Decisions to alter genitalia may be based on misguided assumptions of normal dimensions. Recent report dimensions of female genitals (50 premenopausal women).

1. Female Genital Cosmetic Surgery (FGCS)
‘enhancement’ or ‘mutilation’?
Dr Michelle M Fynes
MD MB BCh (Hons) BAO (Hons) MRCOG DU(RANZCOG) DipUS
Subspecialty Accredited Urogynaecologist with RCOG RANZCOG
Specialist Complex Peri-partum Childbirth Injury
Adolescent and Paediatric Gynaecology Specialist
Consultant Urogynaecologist & Honorary Senior Lecturer
St George’s Hospital and University of London
Presented to
Feminism in London Conference 26th October 2013

2. Natural cycle of female development
Halt, reverse, enhance?

3. The Seven Ages of Woman
Hans Baldung
Born: c.1484 Schwäbisch Gmünd Germany
Died: 1545 Strasbourg France
Genital Aging- Geographical Ages of Woman
(found during WWII)
Physical aging

4. Normal Sexual Development
Tanner stages 1-5
Stage I (Preadolescent) - Only papilla elevated above level of the chest wall.
Stage II - (Breast Budding) - Elevate breasts/ papillae (small mounds), wider areola
Stage III – breasts/areolae continue enlarging no separation of contour.
Stage IV – areola/papilla elevated, secondary mounds, increase overall breast tissue.
Stage V – Mature breasts, papillae extend above breast contour, areolar recession.
Stage I - Vellos hair over pubes, no more than on abdominal wall. No sexual hair.
Stage II - Sparse, long, pigmented, downy, straight/slightly curled, hair along labia.
Stage III - Darker, coarse, curlier hair now spread sparse over junction of the pubes.
Stage IV – Adult hair distribution , reduced total quantity, no hair on medial thighs.
Stage V - Hair adult quantity/type, appears as inverse triangle (feminine type).
Coca: a size 6 former Vogue cover girl
claims she's been rejected for being
'too fat‘ 18 February 2010
Size Zero
Model stands waiting for the Rosa Cha show
during a fashion week in NY
Size?
What has gone wrong?

5. Rapid increase in
Body Dysmorphic Disorders (BDD)
1. Somatoform disorder, preoccupation with imagined/trivial defect in appearance.
Exclude other disorders eg weight concern (eating disorder).
2. 1-2% world population meet criteria for BDD (risk male=female). Causes include a
combination of biological, psychological, environmental factors.
3. Psychological trauma stems from mental, physical abuse or emotional neglect,
contributes to developing BDD.
4. Preoccupation with body image in adolescence or early adulthood, self-criticism of
personal appearance, atypical aesthetic-standards.
5. Discrepancy between internal perception of ‘actual’ and ‘ideal self’.
6. BDD symptoms include depression, social phobia, and OCD. Affected individual may
become hostile towards family members for no reason.
7. Diminished QoL, can be co-morbid with major depressive disorder; social phobia
(chronic social anxiety); suicidal ideation 80%, extreme cases linked to dissociation.

6. Do your Bits Look Good?

7. What’s normal?

8. What does the science say?
British Journal of Obstetrics & Gynaecology 2009
• Number labiaplasty operations in UK is booming.
• Surgery is intended to make labia smaller or more symmetrical.
• 70% increase in labiaplasty in the previous year - 1 118 (2008), 669(2007) and 404(2006).
• Surge in demand linked to easier access to explicit sexual imagery.
Observer Newspaper 2010/11: figures from Harley Medical Group (leading UK cosmetic surgery provider)
• > 5 000 inquiries for cosmetic gynaecology in 2010.
• 65% of which were for labial reduction, the rest for tightening and reshaping
“We haven’t completed the research, but there is suspicion that it is related to much greater access to porn,
so it is easier for women to compare themselves with actresses who may have had it done. This
phenomenon has to do with the increasing sexualisation of society. It’s the last part of the body to be
changed.”
King’s College London researcher Dr David Veale (Consultant Psychiatrist)

