2007⁹ (replaced by the Spire Healthcare Hospitals website on cosmetic surgery¹⁰ when they bought BUPA's chain of hospitals, some time before 2010), labia reduction is described as a legitimate form of cosmetic surgery (see Box 1 for some of the terminology used for labia reduction surgery).

The Department of Health's website describes labia reduction this way:

“Purpose: To change the size and shape of the labia… Procedure: Standard genital reshaping simply means reducing the size of the inner labia (the inner genital lips). To do this, the surgeon will cut away the unwanted labia tissue to make the desired shape. Alternatively, they can remove a wedge-shaped section of the labia, leaving the front intact and removing the tissue from behind. This means there is no change in the colour of the labia and makes the surgery less noticeable. Some surgeons use a laser instead of a scalpel to reduce bleeding. The results: The labia will be reshaped to the desired look. The results should be permanent.”⁷

In 2007, the BUPA cosmetic surgery website said this:

“All women are different and labia come in different shapes and sizes. However, some women feel that their labia are too large and request surgery to reduce their size. Labial reduction is a term used to describe a range of surgical procedures that reduce the size and prominence of the inner lips of the vagina (known as the labia minora).”⁹

In 2007, BUPA were charging women from £1,700 to £3,900 to have their labia reduced.¹¹ The Spire Healthcare Hospitals website did not state their prices; women must write or phone for them. Given inflation and the fact of increased demand since 2007, the charges are likely to have gone up. Business must be good, since Spire Healthcare Hospitals list 36 private hospitals around Britain that offer labia reduction.¹⁰ Are there really so many surgeons in the country with nothing better to do?

In January 2010, the Spire Healthcare Hospitals website problematised normal labia by describing them as being a source of discomfort during cycling, walking and sexual intercourse and as a cause of unhappiness and self-consciousness. It also minimised any risk or visible sign of the surgery:

“The labia minora are the inner lips of the vagina. They come in all shapes and sizes, as all women are different. If you feel uncomfortable with the size or shape of your labia, labial reduction surgery could help. Your labia may be causing discomfort during activities such as cycling or walking, or during sexual intercourse. It may be that their appearance makes you feel unhappy or self-conscious. Whether you have always felt this way, or there has been a change with age or after childbirth, surgery could help you overcome the problem… Labial reduction is the term used to describe a range of surgical procedures that reduce the size and prominence of the labia. Any cuts that are made are carefully placed to prevent painful scarring along the rim of the labia, and are closed with dissolving stitches.”¹⁰

Exceptions in the law against FGM

There is a legal exception in both the English/Welsh and Scottish versions of the law against FGM. The 2003 English/Welsh Act says that no offence has been committed if the surgery is necessary for the girl's or woman's physical or mental health. The 2005 Scottish Act gives, as an example of when such an operation may be necessary for physical health, the removal of cancerous tissue on the genitals, and as an example of an operation necessary for mental health, gender reassignment (sex change) surgery. Both examples are legitimate exceptions, one for life-saving purposes and the other for gender identity reasons.

However, the other example of mental health grounds the Scottish Act mentions is “distress caused by a perception of abnormality”. Unfortunately, it does not state when the operation would be considered necessary nor what “a perception of abnormality” means. Instead, it leaves it to the courts to determine “on the facts of the case if a prosecution is brought”.⁵ So far, no one has brought a prosecution; thus, no one is the wiser today.

There is little doubt from the BMJ article that the young women seeking genital surgery were concerned that their labia were abnormal. The women interviewed were described as “anxious” and “suffering” because they perceived their labia to be too large, longer on one side than the other, or not nicely shaped.^* Given that there are as many normal shapes and sizes of labia as of any other body part, research is needed on the extent to which such perceptions of abnormality are valid or are being encouraged in spurious ways, for example through pornography videos and in advertisements for cosmetic surgery in women's magazines (both widely consumed by young women and men today), especially those using visuals of women's bodies in which the labia are made very small or not visible at all, possibly through digital alteration.

In 2008, the British Association of Aesthetic Plastic Surgeons (BAAPS) launched a campaign to stop misleading advertising campaigns using digitally enhanced images of models and the “worrying trend” among some firms to offer financial incentives for surgery, including loans at a high rate of interest.¹² The problem of digitally altered images is arising with more than just the demand for labia reduction surgery. In February 2010, the Royal College of Psychiatrists called for a kitemark (warning symbol) to be placed on digitally enhanced photographs, to raise awareness of how often such manipulation takes place and to stop people from thinking they can achieve “unattainable physical perfection” as portrayed in such images. The College called on the government to set up a forum made up of politicians, experts and representatives from the media and advertising to develop an editorial ethical code on the use of such images as well. In this instance, the impetus was to prevent the portrayal of extremely skinny women, who actually have eating disorders, as being attractive and role models,¹³ but the principle as it relates to portraying adult women with pre-pubescent labia is the same.

The law on FGM and labia reduction in Britain

The laws against FGM were passed in Britain because FGM was being sought here by women from countries, mainly African, where FGM is practised, mainly for their female infants and babies. A number of other European countries passed similar laws for the same reason.

