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[연구]번역_여성생식기 성형술 by Virginia Braun 박사

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여성 생식기 성형술: 현대 논의와 지식에 대한 비판적 개관

 

출처:JOURNAL OF WOMEN’S HEALTH Volume 19, Number 7, 2010

Mary Ann Liebert, Inc. DOI: 10.1089=jwh.2009.1728

출간년도: 2010년

작성자: Virginia Braun 박사

 

초록

여성 생식기 수술은 최근 몇 년간 서구에서 큰 인기를 얻고 있다. 많은 의사들이 관련 수술들을 대대적으로 홍보하고 있으나, 전문가 기관에서는 이러한 시술에 의문을 던지기 시작했다. 수술을 통해 심리적, 감정적, 성생활에 획기적인 변화가 있다는 일부 의사들의 주장이 있지만 이것을 증명하는 신뢰할만한 연구조사는 없는 상황이다.

이 글은 두가지 목적이 있다. 첫째, 소음순 수술 관련 학문적 작업에 대한 검토를 진행하여 여성 성기 수술에 관한 최근 정보 수준을 명확히 하는 동시에 그 한계도 파악한다. 둘째, 일반적으로 의료적 영역에서 언급된 적이 없었던 사회학적, 정신적 우려를 제기하는 일련의 연구를 검토한다. 이 글은 방대한 논점들과 논의를 요약한다.

좁합적으로, 이 글은 소음순 수술 관련하여 축적된 정보의 불충분함을 입증하며 수술 후 생기는 다양한 결과에 대한 연구의 필요성을 강조한다.

 

“오늘 우리는 소음순 수술이라는 극단적인 성형술의 노예가 되는 사회에 살고 있다.”

 

몇 십년전 서구 미디어에서 “질 성형”이 처음 언급한 후로, 질성형은 긍적적인 것으로 보도됐다. 질 성형술은 여성 생식기 수술 (FGCS)에 포함된다. FGCS는 미용적∙기능적 이유로 여성생식기에 행해지는 시술들을 포함하며 구체적으로는 소음순 수술, 질재건술, 음순 확대술, 치골부 지방 흡입술, 음핵 포피 축소술, 질막 재건술, 회음부 재건술, G-spot 확장술이 있다. 하지만 의학적으로 명확히 정의∙구분되지 않았다. 이러한 다양한 용어들을 표준화된 명칭으로 사용할 수 있음에도 이러한 표현들을 피하는데 이는 레이저 질 성형술과 같이 상업적 의료행위와 이윤추구 욕구와 강하게 연관되어 있습니다. 중성인(양성적 특징을 가진 사람)이나 성전환자들을 위한 시술, 전통적인 여성 음순 절제나 기형을 고치는 수술은 논의에서 제외합니다.

수술은 부인과나 성형외과에서 진행됩니다. 또 지역별 규정에 따라 관련 수술을 할 수 있는 의사들이 수술을 진행하고 있습니다.

우리는 성기수술이 서구사회에서 급격하게 늘어나면서 많은 의사들이 이 수술을 홍보하고 있고 특화된 병원들이 많이 등장하고 있는 것을 쉽게 볼 수 있습니다. 그러나 지난 몇 년간 두 개의 전문 기관인 미국 산부인과 학회 (ACOG)와 호주/뉴질랜드 산부인과 학회 (RANZCOG)는 여성 성기 성형술(FGCS)에 대해 공적인 입장을 발표했으며 영국과 독일의 몇몇 의사들도 개인적 의사를 표명하고 있습니다.

수술로 여성의 성기를 향상시킨다는 생각은 새로운 것이 아니지만 미용적 목적에만 둔다는 점은 새로운 것입니다. husband stitches(출산후 질 모양을 잡기 위한 시술로 남은 봉합실)와 James Burt 박사의 ‘‘love surgery’’에서부터 처녀막 재건술과 음핵절제술등 다양한 수술형태에서도 볼 수 있듯이, 여성 성기는 오랫동안 수술로 변형가능한 신체 부위로 인식되었습니다. 이러한 수술은 성적, 심리적 본질의 문제를 해결하기 위해 고안되었으며 일부 시술에서는 여성의 동의가 필요하지 않았다. 수술 당사자들이 충분한 정보를 얻지 못한 경우도 많았다. 이러한 맥락에서, 여성 생식기 성형(FGCS)은 여성을 수술적 피해자로 만드는 큰 장이라는 오명을 썼다. 일부 의사들과 매체를 통해 홍보되는 대안적 기술은 결국 관심을 기우려야하는 여성의 성기와 성적 문제이다. 여성 성기 성형술에 대한 논의를 따라 비록 이것들이 부인과와 성형외과의들의 손에서 나타나지만 이 글은 이러한 다른 집단차이에서 오는 긴장을 검토한다.

이글의 첫 번째 목표는 여성 성형술에 관해 최근에 알게된 것들을 요약하고 평가하는 것이다. 두 번째 목표는 추가적인 논의를 활성화시키기 위해 일련의 수술과 관련된 비평과 우려에 대한 인식을 높이는 것이다. 최근 소음순 절재술이 검토되었으나 이 글에서는 FGCS를 비판적인 입장에서 접근했다.

나는 의학영역, 윤리적, 선택적 문제의 범위를 넘어서 여성에게 영향을 미치는 심리∙사회적 영역의 요소에 대한 연구가 확대되야 한다고 믿습니다. 이러한 수술의 대중화와 일반화는 여성 성건강과 복지(well-being)에 대한 우려를 낳고 있습니다. (....) 수술들은 모든 문화 전반에 나타나는 ‘질 조임’현상과도 연결되어 있다. 여성 생식기 수술이 가진 긴 역사와는 달리 음순 성형술은 상대적으로 새로운 것이다. 소음순 성형술은 1984년 처음 보고 되었다. 1990년 대 후반과 2000년대 초반 30~35개 의학보고와 패션 잡지(유명 의사들의 웹사이트와 에이션시 내용)로 ‘질성형술’은 대중화되었다. 그이후 다양한 의학 사례와 평가들이 보고되었고 다양한 소음순 수술법이 홍보되었다. 다양한 소음순 수술방법에 장점과 단점들은 이 글에서는 다뤄지지 않지만 다른 글들에서는 검토되었다.

 

FGCS의 증거/근거

FGCS 수술 결과에 대해서 믿을만하고 포괄적인 근거는 찾기 어렵다. 미디어, 의사의 개인적 주장, 의사 광고, 출판된 의사 보고서에 따르면, 소음순 수술은 가장 인기있는 수술로 나타난다. 의사들은 소음순 수술을 찾는 여성들이 많이지고 있다는 것을 주장하며, 제한된 데이터에서도 최근 10년간에서 소폭 상승이 있었다는 것을 확인할 수 있다. 영국의 the National Health Service에서 시행된 소음순 수술은 최근 10년간 3배가 늘었다. 1998–1999 사이 400건이었던 것이 2007–2008사이에는 1200로 증가했다. 미국성형외과학회지(ASPS) 자료에 따르면 2005~2006년동안 수술은 30%(793건->1030건)으로 늘었다고 보고했다. (...)

호주 매체는 한해 1200건 이상의 소음순 수술이 진행된다고 보도했다. 하지만 이러한 수치결과에는 몇가지 문제점이 있다. 우선 수술 유행과 보급률이 과소평가되었을 수 있다. 또한 미국 자료들은 부인과 의사들이 아닌 성형외과 의사들이 보고한 자료로 기초로 작성되었다는 한계가 있다. 영국자료들은 상대적으로 기능적 목적의 수술이 진행된 국립의료원 자료를 기초로하여 미용적 목적으로 수술하는 개인병원 수치는 제외하였습니다.

두번째로 질 성형술(vaginal rejuvenation)에 관한 미국 보고에는 문제가 있습니다. 이 질 성형술이 정확히 어떤 시술인지를 명시하고 있지 않을 뿐만 아니라 기술적 용어도 사용하지 않았습니다. 대신 FGCS를 공개적으로 찬성하는 의사 metlock이 명명한 표현들을 그대로 사용하고 있습니다.

ASAPS의 용어활용과 수술홍보와 의료상업화에 대한 무비판적인 수용적인 태도가 반영됩니다.

이와 유사하게 나이는 제외한 수치이지만 수술받은 여성에 관한 수치가 보고되었습니다. 소음순 성형 수술 환자들의 연령대는 20~30대가 가장 많지만, 10살을 포함한 십대에서 50~60대까지에 이릅니다.

질 조임수술은 연령대가 많은 여성들이 선호합니다. 같은 병원에서 행된 수술건수를 보면 총 53건의 질 조임술이 진행되었고 평균나이가 46세인데 만해 총 55건의 소음순 수술 환자의 평균 아이는 30대인 것으로 보고되었다.

FGCS의 성공률과 실패율을 보여주는 이러한 수치들 또한 제한적이다. 의료 사례 보고들은 성공적인 수술과 기술만을 보고하는 경향이 있다. 이런 보고에 따르면 소음순 절제술의 경우 환자의 문족도가 상당히 높고 합병증 비율은 낮다고 보고 하고 있다.

10개 이상의 사례들을 다루는 제한된 숫자의 보고들에서 환자들의 만족도는 90~100%에 이른다. 의사들도 공공연하게 환자들의 만족도가 높고 합병증률이 매우 낮은 수치를 유지하고 있다고 이야기하고 있다.

이들 보고에 따르면 합병증률은 5% 내외이며 가장 많이 발생하는 합병증은 상처(봉합사 열 개)와 동반 통증이다. 수치들은 매우 긍정적으로 보이지만 높은 성공률과 만족도, 낮은 합병등을 증명할 수 있는 충분하 자료들로 채워져있을까? 안타깝게도, 그렇지 않다. 보고된 증거들은 수단, 추적 기간에 문제가 있어 수술 결과에 대해 빈약한 정보를 제공한다.

 

예를 들어 of 407 surgeries, Alter37 reported an in-person follow-up at 2 weeks with only 30% of patients (attributed to the fact that many came from places other than where his surgery was) and via a written questionnaire with just 41%.

 

또한 부정적인 보고를 한 환자들에 대한 내용에 대한 사려가 없다. 다른 의사들이 사용한 수단들이 일잔적으로 과학적으로 적합하지 안으며 비교 대상이 없다. FGCS 시술받은 환자들의 보고는 다른 성형외과 수술의 합병증들과 같다.

 

장기간 적 조사와 적절한 의학 결과 연구로 심리적 성적 결과모두를 다루고 있어 심리 측정상으로 (조직/체제가) 탄탄한 심리적 측정방식이 필요하다.

 

이상적으로 평가는 수술결과와 이해관계가 있는 사람이 해서는 안됩니다.

더 나아가 6명의 소음순 수술을 한 여성들에 대한 질적 연구로부터 반결된 결과들은 수술후 여성들의 만족로의 양면성(양면 가치/반대 감정 병존)을 강조합니다.

 

큰 범주의(넓은 범위)를 대상으로 하는 질적 연구를 제시하는 것은 FGSG를 경험한 여성들의 경험에 대한 더 깊은 이해를 만들어냅니다.

아마도 더 주요한 것은 Liao et al의 설명에도 나와있는것처럼 ‘소비자들의 만족도와 의적 효과를 혼동해서는 안됩니다.’

소음순 수술을 특정 수술법과 기술들은 불충분한 미용적 기능적 결과에 대한 정보를 제공하기 위해 기록되었습니다.

 

 

몇몇 비판적 질문들이 인쇄된 효과적인 수술 결과들과 특정한 수술법뜰에 대한 제한점과 문제, 여타 수수들의 문제정을 제시하는 의사들 보고하였습니다.

(some commentaries question reported successful outcomes of a published case43,48,67; and surgeons presenting a particular technique sometimes outline the limitations, problems, or risks of other techniques)

 

그러나 이것과 관련하여서 다른 FGCG수술이나 소음순 절재술의 실패에 대한 직접적으로 출판된 연구는 없습니다. 다만 de Alencar Felicio는 부작용문제로 수음순 수술과 회음부수술은 병행되어서는 안된다고 권고합니다.

그러나 수술은 잘못된 결과를 낳기도 합니다. 소음순 수술의 악몽이라는 검색결과를 쉽게 볼 수 있습니다. 또한 의사들도 다른 의사들의 잘못된 수술들을 바로잡는 수술들을 진행한다고 보고하고 있습니다.

 

캘리포니아의 소음순 의사는 심지어 구체적으로 “소음술 재수술(Labiaplasty revision)”이라는 광고를 내걸었고 소음순 재수술을 필요로하는 여성들의 숫자가 최근 몇 년사이에 급격하게 늘고있다고 언급하였습니다. 이러한 시술들이 그럴수 있다는 증거들과 종종 발견되는 심각한 결과들은 모든 의료 개입은 항볍정과 실패를 할 가능성이 있다는 것을 우리에게 상기시켜줍니다.

