A medico-legal reflection on female cosmetic genital surgery and Female Genital Mutilation - an intersectional feminist critique of choice-feminism

On face-value, choice feminism empowers women to take control of their own lives; however this naive view disregards the intersectionality which feminists must acknowledge and encourages harmful professional self-regulation from surgeons.

Linda Hirshman introduced the phase “choice feminism” to consolidate the widespread belief in the US that the women’s rights movement liberated women to make choices regarding their wage work and unpaid labour within the home. In a modern context, ‘choice feminism” is applied broadly. Third wave feminists such as Jennifer Baumgardner and Amy Richards arguably expanded the term by coining feminism as every life choice a woman makes, so long as it is accompanied by “a political consciousness”. [32] The subjective nature of what constitutes a level of ‘political consciousness’, allows for the broad use of the term ‘choice feminism’ to defend actions as morally justified, avoiding the often necessary re-assessment of those actions from an intersectional perspective.

Female Genital Mutilation is a procedure where the female genital organs are injured or changed and there is no medical reason for this, [33] while a labiaplasty is a procedure where the female genital organs are surgically changed, usually there is no functional reason for this. [34] These definitions have caused purely aesthetic labiaplasties to fall under the definition of FGM. Both ‘procedures' have the potential to cause short and long term damage to both physical and psychological health. It must be stated that it is naive to argue that the horrific and traumatic practice of FGM is completely equal to women consenting to labiaplasties conducted by a medical professional, it would be naïve to ignore the potential overlap between the two practices, ethically and legally. Especially if women are under mental duress or feel a societal obligation to have a labiaplasty. This essay focuses on cosmetic labiaplasty, not labiaplaties which arise due to medical necessity such as tears after childbirth or removal of cancerous tissue.

The World Health Organisation categorises the different types of FGM, for the purposes of this paper we will focus on types 1a and 2a, as they arguably mirror surgical approaches to labiaplasties. Type 1a is the removal of the clitoral hood, in labiaplasties, reductions of clitoral hoods are commonplace. [1] Type 2a is the removal of the labia minora only, reflecting most common form of labiaplasty. Cosmetic labiaplasty is the most popular cosmetic gynaecological surgery in the UK despite the procedure falling under FGM type 1a or 2a.

Studies show that women having undergone mutilation of their genitalia fall below the threshold of sexual function however there is a severe lack of studies on sexual dysfunction specifically after cosmetic labiaplasties within the western world. With the American College of Obstetricians and Gynaecologists advising against the procedure due to the lack of safety and efficiency data, the push from choice feminists to remain on the path of allowing women to undergo cosmetic genital surgery without legal regulation enables FGM.

The lines of morality are too blurred for the law to come to a clean distinction. Choice feminists would argue that since FGM is not the choice of the women who are victims of it, it is not covered by choice feminism. Such a generalisation is simply inaccurate and shows a lack of understanding of the cultural interplay. This was documented in a 2001 study including 282 female students in Egypt, it was found that 60% favoured some form of FGM and considered it beneficial. [2]

FGM has no health benefits and is recognised to cause severe short and long term damage to both physical and psychological health. [3] Several studies have been conducted into the long-term side effects of FGM, predominately, lack of sexual pleasure. These studies use the Sexual Quality of Life questionnaire (SQOL-F) in order to assess the devastation FGM has had.

A study conducted between 2007 and 2008 questioned 130 women with FGM and 130 women without FGM using the SQOL-F. Significant differences were found between the two groups. The control group without FGM scored higher in every category including arousal, satisfaction, lubrication, and orgasm. [4] A further study was conducted in 2012 where 73 women who had undergone FGM were compared to a control group of 37 women who had not undergone FGM but were from a similar cultural background found the same pattern, with women who had undergone FGM rating their quality of life 26.4 points lower than women within the control group. [5] A further study was conducted in 2022 with 300 women who had undergone FGM and 300 women who had not but came from a similar cultural background. The same pattern was found, with the group of women who had undergone FGM scoring their quality of life significantly lower than the women in the control group who had not undergone FGM. Women within the FGM group viewed themselves as 0.16 times more worthless and 0.32 times more sexually repressed. [6] Two of the studies listed concluded that type 3 FGM differed most significantly from the control group, [7], [8] which is evidence for type 3 being the most destructive to a woman’s sexual pleasure.

