Volume Eight, Issue 1
Virginia Braun and Leonore Tiefer [*
“[T]oday we have a whole society held in thrall to the drastic plastic
of labial rejuvenation” (Elliott, 2008
Following a British Channel 4 documentary on the ‘designer vagina’,
screened in 2008, Channel 4’s website for the show ran a poll which
asked visitors ‘have you considered having a designer vagina?’ (see
 While viewers of the site (and thus
voters) are likely to have a particular interest in female genital
cosmetic surgery (FGCS), the result still indicates an incredibly high
proportion of women dislike their genitalia enough to have considered
surgery as an option. However, it is not much lower than the proportion
of women indicating, in both unscientific and scientific surveys, that
they would have cosmetic surgery -- of any sort (e.g., Aitkenhead,
Asthana, 2005; Most women 'want plastic
surgery'," 2001; Sarwer et al.,
2005). Cosmetic surgery has become a normalised practice within,
beyond, the west (see Blum, 2003;
Brooks, 2004; Davis,
Elliott, 2008; Fraser,
2003; Pitts-Taylor, 2007, for
around normalisation), and now constitutes a viable solution to
multiple forms of bodily distress for many women, and, increasingly,
Cosmetic surgery culture -- which is wrapped up in celebrity culture
fantasies of fame and beauty, as well as consumerism and economic
factors (see Blum, 2003; Elliott,
2008) -- invites us into a regime of
self-surveillance and technologically-mediated bodily self-improvement;
it invites a focus on the minutiae of bodily imperfection. The body has
become the starting point for radical
self-transformation (Elliott, 2008); if
we do not like something, and
can afford it, a surgeon can change it (although not always
successfully, and often at a [small] risk to life, e.g., Landman,
2004). Cosmetic surgery is material, a carving into flesh; it is also
profoundly psychological -- a form of psychotherapy
(Fraser, 2003; Gilman, 1998, 1999), aimed at providing an embodied
solution to a psychological concern -- the person’s perception of a
particular body part, and anxiety and distress that causes.  The idea
that cosmetic surgery is ‘healthful’ and producing of inner wellbeing
is now a common part of discourse around it (Pitts-Taylor, 2007).
Although genital distress is nothing new for women, women’s genitalia
were, until recently, largely excluded from the intense
self-surveillance and improvement imperatives that cosmetic surgery
culture mandates. The ‘designer vagina’ phenomenon has changed that,
with a wide range of female genital cosmetic surgery procedures
targeting every part of women’s genital anatomy. These procedures aim
to alter aesthetics (and/or function). They are performed in the
absence of clear pathology, and without an evidence base (Cartwright and Cardozo, 2008;
The American College of
Gynecologists, 2007; Tracy, 2007),
and carry “real risks of potential
Royal Australian and New Zealand College of
Obstetricians and Gynaecologists, 2008). The most common procedures
appear to be labiaplasty (reduction of labia minora), and vaginal
‘tightening’. Although still not vastly popular, limited statistics
indicate these surgeries are increasing rapidly (Liao and Creighton,
There is scant reliable information about these procedures. Some
clinical case reports exist (e.g., Alter,
1998; Choi and Kim, 2000;
Di Saia, 2008; Fliegner, 1997; Giraldo, González, and de Haro,
2004; Hodgkinson and
Hait, 1984; Maas and Hage,
2000; Munhoz et
al., 2006), mainly focused on technique, and some authors report
than a few cases (de Alencar
Felicio, 2007; Pardo,
Ricci, and Guilloff, 2006; Pardo,
Solà, Ricci, Guilloff, and Freundlich, 2006; Rouzier, Louis-Sylvestre, Paniel, and
2000), but there is not much beyond that. Some discussion about
is starting to appear, in limited form (e.g., Cartwright and Cardozo,
Labiaplasty: The Great Ethical Debate," 2007; Goodman et
al., 2007).  By far the most ‘extensive’
literature on the topic is
critical (feminist) commentary and research (e.g., Adams, 1997; Braun,
2005, 2006, 2009a,
2002; Green, 2005; Liao and
Creighton, 2007; McNamara, 2006;
Sullivan, 2007; Tiefer, 2008a).
In this paper, we critically examine FGCS in the west, locating the
practice and process within broader structural, political,
sociocultural and economic factors and practices. We argue that the
practice and discourse of female genital cosmetic surgery works to
promote one genital aesthetic
as ‘right’, and simultaneously pathologise genital diversity in women.