이러한 이야기들은 미화된 광고와 매체보도에 대해서 번쩍 정신이 들게하는(심각 진지하게 만드는/환기시키는)대위법입니다.

이러한 수술들은 몇몇 의사들의 광고와 웹사이트에서 형성되었고 많은 매체애서 보도되어 질낮은 섹스 라이프와 낮은 자존감을 가진 여성들이 수술을 통해 회복되어왔다는 심리적 성적 변화를 만들어내었습니다.

예를 들어 성형수술과 재건 수술에 대한 편지에서 일부 의사진이 다음과 같이 주장했습니다. 우리의 모든 환자들은 결과에 매우 기뻐습니다. 이들중일부는 수영복 모델들이었는데 이 런 문제들에 굉장히 당황스러워하고 있습니다. 그녀는 수술이전에 한번도 진지한 관계를 가져본적이 없습니다. 간단하게말해 그이후에 그녀는 프로 골퍼와의 결혼을 소식을 알려왔습니다. 비록 이런 변화들이 실제로 가능하다 하더라도 이러한 성적 심리적 변화가 일어난다는 것에대한 증거는 없습니다.

 

질 조임 수술두의 이유/근거에 의문을 제기하면서 질의 해부하적 구조와 성적 기능을 연관시킬 필요는 없습니다. (Vaginal anatomy and sexual function are not necessarily associated, calling into question the rationale behind vaginal tightening procedures)

 

다양한 질 문제에 관한 수술들은 질 사이즈, 성기능 수술간에 분명한 관계는 없습니다.

간성(암수 두 가지 형질이 혼합되어 나타나는 일)에 대한 성기 수술은 감각, 성 모두에 영향을 미칠 수 있습니다. 음문 암(vulval cancer)의 수술은 성적 기능에 부정적인 영향을 미치는 것으로 발견되었습니다.

뿐만 아니라, 성욕구가 일어나는 동안 성적 쾌락과 연관이 있을것으로 생각되는 소음순 충혈과 소음순 절제가 이것에 어떤 영향을 미치는지에 대해 정확하게 밝혀지지 않았습니다. 이것들을 수술을 통한 정상적인 혈관이나 신경손상과는 다릅니다.

소음순은 성적 발기능력과 관련되어있는 매우 민감한 신경조직들이 섬유질을 포함하고 있어서, 생식기의 어떤 부분이라는 절개하는 것은 성젹 경험의 중요한 요소인 감각성을 위태롭게 합니다.

 

일부 전문가 기관들은 FGCS에 공개적으로 반대를 지지했습니다. 2007년 9월, ACOG 위원회는 FGCS에 관한 의견서를 출간했으며 다음의 내용이 포함됩니다.

질 재건술, 질 성형, G-spot 확대를 포함한 생식기 수술은 의학적으로 권고되지 않으며 안정성과 효과성은 서류로 입증되지 않았습니다. 장기간의 만족도, 안정성, 합병증률을 평가하는 어떠한 충분한 연구도 출간되지 않았습니다. 다른 부인과 전문가 집단도 같은 의견 일치를 보였습니다. 덜 공식적이지만 ASPS의 대변인은 주의를 제안하는 시카고 선타임즈인 인용하면서 “나는 이러한 시술들이 진행되는것에 되애서 오랜동안 심사숙고해고 해왔습니다. 몇 부인과 의사들은 그들의 목소리를 공개적이고 전문적으로 현재 시행되는 절차, 수술법, 정보에 대해서 목소리를 높이고 있다. 또한 환자들과 성기 성형술의 장점과 단점에 대해서 환자들을 상담할 수 있는 이용가능한 정보들이 여전히 불충분하다고 결론지었습니다. ”라고 권고하였습니다.

 

현재에 보고되지 않은 조산 합병증과 같은 위험성에 대한 좀 더 구체적이고 장기적인 평가가 진행되어야합니다.

Goodman은 생식기 수슬은 아직은 완전한, 조사, 이해, 의사 훈련, 마취법, 수술 기술, 수술후 모니처링과 엄격한 기준, 개념과 시술들이 이루어지지 않은 상황입니다.

 

몇몇 가이드라인은 네덜란드에서 개발되기 시작했습니다.

그러나 이러한 비판과 광고와 대중매체사이의 대조적인 주장에도 불구하고, 어뗘한 규정도 존재하고 있지 않다.

 

소문에 의하면(항간에) 여성들은 미용이나 기능적 이유 때문에 FGSG를 하려고 합니다.

일부는 미용적 이유가 지배적이라고 주장합니다. 그렇지만 다른 일부는 기증적 이유를 강조합니다. 미용적 이유는 대부분 생식기 생김세를 싫어하는 것과 연결되어있습니다. 구체적으로는 소음순 모양, 색, 대칭성 등을 들 수가 있습니다.

기능적인 면은 성관계시 질 늘어짐이나 운동이나 꽉끼는 옷을 입었을 때 불편함과 연관이 있습니다. 성적인나 사회적인 어색함과 쑥쓰러움인 심리적인 요인도 수술을 하는 원인중 하나로 언급됩니다. 막연하게 증상으로 특징지어진 것과 같이 이런것들의 시작은 언제난 완벽하게 조사되지 않았다는 점을 지적합니다.

(Likes et al.27 characterized such ‘‘symptoms’’ as vague, pointing out that the origin of these is not always fully investigated.)

 

 

 

유사하게, 소음순 절제술의 검토에 보면 수술들들은 요구에 의해서 시작되었고 공식적으로 평가되지 않은 심리적 신체적 어려움에 대한 구두 보고에 따라 정당화되었습니다.

 

비록 기능적인 부분에 집중하거나 미용적이 부분이 성형영역에서 재건이나 미용으로 나뉜다할지말도 실제적으로 이러한 구분은 유지하기가 힘듭니다.

미용 여성 생식기 수술이 기능적 관점에서 논의가 된다 하더라도 기능은 수술후 심리적인 변화에 대한 주장을 통해 언급됩니다.

(Even aesthetic FGCS procedures are often talked about in functional terms, and function is invoked through claims of postsurgical psychological transformation)

질적인 조사는 이러한 다양한 수술 동기의 복잡성에 대한 이해를 높였습니다. 이러한 동기들은 분명하거나, 간단하거나 개별적일 필요는 없습니다. (Qualitative research allows a bit more 1398 BRAUN)

 

여성들의 말에 따르면 그들은 비정상성이라는 인식과 소음순이 그들의 성생활에 미치는 영향떄문에 소음순 수술을 한다고 합니다. 이유들의 범위들은 광고에 반영되며 미용적, 기능적 개선이 성적 기쁨과 심리적 행복(만족감)을 높이는데도 영향을 미친다고 주장합니다. 분명한 것은 많은 여성들인 심리적 이유도 수술적 염려를 해결하기 위해 수술을 한다는 것입니다. 예를 들어, Giraldo et al.39는 다음과 같이 주장합니다. 심리적 이유는 여성들이 자신의 소음순 크키를 줄이이는 가장 주요한 이유이다.

소음순 너머에 생식기 구조에서 융기된 부부은 종종 미용적으로 사적으로 불편한 것이라고 여겨집니다. 여성들이 이러한 것들이 단순히 선척적인것이고 소음순이 크다는 것이 일반적으로 임상적 의이가 없다는 것을 알고 난 이후에도 많은 여성들은 여전히 불만적과 심리적 고통을 받는다. 이러한 현상은 논리적으로 자신감 부족, 자존감 결여, 자기 비하감, 감소된 성욕등의 결과를 낳을 수 있다.

심리학은 미용적 수술을 심리적인 정당성을 제공하고 이러한 수술들을 받아들여질만한 것으로 느껴지게 합니다. 심리에 대한 문헌들을 보면, 비록 미용 수술이라도 몸에 대한 고통에서 나올 수 있는 적절한 방법으로서의 기능성이 있다고 설명했습니다.

예를 들어 미용확대 수술은 몸과 마음간의 일치를 형성하는 수단과 편안한 구현된 자아를 형성하는 수단으로 정의되어왔습니다.

무언이 근적이고 미용적이냐는 질문은 FGCS가 개인병원이 아닌 공공의료서비스내에서도 시행되면서 좀더 복잡해졌습니다.

 

그러나 수술을 위한 이유는 어쩌면 여성들이 생각할 때 의사들이 듣기 원하는 것들이다.

(However, the reasons (given for surgery) may be the ones women think surgeons want to hear; 기능적 설명들이 강조되어야 합니다.

수술적 맥락(공적 의료 시스템, 사적 의료)은 수술을 원하는 이러한 보고된 이유들을 평가할 때 참작되어야 한다.

소음순 절제술의 경우, 지정된(지적된) 소음순 비대의 상태가 소음순 절재에 대한 분명한 으료적 보증으로 사용되고 있습니다.

이전 보고들에서 소음순을 음문에서 날개모양으로 튀어나온 부분이나 Jeffcoate’s Principles of Gynaecology에서 개의 귀모양으로 묘사한것처럼 초기에는 “비정상”의 분명한 측정도구가 없습니다.

이후에 특정한 증거는 없지만 소음순 비대 정의에 초점을 맟춘 글이 있고 정의는 상당히 다양합니다:일부 연구자들은 뿌리에서 끝부분까지가 5cm일 경우로 정의합니다. 3cm~4cm로 정의하는 연구들도 있습니다. 몇몇 연구들은 좀더 전문적인 분류가 되어있는 경우도 있습니다: type I, <2 cm; type II, 2 cm–4 cm; type III, 4 cm–6 cm; type IV, >6 cm40 혹은 ‘‘진짜 소음순 비대가 아닌 경우 (<2 cm)“, ‘‘보통의 비대증’’ (2–3 cm), and ‘‘심각한 비대증(4 cmþ)”. 비록 때때로 정상 범위(변종/이형)으로 정의되더라도, 비대증은 비정적상인 구조로 언급됩니다. 예를 들어 Pardo et al.,57를 보명 소음순 2cm이하를 정상범위로 보고 있으며 이는 2cm이상은 비정삭적으로 크다는 것을 시사합니다.

Likes et al.은 라고 소음순 비대증 정의에는 과학적 증거가 부족하다는 결론을 내렸습니다.

(소음순 비대증의 기타 문제적 양상은 이후에 논의하도록 하겠습니다)

가장 폭넓은 밤위에서, FGCS의 근본적인 이유는 외부적인 요인없이 이러한 수술을 여성들이 선택하는 것입니다.

수술을 하는 여성들은 전형적으로 비록 한명이 가끔 다름 사람들의 언급이나 농담이 있었다고 했지만 FGCG를 선택이나 그들의 감정에 영향을 준 사람이 없었다고 보고합니다. 독일 연구에 따르면 482명중 14%은 그들의 파트너로부터 언급(평가)를 받았다고 보고했습니다. 전체 여성중 7%는 다른 여성에게서 비판을 들었습니다.

 

이 문제를 체계적으로 접근한 유일한 보고서에 따르면 131명중 6.9%가 이성과 동성을 포함한 섹스파트너나 친구가 한 말에 영향을 받았다고 보고했습니다. FGCS에 대한 논의와 비평에서도 볼 수 있듯이, 개인적 선택이라는 아이디어는 수술에 대한 도덕적 수용성 주장을 뒷받침하지만 문제가 있습니다. 지난 10년간 FGCS시행하는 의사들의 확산과 평행하여 FGCS에 대한 비판의 목소리도 높아지고 있습니다. 이료개 내외와, 학계에서 FGCS의 시술, 광고, 결과에 관한 수많은 목소리르 높이고 있습니다.

 

여기서 나는 도덕과 선택이라는 두 개의 큰 논의 문야와 좀 더 넓은 의미의 이슈로서 광고, 미용적 측면, 치료적부분도 논의하겠습니다. 소음순 수술이 주로 의료적, 미용적이유를 가지게 되고 있고 이 논의에 쓰여진 인기와 가장 인정받았다,입지를 굳힌 것으로 간주됩니다.

(As labiaplasty has tended to predominate in the medical, academic, and popular writing on this topic and is seen as ‘‘the most established’’ 9 FGCS, much of the debate specifically refers to labiaplasty.)

이러한 논의들은 여성 몸과 성, 생체의학, 신자류주의, 선택, 기관등과 교차하며 이 글에서 완전하게 개발할 수 없었습니다.

 

윤리에 대한 논의들은 FGCS에 대한 생체의학적 논의들에 가장 중요한 것이었이며 이중 몇몇은 구체적으로 minors와 관련이 있습니다.

논이는 주로 생체의학적이고 윤리적인 원칙에 3가지(자주성, 무해성, 선행/이익 )가 언급되어왔습니다. 또한 권리, 선택과 강제, 피해와 이득에 무게를 두었습니다.