9. Visual depictions of female genitalia differ depending on source
Helena Howarth, Volker Sommer, Fiona M Jordan
Background:
• Very little research describes normal human variation in female genitalia
• No studies compare visual images women might use in constructing their ideas of average and
acceptable genitalia
Aim:
Do visual depictions of the vulva differed according to their source capture normal variation and
influence perceptions of ‘normality’ ?
Comparative analysis conducted measuring:
(a) Published visual materials human anatomy textbooks in a university library
(b) Feminist publications (print and online) depicting vulval morphology
(c) Online pornography, focusing on the most visited and freely accessible sites in the UK.
Findings:
1. Post hoc tests showed that labial protuberance was significantly less (p<0.001, equivalent to
approximately 7 mm) in images from online pornography compared to feminist publications.
2. All 5 measures of vulval features were significantly correlated (p<0.001) in the online pornography
sample, indicating a less varied range of differences in organ proportions than the other sources
where not all measures were correlated.
3. Women and health professionals should be aware that sources of imagery may depict different
types of genital morphology and may not accurately reflect true variation in the population
4. Consultations for genital surgeries should include discussion about actual and perceived range of
variation in female genital morphology.
Journal of Medical Humanities 2010;36:75-79

10. What do women think is normal?
Requests for cosmetic genitoplasty: how should
Healthcare Providers respond?
A new complaint
• Decisions to alter genitalia may be based on misguided
assumptions of normal dimensions. Recent report dimensions
of female genitals (50 premenopausal women)
• Labial and clitoral size and shape, vaginal length, urethral
position, colour, rugosity, and symmetry varied greatly.
• These findings bring into question assumptions about
“normal” genital appearances
• More women troubled by shape, size, proportions of vulvas
BMJ 2007; 334: 1090

11. What do women think is normal?
Requests for cosmetic genitoplasty:
How should Healthcare Providers respond?
A new complaint
• Elective genitoplasty is apparently a “booming business.”
• Advertisements cosmetic genitoplasty common, often include
before/after images and life changing narratives
• Google produced 490 000 results when entered “labial reduction”.
47/50 results were advertisements from UK clinics offering cosmetic
genital surgery.
• TV and articles in women's magazines on “designer vaginas” may also
fuel desire for surgery, especially with the rising popularity of cosmetic
surgery in general.
• The latest survey by the British Association of Aesthetic Plastic Surgeons
reported a staggering 31% increase uptake of cosmetic surgery in the UK
• Women accounted for 92% of this uptake.
BMJ 2007; 334: 1090

12. Normal is what is sold to you through multi-media!
1. Our own opinions, and how we see ourselves our self ‘body’ image is based on what we
experience and ‘see’ in the world around us.
2. This ‘truth’ is how we gauge confidence, self-esteem, in how we ‘look’.
3. How do we measure up to our girlfriends, peers or icons
4. Programming starts in childhood and is modified by family, school and education
5. What do our children and adolescents see?

13. What are the drivers?
Consumer
• Aesthetic: desire achieve certain look
• Physical symptoms: real or Imagined
• Psychosexual issues
• Disposable income
• Designer influence
Provider
• Size of the market and projected
expansion
• Profit
• Risk: litigation
• Market control: GMC, Government (CQC),
advertising standards
Multimedia influences?
Consumerism versus Science
> 45, 000 Google references versus <100 Medline references for scientific publications

14. Female Genital Cosmetic Surgery (FGCS)
Common Procedures
• Labiaplasty: removing a section of labia tissue
• Hymenoplasty: hymen is restored ‘re-virginification’
• G-spot amplification: collagen is injected to the G-spot
to increase its size; alleged to increase arousal
• Vaginal rejuvenation: when tissue of the vagina is
strengthened – tighter/smaller/more symmetrical
• Liposuction vulva: erase ‘Camel Toes’
• Rejuvenation vulva: inject fillers to ‘plump it up’

15. Labiaplasty
British women hanker for designer vaginas: labiaplasty sees 109
per cent rise to become third most sought-after surgery.
Procedure costs from £1,300 to £3,700
Growth driven by increased consumer awareness
PUBLISHED:16:51, 16 August 2013
Would you have the 15-minute 'designer vagina' jab?
FORGET facial fillers to reduce lines and wrinkles, a cosmetic treatment that
promises to plump up a woman’s most intimate area is coming to the UK
early next year.
The Labial Puff, a groundbreaking vagina rejuvenation jab that works in a
similar way to lip and facial fillers, promises to boost volume, reduce wrinkles
and add elasticity "down there" in just 15 minutes.
Published: Wed, October 23, 2013
Designer vagina surgery the new cosmetic trend -
would you have a nip, tuck down below?
Tears streaming down her face, Debra Hooker gently pushed her husband
off and shook her head.
It was nothing to do with having a newborn to care for, Debra was simply
too ashamed of her body. But now, after designer vagina surgery, Debra’s
marriage has been given a new lease of life.
And she’s not the only one to benefit. Statistics show that vaginal surgery
is fast becoming one of the most requested surgical procedures
PUBLISHED: 21 Mar 2011 09:00
NHS figures 2009- 70% increase in the number
of women having labiaplasty via NHS.
1,118 (2008); 669(2007); 404(2006).
Private Clinics 200% increase 2011-2012