Rather than only discussing this surgery theoretically and
academically, as previous critiques have done, we identify a range of
factors and interventions to disrupt this trend and the concurrent
pathologising of the genitalia. The broad framework we draw on is from
critical health psychology (e.g., Murray,
2004; Stainton Rogers, 1996).
(Campbell, 2004), critical health
psychology instead adopts a more
constructionist approach (Stainton
Rogers, 1996), and theorises health
and illness as intrinsically socially and politically located (Stam,
2004). This suggests an analysis of the role of economic, political
social factors, both locally and globally, is crucially important in
understanding, theorising and analysing health (Murray and Campbell,
2003); it also locates a more diverse array of targets beyond the
individual in interventions for change.
Bodies of Difference: Pathology and
To note that (western) women often have problematic relationships with
their bodies is to state the obvious. A significant majority of women
see their bodies as inadequate in some way (e.g., Harris and Carr,
2001), failing in the quest for feminine bodily perfection, or even
‘adequacy’. The cultural idealisation of a certain (typically
unrealistic) bodily form is a key factor in making female embodiment
problematic for many women. But within the range of diversity of female
bodies, certain have been further marked as pathologically different -- for
instance fat, non-white or ‘inappropriately’ sexual bodies (Gilman,
1985; Terry, 1990) -- and thus as
inherently suspect, irredeemable in
that particular embodiment.
Within consumer culture, women’s bodies occupy a location as commodity
(Haiken, 1997; Negrin,
2002), but they
are not singular commodity
units; women’s bodies have long been “dissected into physical parts”
(Duke and Kreshel, 1998,
p. 49), and diversity and pathology extend
to particular body parts as well as to whole bodies. The
pathologisation of certain (non-white) facial features -- and surgical
‘correction’ thereof -- has a long but also changing and variable
history (e.g., Gilman, 1999; Kaw, 1998; Pitts-Taylor,
2001). A relatively recent example of this shift from bodily
to ‘pathological’ difference can be illustrated with reference to
breasts. In the 1950s, the small breast -- which at certain times in
western history has been the most aesthetically desired -- became a
‘deformity’; women suffered the newly created medical condition of
‘hypomastia’ (Hausmann, 1992, cited in Adams,
1997), which persists to
this day -- the solution: augmentation mammaplasty, the currently most
popular form of cosmetic surgery (now typically for ‘inadequate’ rather
than ‘absent’ breasts).
This same shift to pathologising diversity is now occurring for women’s
genitalia. Here, we can identify a similar pathologisation through
language, with the appearance of ‘hypertropic’ labia minora. Women’s
genitals show broad diversity in all aspects (Lloyd,
2005), and visible labia minora are
statistically ‘normal’ and probably more common than invisible ones
(Corinna, n.d.). Yet labia minora are
identified as hypertrophic if
beyond the labia majora to a certain degree. How much is a matter of
much debate, with definitions touted -- with no apparent evidence base
--ranging from 2cm to 5cm (see de
2007; Goodman et
2007; Maas and Hage, 2000;
Pardo et al., 2006; Rouzier et al.,
2000). A description of ‘protrusion’ invokes
abnormality, but the label/diagnosis of ‘hypertrophy’ locates certain
genital appearance firmly
within the realm of the medical and the pathological. The language is
evident in medical discourse, but is also being used by women (and men)
to identify particular morphologies: for instance, various girls on a
recent online discussion board identified that “I have hypertrophic
labia minora” (See
condition, a surgical solution is implicitly
rationalised and justified, over other possible ‘solutions’ -- because
this becomes a real and authentic (material) problem, it needs to be
A pathological interpretation of women’s genitalia is, however, hardly
new, and is a continuation of a long history of western pathologising
of women’s reproductive (and sexual) bodies more generally (e.g., see
Ussher, 2006). Over the last few
centuries, the genitalia of women
deemed inherently suspect either by race (e.g., Black women) or by
sexuality (e.g., lesbian women; prostitutes) have been subject to
scientific scrutiny. From the 19th and 20th Century European public
display of the genitalia of the Southern African Khoikhoi woman, Sartje
Baartman, with her elongated labia (the so called ‘hottentot apron’),
to the 19th and 20th Century measurements of the vulvas of prostitutes
and lesbian women (Gilman, 1985; Somerville, 1997; Terry, 1990, 1995)
diagnosis, it is still an excess of tissue that results in
‘hypertrophic’ labia minora -- the ‘too fleshy’ vulva (Davis,
2002) remains problematic. This troublesome real-life fleshiness
with theorising of the (female sexual) body as abject (Kristeva, 1982),
a deeply problematic, fluid, messy, seeping body that furnishes no
clear boundary for the self, rendering subjectivity problematic. While
the abject has often focused on fluidity -- Grosz (1994) argued, for
instance, that “women’s corporeality is inscribed as a mode of seepage”
(p. 203) --a similar analysis can apply here, where the offending
article is tissue not ‘neatly’ contained with a seamless corporeal
boundary. In Covino’s (2004) analysis of abjection and cosmetic
surgery, cosmetic surgery is a practice that ‘amends’ the abject body;
in FGCS, the ‘messy’ labial tissue is replaced with the ‘clean slit’
(Davis, 2002, p. 12).