일부는 행복과 치료의 문제, 위험성의 문제 같은 추가적인 원칙의 필요에 대해서 자세히 설명습니다.

Some expound(자세히 설명하다) the need for additional principles, such as truth telling and risks, and touch on the question of healing vs. happiness.

3가지 일반적인 도덕율의 매우 좁은 틀은 FGCS가 도적적으로 정당하는 주장을 가능하게 알 수 있습니다.더 많은 시각들은 더 많은 문제제기를 하게 됩니다. 비록 일부에서는 외부 생식기를 축소하는 성형술을 원하고 이것을 나쁘다고 할만한 이유가 없다고 주장합니다.

다른 사람들은 이것을 지지하는 증거가 적지만 생명에 지장을 주지 않은 이러한 시수들은 도덕적, 윤리적 딜레마를 제기할 수 있습니다.

(Liao et al.,) 예를 들어, 최근에 다음과 같은 결론이 나왔습니다.

개발하려는 노력이 없고 고지에 의한 동의 뒤에 윤리적인 부분은 대단히(엄청나게) 양보되었기 때문에 상업적 압력의 의해 인식된 결함에 의해 성기관에 행해지는 수술에 대한 결정이 이루어지고 수술 위헝과 이익에 대한 믿을 반한 정보가 없고 대체방법에 대한 제안이 없없습니다.

((Where decisions (to operate on healthy sex organs) are triggered by a perceived defect(결함) (informed by commercial pressures), where reliable information (on risks and benefits) is unavailable and where there is no provision of alternatives // because there is no concerted effort to develop them, the ethics behind informed consent are vastly compromised.))

Sokol은 여기서 더 나아가 의사들이 FGCS요구에 굴복해서는 안된다고 주장합니다. 몇몇 권위자들은 FGCS를 여성 성기 손상으로 봅니다. 다른 사람들은 일부 FGCS는 기술적으로 법을 침해하는 경우가 있고 FGM 정의에 들어가기도(fit) 법적 정밀 조사의 대사가 된적도 없다는 점을 언급했습니다.

이것은 서양 여성은 자유롭게 FGCS를 선택할 수 있는 생각에 기댄 도덕의 이중 잣대라고 특징지을 수 있습니다.

환자 선택(자율성)은 가장 일반적으로 FGCS를 윤리적으로 정당화할 때 사용되는 언어 있지만 개념은 광범위한 분석이 필요합니다.

수술을 할 자율성에 관하여서 강압성이 환자가 수술로부터 자유로워질 필요에 영향을 미치고 이것은 마켓팅과 광고를 포함한다. (For autonomy(자치권) to operate, the coercive influences a patient needs to be free from include surgeon practices, and this covers marketing=advertising.)

ACOG 110은 “ ‘선구자와 세계를 이끄는’와 같은 마켓팅 용어들은 오해의 소지가 있고 잠재적으로 신체적, 정서적으로 연연한 여성들에게 호소력이 있다고 언급했습니다. 만약 사회적규제(통제)가 광고나 미디어를 통해 제정되어진다. 이는 자유로운 선택을 가장한 것이 문화적으로 제한(억제)하다.

몇몇은 여성들 그들의 외모를 바꾸라는 상당한 사회적 매체적 압박이 존재하는데 자발적인 개인의 선택이 어떻게 가능하냐는 반문을 하는 경우가 있다. 또한 환자의 자율성은 여성들이 내리는 선택들의 맥락에서 답을 해야한다.

자신의 몸과 성에 대한 모든 여성들의 인식과 감정에 대한 문확적인 영향력을 잘 알려져있다. 몸은 특정한 맥락에서 역사적이고 문화적으로 특정한 의미를 부여받습니다.

Sullivan은 윤리적 강제는 사회적 이미지- 지각의 개요/윤곽-들에서 정보를 얻습니다(심문/추궁합니다). 이러한 이미지들은 상징화된 객체와 특정한 몸에 대한 차별을 조장하는 그들의 효과적인 투자로 구성되어있습니다.

 

((argues that ‘‘the ethical imperative is to interrogate the ‘social imaginaries’—the perceptual 지각의 schemas—that constitute(이 되는 것으로 여겨지다. 구성되다_ embodied(상징하다/ 구현하다) subjects and their affective investments(투자) in ways that incite and then discriminate against(을 냉대, 차별대우) particular bodies and bodily practices.’’))

 

특정한 사회문적 요소들은 FGCS를 논리적으로 선택하게 합니다. 여성성기에 대한 부정적인 사회 문화적 묘사는 “외음부의 역겨움이 사회적 진실”라는 것을 의미합니다.;

성의 질병화는 의료적 분석과 해결방법, 대한전 접근들의 없앰에 우선순위를 매깁니다.

많은 여성들이 실제 다양한 음문들의 외형에 대한 인식이 없는 상황에서 성형수술의 일반화는 누구나 할 수 있는 거라는 인식을 만들고 음모 제거의 일반화와 음란문은 외음부의 외형에 시선을 집중시킵니다.

이러한 맥락은 미디어와 수술을 하고 싶은 욕구를 충동시키는 FGCS광고를 포함합니다.

(See Braun91 for more discussion about choice=agency=culture and FGCS.)

이러한 정보에 근거한 선택에 대한 개념은 수술에 대한 여성의 욕구를 (자신감,권위)를 약화시킬 때 문제가 되고 복잡한 문제가 됩니다.

(The notion of informed choice is further rendered problematic if desire for surgery

undermines women’s interest in risk, 51 which is again a complex issue)

Goodman은 환자들이 FGCS를 상대적으로 위험이 적은 수술로 보지만 한 미디어 기사에 따따르면 한 여성 지스팟 수술을 받은 여성은 68개의 부작용 가운데 오직 1개만 기억해낼 수 있었습니다. 자율성의 원칙은 환자과 무조건 받아들여한다는 것을 의미하지는 않습니다. 자율성에 대한 존중은 수술외적인 부분과 일반적은 성형술과 관련해 논의되고 있는 지점/이슈들에 대해서 이야기하는 것도 포함합니다. (can involve talking patients out of surgeries,)

Tracy은 ACOG’의 입장은 “비록 수술의 하기로 한 환자의 결정은 존중되어야 한다고 하더라도 이것을 고수할 필요는 없습니다. 만약 이러한 결정이... 위험의 정도에 대한 심리학적 이해에 대한 갈등과 함께 ”라고 언급했습니다.

Tracy는 또한 부인과 의사들이 이러한 수술을 원하고 현급으로 지불을 원하는 환자들의 압박이 있었을 것이라는 것을 인정했습니다. 그녀는 정신 요법이나 다른 중재나 조정은 성공적일 수 있지만 위험에 대해서는 확실히 때문에 이러한 압박/강제가 수술을 착수하게 하고 제의했고 주의가 필요하다고 주장했습니다. ‘해롭지 않기 때문에 일단 해라’라는 식의 내용은 신중하게 받아들여합니다. FGCS가 최근 최소한 실제 사례에 기초한 증거들이 없다는 것이 알려지고 있고 매우 검증되지 않은 시술이라는 것입니다.

이러한 시술들이 해롭지 않다는 충분한 증거가 없을 뿐만 아니라 다른 일반적으로 필수적이지 않은 성형 수수롸 비교해서 위험도가 얼느정도 인지 가능한 것인지 대한 충분한 접근이 없습니다. 성의학에서, 효과가 없는 것으로 보여지는 시술을 진행하는 것은 비윤리적인 것으로 간주됩니다. 논의된 예들에는 성기 확대술과 FGM이 포함되었고 잠재적으로는 포경도 포함됩니다. FGCS은 또한 이러한 정의에도 들어맞습니다.

이러한 논의들이 제한하는 것은 비록 좁은 의미의 표준이라고 하더라도 FGCS에 위험과 이익에 대한 증거의 부족으로 FGCS의 윤리성이 잠재적으로 약화되었다(깍였다)

그러나 좀더 넓게 보면, 좀 더 복잡한 윤리적 문제들이 떠오릅니다.

 

마케팅과 Medicalization(치료/환자로 받아들임) 상업적 강요의 영향은 문제입니다. (최근 전체 성형수술영역과 관련하여 언급된 점)

 

영국의 의사들은 공겨적은 마켓팅은 이러한 수술에 대한 수요를 높이고 있고 정보의 부족에도 불구하고 이러한 수술들을 번창하게 하고 있습니다.

최근 국제 비뇨학회 저널의 사설에서, Pauls은 이 수술분야에서 독특한 점은 큰 자본 이익 창줄이 이산업을 급속로도 키우고 잇어 가장 시장성, 경제이 있는 분야라는 점이라고 주장했습니다.

비록 일부 의사들이 기술과 환자들의 만족도에 대한 사례 발표들이 있었다고 할지라도 다른 사람들은 그렇지 않았습니다. 또한 사례들의 측정방식도 제한적입니다.

FGCS에 대한 광고해왔던 의사들중 한명인 Matlock은 그만의 것으로 알려진 술법에 대해서어떤것도 출판하지 않은 것으로 나타났습니다.

그러나 이것들은 대부분은 결과에 대한 증거를 기반으로 판매가 되며 Matlock은 비용을 받고 훈련과정을 제공하며 훈련을 받은 의사들을 광고할 수 있고 그의 기술법들을 상용할 수 있습니다. 점차, FGCS은 일반적인 삶, 심리학, 몸, 성의 넓은 의미의 의료화로 비평받고 있을뿐만 아니라 최소한 소음순 비대증의 병명과 관련이 있습니다.

여성의 성적, 생식기적 문제를 치료하는 수술의 대안은 거의 논의되고 있지않고 FGCS에 대한 대부분의의학적 인기있는 논의에서는 다뤄지지 않고 있다.

메시지는 건강한 성을 개발을 격려하는 것을 하지말아야한다는 것이아니다. 자전가 의자를 교체하는 것처럼 “ 문제적 질...은 수술을 통해서 바꿀 수 있다는 것으로 대하는 것이다.

핵심 질문은 수술이 기존 질병을 치료하느냐 아니면 질병을 미끼로 돈을 버는 것인냐는 것이다. Conroy는 이것이 질병을 미끼로 돈을 버는 행위이며 서구 의학계는 여성 생식기 절제를의 발달을 자연적, 생물학적 다양성이 결함이며 칼을 대야하는 문제라는 여성의 불안을 증폭시켜 이용해 부축이고 있습니다. Liao와 Creighton는 생식기성형술의 제공은 수술이 필요없는, 용인할 수 있는 범위를 좁이고 더 나아가서는 성형 수요를 증가시킨다고 제안합니다. 이 분야에 수술을 시행한 의사들 의사들이 반박을 제기하고 있지만 “완전히 새로운 걱정은 새로운 기술존재와 발달에 의해 창조된다”는 가능성이 있다는 것입니다.

만들어진 평범함과 미적 이상에 질문을 던지는 것도 중요합니다. 매우 적은 수의 의사들은 모든 여성의 성기는 “원칙척으로 정상이고 여성 성기 아름다음이라는 개념은 매우 문화에 기반한다” 입장을 밝혔습니다. Alter의 설명에 다르면 대부분 소음순의과 클리토스 덮는 살 부분의 아름다움이 대음순보다 튀어나오지 않는 것이 전형적이라고 설명하고 있습니다.

일반적으로 FGCS를 하고자하는 여성들이 원하는 생식기는 사춘기이전의 여자아이들의 깔끔한 성기모양입니다. 어려보기지만 부드러운 느낌의 음문, 소음순이 대음순보다 더 나오지 않을 것, 클리토스는 예쁘게 가려져있고 질은 조여져있을것입니다.

전후 사진을 포함한 이러한 시술에 대한 설명과 광고들은 음문의 이러한 특정한 모양이 음문의 이상적인 모습이라고 홍보합니다.

 

 

이러한 “완벽한” 음문은 나이, 비율, 거리, 색, 크기, 모양들에 대한 다양양성과 정상적인 범주의 한 끝에 존재한다.

(This ‘‘ideal’’ vulva exists at one end of the spectrum of normality and diversity related to shapes, sizes, colors, proportions and distances, as well as age.)

That Lloyd은 어떤한 성기의 측정(치수)와 나이, 동등성(parity), 민족성, 호르몬제 사용여부, 혹은 성경험도 사이에 중대한 연계성이 없지만 이런 요인들은 음순비대의 상당한 원인으로 주장되고 있습니다.

