Cosmetic surgery is not a new phenomenon. Facelifts, nose jobs, breast reduction and breast implants have been common among women for decades, and the profession and practice of cosmetic surgery is well established in many countries, including many developing countries. However, in the past 10–15 years, there has been a seismic shift in what is considered possible and desirable to change as regards the bodies we are born with. What has been labelled a “body-changing culture” is being popularised and becoming pervasive in many societies, and now includes changes to almost all parts of the body, especially the most intimate ones, through a growing list of surgical procedures. Author Naomi Wolf argues in The Beauty Myth that the most frequent cosmetic procedures are currently being performed on the areas of women's bodies most associated with “femaleness”: thighs, stomach, buttocks, and breasts.Footnote1 But this has gone further to include vulvas and vaginas, and for men, penises.
Very few people I have spoken to in the sexual and reproductive health and rights field, especially those older than 35, were aware of this “culture”, let alone the extent of it, whether in their own countries or elsewhere. I decided to take it up in the journal because it seems to be having an important influence and it is highly relevant to our work.
Why surgery? Human beings have always tried to make themselves look attractive and beautiful, with clothes, jewellery and other adornments, hair styles and colouring, and beauty products, but apparently these aren’t enough anymore. Surgery – for the most part emanating from the private, profit-making health care sector, including in plastic surgery and obstetrics and gynaecology – has entered the beauty industry, and has become a high-earner with a powerful and growing influence. As Leonore Tiefer describes this phenomenon in her paper here: “new attention to women’s sexual emancipation around the world can be co-opted by medicalisation even as formal patriarchal oppressions recede”.
Women are of course the prime targets of this industry. In both the UK and Brazil, as Melanie Latham and Daniela Dorneles de Andrade note in their respective papers, something like 90% of cosmetic surgery is done on women. Moreover, in Brazil, which has the highest rate of cosmetic surgery in the world after the USA, approximately 15% of cosmetic surgery reported in 2009 was on adolescents younger than the age of 18.
Men are also increasingly being targeted, however. A poster in the London Underground in 2009, for example, claimed that one-third of men had been thinking about cosmetic surgery, and unsolicited e-mails offering both pills and surgery for better and longer erections and larger penises are among the most common kinds of spam. Based on viagra sales, according to a review of a book about impotence, it would appear that many men are “so exercised by the thought of impotence that they will believe virtually anything”, and are “infinitely suggestible and… exploitable” when trying to overcome impotence.Footnote2 Hmm, I thought it was only women who were described that way. Perhaps men too may be susceptible to the lure of cosmetic surgery, possibly older men who are seeking to regain lost youth as well as increase virility.
The procedures and terminology
The language of cosmetic surgery – or aesthetic surgery, as the industry likes to call it – is a study in itself. The papers and Round Up summaries in this journal issue and their sources use the following terms for a mind-boggling list of procedures: labia reduction, labiaplasty (also called nynfoplastia in Brazil), genitoplasty, pulling the labia to make them longer, filling or replenishing of the labia majora, female genital reshaping, intimate surgery (translated from the Brazilian cirurgia intima), vaginal narrowing or tightening (e.g. after vaginal delivery or for increased pleasure for men), vaginal rejuvenation, hymen reconstruction, hymen repair (for restoration of virginity),Footnote3,4 clitoral lift, clitoral hood reduction, clitoral repositioning, breast reduction, breast augmentation, breast lifting, liposuction, and abdominoplasty (tummy tuck). And how about G-spot augmentation?
Then there is the terminology surrounding female genital mutilation – or cuttingFootnote5 or circumcision or excision – and the reconstructive surgery that has developed to address the physiological problems it creates. This includes, according to Elena Jirovsky’s research in Burkina Faso, surgery to the vaginal opening if it has become too small due to adhesions, or the removal of perturbing scar tissue and keloids. More recently, she reports, a surgical procedure to reconstruct the excised clitoris has emerged, developed by a French surgeon. There are, in addition, the use of different products to achieve similar effects that are available in Bobo Dioulasso – lubricants to ease an FGM-narrowed opening to the vagina, and chemical or herbal powders to narrow a normal vagina, both intended to make sex more pleasurable, along with perfumed wax as an aphrodisiac. In South Africa, Fiona Scorgie et al found that some women in KwaZulu-Natal make small cuts in their vagina, breasts and abdomen to insert “love medicines” to ensure the fidelity of their partner.
