As someone very interested in the field of the medical humanities, I spend a lot of time reading journal articles and books grounded in fields of medical anthropology, medical sociology, social medicine, and the history of medicine. Having come across many different diseases and etiologies, I have, however, never come across any work related to labiaplasty. Therefore, when I learnt Hayley Cundill, a recent graduate of medical anthropology from The University of Pretoria, had written her master’s thesis about labiaplasty, I reached out for an interview.
Labiaplasty is a plastic surgery procedure done to alter the size, typically by reduction, of the labia minora or labia majora, the folds of skin surrounding the vulva. One of the most important things I learnt upon reading Hayley’s thesis is that I do not know the anatomy of the female genital region and nor do a lot of my female or male friends. Commonly, if not always, this region goes by the name of the vagina – a label I have given it my entire life, along with all my biology and PSHE teachers. What we really mean, however, is the vulva. The vulva is the female genital region situated on the outside of the body and includes the labia majora, labia minora, clitoris, clitoral hood, urethral opening, and vaginal opening. So what is the vagina you may wonder? The vagina is the muscular canal where babies and menstrual blood pass through. It is also the area of the female genitals that a penis will penetrate during sex – could this by why vagina is the go-to name not vulva? I wonder. Learning that I had been wrong about the anatomy of my genitals for almost twenty-one years of my life felt unsettling, shocking, and sad. How could I have been a woman for this long, attended an all-girls school for five years and also developed a deep interest in medicine, biology and health and not known this? Importantly, addressing this anatomical knowledge gap and highlighting the correct terminology now is essential for the rest of this article.
Where such little research has been done on labiaplasty, my first question for Hayley was why she decided to explore it: “Three of four years ago I came across an article in the cosmopolitan on the ‘barbie vagina’ and was really amused by it because from my experience, from what I can remember as a young girl, a barbie doesn’t have one – it just has a flat area of plastic.” While the timing wasn’t right then for an in depth research project about this topic, Hayley kept it in the back of her mind, becoming particularly reinterested when Hannah Dines, a Paralympic cyclist, spoke about having to get labiaplasty because her cycling seat had damaged her vulva so badly: “This was when I was like okay wow, labiaplasty is a thing and its happening a lot more frequently than we think. I began wondering whether this is something that was happening in South Africa and wanted to explore how popular it was. That was kind of where I started”.
To explore this, Hayley conducted an ethnography amongst plastic surgeons, aesthetic gynaecologists, clinical sexologists, and sexual health advocates based in South Africa. Her research, while focusing on such a niche topic and surgical procedure, catalyses many, big, relevant questions about societal beauty standards, the historical production of scientific knowledge, and ethical questions related to the recording of data. Importantly, Hayley’s research on labiaplasty falls at a very unique time where we have multiple, trending surgical vulva procedures happening simultaneously: the husband stitch, a procedure that happens after vaginal birth where tears in the vaginal opening get repaired so that it retains its tightness and consequently, pleasure for penal penetration, and FGM, a widespread procedure commonly occurring in South Africa, Kenya, and the middle east where the vaginal opening is sewed up to prevent a woman from having sex. And then of course labiaplasty, which happens a lot, just never spoken about. Where much research has been produced on FGM, Hayley felt it particularly important to explore labiaplasty and generally what constitutes genital mutilation: “I think the narrative we have about these different procedures at the moment is really interesting. I heard a lot that labiaplasty is empowering for a woman and especially because it isn’t FGM. The idea of putting this on a pedestal because it’s not FGM, it’s something you choose to do, it’s not something that’s done to you, is interesting. I think it's over simplistic to place these two in complete opposition to each other - the lines are blurred”.