몇몇 저자들이 제공하고자 하였던 원인에 대한 아이디어는 큰 소음순을 가진 여성들은 정상이 아니라는 구조를 형성합니다. (사진기 소녀의 음순 비대증은 조금 다른 이야기입니다. 45) 더나아가, 몇몇 의사들은 소음순 비대칭이 형태학상 결함이라고 명쾌하게 정의하며 대칭으로 만드는 것이 목적이라고 말합니다. 오직 한명만 태어날대부터 혹은 자라면서 보여지는 비대칭은 정상적인 것이며 수술후에도 어느정도의 비대칭성은 유지하는 것을 시도하려고 하고 있습니다.

 

Genital Aesthetics, Pathologization, and Production of New Anxieties

 

생각해봐야할 문제는 이러한 특정적이고 좁은 의미의 완벽한 음문의 모영과 이러한 수술의 증진을 통해 시장형성이 새로운 불안이냐하는 거시다. 문랴게서 여성성기의 다양성에대한 일반저긴 이해가 많이 부족하는 전제하에서, 이상적미의 좁은 의미의 재현의 효과는 항상 이의가 제기되어 왔다. 몇몇 여성들은 이미 그들의 음순이 정상이 아니라고 느꼈다고 밝혓다. 특히 음순이 튀어나와 있거나 비대칭일 경우에 그러 했다. 최근 독일 조사 연구(85)에 보면 482명중 절반에 해당하는 435가 자신의 음순이 비정상이라고 느꼈고 음순 모양이 중요하다고 말했다. 76%는 종종 자신의 음순을 측정해보고 38%는 정기적으로 다른 여성들의 음순들을 보고 있다고 대답했습니다. 이중 71%는 자신의 음순을 정상적일고 생각하고 있소 14%는 비정상적이라고 생각했고 7%는 소음순 수술을 고려하고 있었고 이 집단은 나이가 많은 집단중에서도 나이가 많은 편이었습니다다. 이 조사는 3개 사이트를 통해 진행되었는데 각 사이트별 답변자 평균 나이는 각각 22, 40, 41세였습니다.

이 저자들은 새로운 문제가 점점 발전되어 가고 있으며 여성 생식기 모양에대한 걱정을 고조시킨다고 주장했습니다. 음문의 다양성은 치료화는 실제로 일어나고 있어며 이는 오래된 문제의 다른 변형일 뿐입니다. 긴 음순은 오랜 시간동안 생식기와 여성 병리학의을 보여주는 것이이었습니다(88). 역사적으로, 여성의 음문 측정은 생식기 형태와 여성동성애 상태간의 연관성을 확인하는 것을 목표로 합니다.

 

(An interest in genital measurement and what it might mean continues around intersex

individuals, where genitals beyond (or within) certain dimensions were framed as

not male and not female and, thus, problematic and (typically) needing surgery.(139,140))

이것은 또한 여성 질과 클리토스 사이를 명칭하는 ‘C-V distance에 관한 논의에서도 계속됩니다. 최근 LA타임즈 기사에보면 이 거리가 2.5 cm이하일 경우에 성관계동안 오르가즘을 느낄 수 있다는 주장을 하였다.

FGCS에 과한 문헌들을 보면, 여성 생식기 다양성과 문제가 되는 여성생식기 크기에 대한 인식과 인정사이에는 일반적인 모순이 있습니다. 예를 들어 여성 생식기 사이즈는 굉장히 다양합니다. 비대증은 ...“’(33)

비대증이라는 표현을 정상범주를 넘어선것이며 이는 비대함을 결정하는 일반전 사이즈의 추정에 기대어 나온 개념입니다.

이러한 용어들이 정상적인 범주에도 적용되고 있습니다. 예를 들어 di Saia(38)는 Lloyd et al.131 에서 정상범주 소음순에도 비대하다고 표현했습니다.

언어는 정보전달을 하는데 간단한 도구가 아닙니다. 이것은 현실의 창조와 연관이 있습니다.

(it is bound up in the creation of reality as it represents it) 142,143

이것은 정상과 병리적학적의 개념을 재형성합니다. 소음순 비대증은 정상적인 범위가 치료가 필요한 문제가 될 수 있다는 완벽한 예입니다.

이것은 의료적 진단의 영역밖으로 이 단어가 옮겨갔다는 입증되지 않은 증거입니다.

(There is anecdotal(입증되지 않은, 일화적인) evidence that this language has shifted outside the realm of medical diagnosis.144) 소음순 수술 윤리성에 관해서 출판된 논의에서, Bachmann은 소음순이나 클리토스, 치골부분이 못생겼다거나 수술로 보건하여 좀 더 아름다운 크기와 모양을 만들 수 있다는 거슬 추론하는 언어사용은 삼가야한다고 합니다. (66)

그러나 FGCS에 주변에 이런 용어들은 만연해있습니다. 여성 건강 전문가들고 교육자들의 도전점은 핵심 어려움은 소음순에 대한 새로운 용어를 개발하는 것입니다. 이 언어는 정상적인 소음순이 존재한다는 개념을 은연중에 강화시키지 않고 예쁘지 않고 병리학적인 상태, 뛰어나와있는 어감이 없는 용어여야 합니다.

 

좁은 의미의 미는 포르노그래피와 연관이 됩니다. Matlock의 책 디자인된 책의 한 부분(챕터)에서 소음순 절제술을 “ 음란물: 레이저 질 성형술 디자인으로의 아름다워짐”로 이름붙였습니다.

Matlock은 많은 여성들이 플레이 보이지의 여성들과 같은 질 보영을 갖고 싶다고 설명합니다. 이상적인 생식기 이미지로서의 포르노그래픽의 이미지와의 그의 재귀용법이 아닌 관계는 중요한 포인트를 가리킵니다. 의사들은 문화적 영향을 받은 개인적 가치를 가져오고 이것들에 대한 일하는 것을 선호합니다. 그들은 아마도 정상적인 소음순 다양성과 사이즈에 의 관련하여 정상성에 대한 지식이 부족할것입니다.

그러나 건강관리 전문가들은 여성 생식기와 음문에 대한 걱정은 비정상이라는 인식을 강화하고 이의를 제기합니다.

비록 일부 의사들이 음순의 정상성과 다양성을 안심시키는 것은 보통 환자들의 걱정을 가라앉히는데 충분하며, 평범성의 확언(장담)외에 전문가에게로의 위탁은 실제적으로 여성에게 그년는 일반적인 생식기의 외형범주의

 

Although some surgeons note that reassurance( of vulval normality and diversity) is

usually enough to allay patient concerns,42,43 an assurance(확언,장담) of normality

alongside(옆에, 나란히) a referral(위탁) to a specialist can actually tell the woman that

(she is ‘‘outside the sphere of normal genital appearance.’’(61))

 

이러한 의사-환자간의 관계는환자가 중심에 있고 좋은 시술같지만 여성의 부정적인 성기 인식을 강하기 때문에 의료서비스와 세팅에서 생식기문제가 진행되어야하는지 심사숙고가 필요하다. 현재, 비뇨기과의사들을 대상으로 해서 오직 한가지 세트의 안내만 진해되고 있다. (77)

 

Ramifications of FGCS into the Future

 

일반적으로 분명히 FGCS 인기가 높아지고 있다.

“더 많은 사람들의 몸을 수술위에 올이도록 유혹하는” 새로운 시술법에 대한 언론 보도 , (148,149)가 FGCS분야에서도 동일하게 일어나고 있다.

비록 다양한 방법으로 진행되는 다른 시술이지만 가슴 확대술로 FGCS의 미래 전망을 (탐사/탐험) 예측해볼 수 있습니다. FGCS처럼 가슴 확대술로 1950년 경부터 유방왜소증이라는 새롭게 창조된 조건에 대한 해결책으로서 정당화되었습니다. 하지만 현재 필요성의 의학적영역을 넘어서서 괜찮은것이라는 의미까지 확대외었습니다.

이 수술은 급격하게 늘었났고 최근 미국에서 가장 드물었단 시술이 가장 일반적인 성형수술이 되었습니다. 예를 들어 ASAPS 잘요를 1997~2008년 사이에 시술 숫자가 3배이상늘었다고 합니다. FGCS를 하고 있는 의사들이 작성한 비교에 보면 “ 이건은 기본적으로 유방 확대술이 30년전에 있었던 곳에서 뛰어나온것과 같다. ”라는 표현이 있고 (151)

 

((offers little to suggest FGCS will prove(입증,증명하다) to be a passing curiosity rather than, as one Australianplastic surgeon claimed about labiaplasty, procedures that are ‘‘here to stay.’’50))

잠재적으로 FGCS는 여성들이 미래에 관심을 가질만한 성적, 생식건강법이 될것이며,

비판적 관심뿐만 아니라 의학적 사례와 연구가 필요하다.

우리는해당 시술로 상당한 이익을 얻고 있는 의사들에 의한 부적절한 증거들만 있는 상황에서 몸에 시행되는 수술에 대해 기술적인 질문들 던질 도덕적 의무가 있다고 생각합니다. 우리는 자연적인 몸이 존재론적인 진실이라고나 어떠한 미용적, 의료적 시술과 개입이

무조건적으로 잘못된 일이라는 것을 주장하는 것은 아닙니다.

다만 FGCS의 경우, 이러한 의료적 개입은 많은 문제적 측면들을 가지고 있습니다. FGCS에 대해서 글을 쓰면서 Wilding 은 “엄청난 심리적, 감정적, 문화적, 정치적기원과 역사를 가지고 있는 이슈들에 대한 질문받지 않은 의료적 해결책에 대한 저항“이라고 말했습니다.

이 글은 의료적 차원을 넘어서 FGCS이 대한 논의하는 것을 넘어 생식기에 대한 정신적 스트레스를 이러한 시술들의 검정과 질문을 던지는 것이 필요하다는 것을 보여주는 것을 목표로 합니다. FGCS와 관련해서 주장되는 변화들은 단지 물리적 신체에만 연관되는 것이 아닙니다. 이것들은 심리 작용이며 사회 뭐화적인것입니다. 작은 음순은 더 이상 자신감을 만들어 내지 않고 이것은 마음이 형성하는 것입니다. 거기에는 의심할바없이 작고 대칭의 소음순을가진 여성들이 성적 자신감을 가지고 있지 않다는 것입니다. 이와같이

이와같이 비대칭한 소음순이 예쁘지 않거나 성적 매력이 없다는 인식은 실제 사실을 반영한 것이 아닙니다. 이것은 소음순 형태에 대한 특정 사회문화적인 매세지가 반영된 개인적 판단입니다. 비슷하게 이 문제를 해결하게 위해 수술을 한다것도 자연스럽지 않습니다. 여성의 성의 질병화/의료화, 성형수술을 일반화, FGCS 홍보라는 맥락에서 타탕성을 얻습니다. . (99,114)

몸은 항상 사회문화적으로 생산되어 왔고 영향받아왔기 때문에 마음에 영역의 문제입니다. 개인이 보고, 알고, 경험하고, 욕망하는 것은 사회적으로 양산된것입니다. 이것은 순순하게 정신적인 인식과정과 물리적 세포에서 나오는 것이 아닙니다.

FGCS에 대한 놀이들은 불행하게도 양극화되는 경향이 있습니다. 한쪽은 이러한 수술들이 환자들을 돕고 심리적 스트레르르 경감한다고 주장하며 다른 한쪽에서는 이러한 수술들과 광고들이 새로운 문제를 창조하며 새로운 마컷이며 굉장히 위험한 해결책에 시작하는것이라고 지적합니다. 양극화된 쪽으로 생각하는 대신에, 이 두쪽 모두가 가능하는 것을 보는 것이 좋을것같습니다. 동시에 이것은 잠재적으로 여성의 성생활과 자존감을 높일 수 있고 스트레스를 경감시킬 가능성도 있습니다. 하지만 동시에 이 시술법에 대한 홍보는 전반적으로 몸에 대한 걱정이 없거나 맞춰야하는 규범이 되어 모든 여성들에게 부정적인 결과를 낳을 수 있습니다. 이렇게 하여, 여성들로부터 영향력, 권력을 빼앗는것처럼 보일 수 있다. 이렇게 하여, 수술은 어쩌면 개개 여성들에게 생식기 성적 해방이 될수도 있지만 이런 선택들을 여성들이 선택한다고 하는 매락에서 하는 역할을 아무것도 없다.(이것인 이러한 수술을 선택하는 여성에 대한 이해나 맥락을 향상시키는 것은 아닙니다.)