Too big, too small, too narrow, too wide, too high, too low, too flabby, too wrinkled. The permutations are endless. What a great way of making money!
What’s in the journal on cosmetic surgery?
The papers in this journal issue are about cosmetic surgery in Sweden, UK, USA, Brazil, Burkina Faso, Iran, and South Africa, and in the Round Up on Cosmetic Surgery also Senegal and Lebanon. Most are about surgery on women’s genitals; only one focuses on breast modification surgery. The only information about cosmetic surgery on men is a review of studies on penis enlargement, summarised in the Cosmetic Surgery Round Up, which leaves less to the imagination than one might have hoped. Hovering in the background of all these papers are many other common forms of cosmetic surgery, but given our remit, it seemed just as well that we did not attract papers on the pros and cons of eyelid surgery or nose jobs.
Unusually, there are a number of powerful artistic and photographic depictions in these pages that challenge both the eye and the mind. Perhaps I chose them because I see no beauty in cosmetic surgery, but this is about surgery after all, which is never pretty. They certainly reveal what the “medicalisation” of the beauty industry is about.
The cover covered
Following this editorial, you will find the cover and inside title page that I dearly wanted to use for this journal issue, followed by the debate for and against my using it that involved most of RHM’s board members, editors of the other language editions, staff, consultants and authors, which closes with a strong defence by me of the value of that cover.
Issues these papers raise
The relationship between what is labelled female genital mutilation and female cosmetic genital surgery is the subject of more than one paper included here, and I was glad to see that I am not alone in finding commonalities between the two. There is legislation in both Europe and Africa against FGM but none against female cosmetic genital surgery that I know of. A paper I wrote shows that the legislation in Britain defining and banning FGM uses the exact same terms for it as the UK Department of Health’s website to describe female cosmetic genital surgery. Johnsdotter and Essén also conclude, from their work in Sweden, that there are inconsistencies in law and practice between FGM and female cosmetic genital surgery that need to be addressed, in order to find “a consistent and coherent stance in which key social values – including protection of children, bodily integrity, bodily autonomy, and equality before the law – are upheld”.
In several papers, there are hints that the medicalisation of FGM, that is, its provision by medical professionals in order to make it “safe”, is creeping in, in spite of this option being rejected at the 2009 WHO/UNFPA/UNICEF Technical Consultation on Medicalization of Female Genital Mutilation. Jirovsky notes that according to the report of the consultation, some 2% of excisions in Burkina Faso are being conducted by medical personnel. Some of the people she interviewed for her study supported this change. They argued that that is how male circumcision is now being done, that girls deserve equal safety, and that it would avoid complications that force women to have repair surgery later. In the US, meanwhile, the American Academy of Pediatrics has issued a policy statement “Ritual Genital Cutting of Female Minors” that in effect calls for changes in US federal and state laws to enable paediatricians to “reach out to families by offering a “ritual nick” such as “pricking or incising the clitoral skin to satisfy cultural requirements”.Footnote6 It would appear that male circumcision and cosmetic genital surgery will affect policy and practice on FGM, making a response that takes all three into account important.
Questions of informed consent and regulation of the practice of cosmetic surgery are also raised in a number of papers. Melanie Latham shows that in spite of much new legislation on the regulation of health care in Britain in the past decade, including cosmetic surgery to some extent, much of what happens with cosmetic surgery is left to self-regulation by the profession, in spite of concerns that self-regulation does not work well enough to protect patients. Questions of whether and how all of these practices should be regulated remain to be answered. Although there is much criticism of every type of cosmetic surgery, female genital mutilation is alone among these practices to have led to a global campaign to stop it altogether. Jirovsky’s analysis of that history is well worth pondering.