Labia reduction appears to return the vulva to a pre-pubescent state
(Fitzpatrick, 2007; Liao and Creighton, 2007; Manderson, 2004);
arguably, to a pre-sexual body. This might appear an odd claim, as FGCS
is often directly marketed around the improvement to one’s sexual life
that will ensue (Braun, 2005). But perhaps
here we are seeing a process
not too dissimilar to the measurements of the labia of lesbian women,
or even the western 19th and 20th Century clitoridectomies on young
girls (Green, 2005; Rodriguez, 2008; Sheehan, 1997). Perhaps this, too,
is about the policing or production of appropriate embodied
(hetero)sexuality for women, but now appropriate sexuality is
understood by women as accessed through particular genital morphology.
Although Manderson (2004) suggests
that ‘messy’ labia minora are
associated with ‘promiscuous’ women, and these are stigmatised (see
also Bramwell, Morland, and Garden,
2007), we wonder if something
quite different is happening. It appears that ‘long’ labia (and indeed
a ‘loose’ vagina) signal, to some women, a body ‘unfit’ for --
undeserving of -- sexual activity, and, even, of questionable womanhood
(see Braun and Wilkinson, 2005,
“obsession with sexual gratification” (Hart and Wellings, 2002, p.
899) and sexual pleasure is framed almost as an individual’s right (see
Braun, 2005, for more on this), this is a
tenuous position to occupy,
rendering surgery a legitimate avenue down which seek what is both
entitlement and obligation (Hawkes, 1996)
-- a sexual body.
While the too-present vulva -- hypertrophic
a very similar logic is evident in the construction of both
‘deformities.’ Based on the premise of gendered dimorphism, each
identifies as pathological a body that blurs the boundaries between
distinctly ‘female’ or distinctly ‘male’: hypomastia renders the chest
potentially ‘male’; ‘too long’ labia render the vulva open to a male
reading (see also McNamara, 2006):
“My inner labial lips were long, messy
and flappy and, worst of all, they hung down outside the outer lips. It
looked like I had a small penis dangling down and I couldn’t stand to
see myself naked” [Company Magazine, UK, 2003]
Similarly, ‘excess’ labia majora tissue is also viewed through such a
“‘The outer layer can become almost
scrotal, very wrinkly and lax,’ Dr. Romanzi said.” (Singer, 2008
These accounts are not so far removed from Havelock Ellis’
identification of the labia majora of a lesbian woman as resembling
“fleshy sacs” (Ellis, 1915, cited in Somerville,
1997, p. 42).
Somerville notes that “the ‘fleshy sacs’ of this woman … invoked the
anatomy of a phantom male body inhabiting the lesbian’s anatomical
features” (1997, p. 42). In
interpreting certain female genital
morphology as ‘masculine’, these accounts reveal the societal
importance of visible gender dimorphism. This is equally evident in the
past -- and even current -- surgical alterations of the genitals of
intersex infants. Ann Fausto-Sterling (2000), for instance, highlights
the ‘unacceptable’ grey area between the acceptable size (<1cm) of a
clitoris and the acceptable size (>2.5cm) of a penis in a newborn.
The logic of dimorphism is evident also if you consider FGCS in
comparison to male genital cosmetic surgery. In the former, reduction
of tissue and ‘size’ is paramount; in the latter, the production of a
larger penis is key (Cochrane,
These accounts also, importantly, reveal the limits of knowledge of
women’s genital diversity, and of imagination around what women’s
genital diversity can (or should) be. In our sociocultural imaginary,
it seems that female genitalia occupy a morphology far more limited
that their physiological reality (as demonstrated by Blank, 1993; Lloyd
et al., 2005). And this discrepancy, between material flesh and
imaginary morphology, can produce considerable psychological distress
for some women (e.g., see numerous entries on
recent years, and that they’ve “been
seeing more and more -- often unfounded -- worries about labia as the
years have gone by” (Corinna, n.d., para 1). A key point to make is
that how we ‘come to know’, ‘see’ and indeed read body parts as flesh,
and beyond that, how these are personally and socially meaningful,
depends on culture, on the discursive contexts which render visible and
invisible various different objects and meanings (Pitts-Taylor, 2007).