 

(확신컨대(거의 틀림없이) 관행들과 FGCS에 홍보는 여서의 생식기 수술을 만들고

Arguably, the practice and promotion of FGCS render women’s genitalia surgical,81

reinforcing a model of women’s genitalia as in need of surgery and women’s genital

concerns as fixable through surgery.3)

 

Conclusions(결론)

 

나는 FGCS에 관한 최근의 증거들에 대한 검토와 평가를 하였으며 관련하여 급증하는 쟁정들에 대해서 논했습니다. 이러한 시술에 효과성과 안정성과 관련하여 상당한 염려가 존재할 뿐만 아니라 의문을 재기할만한 점들이 있다는 증거들이 현재 존재하고 있다. 최근 FGCS는 일련의 수술절차로 분류되어야 하며 이것들의 대한 효과를 증명하는 증거들이 뒷받침되지 않는 이상 임상적으로 보여져서는 안됩니다. FGCS에 대한 논의들이 보여주듯이 FGCS의 맥락과 시행들은 보다 기술적, 수술적 결과에대한 임상적 보고에서 알려진 일반적인 내용들 보다 좀더 복잡하며 미묘한 차이가 있습니다. 도덕적, 선택, 질환의 치료, 의료와와 관련한 문제가 되는 부분들이 여전히 남아있습니다. 만약 FGCS이 아주 흔한일이 되지 않거나, 검토되지 않은 수술 영역이 된다면, 공적인 FGCS에 대한 논의가 넓게 그리고 비판적인 수준에서 진행되는 것은 필수적입니다.

 

마지막으로 Tiefer의 언급을 지지합니다.

소음순 수술관련 광고 금지. 해당 산업(시술을 시행하는 의사)들에 기금을 조성하지 않는 조사와 연구, 장기간 동안 진행된 심리적•물리적 측정을 포함한 다양한 방법론의 연구, 종합적인 성 교육, 성별차이에 따른 불만적과 불만족의 원인에 대한 주목, 다양한 이해관계 갈등에서 전문적인 중재와 제재, 모든 전문가들이 참여하여 폭로와 명료성 보장.

 

FGCS와 관련하여 현재 우리는 이 상황에서 꽤 많이 왔습니다. 실제적인 수준에서 환자들의 욕구와 염려들을 다루는 가이드라인인 개발되어야 하면 이것은 매우 중요한 단계이다.

FGCS는 여성생식기의 외형과 관련하여 여성의 심리적 스트레스를 경감하게 위해 수술을 하려고 하는 여성 건강서비스 제공자들에게

 

FGCS presents a potentially complex challenge for providers

of women’s health services who aim to intervene to

relieve patient distress in regard to genital appearance. The

professional and public discussion around FGCS needs to be

far broader than whether or not surgery might resolve an

individual woman’s concerns. As well as reviewing evidence

about FGCS, this article has summarized key debates in order

to aid critical discussion about this problematic form of cosmetic

intervention.

Disclosure Statement

The author has no conflicts of interest to report.

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Address correspondence to:

Virginia Braun, Ph.D.

Department of Psychology

The University of Auckland

Private Bag 92019

Auckland Mail Centre 1142

Auckland

New Zealand

E-mail: v.braun@auckland.ac.nz

FEMALE GENITAL COSMETIC SURGERY 1407

 

Copyright of Journal of Women's Health (15409996) is the property of Mary Ann Liebert, Inc. and its content

may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express

written permission. However, users may print, download, or email articles for individual use. Female Genital Cosmetic Surgery: A Critical Review

of Current Knowledge and Contemporary Debates

Virginia Braun, Ph.D.

Abstract

Female genital cosmetic surgery procedures have gained popularity in the West in recent years. Marketing by

surgeons promotes the surgeries, but professional organizations have started to question the promotion and

practice of these procedures. Despite some surgeon claims of drastic transformations of psychological, emotional,

and sexual life associated with the surgery, little reliable evidence of such effects exists. This article

achieves two objectives. First, reviewing the published academic work on the topic, it identifies the current state

of knowledge around female genital cosmetic procedures, as well as limitations in our knowledge. Second,

examining a body of critical scholarship that raises sociological and psychological concerns not typically addressed

in medical literature, it summarizes broader issues and debates. Overall, the article demonstrates a

paucity of scientific knowledge and highlights a pressing need to consider the broader ramifications of surgical

practices.

‘‘Today we have a whole society held in thrall to the drastic plastic of labial rejuvenation.’’1

‘‘At the present time, the field of female cosmetic genital surgery is like the old Wild, Wild West:

wide open and unregulated’’2

In the decade or so since the first Western media reports of

the ‘‘designer vagina,’’ there has been extensive and often

overwhelmingly positive3 media coverage about this cluster

of genital procedures, which are better termed ‘‘female genital

cosmetic surgery’’ (FGCS) or ‘‘vulvovaginal esthetic surgery.’’

2 FGCS covers a range of procedures that aim to change

aesthetic (or functional) aspects of women’s genitalia but that

are not medically indicated.4 It includes labia minora reductions,

vaginal tightening (‘‘rejuvenation’’), labia majora ‘‘augmentations’’,

pubic liposuction (mons pubis, labia majora),

clitoral hood reductions, hymen ‘‘reconstruction’’, perineum

‘‘rejuvenation’’, and ‘‘G-spot amplification’’. A confusing array

of terms associated with even the same procedure has led

to calls for standardized nomenclature in this area, which

eschews terms that are proprietary2,5 and strongly linked to

commercialized medicine, such as ‘‘laser vaginal rejuvenation’’.

It excludes genital surgery for intersex or trans people,

traditional female genital cuttings, or repair of obvious

anomalies. Procedures are performedmainly by gynecologists=

obstetricians and plastic surgeons,6 as well as some urologists

and various others (depending on local regulations related to

who can perform surgery).

We are frequently told this surgery is increasing rapidly

in the West, and the number of surgeons promoting these

procedures—and setting up specialist clinics—certainly appears

to have increased substantially. Within the last few

years, however, two professional bodies, the American College

of Obstetricians and Gynecologists (ACOG) and the

Royal Australian and New Zealand College of Obstetricians

and Gynaecologists (RANZCOG), have issued public position

statements against FGCS,4,7 and less formal but nonetheless

insider=professional critiques have appeared in both the

U.K.8,9 and Germany.10 (The literature around FGCS expands

beyond the English language,10–18 but my focus is on the

English-language publications.)

The idea of surgery to ‘‘improve’’ women’s genitalia is far

from new, although a focus (just) on aesthetics is. From ‘‘husband

stitches’’ and Dr. James Burt’s ‘‘love surgery’’ through to

‘‘revirginations’’ and clitoridectomies,19–23 women’s genitalia

have long been seen as a surgically alterable part of the female

body. Such surgeries were intended to resolve ‘‘problems’’ of a

sexual or psychological nature. With some, thewoman’s or girl’s

consent was not always deemed necessary; sometimes she was

not even informed. Given this context, FGCS has been framed

as ‘‘the latest chapter in the surgical victimization of women in

our culture.’’24,25 The alternative account, promoted by some

surgeons and media, is that, finally, women’s genitalia and

sexual problems are getting the attention they deserve.

Department of Psychology, The University of Auckland, Auckland, New Zealand.

JOURNAL OF WOMEN’S HEALTH

Volume 19, Number 7, 2010

ª Mary Ann Liebert, Inc.

DOI: 10.1089=jwh.2009.1728

1393

Following a call to debate FGCS now, even though it might

appear to be ‘‘on the fringes of obstetrics and gynecology’’26

and cosmetic surgery, this article examines the tensions between

these different accounts. My first aim is to summarize

and evaluate what we currently know about FGCS, as performed

in Western countries, and what we do not. My second

aim is to raise a series of concerns=critiques in relation to the

procedures in order to stimulate further debate. Although

labia reduction has been reviewed recently,6,27 I engage more

critically with FGCS and the issues it raises and integrate literature

from biomedical and social science=humanities

scholarship. I argue that the scope of the debate needs to go

beyond medical practice, beyond a narrow view of ethics and

choice, to consider a range of psychological and societal factors

affecting women. The emergence of these procedures as

material practice and, particularly, their entrance into public

discourse raise significant concerns for women’s sexual and

reproductive health and well-being.

The Emergence of FGCS

Stemming from the work of J. Marion Sims in the mid-1800s

to repair vaginal fistulas19 and subsequent ongoing surgical

repair of vaginal vault=uterine prolapse, vaginal tightening

procedures emerge from a long (Western) history of gynecological

repair. They also link into a wider long-standing crosscultural

valuing of the ‘‘tight’’ vagina.28 In contrast to that long

history, the idea of surgical labial alteration appears relatively

new. The first report of cosmetic labiaplasty procedures appeared

in 1984.29 In the late 1990s and early 2000s, with the

appearance of more clinical reports30–35 and considerable

media coverage in the glossy women’s magazines (driven in

part by high-profile surgeons with websites and public relations

agents), ‘‘the designer vagina’’ entered public discourse.

Since then, various clinical case studies and commentaries

have reported on or promoted different techniques for labial

reduction31,36–41; some reports have been specifically oriented

to functional repair42,43 or to specific populations, such as

youth44,45 or patients with certain illnesses.45,46 The method

of simple amputation of labial tissue, identified as the traditional

approach,37,41 is still common47 but is frequently condemned

by other surgeons, for both aesthetic and functional

reasons.31,37,38,41,47,48 The pros and cons of different techniques

of labial reduction are not considered here but are

reviewed elsewhere.27,48

The Evidence of FGCS

There are few comprehensive or reliable data with regard

to frequency or outcome of FGCS. Labiaplasty appears to be

the most popular procedure, based on media and surgeon37

claims, surgeon advertising, and published surgeon reports.

40,47 Surgeons tend to claim an increase in numbers

seeking labiaplasty,15,38,47,49,50 and the limited data do suggest

a general increase in popularity across this decade. Labiaplasty

operations performed on the National Health Service in

the U.K. almost trebled across a decade: from under 400 in

1998–1999 to nearly 1200 in 2007–200851,52; U.S. data from the

American Society of Plastic Surgeons (ASPS) indicated a 30%

increase in ‘‘vaginal rejuvenation’’ between 2005 and 2006

(from 793 to 1030).53 The ASPS has not collected FGCS data

since then, but the American Society for Aesthetic Plastic

Surgery (ASAPS) reported on ‘‘vaginal rejuvenation’’ for 2007–

2008. This time, although the number of surgeries was considerably

higher in absolute terms, a 22% decline was reported:

from 4506 to 3494 procedures.54 A decline was not

specific to FGCS, however; cosmetic procedures overall were

down 15% in 2008, a downturn attributed to the economic

environment. In Australia, media reports claim more than

1200 labiaplasty procedures each year.50

There are problems with such statistics. First, they are

likely to underestimate prevalence. The U.S. data are limited

by who collects them and who reports, with a focus on

plastic surgeons (rather than gynecologists, for instance); the

U.K. data are limited to those performed free on theNational

Health Service (thus requiring a functional assessment) and

exclude those performed privately, with possibly less functional

intent. Second, the U.S. reporting of ‘‘vaginal rejuvenation’’

is problematic. It is not clear exactly what procedure

is being referred to, as it is not a technical procedural term.

Instead, such (trademarked) nomenclature comes from the

highly FGCS-promoting surgeon Dr. Matlock.55 The uptake

of the term by ASAPS and ASPS reflects an uncritical

adoption of surgeonmarketing and the commercialization of

medicine.

Similarly, there are few reported data on which women are

having the procedures, except in relation to age. Cosmetic

labiaplasty patient age ranges from early teens (requests as

young as 10) through to the 50s or 60s, with the 20s and 30s

predominating.29–31,33–35,37,40,56 Vaginal tightening appears to

be performed on older (postpartum) women: one report of 53

cases lists the mean age as 46 compared with a report of 55

labiaplasty cases from the same clinic, where the median age

was in the 30s.57,58

Data demonstrating the success (and risks) of FGCS are also

limited. Clinical case reports tend to report successful surgeries

or techniques. For labial reduction, patient satisfaction is

reportedly very high, and complication rates are low.27 In the

limited number of articles reporting on more than 10 cases,

reported patient satisfaction typically ranges from 90% to

100% (Table 1). Surgeons also claim more anecdotally that

‘‘patient satisfaction has been very high, with complications

rates remaining very low.’’40,47,59 Reports of complication rates

tend to be<5%,27 and the most common complication appears

to be wound=suture dehiscence, followed by pain.