The types and seriousness of complications from breast implants are well covered by Diana Zuckerman. She reports that in spite of a US Food and Drug Administration (FDA) requirement that women be fully informed about breast implants before getting them, many women seem to know very little about the risks and problems involved, e.g. that they wear out after ten years, may rupture and leak (leading to sometimes complicated surgery to remove or replace them), may reduce the ability to breastfeed, may lead to loss of sensation in the nipple, and can prevent mammograms from being accurate. The need for and lack of surgeons skilled in dealing with broken, ruptured and leaking implants and the breasts they may have damaged, is also disturbing. At least there are a few in the US; women in other countries may not be so lucky. Of great concern, even after all these years, is that there seems to be little independent research on long-term risks and complications of breast implants, as most research in the US seems to be funded by the manufacturers of the implants.
The risks and complications of genital cosmetic surgery are touched upon by a number of the other papers, but not explored in any detail, not least because few data seem to exist. Salehi observes, anecdotally, high rates of dissatisfaction among women having all forms of cosmetic surgery in one Iranian hospital, and says many women return with complications. Melanie Latham mentions legal suits in the UK over disfigurement due to scarring and injury due to infection, including 264 cases of patients who received payouts totalling £7 million in compensation over a period of 13 years. But these are not the full picture, because the full picture is not available. Is there any country where data on the side effects, risks and complications of breast implants and female genital cosmetic surgery must be reported centrally and published? It seems not.
Interestingly, the dubious practice of penis enlargement does seem to have been studied, at least as regards complications, though the 34 studies identified in the review we summarise were about small cohorts of men only. Even so, the review identifies the following complications: penile deformity, paradoxical penile shortening, disagreeable scarring, granuloma formation, migration of injected material, and sexual dysfunction, which were reported frequently in these studies. Poor short- and long-term patient satisfaction rates following a range of procedures were also reported in most studies. The review concludes that “the procedures remain highly controversial, reported complications were unacceptably high and patients should be discouraged from undergoing these invasive treatments”.Footnote7 But has any country where penis enlargement is being touted made regulations to this effect? Are men seeking this surgery fully informed of these risks either?
Self-image and well-being before vs. after surgery
Even after reading all these papers and others, I am left with the question of whether the surgery “works” – that is, are people’s lives actually changed for the better after cosmetic surgery, and is the surgery perceived to have been worth it? Are the altered body parts as beautiful or improved as has been promised or hoped for? Do those body parts remain as beautiful over the longer term as in the short term? If people’s self-image does improve, how long does it remain improved? And is a woman’s sex life really better after a few millimetres or even a centimetre or two have been “trimmed/cut/excised” from her labia? Does the husband who pressured his wife to make herself look younger really perceive her differently afterwards? Does she perceive herself to look younger; does she feel younger? Where are the answers? I’m not talking about individual success and failure stories that are becoming common in the popular media. To combat this industry, or even to support its claims, independent, in-depth, population-level qualitative and quantitative research is needed.
I find it cause for despair that women are pursuing genital surgery because pornographic videos have made them believe their labia are “abnormal” or “uneven” or “showing” or that their vaginas aren’t “tight enough”. This was explored in a TV documentary on female cosmetic genital surgery in the UK in 2008, reviewed here by Tracey Plowman, in which it is reported that women in porn videos have no visible labia – whether through digital alteration or due to surgery – and that that is the “model” women seeking labia reduction surgery are striving to emulate. The other reason given is that having one’s labia sticking out of skimpy knickers looks awful. Hmmm. As a journalist from the magazine Time wrote two years ago:
“By promoting a narrow definition of what is normal, the surgeries may discourage women from grappling with a morass of cultural and personal forces shaping their body image and sexual identity.”Footnote8
Speaking as someone who has had major and minor surgery for health problems several times and watched many others go through it, I find it hard to imagine anyone who doesn’t really need surgery happily running after it, finding it a salutary experience and then going back for more. Shall I conclude, like some of the Brazilian surgeons interviewed by Daniela Dorneles de Andrade, and as the British psychologists did, who did one of the first studies of young women who had had labia reduction surgery,Footnote9 that at least some of the women may have underlying psychological problems that they hope surgery will resolve? I don’t know, but I think it is important to find out. I do know what I think about the surgeons who have made that judgment and who are profiting from it, and the clinics offering loans to women who are too poor to afford this surgery.