Given the normalisation of cosmetic surgery, one concern we have is
that for women who already have significant genital concerns, surgery
will come to occupy a position in which it is seen as the only solution
to the distress. Any other potential approach to treat this
psychologically (let alone socio-politically) is taken out of the
equation. What this does is not only undermine other non-surgical
‘treatments’ and promote FGCS -- a general feature of medicalisation
processes (Doyle, 2007). It also
naturalises, normalises and
individualises the experience of genital distress for women, locating
the problems she perceives as an almost inevitable response to
unappealing physiology. What is unappealing becomes almost as given
(e.g., who could possibly like
‘long’ labia minora?) and her response
is located legitimately within herself/psychology because of this. Any
social influence on her aesthetics and desires disappear. Aesthetics
become a matter of (almost) the obvious, rather than the socially
constructed. With the numerous before-and-after photos on surgeon
websites or occasional clinical case reports of labiaplasty, for
instance, we are expected to naturally agree that the ‘after’
an improvement on the ‘before’. This undermines the possibility of
‘undoing’ such aesthetics or perceptions through other levels of
interventions, be they psychologically or socially oriented.
A second important concern is that with the (re)pathologisation of
genital diversity for women, through the promotion of certain
‘desirable’ vulval and vaginal states, any partially formed or vague
anxieties that women might already have could be enhanced, and develop
into more significant ‘distress’ about their vulva. Another possibility
is that women who had no concern about their vulval appearance might
suddenly pay attention to, and dislike, their vulvas if they differ
from the ideal “clean slit” (Davis,
2002, p. 12) of FGCS
discourse and imagery. It could be that “a brand-new worry is being
created” (Davis, 2002, p. 8), and
that things like advertising
and media coverage produce a
demand for FGCS (Liao and
2007). This is in line with Elliott’s (2008)
system relies, of course, on a perpetual cycle involving
the (personal) identification of deficiencies, and the consumption of
offered up (temporary) solutions (Bordo, 1997).
But FGCS did not emerge in isolation, and likewise women’s (potentially
increasing) genital concerns have not appeared in isolation. In line
with a critical health psychology approach, which moves beyond the
individual to consider contextual influences on women’s perceptions and
desires around their sexual and reproductive bodies (e.g., see Bordo,
1993; Martin, 1987; Ussher, 2006), numerous (gendered) contexts
be considered if we are fully to understand this practice, and even the
desire for it in the first place. We now briefly discuss various
continuities between these concerns and FGCS practices, from a range of
different perspectives, before considering interventions and activism
to disrupt the pathologisation of female genital diversity.
Continuities for Genital Distress and
Female Genital Cosmetic Surgery
Women’s perceptions and experiences of their genitalia are far from
straightforward, positive, or even neutral (e.g., see Berman, Berman,
Miles, Pollets, and Powell, 2003; Bramwell and Morland, 2008; Braun and
Wilkinson, 2003, 2005; Ellis, 2006; Ensler,
1998; Green, 2005;
Morrison, Bearden, Ellis, and
Harriman, 2005; Reinholtz and
Muehlenhard, 1995). Numerous concerns, often related to appearance,
expressed by women, and “many women nurture fearful fantasies about the
abnormality of their genitals” (Laws, 1987,
p. 9). This reflects the
wider sociocultural context (Braun
2001), in which
“pudendal disgust is a social reality” (Tiefer,
2008a, p. 475). A
diverse range of negative sociocultural genital meanings persist in
women’s everyday contexts -- for instance in slang, in which visible
labia minora are pathologised through crude slang such as “beef
curtains” and “fishy fanny flaps” (Braun and Kitzinger, 2001). In
such contexts, it is not surprising that women experience genital
More specific, and newer, shifts in cultural norms also help make sense
of the ‘rise’ of the designer vagina. Two central factors in western
cultures relate to pubic hair removal and pornography -- evident in
woman’s comment related to an online labiaplasty poll: “I blame porn
for this. And Brazilian waxes. Nobody was comparing lips when they were
nicely hidden in the bush” (ClatieK, posted 30 October 2008,
Labre, 2002; Tilley, 2007),
to the point it has been claimed as
“routine” (Trager, 2006, p. 117)
and “entirely mainstream” (Cochrane,
2007, p. 30) in adults and adolescents -- so much so that some
reportedly having ‘permanent Brazilians’ (McLean,
2007). The removal of
most or all pubic hair makes the vulva more visible (Green, 2005), and
more an object of attention (and also more prepubescent, Peixoto Labre,
2002). It is indicative of a shift from the vulva being a part of
women’s ‘natural’ body where modification was not mandated, to being a
part almost inherently inadequate