Some FGM activists are concerned that the practice of labiaplasty would provide a workaround for people wishing to inflict FGM type 1a or 2a on women and girls. [9] Labiaplasty is advertised to women within the UK using language such as “neat and attractive” [10] with one UK clinic describing women who have not undergone labiaplasty as “often the subject of comments either from their partners or even from friends and colleagues in the gym or swimming pool”. [11] This attempt to shame women their anatomy is mirrored by the arguments in favour of FGM and using it to create a smooth, clean vulva with no “inner flesh” to make the vulva “more beautiful”. [12]

Both FGM and cosmetic labiaplasties were born out of shaming women for their natural anatomy. The act of mutilating female genitalia in a western context can be traced back to the writings of Dr. James Burt in 1975. In his book “The Surgery of Love”, [13] in which he both shamed and blamed women for their anatomy, claiming the vagina was “structurally inadequate for intercourse”. It is difficult to ignore the parallels of the labiaplasty and FGM both being born from shame inflicted, from men onto women. However that is where the similarities end in terms of origin. While FGM is inflicted in order to decrease sexual pleasure, the “Surgery of Love” aimed to increase it. The procedure involved the partial or full removal of the clitoral hood and relocation of the vagina. [14] Dr Burt claimed that the labiaplasty would turn his patients into “horny little mice” while, horrifically, claiming that “the difference between rape and rapture is salesmanship”. Dr. Burt’s disregard for women’s consent was acted upon when he started performing his “love surgery” on women without their consent, creating both a medical and legal horror story but also a cautionary tale of the limits of professional self-regulation. [15] It is difficult to believe that a surgery with such horrific and misogynistic roots would become the most popular cosmetic gynaecological procedure in the UK. [16] In 1988, the Ohio Medical Board cited Burt for alleged "experimental and medical unnecessary surgical procedures, in some incidents without proper patient consent.”. [17]

Section 1(5) provision of the Female Genital Mutilation Act 2004, allows labiaplasties so long as the mental health of the woman is “suffering”. This irresponsibly wide scope further opens doors for lawful FGM. It goes on to state that the only exception to this is if the procedure is ‘required as a matter of custom or ritual’.

While this might be true of some women who opt to undergo labiaplasties, it cannot be all of them. Does this not leave surgeons preforming labiaplasties purely for aesthetic purposes, rather than in a “necessary” attempt to improve the mental health of their patient, open to criminal charges under the Female Genital Mutilation Act 2004? The government guidance does not provide clarity on this issue, stating that the defence of labiaplasties being necessary for the patents mental health is ‘unlikely to apply where the surgery is purely to alter the appearance of the genitals’, [18] it must be proven to be necessary for mental health. It is important to note that there is yet to be a case brought forward under this provision due to a labiaplasty. Potentially for this reason, private practices continue to advertise labiaplasties to women who desire one purely for aesthetic purposes, not improvement of mental health. Ignorance of this provision shows a desperate need for further, more explicit regulation on labiaplasties specifically.

The wording of section 1(5) of the Female Genital Mutilation Act is important. The procedure must be “necessary” for the mental health of the patient in order to be excluded from satisfying the requirements of FGM under the act. Necessary is defined in the Cambridge Dictionary as “needed in order to achieve a particular result”, the “result” in this case being improved mental health. When adopting the ordinary definition of the act, if something else, potentially non-invasive, was to change the circumstances so that a labiaplasty was no longer “needed in order to achieve an improvement in [mental health]”. Then it would become unlawful. Furthermore if there is a method available which would result in women no longer needing a surgery, should it not be attempted first? Studies have suggested that a percentage of the women opting to undergo labiaplasty do not completely comprehend the potential long term consequences of undergoing this procedure which has no medical benefit to them simply because they hope it will improve their mental health. One study has been conducted on effects of counselling on reducing the desire for labiaplasty wherein women attended 3 hours of counselling broken up in 1 hour appointments. During these sessions the women were informed of the function and importance of the vulva, vagina and pelvic floor as well as the negative consequences which can arise from removing vital areas of the vulva through a labiaplasty. 35% of the women chose to refrain from undergoing surgery, while 65% choosing to go ahead is is a significant percentage, it is logical to factor in that many of these women would have already made up their mind prior to the counciling, furthermore this study only included thee 1 hour sessions, this was potentially not enough. [19], [20] For 35% of those women, a labiaplasty was no longer “necessary” to improve their mental health, and that was just testing one method of improving mental health through self-care and eduction. My point is that there are many methods of improving ones mental health that does not include a surgery, mirroring forms of FGM, created by a man who was not a surgeon and was later charged with performing an unnecessary medical procedure, with a potentially 20% risk of complications. [21]