A further unique element to Hayley’s research was her choice of anthropological method: studying up. Where anthropology has almost exclusively focused on exploring those beneath us, largely because these groups of people are more accessible and less private, consequently, those above us, those in positions of power, are seldom studied. On why this particular method was suitable for her research, she said: “Firstly, it was the time frame – finding women who had had labiaplasty and were happy to speak about it would have been incredibly hard and of course getting ethical approval for that too would have been hard. Doctors however would be much more comfortable talking about pieces of anatomy whereas a woman might feel a little bit shy. Secondly, I was also really inspired by a French anthropologist, Bruno Latour, whose book ‘Laboratory Life’ discusses how you can’t produce scientific knowledge without acknowledging the social processes behind it. As someone studying scientists and therefore people in a social stratum above him, he was studying up. Thirdly, I think it is a really interesting method: it allows anthropologists to access spaces and therefore knowledge that usually we don’t get access to. For example, as a general person you don’t just have access to the knowledge of a plastic surgeon. But as an anthropologist who is employing this method of ‘studying up’ you have a very privileged place to be able to access these spaces. And, lastly, my main aim was trying to get the knowledge from where it came from. I wasn’t trying to understand surgical procedures from a patient’s perspective, it was more about trying to understand a trending surgery or trending aesthetic from a doctor’s or surgeon’s point of view. In this sense, this method just fit my aims very well."
Hayley’s thesis begins with a vignette of her familiarizing herself with and getting comfortable saying the word ‘vagina’ : ‘vagina, vagina, vagina’ she repeats to herself in the car, later learning to reframe as ‘vulva’ of course. I asked Hayley what her experience was of learning the correct anatomical names and whether her comfortableness saying them changed over time: “All throughout our lives we tend to only use nicknames for a part of our anatomy, and I did feel uncomfortable saying the correct terms all the time - it definitely wasn’t a natural thing for me to do. But, from talking to the sexual health advocates I spoke to, it became very important that we use the accurate names because there is a certain truth to using the right name: for example, the vagina and the vulva. Also, it wasn’t awkward for the doctors or surgeons – they are used to it - so I wanted to get comfortable with it too because we shouldn’t feel awkward about it. It was sort of overcoming a personal hurdle and realizing the impact of being comfortable with it.” Upon hearing Hayley say this I started remembering all the nicknames and pseudonyms I had given my vulva: v-area, ‘down there’, ‘that area’, *break in sentence and hope they fill in the blank*. Noticing this again made me unsettled: why had I never had the confidence to say the correct terms? Of course, partly because I simply did not know the right terminology, but ‘vagina’? Could I not have at least managed that?
The answer to this lies in a very important part of Hayley’s research: history. “When we look back in history, we have to look at what body has been affirmed, and that isn’t a black body, or a woman’s body, it is a white, male body. And also looking at the history of aesthetics and how social ideas shape aesthetics and ideas of the ‘body beautiful’. I only really start at the end of the renaissance period, but these issues about women's anatomy being a myth and silenced goes way back”, said Hayley. She mentioned that at the start of this project she never expected to become so interested and passionate about the role of history in women’s health, but that now she is fascinated by it and hopes to become part of the scholarship that is interrogating why women's health has been shaped the way it has. Clearly then, my inability to say the right word was the result of years of silencing and oppression of women and their anatomy. Importantly, years of subpar sexual health education had a role to play too.
Upon discussing the topic of sexual health education, Hayley and I seemed to go back and forth exchanging stories, memories, and remarks about how terrible our sexual health education had been. The relationship between sexual health education and labiaplasty was of particular importance to the sexual health advocates Hayley interviewed: where the plastic surgeons and aesthetic gynaecologists cited social media and therefore a dissipation and subsequent homogenization of beauty ideals as reasons for why women desire a ‘neat’ and ‘tucked’ vulva through labiaplasty, the sexual health advocates blamed a lack of comprehensive sexual health education. “I really resonated with that because of course if you don’t understand the natural variants of a vulva, then of course you are going to compare yours to others and then want to change it through labiaplasty”. In only a snapshot of our tennis game of ‘How Bad Was Your Sexual Health Education’, we discussed how sexual health education for girls is very preventative in tone and style, focused on how not to get pregnant or get an STD: “We get shown these big, scary, gross photos of STD-infected genitals and that’s commonly where the ‘education’ stops. But what does that really teach someone about having sex and about how their anatomy looks and works. Not very much. We have this whole taboo around it because ‘oh what if she gets pregnant’ but it’s actually about drawing to light that there are natural variants of a vulva and you don’t need to feel insecure about it.”