It is important to reiterate that in British law, female genital mutilation for non-therapeutic reasons is a criminal offence. According to the qualitative interviews in the BMJ article, most if not all of the women's reasons for the surgery were non-therapeutic, their anxiety and “suffering” notwithstanding. The Scottish law says:

“…When assessing a person's mental health, no account is to be taken of any belief that FGM is needed as a matter of custom or ritual. So an FGM operation could not be carried out legally on the grounds that a person's mental health would suffer if they did not conform with their community's prevailing custom…”⁵

When does a fashion become part of culture or a custom or ritual? Only when you come from Africa? In other words, if a woman (probably of African descent) asks a medical practitioner in Britain for her own or her daughter's genitals to be partially or fully excised for traditional or cultural reasons, she will be told it is a criminal offence. Yet if any woman perceives her own genitals to be an abnormal shape or size, even though they are perfectly normal, or wants them to be “trimmed” or removed for cosmetic reasons, the surgery is considered legal and brings in a hefty fee, because it is called labia reduction and cosmetic surgery, and the woman has consented to it. While many have argued that labia reduction is not unethical and should not be illegal because consent is given, the fact is that consent (or its absence) is not the main issue under the British laws on FGM. The laws are about banning the procedure as a harmful practice. So – is it or isn't it?

Ironically, while the UK Department for International Development is supporting efforts to combat female genital mutilation in other countries, the Department of Health is providing information about labia reduction on its website as a legitimate medical procedure. Why has the connection not been recognised? Or rather, why is it being ignored?

Conclusions and recommendations

The history of the surgical abuse of women's bodies to resolve psychological problems, e.g. unnecessary hysterectomies to control hysteria, is now being joined by unnecessary “cosmetic” surgery to alleviate anxiety about having abnormal genitals. There have always been surgeons ready to wield the knife on women's bodies; unnecessary episiotomies and unnecessary caesarean sections are contemporary examples. As Ronan Conroy, lecturer in epidemiology at the Royal College of Surgeons in Ireland put it: “…vulval remodelling to make the vulva appear more childlike” is part of the “latest chapter in the surgical victimisation of women in our culture”.¹⁴

The Department of Health's website advises potential patients to check whether the facility and surgeon that women approach for this surgery are experienced.⁸ But what does “experienced” mean and how are individual patients supposed to ascertain this? This is an area that calls for independent investigation, commissioned by government, and national policy. In spite of a series of laws since 2000 regulating many aspects of health care provision in the UK, Melanie Latham argues that cosmetic surgery is not well regulated and much has been left to self-regulation.¹⁵ In contrast, when human embryology research and assisted conception procedures began to appear, a government commission (Warnock) was set up, a complex set of regulations was developed, laws were subsequently passed and have been amended and updated, and the Human Fertilisation and Embryology Authority was set up to monitor and regulate research and service delivery, and ensure quality of care (see <www.hfea.gov.uk/>).

I believe cosmetic surgery requires the same oversight and regulation. Thorough investigation is needed of many aspects of labia reduction and other types of genital modification surgery, including: who is carrying it out and where, the quality of care in these facilities and level of fees being charged, how and where the practitioners are being educated and trained, what if any benefit the procedures have for physical or mental health and for quality of life and relationships, and whether the procedures are being promoted in an unethical manner by playing on women's poor self-image and lack of confidence about their looks, and their fears of not being able to find a partner or enjoy sex because of the shape of their labia, especially young women. The views of (young) men and the role they play in their partners seeking cosmetic genital surgery, as well as the role of the media, are equally important to investigate. On the basis of this evidence, policy and regulations should be developed.

Information is also needed on all the forms this surgery takes, and the frequency, type and extent of adverse effects and complications of labia reduction and other genital cosmetic surgery. The Department of Health's website says about labia reduction:

“After the surgery, the genital area will be swollen and painful and it is therefore likely that you will be unable to have sexual intercourse for six weeks. There is also the risk of infection, permanent colour change and loss of sensation.”⁸

The Spire Healthcare Hospitals website says only:

“You can expect soreness and swelling for a few days after the operation and you will probably need to take some time off work to rest and recover.”¹⁰

In neither case is this sufficient. Research and data are lacking and clinics/hospitals should be required to record and report adverse effects and complications centrally, and these should be published with any informational material and centrally on the Department of Health's website. As the authors of the 2007 BMJ article say in a paper published in the BJOG, research is also needed on long-term sexual function, as genital surgery may “damage the nerve supply and is associated with impaired sensitivity and impaired sexual function”.¹⁶

Lastly, from a law and policy point of view, either the laws against FGM should be invoked to stop anyone carrying out labia reduction surgery and possibly other forms of genital cosmetic surgery for non-therapeutic reasons, if the evidence warrants that step, or the laws against FGM in Britain should be re-considered in the light of these practices.

Acknowledgements

Thanks to Toni Belfield for information about the Royal College of Psychiatrists' call for an ethical code on digitally altered images, and for encouragement to write about this issue.

Notes

* Women with long labia (4+ cm long) may be referred for labia reduction surgery; such cases are rare and considered therapeutic.