without at least some minor
modificatory (e.g., depilatory) practice. FGCS is part of this shift in
status. Cochrane (2007) notes a link
between this trend for pubic hair
removal, and “the rise and rise of vaginal cosmetic surgery” (p. 30);
and it is frequently noted in women’s narratives of FGCS presented in
When it became all the rage to get
heavy bikini waxes and have almost
no pubic hair, my prominent labia really started to bother me (Marie
Claire, UK, 2000)
This hairless norm has also been linked to pornography (Peixoto Labre,
2002), as has FGCS, and especially to magazines such as Playboy: “by
2001, pubic hair seems to almost have disappeared from the pages of
[Playboy]” (Peixoto Labre,
2002, p. 120). In recent years, ‘mainstream’
pornography has come to occupy a more normalised position within
western heterosexual relationships (Häggström-Nordin,
Sandberg, Hanson, and Tydén, 2006), so that heterosexual women
may well be exposed to a range of (depilated) supposedly particularly
desirable vulvas, to which they can compare their own. In media
accounts, women locate these vulvas as desirable:
I really wanted my genitals to have the
tight, tucked-in look that I’d
seen in men’s magazines (Cosmopolitan,
Numerous sources indicate women or take porn images to surgeons to
demonstrate the vulva they want (Green, 2005;
Liao and Creighton,
Women sometimes come armed, says
[surgeon] Martin Rees, with a porn
magazine, a variant on taking a picture of some celeb to the
hairdressers” (Metro, NZ, 2005)
[Lisa’s] deciding exactly what looks
she’s going to plump for. But
she’s not looking at beautiful bodies and faces in a fashion magazine;
she’s looking at full-frontal shots of vaginas in Playboy. (Shine,
Broader contemporary cultural influences related to women’s genital
perceptions, desires and practices include marketing by surgeons and
medicalisation. Medicalisation is a process whereby ‘problems’ -- which
might already ‘exist’ or be newly created -- are located within the
biological, and the influence of the social or psychological are
ignored or downplayed. Solutions to these problems similarly prioritise
the biomedical at the expense of the psychological or social (Conrad,
2007). In the final section of the paper, where we discuss action
activism against FGCS, we situate our analysis within broader processes
like medicalisation and disease-mongering, as well as advertising and
Action and Activism against Female
Genital Cosmetic Surgery: A New View
FGCS is clearly a problematic group of practices, and the practice and
discourse around them (re)pathologises women’s genital diversity,
potentially creating a self-referential cycle in which surgery becomes
more and more popular and diverse genital morphology less and less
acceptable. While academic critique of this nature is vital, it is
simply not enough; public and political level action is needed to
intervene to challenge this process. One area of female genital cutting
where this has occurred is in relation to practices commonly referred
to female genital mutilation (‘FGM’) (which tend to be distinguished
from (western) FGCS by a rhetoric of choice, Braun,
2009a).  In contrast,
challenging the practice and growth of FGCS is a new area for feminist
activism. Before discussing activism against FGCS, we briefly survey
some activism against ‘FGM’, as well as activism aimed at intervening
in other practices which promote one bodily singular ideal or norm and
problematise embodied diversity and difference.
Various feminists from around the globe have campaigned against ‘FGM’
on every continent and in every medium and venue for many years. As a
consequence, many countries have banned it (see Rahman and Toubia,
2000). A widespread international coalition of activists as well as
institutional agents such as the UN, WHO, and the European Parliament
work to bring the issues before the public in a variety of forms (see
raising the level of public disapproval (e.g.,
Olembo, 2007). The key discursive moves
in the global anti-‘FGM’
campaign were, first, to include FGM within the rubric of “violence
against women” and, second, to reframe violence against women as
human rights issue , as one of
a number of ‘harmful cultural practices’
(Jeffreys, 2005). These shifts, which
occurred over a period of years
towards the end of the twentieth century, expanded the discussion of
FGM beyond the frame of “gender and health,” allowing large and
well-funded human rights organizations such as Amnesty International to
become involved (e.g.,
Another area of much more limited activism in the west, but one which
has resulted in some success, is around the medical/surgical practices
for intersex infants. Arguing for diversity and against
pseudobiological binaries, feminists have challenged the involvement of
genital surgery in the management of intersex individuals since the
1970s (Kessler and McKenna, 1978). Intersex individuals themselves
began to advocate in an organised fashion against genital surgeries in
the US in 1993, with the founding of The Intersex Society of North
America (ISNA) (http://isna.org; see also
Hegarty and Chase, 2000).