The idea of naturality, of having a ‘natural’ vulva or anatomy more broadly, is another theme that Hayley interrogates in her research. Tied to ideas of symmetry, our notion of what a natural anatomical part looks like has changed significantly. As Hayley illustrates, nowadays, we are seeing an increasing trend and desire for something that is fake, but looks natural and authentic, consequently allowing us to ‘pass’ as normal, natural, or in some cases, western looking. This can especially be seen in the case of eyelid surgery in North Korea - a surgery that inserts a slight crease in the eyelid to make someone appear more European, Europeanism of course being linked to ideas of higher employability and beauty. In relation to vulvas, Hayley explains that women have a desire to achieve a ‘constructed aesthetic’ that is a natural looking, short and symmetrical labia, implying that long, asymmetrical labia are unnatural, which, in fact they are not. I was curious then as to whether the plastic surgeons and aesthetic gynaecologists, through providing labiaplasty, were actually reinforcing these damaging beliefs about what constitutes a natural or unnatural vulva: “I don’t think it is a deliberate perpetuation of these ideas – I think it’s a socialization of medical ideas about what the body looks like. That for me was why history is so important because these ideas have such a long and painful history that have been reproduced and reproduced and reinforced and reinforced. I think because of these historical ideas that long labia are synonymous with a ‘primitive’ woman, as anthropologists then would write, it has become so entrenched in society. Of course, medical knowledge production isn’t separate or cut off from society, so it gets interwoven.” Acknowledging anthropology and medicine's dark past, Hayley said that “we definitely have ourselves to be accountable about where these ideas have come from. We should be questioning these ideas a lot more”.
The idea of there having been a medicalization of societal ideas into standardized surgical practice was particularly interesting. Where symmetry is associated with the ‘perfect’ vulva, symmetry as a state and shape, is also the desired outcome for surgeons. In surgical practice and part and parcel of ‘the art of surgery’, is the aim to make something look symmetrical: “With surgery I guess the whole idea is trying to make something look natural and for them this is achieved through making it symmetrical. But often things that are natural aren’t symmetrical, our vulva being a prime example,” said Hayley. In this sense, the production of these ideas seems to operate in a vicious cycle, with one element reinforcing the other. This raised questions for me regarding the role of a doctor and concepts of doing no harm and iatrogenesis, especially in relation to mental health. Commenting on this, Hayley said: “I found it interesting when the plastic surgeons would describe labiaplasty as being a type of therapy as it removes someone's insecurities. But then, with the sexual health advocates, they would say ‘well if mental health is so important then shouldn’t we be educating people, not doing surgery on them?’” As with many debates regarding medicalization, here there exists a dual viewpoint – one being a short-term fix, and the other long term.