The measures reported appear very positive, but do they

constitute evidence of high-quality, high-satisfaction, and

low-risk outcomes? Unfortunately, they do not2,6,9: the evidence

reported is problematic in terms of time frames of

follow-up and measures used (Table 1), providing ‘‘scanty

details as to ascertainment or evaluation’’ of cosmetic (and

other) outcomes.6 For instance, of 407 surgeries, Alter37 reported

an in-person follow-up at 2 weeks with only 30% of

patients (attributed to the fact that many came from places

other than where his surgery was) and via a written questionnaire

with just 41%. There was no consideration that those

not responding might report a markedly different experience

from those who did respond; evidence suggests they do.60 The

measures used by different surgeons are typically not scientifically

validated and are not comparable.9,27,61,62 This critique

of patient report outcome measures for FGCS is in line

with those for other plastic surgeries.63,64

Psychometrically robust psychological measurement is

needed for FGCS, with long-term follow-up, alongside appropriate

clinical outcome studies that assess both sexual and

1394 BRAUN

Table 1. Summary of Labiaplasty=Female Genital Cosmetic Surgery Reduction Outcomes Reporting at Least 10 Cases

Study No. of cases Time frame Patient age Physical follow-up When Outcome Other follow-upa When Outcome

Alter, 200837 407 2005 and

2006

13–63

(mean¼32)

123 (30%) 2 weeks Further surgery

required:

12=407 (2.9%b)

166=407 (41%)

(mailed

questionnaire)

At least

4 months

postoperative

Significant

complications:

18=407 (4.4%b)

USA Increased sexual

sensation:

38=166 (22.9%)

Decreased sexual

change:

9=166 (5.4%)

Less discomfort:

148=166 (89.2%)

More chronic

discomfort: 3 (1.8%)

Any increase in

self-esteem:

155=166 (93.4%)

Any improvement

in sex life:

118=166 (71%)

Would do again:

163 (98.2%)

Pardo

et al.,

200657

Chile

55 10=2003–

11=2004

10–55

(med¼31–40)

100% 7 days;

35–40 days

postoperative

Minimal wound

dehiscence:

3 (5.4%)

100%

(questionnaire)

60 days

postoperative

Aesthetic outcome

Very satisfied: 50

(91%) Satisfied:

5 (9%)

Mild-moderate

pain, 5–7 days:

2 (3.6%)

Functional outcome:

Very satisfied:

55 (100%)

Rouzier

et al.,

200030c

163 4=1989–

2=1998

12–67

(med¼26)

162 (99.4%) 1 month

postoperative

A ‘‘satisfactory’’

anatomic

result: 151 (93%)

98=163

(60%; 73%

of the 134

contactable)

(mailed

questionnaire)

6–109 months

postoperative

(med¼30)

Overall: 94/98 (96%)

satisfied; 3(3%)

not satisfied;

1 (1%) no response

France Further surgery

required

(wound

dehiscence):

11 (7%)

Aesthetic outcome:

87/98 (89%) satisfied;

10 (10%) not

satisfied; 1 (1%) no

response

(continued)

1395

Table 1. (Continued)

Study No. of cases Time frame Patient age Physical follow-up When Outcome Other follow-upa When Outcome

Functional outcome:

91/98 (93%) satisfied;

3(3%) not satisfied;

4(4%) no response

Preoperative

discomfort relieved:

96% (77=80 patients

reporting this)

Postoperative pain:

64% (1–60 days;

med¼7)

Postoperative

discomfort: 45%

Entry dyspareunia:

23% (3–90 days;

med¼28)

4 patients (4%)

would not undergo

procedure again

Maas and

Hage,31d

2000

13 10=1992–

03=1999

19–42

(ave¼30)

100% Unclear No problems:

11=13 (85%)

Unclear Unclear Overall ‘‘pleased

with appearance

of their genitalia’’:

100%

Holland Hematoma: 1 Resolution of

functional

problems: 100%

Wound

dehiscence: 1

No discomfort

with intercourse:

100% (previously

reported in 8=13)

‘‘Minimal

postoperative

discomfort’’: 100%

No pain 2 weeks

postoperative:

100%

Giraldo

et al.,

200439

15 04=1996–

10=2002

22–45

(Mean¼34)

100% Unclear Uneventful

healing:

13=15 (87%)

100% (unclear

how, no

scientific

scale)

6–80 months

postoperative

(mean¼30)

‘‘All. . . fully satisfied

with. . . the

appearance of the

external genitalia’’

1396

Spain ‘‘Minimal

dehiscence’’:

2=15 (13%)

‘‘All . . . stated their

problems of

discomfort and

anxiety had

resolved . . . greater

self-esteem

and confidence

socially and in

their personal

relations’’

Munhoz

et al.,

200641

21 05=1998–

12=2004

38 (31–49) 100% Weekly for

first month,

monthly

thereafter

Complications in 5/21:

Wound dehiscence:

2 (10%)

Flap infection: 1

(5%)

Flap necrosis: 1

(5%)

Hematoma: 1

(5%)

100% (informal

questionnaire

of patient

satisfaction;

independent

surgeon

assessment of

aesthetic

outcome)

6–77 months

(age 46); 3–7

months for

aesthetic

evaluation

Cosmetic outcomes

(surgically judged)

mean

Very good:

18=21 (86%)

Satisfactory:

3=21 (14%)

Residual

asymmetry:

5=21 (24%)

Brazil Patient aesthetic

satisfaction:

Very satisfied: 20=21

(95%)

Satisfied: 5=21 (5%)

aIn some cases, it was hard to tell if follow-up times given were for physical or other follow-up. In those cases, times have been reported in this column.

bNote that some of Alter’s calculations of percentages are based on the total number of surgeries not the total number of respondents. This assumes that no complications were found in those who he

did not physically examine or did not return the questionnaire and that no patients went to other doctors for further surgery. More accurate would be to state that 12=123 (9.78%) required further

surgery, and overall either 18=166 (10.8%) or 18=(166þ123) (6.2%) suffered ‘‘significant complications.’’ (It is not clear how much overlap there was between the questionnaire mailed to all patients and

the physical examination samples, making assessment difficult.)

cNote that in Rouzier et al.’s study, patients were operated on only if their labia minora measured _4 cm, as this was the size deemed necessary for a functional problem and for there to be enough

tissue to produce a satisfactory aesthetic outcome. Rouzier et al. present variable satisfaction rates, making it difficult to assess the study fully. In their table, they report overall satisfaction at 94%.

Elsewhere, they report 83% overall satisfaction, but it is unclear if this figure relates only to the proportion of patients who experienced some complication (e.g., entry dyspareunia postsurgery).

dOutcome details in this report are vague and minimal, making it hard to assess.

1397

psychosocial outcomes9,27,51; ideally, assessment should not

be conducted by those with fiscal interest in the outcome.65

Further, findings from one retrospective qualitative study of

6 women’s experiences of labial reduction61 highlight some

ambivalence in women’s reported satisfaction after the surgery,

51 suggesting that larger-scale qualitative research would

fruitfully generate a fuller understanding of experiences of

women who have had FGCS. Perhaps more importantly, as

Liao et al.6 comment, ‘‘consumer satisfaction should not be

confused with clinical effectiveness.’’

Certain techniques for labiaplasty (excisions) have been

noted to provide ‘‘inadequate cosmetic and functional results’’

66; some commentaries question reported successful

outcomes of a published case43,48,67; and surgeons presenting

a particular technique sometimes outline the limitations,

problems, or risks of other techniques.37 There are no published

studies, however, that directly report the failure of a

technique of labial reduction or other FGCS procedures (although

de Alencar Felicio40 recommends that labiaplasty

and perineum surgery should not be combined because of

adverse outcomes for the patient). However, surgery does

go wrong. Online accounts of ‘‘labiaplasty nightmares’’ are

easily found,68 and surgeons report that they see and attempt

to fix other surgeons’ botched procedures.37,50 One California

labiaplasty surgeon even advertises specifically for

‘‘labiaplasty revision’’ and notes that the number of women

needing labiaplasty ‘‘repairs’’ has ‘‘dramatically increased’’

in recent years.69 Taken as evidence that these procedures

can, and do, go wrong, with often devastating effects for the

patient, it serves to remind us that ‘‘every medical intervention

has a complication and failure rate.’’70 Such stories are a

sobering counterpoint to glorified advertising claims and

media coverage.

These surgeries have been framed by some surgeons in

advertising and websites and in much media coverage as resulting

in a psychological and sexual transformation of the

woman, whose prior poor sex life and low self-esteem have

been restored through the surgery.3 For instance, one group

of surgeons in a letter in Plastic and Reconstructive Surgery

claimed that:

Every one of our patients has been delighted with the results.

Among them was a bathing suit model who came to us

very embarrassed about this problem. She had never had a

serious relationship before the procedure. Shortly thereafter,

she sent us the announcement of her wedding to a professional

golfer.59

Although changes are indeed possible, there is no evidence

to support the frequently made claim that sexual and psychological

changes will (or should) occur.9 Vaginal anatomy

and sexual function are not necessarily associated,71 calling

into question the rationale behind vaginal tightening procedures.

Surgery for various vaginal problems shows no clear

relationship among surgery, vaginal size, and sexual

(dys)function.72–74 Genital surgery on intersex people can affect

both sensation and sex,75,76 and surgeries for vulval cancer

have also been found to negatively affect sexual function.27

Furthermore, it is not yet understood exactly how labia

minora engorgement during sexual arousal may be involved

in sexual pleasure and how labial removal might affect

this.27 That is quite apart from the possibility of damage to

nerves or normal blood vessel supply through surgery.6,9,27,62

Because there are many highly sensitive nerve fibers contained

within the labia minora, which are linked to sexual

arousability, ‘‘incision to any part of the genitalia could

compromise sensitivity—an important aspect of sexual experience.’’

51

The response of some professional bodies has been to advocate

against FGCS. In September 2007, an ACOG committee

published an opinion paper on FGCS,4 which concluded

that:

[These] procedures, including vaginal rejuvenation, designer

vaginoplasty, revirgination, and G-spot amplification, are not

medically indicated, and the safety and effectiveness of these

procedures have not been documented. No adequate studies

have been published assessing the long-term satisfaction,

safety, and complication rates for these procedures.4

Other gynecologists=professional bodies have concurred.

7,77 Less officially, a spokesman for the ASPS was

quoted in the Chicago Sun Times as suggesting the need for

caution, and advising that ‘‘I would think long and hard about

undergoing one of these procedures.’’78 Some gynecologists

are raising their voices publicly and professionally against

current processes, practices, and knowledge,8,9,50 with Renganathan

et al. concluding that ‘‘the available evidence is still

insufficient to counsel the patients regarding the advantages

and complications of cosmetic genital surgery.’’9 More detailed

(and longitudinal) assessment of risk needs to be done,

including in areas currently not reported on, such as obstetrical

complications.6 Goodman argues that ‘‘because genital

plastic surgery involves concepts and procedures that are not

yet fully researched nor understood, stringent guidelines for

training, anesthesia, surgical technique, and postoperative

monitoring, among others, should be established.’’2 Some

guidelines are starting to be developed in Holland.77 However,

despite such critique and the contrast between advertising

and media claims,3,79 no regulation has yet occurred.

The Rationale for FGCS

Women reportedly seek FGCS for aesthetic and/or functional

concerns.6,30,37,56 Some claim aesthetic concerns predominate,

38,39 whereas others highlight functional reasons47

(Table 2). Aesthetic concerns appear primarily linked to a

dislike of some very specific aspect of vulval appearance,

particularly the visibility of labia minora, or their shape, color,

or asymmetry. Reported functional concerns relate to vaginal

‘‘laxity’’ during intercourse or discomfort=irritation from the

labia when exercising, wearing tight clothing, or during intercourse.

2,9 Psychological concerns (e.g., sexual or social

embarrassment) are also noted as a reason women seek surgery.

38,49 Likes et al.27 characterized such ‘‘symptoms’’ as

vague, pointing out that the origin of these is not always fully

investigated. Similarly, in their review of labial reduction,

Liao et al. noted that ‘‘surgery appeared to have been offered

on demand, justified by verbal reports of physical and psychological

difficulties that were not formally evaluated, preor

post-surgery.’’6

Although a focus on function or aesthetics divides the field

of plastic surgery into reconstructive and aesthetic, in reality,

the separation is impossible to sustain.62 Even aesthetic FGCS

procedures are often talked about in functional terms, and

function is invoked through claims of postsurgical psychological

transformation.3 Qualitative research allows a bit more

1398 BRAUN

understanding of the complexity of these motivations, which

are not necessarily unambiguous or simple or discrete.61

Women’s accounts that they sought labiaplasty because of

perceptions of abnormality and the impact of their labial appearance

(or their perception thereof ) on their sex lives61 fit

both media coverage and surgical accounts.3,79 The range of

reasons is also reflected in advertising, which claims both

aesthetic improvements and (functional) increases in sexual

pleasure and psychological well-being.3,79

What is certain is that many women seek surgery to address

psychological concerns. For instance, Giraldo et al.39 claimed

that:

Psychological concerns are the most important reason for

women to have the size of their labia minora reduced. Protuberance

of these genital structures beyond the labia majora is

often considered to be aesthetically and socially inconvenient.