Partly as a result of activists' research, education, and advocacy,
a new standard of care was published in the medical literature in
2006 representing negotiations among many stakeholders in this debate
(Lee et al., 2006). 
authority that stresses the
reality of a two sex model with surgical "correction" for "deviations"
is still dominant in this area (Karkazis,
Another related area of feminist activism can be seen around what we
might call western ‘body politics.’ For example, there have been
numerous challenges to the narrow range of media portrayals of women’s
bodies in advertising and other media (e.g., Bordo,
1993; Gill, 2008;
Kilbourne, 1999). Many public health
campaigners have raised awareness
of commercialized “beauty practices” as a source of danger and
oppression (e.g., http://phsj.org/?page_id=10),
Finally, although space precludes a detailed focus, there has been a
long feminist history of activism related to women’s health issues,
including extensive activism around breast implant surgery (for a
timeline and links, see http://www.commandtrust.com/implants.html).
Although critical feminist commentary about FGCS has appeared in
scholarly, print media and online articles, as well as in more informal
online blogs and commentaries (e.g.,
Anna, 2007; Corinna,
are as yet only a few indications of feminist activism. This absence of
activism perhaps reflects the dominance of choice rhetoric related to
western bodily practices (see Braun, 2009a),
invisibility of women’s
genital diversity, rather than against surgical
interventions, per se. For example, the ‘Everyday Bodies Project,’
started in 2004, posts self-photographed images of women’s genitals to
a signed-up online community, to combat ignorance and concerns about
‘abnormality,’ and to challenge the typically uniform (edited) genital
imagery most available to women (Parker, 2007).
vulval images to “make it clear that diversity is the
positive attitudes towards their genitalia, especially as
teens can be influenced by TV surgery “makeover” shows and pro-surgery
articles and imagery in magazines (Corinna,
n.d.; Redd, 2008), and
increasingly express concerns about vulval normality, as discussed
Our work has focused on FGCS as part of a wider critique of the
medicalisation of women’s bodies and sexualities and the creation of
new homogeneities and new norms for sexual function and experience. It
is situated within The New View Campaign (see http://www.newviewcampaign.org),
reaction to the escalated medicalisation
of women’s sexual ‘problems’ that followed the blockbuster success of
Viagra (Tiefer, 2008b). Most of The New
View’s work to date has focused
on analyzing and publicizing the harms to women, and to the
understanding of sexuality, from the new sexuality medications and
medical framings of sexual life (see http://newviewcampaign.org). The
Campaign based our analysis of harm on similar feminist critiques
arising from scandals about sex hormones (HRT, National Women’s
Network, 2002 ), dangerous contraceptives (Dalkon shield, Hicks, 1994
), and birthing practices (unnecessary hysterectomies, Morgen, 2002 ).
Ten years on, The New View Campaign’s perspective on the medicalisation
of sexuality has expanded greatly. In our discussions of “the hunt for
the pink Viagra,” for example, instead of focusing attention solely on
urologists and other physicians as usurpers of sex research and women’s
sexual health care, we now see them as overt or disguised agents who
promote the profit-seeking agenda of a global pharmaceutical industry.
We now understand that the influence of the pharmaceutical industry
grows because it benefits from favourable governmental and professional
organization regulations regarding advertising, education and drug
approval (Tiefer, 2008b). Over these 10
years, our understanding of
medicalisation and sexuopharmaceuticalisation has moved beyond simply
targeting doctors and drug company representatives to include wider
networks of influence including political, media, corporate,
educational, and professional interests. Doctors and drug companies
alone would be unable to accomplish hegemony over research and
professional education practices without the active collusion of these
wider networks (Tiefer, 2008b).