Through discussing this further and highlighting more of the complexities surrounding labiaplasty, I came to realize that plastic surgery is, in fact, a very complex specialty. All too often, we consider plastic surgeons as doing boob jobs on Harley Street for rich clients and enjoying nice holidays. But, as Hayley’s thesis highlights, there are, unsurprisingly, many more elements to it. Firstly, plastic surgery can be considered one of the few specialties where a patient will tell the plastic surgeon what they want - the patient will come to them. By comparison, in most other specialties, while shared-management plans exist of course, it is largely guided by the doctor, who adopts a paternalistic role all throughout. Secondly, and related to this, is managing patient expectations: “It is one of those specialties where managing patient expectations is very intense, especially if plastic surgeons see any botched surgeries. I think we often see plastic surgery as a very simple space but actually there’s loads of things chucked into one bowl and there’s no right answer for everything”, said Hayley. Developing, Hayley said a further factor that complicates plastic surgery and makes managing patient expectations harder, is issues such as body dysmorphia: “One of the plastic surgeons I interviewed had a patient of his return who had had a facelift done. She came to him basically kicking and screaming saying ‘my earlobes are 8mm out!’. His response to this was ‘well thank god for surgical pictures because they clearly show there is less than a 1mm difference between them’”. In this sense, sometimes surgeons can only do so much before the perception of our own body comes into play – as the saying goes: if you go looking for it, you will probably find it.
The issue of botched surgeries raised questions for Hayley regarding the recording of data. Throughout her research, she frequently found she couldn’t access any data relating to how many labiaplasties had happened. By comparison, with the NHS, this information is readily available and easily accessible. Commenting on this, she said: “This really shocked me. Here in South Africa, we have such a divide between public and private medical practice. Private practice really is a space where certain things aren’t regulated, there’s no state oversight over how and why things are happening. For example, if you, as a private practice doctor, put something different down or record it differently then no one is going to know. One of the doctors I asked about this said, ‘I mean you can go and find that data, it is sitting in doctors rooms, but it will take you too much time so I wouldn't bother’. This really unsettled me.” Importantly, Hayley also highlighted that for other plastic surgeons there is huge push to produce accurate data and achieve transparency: “This was another juxtaposition and complexity which I found fascinating but also scary”.
Speaking of being unsettled, personally, I was slightly taken aback by the references to the women getting a labiaplasty who are therefore seeking a ‘childlike’ or ‘pre-pubescent’ looking vulva. Upon discussing this with Hayley, she said that, for her, this parallels ‘the husband stitch’ - of needing to be what we were before childbirth. Again, highlighting the positive role adequate education can play, she said: “We need girls to be learning about what happens after birth and the changes that happen to your vulva and vagina afterwards and most importantly, that it is normal. Without education you have no idea what is happening”. I remarked that it would be interesting to see what a woman seeking labiaplasty would say if someone described her desired vulva in this way: “So you would like it to look childlike?”. I wonder whether painting it in this way might make her question why she is seeking this surgery and where the motivation has come from.
Overall, Hayley’s ethnography raises some seminal questions and points. Primarily, is the issue of female genitalia having been silenced, rejected, and hypersexualized all throughout history, and related to that, issues relating to which bodies are affirmed in society and which aren’t. Hayley’s work, through an exploration of medical history, taps into the ugly, sexist, and oppressive side of history, posing questions for the current trajectory of medical practice and production of scientific knowledge. In a similar vein, while her subject position and lack of available data didn't allow for an interrogation, Hayley’s research also raises questions about a black woman’s sexual experience and awareness of her anatomy. Further, in speaking to plastic surgeons, it highlights the complexities of plastic surgery and situates it as a specialty in the epicentre of important discussions regarding the normative body. And, through gaining sexual health advocates insight, it paints vivid the importance of adequate sexual health education in teaching girls and women about their anatomy and how to enjoy sex - not as something purely for reproductive purposes, but for her own pleasure.
Through interviewing Hayley and reading her thesis, I feel considerably more empowered to be a woman, aware of my anatomy and of where the insecurities I sometimes have about my own vulva originate from. Upon asking Hayley what she hopes will come from her research, she said: “I hope that the small bit I have done starts a conversation about the views of and taboo about labiaplasty, why vaginas, vulvas and labias look the way they do and why we haven’t really spoken about it. I hope that this starts a discussion for something else”. Finally, if in reading this article you felt slightly uncomfortable with all the references to female anatomy, I hope you are now able to begin questioning and understanding why. For now though, “vulva, vulva, vulva!”, I say loud and proud.