. . . Even after she has been assured that it is simply

congenital and that enlargement of the labia minora normally

has no clinical significance, many women remain dissatisfied

and suffer psychological distress. . . . [Jokes about labia minora]

can logically result in lack of self-confidence, loss of selfesteem,

feelings of belittlement, and diminished libido, with

the consequent psychological repercussions.39

Psychology provides a moral justification80 for cosmetic

surgery, rendering it acceptable. Through reference to psychology,

even aesthetic procedures can be reframed as about

functionality3 and as a legitimate way to move beyond bodily

distress.81,82 For instance, breast augmentation surgery has

been identified as ‘‘a means of establishing congruency between

the body and mind, or developing an embodied self

that was comfortable.’’83 The question of what is functional

and what is aesthetic (and where psychology fits) becomes far

more complicated when FGCS is performed as part of a public

health service51 rather than in private healthcare. However,

the reasons given for surgery may be the ones women think

surgeons want to hear; functional accounts may be emphasized.

9,61 The context of surgeries (public health system, private

healthcare) needs to be taken into account when

evaluating these reported reasons for seeking surgery.

Table 2: Reported Reasons for Seeking Labiaplasty

Study No. of cases Aestheticsa Medical=functional Psychologicala

Alter, 200837 407 402 (98.8%) any aesthetic

54 (13.3%) only aesthetic

348 (85.5%) aesthetic and

discomfort

353 (86.7%) any discomfort

5 (1.2%) only medical

348 (85.5%) discomfort

and aesthetic

Rouzier

et al., 200030

163 (87%) any aesthetic 64%: discomfort in clothing

26%: discomfort exercising

43%: entry dyspareunia

Miklos and

Moore, 200856

131 89 (68%) any aesthetic

49 (37%) only aesthetics

40 (31%) aesthetics

and functional

82 (63%) any functional

42 (32%) only functional

40 (31%) functional and

aesthetics

49=82 (60%) painful=

uncomfortable intercourse

45=82 (55%) discomfort

wearing clothing

38=82 (46%) discomfort

during exercise or activity

Pardo et al., 200657 55 53 (96%) any aesthetic 32 (58%) any functional 13 (24%) any psychological

Munhoz

et al., 200641

21 21 (100%) aesthetic

complaints

13 (62%) interference

with intercourse

10 (48%) poor hygiene

7 (33%) difficulty wearing

tight-fitting pants

Maas and

Hage, 200031

13 ‘‘Most dissatisfied with

the appearance

of their labia’’

13 (100%) functional

problems:

8 (61%) cycling

8 (61%) discomfort with

intercourse

4 (31%) walking

3 (23%) sitting

2 (15%) personal hygiene

9=13 (69%): self-esteem=

aesthetic concerns

Jothilakshmi

et al., 200944

6, aged

11–16

1=6 (17%): labia

too prominent

under swimwear

3=6 (50%)

2, labia caught in

underwear

1, vulval irritation

2=6 (33%)

1, worried about being

teased about long labia

1, embarrassment caused

by long labia

aPsychological reasons (such as embarrassment or self-esteem) were often either not explicitly assessed or appeared to be subsumed under

aesthetic, i.e., nonfunctional, reasons.

FEMALE GENITAL COSMETIC SURGERY 1399

In the case of labiaplasty, a condition designated hypertrophy

of the labia minora84 is used to provide an apparent

medical warrant for labial reduction. Described in early case

reports as labia that ‘‘protruded in a wing-like fashion from

the vulva’’84 or, in Jeffcoate’s Principles of Gynaecology as ‘‘like a

spaniel’s ears,’’30 no explicit measurements of ‘‘abnormal’’

protrusion were initially given.84 Later articles have focused

on defining what counts as ‘‘hypertrophic’’ labia minora—

usually with no apparent evidence base—and this varies

substantially: some researchers claim 5 cm or more from base

to tip,31,42 others claim 4 cm30,43 or 3 cm(defined as ‘‘moderate

to large labia minora hypertrophy’’41). Some offer more specialized

classifications: type I, <2 cm; type II, 2 cm–4 cm; type

III, 4 cm–6 cm; type IV, >6 cm40 or ‘‘lacking true hypertrophy’’

(<2 cm), ‘‘moderate hypertrophy’’ (2–3 cm), and ‘‘severe hypertrophy’’

(4 cmþ).57 Although occasionally identified as ‘‘a

normal variant,’’29 hypertrophy tends to invoke abnormal

anatomy. Pardo et al.,57 for instance, defined labia minora of

<2 cm as of ‘‘normal size’’, which implies that anything larger

is abnormal. Likes et al. concluded that ‘‘the definition itself of

labial hypertrophy lacks scientific evidence.’’27 (Other problematic

aspects of the label hypertrophic labia are discussed later.)

At the broadest level, the underlying rationale for FGCS is

that women ‘‘choose’’ these procedures, without outside influence.

Women undergoing the procedure typically report

that no other individual influenced their feelings or choice to

have FGCS, although one occasionally finds reference to jokes

or comments by others.39 A Dutch study found 14% of a

sample of 482 women reported receiving comments on their

labia from a partner; 7% received comments from other

women.85 In the only study to assess this systematically

among women having FGCS, 6.9% of 131 women reported

being influenced by a male or female sexual partner or

friend.56 The idea of individual choice underpins the ethical

acceptability of the procedure but is problematic, as debates

about and critiques of FGCS show.

Paralleling the proliferation in the last decade of surgeons

who offer FGCS, voices critical of FGCS have also increased.

Coming both from outside medicine3,19,20,65,79,86–91 and inside

medicine=health,4,7–10,51,92–94 as well as outside the academy,

95–97 these voices have raised numerous concerns in relation

to the practice, marketing, and implications for women’s

health, of FGCS. Here, I discuss ethics and choice (two primary

areas of debate), as well as broader issues related to

advertising, aesthetics, and pathologization. As labiaplasty

has tended to predominate in the medical, academic, and

popular writing on this topic and is seen as ‘‘the most established’’

9 FGCS, much of the debate specifically refers to labiaplasty.

These debates intersect with critical scholarship

around women’s bodies and sexualities, (bio)medicalization,

98–103 and neoliberalism, choice and agency,91,104 which

cannot fully be developed in this article.

Ethics, FGCS, and Choice

Discussion of ethics has dominated the biomedical ‘‘debate’’

around FGCS,2,9,27,62,65,66,92,94,105,106 some of which has specifically

related to minors.44,62,77,106 The debate has primarily

invoked three biomedical ethical principles (autonomy, nonmaleficence,

beneficence) and focused on rights, choice=

coercion, and harm=benefit. Some expound the need for additional

principles, such as truth telling and risks,2,27 and touch

on the question of healing vs. happiness.65,66,92 A very narrow

framing of the three common ethical principles may allow for

the claim that FGCS is ethically justified; a broader view raises

more questions.

Although some claim that ‘‘for women who wish to have

cosmetic reconstruction of the external genitalia, there is no

valid reason to deny them this right,’’66 others contend that

‘‘the performance of a procedure for a non-life-threatening

condition, with minimal evidence to support it, is likely to

pose a moral and ethical dilemma.’’9 Liao et al., for instance,

recently concluded that:

Where decisions to operate on healthy sex organs are triggered

by a perceived defect informed by commercial pressures,

where reliable information on risks and benefits is unavailable

and where there is no provision of alternatives because there is

no concerted effort to develop them, the ethics behind informed

consent are vastly compromised.6

Sokol92 takes it further, arguing that doctors ‘‘should not

succumb to requests’’ for FGCS. Some authors view FGCS as

female genital mutilation (FGM)24,25,90; others note that some

FGCS technically violates laws around and fits within (legal)

definitions of FGM,62,87,88,107–109 but this has ‘‘not been subject

to legal scrutiny.’’87 This has been characterized as a ‘‘double

standard of morality’’107 that relies on the idea that Western

women freely choose FGCS.87

Patient choice (autonomy) is most commonly used to ethically

justify FGCS, but the concept needs broader analysis.

For autonomy to operate, the coercive influences a patient

needs to be free from include surgeon practices, and this

covers marketing=advertising.2,65,66,79 ACOG110 noted that

(easily found) marketing terms, such as pioneer and worldleading,

are misleading and potentially attract vulnerable

women.2 If social control is enacted through advertising and

media, which ‘‘create the guise of free choice,’’90 free ‘‘choice’’

becomes culturally circumscribed. Some ask how autonomous

individual choices can be when considerable societal

and media pressure exists for women to alter their appearances66,92,104

and note that ‘‘patient autonomy must answer to

the context in which women are making . . . choices.’’6 The

influence of culture on all women’s perceptions and feelings

about their bodies109,111 and their sexuality112 is well recognized:

bodies gain meaning within historically and culturally

specific contexts.87 Sullivan argues that ‘‘the ethical imperative

is to interrogate the ‘social imaginaries’—the perceptual

schemas—that constitute embodied subjects and their affective

investments in ways that incite and then discriminate

against particular bodies and bodily practices.’’87

Certain sociocultural factors cluster to make women’s

‘‘choice’’ for FGCS almost logical: negative sociocultural representations

of women’s genitalia113 mean ‘‘pudendal disgust

is a social reality’’65; medicalization of sexuality99,114 prioritizes

medical analyses and solutions, obliterating alternative

approaches26; the normalization of cosmetic surgery81,115,116

makes it something for everyone; and the normalization of

pubic hair removal117–120 and pornography65,121 bring visual

attention to (certain versions of ) vulval appearance,77 even as

many women remain unaware of the reality of vulval diversity.

9,77,122 The context also includes media coverage of, and

advertising for, FGCS, which ‘‘may also fuel the desire for

surgery.’’51,65 (See Braun91 for more discussion about

choice=agency=culture and FGCS.)

1400 BRAUN

The notion of informed choice is further rendered problematic

if desire for surgery undermines women’s interest in

risk,51 which is again a complex issue.104 Goodman2 noted

that patients view FGCS as ‘‘relatively risk-free,’’ yet one

media article reported a woman who had received a ‘‘G-shot’’

who could only recall one of the 68 listed risks.123 The principle

of autonomy does not mean the patient’s will must be

obeyed: respect for autonomy can involve talking patients out

of surgeries,92,124 a point raised in relation to cosmetic surgery

generally.70 Tracy125 notes ACOG’s position is that ‘‘although

the decision of a patient to have an elective procedure should

be respected, it doesn’t necessarily have to be adhered to, if

this decision . . . conflicts with the physician’s understanding

of the level of risk.’’125 (Tracy125 also acknowledges the pressures

that gynecologists may experience from patients who

want this procedure and want to pay cash. She suggests this

pressure=coercion may lead doctors to undertake the surgery

and urges caution, as psychotherapy or other interventions

may be successful, and risks are not yet established.) ‘‘First do

no harm’’ must be taken seriously.70

As FGCS can currently be viewed as at least a ‘‘non-evidence

based practice’’51 and even ‘‘an extreme and unproved intervention,’’

51 there is insufficient evidence to claim these procedures

are clearly not harmful,4 nor is there enough to assess

how much risk there might be compared with other more

common elective cosmetic surgeries.125 In sexual medicine,

providing procedures that have been ‘‘demonstrated as ineffective’’

has been deemed unethical.126 Examples discussed

include most penile augmentation, FGM, and, potentially,

male circumcision. FGCS appears also to fit this definition.

What these discussions suggest is that even by narrow

criteria, the ethicality of FGCS is potentially undermined by a

lack of evidence of benefit and of risk or lack thereof. However,

looking more broadly, more complex issues emerge to

muddy the question of ethics further.

Marketing and Medicalization

The influence of commercial imperatives is problematic65 (a

point recently noted in relation to the whole field of cosmetic

surgery70). British surgeons have noted that ‘‘aggressive marketing

has increased the demand for these procedures and

enabled themto flourish despite the paucity of evidence.’’9 In a

recent International Urogynecology Journal editorial, Pauls

claimed that ‘‘what is unique to this area is the patented and

secretive nature of some of themostmarketed technologies and

the large financial gain driving this industry.’’94 Although some

surgeons are publishing case reports of techniques and even

reporting patient satisfaction (however limited their measures

might be9), others are not.One of the surgeonsmost publicizing

of FGCS, Dr. Matlock,55 appears not to have published anything

about his trademarked techniques. However, they are

highly marketed using (ostensibly) evidence-based claims about

outcomes,79 and Matlock offers training (for a fee); trained surgeons

can then advertise—and use—his techniques.

Increasingly, FGCS is being critiqued as part of the wider

medicalization of bodies, sexuality, psychology, and general

life,65,86,92,93 not least in relation to the label, hypertrophic

labia minora. Alternatives to surgery for ‘‘treating’’ sexual or

genital ‘‘problems’’ in women are rarely even raised and certainly

not promoted in much medical and popular discourse

about FGCS.89 The message is not that women should be

encouraged to develop a healthy sexuality. It is ‘‘that a

‘problematic’ vagina . . . can be fixed through surgery’’ rather

than change anything else,127 such as a bike seat, for instance.