A new social movement has grown to challenge the public health impact
of various corporate practices (Freudenberg,
2005). Academics and
non-profit reform groups have revealed how, in their pursuit of
profits, corporations use advertising, public relations, and lobbying
to defeat or water down progressive regulations that would protect the
health of the public. For example, instead of banning cigarette ads
entirely, laws only ban them in newspapers, some magazines and
television, while permitting ads on billboards and other magazines. In
addition to academic and theoretical critique, activism for change has
involved these ‘reformers’ challenging the unhealthy policies and
practices of corporations by using the very same tactics: media
advertising, public relations and lobbying to influence regulation,
legislation, and research.
The concept of disease-mongering
 emerged as an important tool for
analyzing how the sexual medicine industry (which is larger than just
the pharmaceutical industry) was manipulating the media and public
opinion to create markets for a medicalised
view of sexual problems
(Moynihan and Cassels, 2005).
have themselves become disease-mongering tactics used to
market drug products (cf Payer, 1992).
This involves practices such as:
taking a normal function and implying that there is something wrong
with it, and it should be treated; assuming suffering that isn’t
necessarily there; defining as large a proportion of the population as
possible as suffering from the ‘disease’; using an end point in
clinical research that advantages the pharmaceutical company rather
than being important to the public; promoting technology as risk-free
magic (Tiefer, 2006). Most of these are
easily applicable to FGCS.
The New View Campaign’s activism over these years to challenge Big
Pharma’s disease-mongering tactics has consisted of many journalism
interviews, public lectures, debates at medical congresses, public
testimony at government hearings, academic publications, self-published
brochures and teaching manuals, a website and listserv, letters to
government agencies and professional continuing education courses
(Tiefer, 2008b). This multi-pronged
approach has been a key strength of
the Campaign, which has been successful, for instance in helping defeat
the first sex drug for women that came to the US Food and Drug
Administration in 2004.
The Campaign’s interest in FGCS came about because of a sudden
escalation in promotion of this new group of genital surgery procedures
through internet videos and television “makeover” shows. The largest
impetus seemed to come from one particular Los Angeles gynaecologist
who has developed a franchise-like arrangement for training doctors in
trademarked procedures using patented equipment and licensed media ad
campaigns. The combination of medicalisation for a new ‘condition‘
(distress over clitoral, labial and vaginal appearance), and the
flagrant use of business practices which cross the boundaries of
ethical advertising practice (see The American College of
and Gynecologists, 2006), provoked a strong reaction from the New
group. We came to believe that, despite claims that they are about
empowering women and improving women’s sexual pleasure (see Braun,
2005), these surgeries were being recommended out of a misogynist
disregard for women’s genital diversity and a willingness to exploit
women’s lack of knowledge and confidence about their genitals. This
called for action.
A small New York-based feminist group studied the journalism about
FGCS, the websites of the FGCS providers, the complex and extensive
feminist literature on cosmetic surgery, writings about ‘FGM’, and the
New View pro-diversity and anti-medicalisation philosophy, and
developed a campaign to challenge FGCS. The goals of the campaign are:
To achieve these goals, we designed an activist campaign
- To create public concern about the unchecked expansion of the
industry and its lack of scientific research support;
- To pressure professional OB-GYN and plastic surgeons’
to collect data on these procedures, and to censure or sanction FGCS
surgeons who offer services without publishing research outcomes;
- To expand the idea of ’informed consent‘ for FGCS to include
genital education about anatomical diversity through showing
independent illustrative and scientific materials;
- To shed light on the growth of a new set of medical business
practices that uses franchise models, public relations, multiple
advertising avenues, and all the bells and whistles of contemporary
marketing to medicalise everyday bodies, lives, and functioning.
The public rally
was attended by about 30 feminists and photos can be
seen on http://www.newviewcampaign.org/fgcs.asp. Major press coverage
included an excellent article in the largest American newsweekly, Time
magazine (Fitzpatrick, 2008). The resources will remain online
indefinitely. In upcoming conference presentations we plan to use this
activist event as a model for feminists planning public actions to
challenge the continuing pathologisation of women’s bodies and
- Development of a website with resources for press and public
- Letters to medical and governmental agencies and organizations
calling for increased consumer protection, and increased professional
- A 2-hour sidewalk rally in front of a NYC FGCS surgeon’s office
(including guerrilla theater);
- Distribution of a press release announcing the sidewalk rally;
- Collection of a list of individual and organizational endorsers
- Sharing of resources with feminist university organizations to
educate their members about the issues;
- Collaboration with documentarians interested in FGCS.