The complication rate for labiaplasties differs dramatically depending on the source, from 1%-20% [22], [23], [24] , with the most common complications being dehiscence, hematoma, unsatisfactory scarring, infections [25] and necrosis [26] however long term outcomes are yet to be adequately reported. [27] With the American College of Obstetricians and Gynaecologists reaffirming in 2023 that they advise against any cosmetic female genitalia surgery due to the lack of data and studies regarding its effectiveness and overall safety. [28]

Ignorance of the FGM Act within the UK

As discussed, labiaplasties are unlawful under the FGM Act 2004 with exceptions given if the surgery is necessary for the patient’s mental health. However there is yet to be a case brought forward under this provision due to a labiaplasty. Potentially for this reason, private practices continue to advertise labiaplasties to women who desire one purely for aesthetic purposes, not improvement of mental health.

A need for further studies

As previously discussed, FGM results in a decline in sexual satisfaction which is interesting as many studies suggest that labiaplasties result in an increase in sexual satisfaction, [29] reasons for this could include the extreme nature of certain types of FGM, specifically Type 3 which resulted in the lowest scores in terms of sexual gratification. Studies conducted on the sexual gratification of women who underwent type 2 FGM or labiaplasties differ extensively in their findings. It is important to note that many studies who claimed women’s sexual gratification improved were affiliated with private gynaecology practices, some of which were attempting to sell labiaplaties to patients. A study conducted in 2022 without affiliation to private practices offering cosmetic surgery, found that women who had FGM type 2 had an average Female Sexual Function Index score of just 17.3. Anything below 26 is classed as female sexual dysfunction. [30]

In order to understand where the line is in terms of the safety of women and reaching an educated conclusion, legally, as to where FGM ends and labiaplasties begin. There needs to be studies conducted on the sexual satisfaction of women who underwent both labiaplasties, with of without clitoral hood removal, and women who underwent type 2 FGM.

Even if it is found that labiaplasties improve sexual gratification, this is not a defence. In R v Brown, the appellants committed violent but voluntary acts against each other for the purpose of sexual gratification. The appellants were arraigned for aggravated assault under s.20 and s.47 of the Offences Against the Person Act 1861, for inflicting wounds and actual bodily harm on the genital and other areas of the bodies of each other. While it could be argued that Labiaplasty as an unnecessary non-therapeutic surgery might come within the reasonable adornment exception. Unnecessary non- therapeutic surgery that results in serious longer-term harm does not come within the adornment or medical exceptions. [31]

Conclusion:

Any cosmetic changes to female genitalia born from shaming women for their anatomy should not have a place within any society. While the UK legislation under the Female Genital Mutilation Act mirrors this sentiment to a certain extent, private practices offering cosmetic gynaecology surgery publicly advertise to women who wish to undergo the procedure purely for aesthetic purposes. So far these clear violations of the FGM Act are yet to result in a single case under the FGM Act. Due to the growing popularity of labiaplasties it is irresponsible to ignore the current legislation covering the procedure. Cosmetic surgeries on female genitalia need clear and concise guidance and legislation which needs to be followed. Labiaplasties fall into categories 1a and 2a of FGM, and while the short and long term suffering of women inflicted with FGM should never be compared to labiaplasty, the similarities of the 1a and 2a procedures with labiaplasties should not be ignored. Especially when they share legislation.

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