Image contributed to the ANAdiva campaign on cosmetic surgery in Beirut, Lebanon, 2009
To be fair, there is also another side of the story, according to Ivo Pitanguy, the father of reconstructive and cosmetic surgery in Brazil. His philosophy is that there is a “right to beauty” – “so that the patient feels himself in harmony with his own image and the universe that surrounds him”. For Pitanguy, there is always a therapeutic objective with cosmetic surgery, which is “not the body but the mind” because “patients notoriously do not have an objective body image”.Footnote10 But is cosmetic surgery really the answer here, because if it is, then we all need it.
Might it be the case that some forms of cosmetic surgery are more dubious than others in terms of their value (including, but not only, to do with their effects on health)? For example, does breast reduction surgery have more value than breast augmentation? If so, how should this be determined and measured? Should all cosmetic genital surgery – on both women and men, as well as infant girls – be considered condemnable and banned?
Pitanguy’s philosophy notwithstanding, I believe the “need” for most cosmetic surgery is a profit-driven, manufactured need, and the articles in this journal issue have only reinforced that view for me. Several of the articles do suggest that some proportion of the women seeking this surgery have psychological problems and vulnerabilities of various kinds for which they were unable to find other solutions. The most poignant of these are the women who seek hymen repair surgery, who may have been threatened with violence if they do not appear to be virgins, as studied by Birgitta Essén et al in Sweden. This is not cosmetic surgery, though; indeed there is no medical name for what this is nor any easy solution.
I come away from editing this journal issue with more questions than answers, but also with relief that I can get away from this subject and get back to the “real” sexual and reproductive health matters. The excited interest I met when talking about this with others over the past year has palled for me. Not only have I not encountered any convincing justification for cosmetic surgery. I have also come to feel sorry for women taken in by it, many of whom I fear will discover that this really is a buy-now-pay-later situation in more ways than one. I sympathise with those, like me, dealing with all the negative natural body-changing that goes with ageing. But being a product of 1960s feminism, I still think we should take pride in our bodies as they are, as hard as that may be on the bad days, and promote some serious consciousness-raising among our children and grandchildren on these matters.
I conclude from this journal issue that the demand for cosmetic surgery, far from being merely a “culture” or a sideshow, is a serious challenge to everyone working on sexuality.
What isn’t covered here
There are several salient topics which this journal issue does not cover, which could make interesting submissions in the future. First, although almost all of these procedures are available from private clinics and providers (86% in Brazil, for example), the papers here are not concerned with the implications for public health systems of this form of commercialised medicine, but only with the phenomenon itself. Yet surely with essential health and medical care subject to serious restrictions in every country in the world, even the most developed, we should be asking from a public health perspective why any health system would tolerate available resources, including skilled surgeons, being consumed by tens of thousands or even millions of people every year for such procedures, let alone to deal with any complications that arise.
Secondly, it seems a growing number of people are travelling to other countries for these procedures, and while one or two papers mention this in passing, none covers it in any depth. Brazil is a favoured destination, for example, and Melanie Latham quotes one source that says an estimated 30,000 UK citizens travel abroad annually for cosmetic surgery at reduced prices. An unknown number of people experience post-operative problems when they return home, which may be serious enough to require reconstructive surgery. This deserves far more investigation as well.
Lastly, two forms of body-changing surgery are not addressed here: 1) reconstructive plastic surgery, which is used, for example, to deal with breast reconstruction following mastectomy, or with scarring and other forms of disfigurement following accidents, burns, etc; and 2) sex reassignment or transsexual surgery. While there is a cross-over between these and cosmetic surgery as regards the surgical skills needed, and plastic surgeons may provide more than one of these kinds of surgery, each has its own literature. We received no submissions on either, and I believe it was as well not to mix them.