Conclusion: The ‘Personal’ Remains
With this paper we have aimed to present both academic critique of the
emergence of FGCS along with activism to challenge the practice. The
case of FGCS demonstrates, once again, the feminist claim that ‘the
personal is political,’ and
that this concept is still as relevant as
when it was first stated. We have outlined cultural factors which make
it entirely understandable that women both experience anxiety and
distress about their genitalia, and seek cosmetic surgery to change
them. Women’s personal distress and desires around genitalia need,
however, to be located within a wider socio-political context, which
includes active practices of medicalisation as well as pathologisation
of genital diversity through the promotion of one ideal vulval form. As
a final point, it is important to realise that it is not just women who
are influenced by culture, economics and practices such as
medicalisation. Health and other related professionals are cultural
members as well as professionals; their practices can reflect, and
reinforce, negative cultural assumptions around women’s genitals,
sometimes in quite subtle ways (e.g., Kapsalis,
1997; Lomax and
Casey, 1998; Pliskin, 1995). For
this reason, comprehensive
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 Different polls give different results. Of the 655
respondents to the
current thefrisky.com poll on the same topic, 17% indicated they would
consider labiaplasty, and 13% that they might (response categories were
worded somewhat differently, see http://www.thefrisky.com/site/post/246-poll-would-you-ever-snip-down-below).
“biggest ever surgery survey” who reported that they would “never
consider having surgery done down there” ("Can surgery better sex?,"
2008, p. 102) - although 15% apparently would, and number of
respondents was not indicated. Sound empirical research on interest and
uptake is lacking.
 In a different way, it is also profoundly
commercial, and tied
into economic factors and imperatives as well (Elliott, 2008; Haiken,
1997; Sullivan, 2001),
which we should not forget in our analyses, and deeply cultural.
 Critics (e.g., Allotey,
Manderson, and Grover, 2001; Conroy,
2006; Essén and
Johnsdotter, 2004; Manderson, 2004;
Sullivan, 2007) have also raised
questions about the practical, moral, ethical and legal aspects of the
different ways western and non-western genital 'cuttings' are treated
in the west, such that FGCS is not subject to legal contestations,
although laws against 'female genital mutilation' technically prohibit
some forms of labiaplasty, for instance (Sullivan,
 There is much controversy over terminology in this
least because the practices are diverse. This has seen the emergence of
less 'judgmental' terms like 'female genital cutting,' which not all
agree with. Our views on these issues are not uniform or singular. We
use the term 'FGM' in this paper, but in scare quotes, although we
recognize that some readers will find it problematic.
 We must acknowledge this account around FGM
activism as singular
and one which focuses on the positives of international efforts against
it. However, much controversy exists in this area, and activism against
FGM (by western feminists/organisations) has been subject to
substantial critique, and there are ongoing debates about who should be
involved in moves to eradicate FGM practices, and how these might be
put into practice. Both insiders (women from countries where various
'traditional' forms of 'cutting' are practiced) and outsiders (women
from countries where they are not) present a wide range of differing
viewpoints in these debates. Critics have suggested that western
activism continues long histories of cultural imperialism and
colonisation, obliterates the complexities of meaning and practices
around genital cutting, and situates African women as 'uncivilised'
within a matrix of cultural influence that can only be challenged by
outside perspectives (e.g., see Abusharaf,
2001; James and
Robertson, 2002; Njambi, 2004).
 The Consensus Statement is not without its critics,
not least in
relation to the shift in terminology, from “intersex” to “disorders of
sexual development” (e.g., http://aiclegal.org/yabb/YaBB.pl?num=1218845029/4;
 Where critical analysts identify that
the creation of new 'diseases' to fit treatments (Moynihan and Cassels,
2005), those within the pharmaceutical industry refer more positively
to 'condition branding' (Angelmar,
Angelmar, and Kane, 2007).
Virginia Braun is a Senior Lecturer in Psychology at The University of
Auckland. Her research is located within feminist and critical
psychology, and focuses on topics related to sex, sexual health, and
female genital cosmetic surgery. She is Co-Editor, with Nicola Gavey
(The University of Auckland), of the journal Feminism & Psychology.
Leonore Tiefer is a clinical psychologist in the Psychiatry Department
at the NYU School of Medicine. She is author, educator, researcher,
therapist and activist in sexology and has keynoted conferences around
the world. In 2000 Dr. Tiefer initiated the Campaign for a New
View of Women's Sexual Problems [http://newviewcampaign.org]
Big Pharma trends. She is the
author of Sex Is Not a Natural Act (2nd edition, Westview, 2004) and