16. Adolescents and the Designer Vagina
Hundreds of girls aged 14 or under are
having 'designer vagina' surgery on the
NHS. 343 operations performed on
under 14s in six years
Researchers want an age limit for the
surgery . PUBLISHED:22 November 2012
Trend: Hundreds of girls are having
'designer vagina' surgery on the NHS, say
researchers from UCHL, led by Dr Sarah
Creighton, claim it is ‘disturbing’ that
there is no minimum age limit for the
surgery.
Websites of companies make
'Unsubstantiated claims of physical,
psychological and sexual benefits were
present on every website’. Labiaplasties,
operations to reshape the labia, the
inner lips of the vagina, have become
increasingly common……. ‘Given the fact
that anatomy continues to change
throughout the lifespan, the younger a
girl begins her FGCS journey the higher
the number of lifetime operations and
the greater and more multiple the risks’
she said.

17. Medical Ethics: four key principles
• Beneficence: provision of benefit whilst balancing this against risk.
• Non-maleficence: ‘primum non nocere’ - first of all do no harm.
• Justice: implies a duty to spread benefits and risks equally in a society.
• Autonomy : patients making their own informed decisions rather than healthcare (society?) providers
making decisions for them. Autonomy requires that a person with capacity is adequately informed, free
from undue pressure (multimedia?) and that there is consistency in their preferences
Adolescent Gynaecology
Age of consent?
Capacity?
‘It is incumbent on all health professionals to act within the law’
Private UK Consultant FCGS
‘Sometimes when I see a patient, I
will tell them that they are
completely normal. I will send them
away and that will be that," he says.
It’s not my job to sell an operation, I
am there to give good quality
advice," he adds. "High street clinics
work on commission, but I'm not a
salesperson. I'm an independent
doctor, with a reputation to uphold’.

18. Medical advertising
When Veronica walked into Dr David Matlock’s
office in 2007, she was there for “designer
vagina” surgery.
Matlock, who claims it was “love at first sight,”
complied to doing the procedure, but also
suggested that Veronica get the ‘Wonder
Woman Makeover’ involves liposuction of the
chin, arms, and thighs and Brazilian butt lift.
After the successful surgery, Veronica agreed to
something else: Matlock’s proposal (on their
first date, no less).
She’s a “walking advertisement”
Veronica has since had vaginal rejuvenation,
labiaplasty and G-spot shot, liposuction to her
chin, arms and legs and, most recently, Botox
injections.
And that’s how you go from this…
In the UK
what
does the
GMC say?

19. Cosmetic Surgery: Royal College of Surgeons
guidance is welcome, but regulation is required
19th February 2013
Clinical negligence law update
In the last few years, the popularity of cosmetic surgery has greatly increased.
Many people opt for procedures, when performed safely, give them excellent results.
But regulation of the cosmetic surgery industry in the UK is in a worrying state.
No accurate statistics relating to how many cosmetic surgeries are carried out in the UK.
British Association Aesthetic Plastic Surgeons: 43,039 cosmetic procedures carried out by members in 2011.
Total number cosmetic surgeries carried out UK is likely to be 130,000.
Around 5% of these procedures end with botched results.
NHS medical director, Sir Bruce Keogh, conducting major review UK cosmetic surgery
Royal College of Surgeons (RCS) published preliminary guidance
The Professional Standards for Cosmetic Practice report.

20. Female Genital Mutilation (FGM) protester
What’s really the difference between FGM and FGCS?
Female Genital Cosmetic Surgery (FGCS)
‘enhancement’ or ‘mutilation’?

21. The Great Wall of Vagina
Artist Jamie McCartney