77 A key question is whether surgery treats a preexisting

problem or it is a case of disease mongering.128

Conroy24 has argued that it is disease mongering and that

Western medicine ‘‘is driving the advance of female genital

mutilation by promoting the fear in women that what is a

natural biological variation is a defect, a problem requiring

the knife.’’24 Liao and Creighton suggest that ‘‘the provision of

genitoplasty could narrow acceptable ranges [for labia minora]

further and increase the demand for surgery even

more.’’51 Although disputed by surgeons operating in this

area,129 there is the potential that ‘‘a brand-new worry is being

created’’88 by the ‘‘existence and deployment of new flesh

technologies.’’89

It is also important to question the aesthetic ideals and

norms that may be being created.86 Very few surgeons note

that all female genitalia ‘‘are, in principle, normal’’42,47 and

that ‘‘the perception of female genital beauty is very much

culturally dependent.’’47 Alter’s account that ‘‘most consider

an aesthetic ideal as labia minora and clitoral hood that do not

protrude past the labia majora’’37 seems typical. What women

reportedly seek through FGCS is a ‘‘neat’’ vulva that resembles

that of a prepubescent girl51,62,130; a fleshy but smoothskinned

(and firm) vulva, with labia minora that do not

‘‘protrude’’ beyond the labia majora; a ‘‘nicely’’ hooded and

‘‘contained’’ clitoris, as well as a ‘‘tight’’ vagina. Accounts and

marketing of these procedures, including before and after

photos, promote this particular aesthetic as the vulval ideal.79

This ‘‘ideal’’ vulva exists at one end of the spectrum of normality

and diversity related to shapes, sizes, colors, proportions

and distances,131–133 as well as age.62,72,132 That Lloyd

et al.131 reported no significant association between any genital

measurement and age, parity, ethnicity, hormone use, or

history of sexual activity is relevant, as such factors are still

claimed as relevant ‘‘causes’’ of labial enlargement.39 The idea

of a cause, which some authors seek to provide,43,45 frames

large labia minora in women as unnatural (prepubescent girls

with hypertrophic labia is a different story45). Furthermore,

some surgeons explicitly identify labial asymmetry as ‘‘a

morphological defect’’57 and promote symmetry as the goal37;

only one40 reports asymmetry as normal (which it is, both in

outcome132 and developmentally62) and attempts to retain

some labial asymmetry after labiaplasty.

Genital Aesthetics, Pathologization, and Production

of New Anxieties

The question to consider is whether new anxieties and,

thus, markets are being created through the promotion of

these surgeries and (implicitly and explicitly) a particular,

narrow, vulval ideal. In a context where there seems still to be

little general understanding of female genital diversity,77,122

the effect of a narrow representation of aesthetic ideals has

been questioned.6 Some women already report feeling that

their labia minora are not normal,31,34,77 especially if there is

any labia minora ‘‘protrusion’’ or asymmetry. A recent Dutch

survey85 reported nearly half (43%) of 482 respondents sampled

at three sites (mean ages 22, 40, 41) considered labia

minora appearance important, and 76% frequently examined

their own labia minora; 38% paid regular attention to the

FEMALE GENITAL COSMETIC SURGERY 1401

appearance of other women’s labia minora. Seventy-one

percent considered their appearance to be normal, 14% abnormal,

and 7% had considered labiaplasty (this was higher

among the older participants). The authors considered this

evidence that ‘‘a new problem is evolving: heightened concern

with the appearance of the female genitalia.’’85,134

Pathologization of vulval diversity is occurring,86 which is the

reappearance of an old ‘‘problem’’. ‘‘Long’’ labia have for a long

time been taken as indicative of vulval and feminine pathology88;

historically, measurement of women’s vulvas aimed to

identify associations between genital morphology and ‘‘conditions’’,

such as lesbianism.135–138 An interest in genital measurement

and what it might mean continues around intersex

individuals, where genitals beyond (or within) certain dimensions

were framed as not male and not female and, thus, problematic

and (typically) needing surgery.139,140 It also continues

in discussion of the ‘‘C-V distance’’, that between a woman’s

vagina and her glans clitoris; a recent LA Times article reported

research that claimed that a distance of<2.5 cm‘‘yield[s] reliable

orgasms during sex’’141—‘‘sex’’ being intercourse.

In the FGCS literature, there is a more general contradiction

between recognizing and acknowledging genital diversity

and framing labial size as a problem. For instance, ‘‘there is a

great variation in the size of the labia minora. When enlargement

occurs. . . .’’33 The word enlargement signals a state

beyond normal but relies on presumptions of normality to

determine what is actually enlarged. Such terms are applied

to normal variation; for instance, the labia minora described

by di Saia38 as ‘‘enlarged’’ fit well within the range of normal

labia minora demonstrated by Lloyd et al.131 Language is not

simply a tool for information transfer; it is bound up in the

creation of reality as it represents it.142,143 It (re)produces ideas

about normality and pathology. The label hypertrophy is a

perfect example of what might otherwise be normal variation

becoming a legitimate problem—a pathological condition.

There is anecdotal evidence that this language has shifted

outside the realm of medical diagnosis.144

In a published debate on labiaplasty ethics, Bachmann

noted that ‘‘language should be avoided that infers that the

labia minora, labia majora, clitoral hood, or the mons pubis

are misshaped or ugly and, through surgery, can be ‘restored’

to a more appealing size and shape.’’66 However, such language

is rife around FGCS.79 A key challenge for women’s

health professionals and educators is developing a different

language for labia minora, which does not implicitly reinforce

the perception that there is a normal=desirable state (i.e.,

‘‘contained’’) and an undesirable and pathological state (i.e.,

‘‘protruding’’).

The narrow aesthetic has been linked to mainstream pornography.

In Matlock’s book, Sex by Design,145 the chapter on

labial reduction is titled ‘‘Centerfold Material: Aesthetic Improvements

with Designer Laser Vaginoplasty.’’145 Matlock

claims many women ‘‘want Playboy-pretty outer vaginas

(aesthetically-pleasing vulvar structures).’’145 His unreflexive

reiteration of pornography images as the vulval ideal (an association

critically noted by many others) illustrates an important

point: surgeons bring culturally influenced personal

values and preferences to the work they do.146,147 They may

also lack knowledge of ‘‘normality’’ in relation to labial diversity

and size.77 How healthcare professionals treat women’s

labial or vulval concerns can reinforce a perception of

abnormality or challenge it. Although some surgeons note

that reassurance of vulval normality and diversity is usually

enough to allay patient concerns,42,43 an assurance of normality

alongside a referral to a specialist can actually tell the

woman that she is ‘‘outside the sphere of normal genital appearance.’’

61 That such doctor-patient interactions, which

might otherwise seem patient centered and good practice,

could reinforce women’s negative genital perceptions indicates

a need to think carefully through how genital concerns

are managed in healthcare settings. At present, only one set of

guidelines (related to labia reduction requests specifically) has

been produced for gynecologists.77

Ramifications of FGCS into the Future

Although one might imagine that FGCS is an unlikely curiosity,

general popularity apparently is increasing. Media

coverage of new surgical interventions ‘‘seduc[es] more individuals

to place their bodies under the surgeon’s knife,’’148,149

and this appears to be happening for FGCS. Although a different

procedure in many ways, breast augmentation can be

used to explore future possibilities for FGCS. Breast augmentation

was, like FGCS, legitimized (in the 1950s) as a solution to

a newly created condition, hypomastia,19 but has since expanded

well beyond the realm of medical ‘‘necessity’’. It has

risen rapidly, froma relatively rare operation to being the most

common cosmetic surgical procedure in the United States in

recent years;54,150 for instance, ASAPS data indicate procedures

more than trebled between 1997 and 2008.54 A comparison

made by a surgeon who offers FGCS, and ‘‘it’s sort of

coming out of the closet. It’s basically where breast augmentation

was 30 years ago,’’151 offers little to suggest FGCS will

prove to be a passing curiosity rather than, as one Australian

plastic surgeon claimed about labiaplasty, procedures that are

‘‘here to stay.’’50 FGCS potentially will become a sexual and

reproductive health intervention that many women express

interest in in the future and, thus, warrants critical attention

now for both clinical practice and research.

I believe we have an ethical obligation to question technological

bodily interventions that have inadequate evidence

bases behind them and from which surgeons earn considerable

income. I am not suggesting that the natural body is an

ontological truth or that any (aesthetic) technological intervention

into women’s bodies is a priori wrong. In the case of

FGCS, however, these interventions have many problematic

dimensions. Writing about FGCS, Wilding called for ‘‘resistance

to the unquestioned technological solutions to issues that

have profound psychological, emotional, cultural, and even

political origins and histories.’’89 This article has aimed to take

discussion of FGCS beyond the medical to show that surgery

need not become an unquestioned solution to genital distress.

Changes claimed to be associated with FGCS are not just

to do with material bodies; they are about psychology and

the sociocultural. Smaller labia do not create more selfconfidence;

the mind does that. There are undoubtedly many

women with ‘‘small’’ and symmetrical labia minora who are

not bursting with (sexual) self-confidence. Likewise, the perception

that asymmetrical labia are disgusting, or simply

sexually undesirable, does not reflect a material truth; it is a

personal judgment that reflects certain sociocultural messages

about genital morphology.113 Similarly, the idea that surgery

will resolve this ‘‘problem’’ is not a natural one; it is logical in a

context of the medicalization of women’s sexuality,99,114 the

1402 BRAUN

normalization of cosmetic surgery,115,152 and the promotion of

FGCS.79 The body is always socioculturally produced and

mediated, and so is the mind. What is individually seen,

known, experienced, and desired is culturally produced; it

does not emerge purely from mental perceptual processes and

material cell masses.

These ‘‘debates’’ about FGCS unfortunately tend to polarize

around a perceived dichotomy: that either these procedures

are helping patients and relieving a preexisting distress or the

procedures and their advertising are creating a new problem, a

new market and ‘‘fueling a dangerous situation.’’94 Instead of

thinking in dichotomous terms, it is most fruitful to see that

FGCS can be both of these, simultaneously. It can potentially

relieve the distress an individual woman feels and may even

improve her self-esteem and sex life (although the evidence for

this is not adequate). At the same time, however, the promotion

of this intervention is creating a situation that is worse for

women overall, one in which women have yet another body

worry and a particular genital normto live up to. In this way, it

can be seen as disempowering for women as a group. Thus,

whereas surgery might provide ‘‘genital liberation’’ for individual

women, it does nothing to improve the context in which

women ‘‘choose’’ these procedures. Arguably, the practice and

promotion of FGCS render women’s genitalia surgical,81 reinforcing

a model of women’s genitalia as in need of surgery

and women’s genital concerns as fixable through surgery.3

Conclusions

I have reviewed and evaluated the evidence that currently

exists about FGCS and discussed the burgeoning debates

about it. Significant concerns exist in relation to the safety

and efficacy of these procedures, not least because the evidence

that currently exists is of questionable quality. FGCS

currently should be classified as a set of procedures not

clinically indicated and without an evidence base to support

their efficacy. As the debates about FGCS show, the contexts

and practice of FGCS are far more complex and nuanced

than is typically acknowledged within clinical reporting of

techniques and surgical outcomes. There remain troubling

concerns related to such areas as ethics, choice, pathologization,

and medicalization. It seems vital that the level of

debate about FGCS be kept broad and critical if FGCS is not

to become a commonplace, unquestioned cosmetic group of

procedures.

At the very least, I would endorse Tiefer’s call for:

a ban on consumer advertising; research that is not funded by

industry; multimethod research which includes long-term

psychosocial as well as biomedical measures; comprehensive

sex education; attention to gender differences in the sources of

distress and dissatisfaction; professional sanctions for conflicts

of interest; and disclosure and transparency by all professionals

involved.65

In relation to FGCS, we are far from this situation at present.

At a practical level, guidelines for dealing with patient requests=

concerns are being developed,2,77 which is an important

step. The issue of adequate surgical training153 remains

another.

FGCS presents a potentially complex challenge for providers

of women’s health services who aim to intervene to

relieve patient distress in regard to genital appearance. The

professional and public discussion around FGCS needs to be

far broader than whether or not surgery might resolve an

individual woman’s concerns. As well as reviewing evidence

about FGCS, this article has summarized key debates in order

to aid critical discussion about this problematic form of cosmetic

intervention.

Disclosure Statement

The author has no conflicts of interest to report.

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Address correspondence to:

Virginia Braun, Ph.D.

Department of Psychology

The University of Auckland

Private Bag 92019

Auckland Mail Centre 1142

Auckland

New Zealand

E-mail: v.braun@auckland.ac.nz

FEMALE GENITAL COSMETIC SURGERY 1407

 

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