In memoriam
We have lost three giants in our field in the few short months of this year – Rhonda Copelon, Ellen Hardy, and Henry P David – whose incredible contributions are summarised in this journal issue.
Other features
Six other excellent papers are published here. The first is about female condoms and the execrable failure of the international community to promote them, a failure which is the more bitter considering the massive resources that have been invested in HIV vaccines and microbicides, which still do not exist, and now male circumcision, which does not protect women partners unless condoms are used. Next is a paper on HIV criminalisation and sex work in Australia, adding to the body of work RHM published on this issue in November 2009.
Another is on four women’s experiences of seeking abortions in Cameroon, where what really mattered was whether the abortion they found was safe or unsafe, since the question of its legality turned out to be irrelevant. The next looks at motivation and satisfaction with early medical vs. early surgical abortion in the Netherlands, and compares the uptake of early medical abortion there with that of four other European countries.
The last two papers are both from India. The one explores the changing influence of mothers-in-law on young couples’ family planning decisions in rural Madhya Pradesh, and their continuing role in deciding when their daughters-in-law may pursue sterilisation. The other explores the greater delays and disadvantages experienced by unmarried young women in Bihar and Jharkhand who need abortions compared to married women of the same ages. It finds that unmarried young women who experienced obstacles were, compared to married young women, most likely to have second trimester abortions, and calls on programmes to take steps to improve access to safe and timely abortion for unmarried young women.
RHM survey: more responses needed
A big thanks to everyone who completed our survey, which was inserted in the November 2009 journal. Your replies have been both interesting and important to us. We are enclosing the survey again in this edition since many of you may still want to complete and return it to us. Those who have already replied need NOT do so again. If you did not have time to reply last time, please do take a few minutes now to complete the questionnaire and return it to us. The more replies we receive, the better we will be able to demonstrate the value of the journal and to maintain its relevance to you, our readers.
Notes
1 Wolf N. The Beauty Myth: How images of beauty are used against women. London: Vintage; 1991.
2 Phillips A. No joke. Review of Impotence: A Cultural History, by Angus McLaren. London Review of Books 2007;29(7 July):24.
3 Some of these forms of surgery may not be new at all. Juliet Richters, Associate Professor, School of Public Health and Community Medicine, University of New South Wales, Australia, recently wrote to me: “I have a gynaecology textbook from the early 20th century by EH Kisch entitled The Sexual Life of Woman in its Physiological, Pathological and Hygienic Aspects (London: Rebman Ltd, 1910), which discusses the forms of the hymen over several pages, with engravings. This is partly, the author says, because knowledge of ‘signs of virginity in the female’ are required ‘not only for the purposes of medical jurisprudence...’” She wondered if there was an industry of virginity diagnosis and restoration in the early days of gynaecology as well.
4 It would be good if someone could explain what the actual surgical procedure is for so-called vaginal tightening/hymen repair. All I have managed to get from people so far is that some stitches are inserted.
5 I find the use of the phrase “women who have been cut”, used by those who favour the term female genital cutting, particularly unpleasant, and although “women who have been mutilated” would be even worse, at least no one uses it. The international community needs to reach consensus on this language instead of introducing terms, and then forcing people to use strings of acronyms to avoid spelling them all out.
6 Equality Now calls on the American Academy of Pediatrics to retract a portion of their policy statement endorsing Type (IV) female genital mutilation of female minors. 26 April 2010. At: <http://equalitynow.org/english/takeaction/newsalert/urgentalert_us_20100429_en.html>.
7 Vardi Y, Har-Shai Y, Gil T, et al. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. European Urology 2008;54(5):1042-50. [Abstract]
8 Fitzpatrick L. Plastic surgery below the belt. Time. 19 November 2008.
9 Lih Mei Liao, Creighton SM. Requests for cosmetic genitoplasty: how should healthcare providers respond? BMJ 2007;334(26 May):1090-92.
10 Edmonds A. Learning to love yourself: esthetics, health, and therapeutics in Brazilian plastic surgery. Ethnos 2009;74(4)465—89.