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Promoting cosmetic surgery

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7535 (Published 08 November 2012) Cite this as: BMJ 2012;345:e7535

Re: Promoting cosmetic surgery

The subject of female genital cosmetic surgery is a node at the intersection of a number of deep and complex debates within UK society.

The first is the issue of normality. Statistically normality is concerned with acceptable deviations from the mean but normality is more often socially defined in terms of tolerability. The crucial issue then becomes who or what decides what is tolerable. Should society define normality? Should normality be defined by the medical profession and if so should this be a collective decision or an individual one? Should normality be defined by the person who is paying the surgical bill? If this is the case, is cosmetic surgery unacceptable on the NHS but acceptable if paid for privately?

Cosmetic dentistry rarely attracts the same criticism as cosmetic genito-plasty.
This brings into consideration a second issue, which is the way in which the value of a woman is socially defined. Feminist sociology has argued that women are demeaned by visual objectification which defines their worth by their bodily appearance. Objectification can be internalised so that some women define their own worth, according to their appearance, judged on a scale of perceived masculine preference. The cultural trap created by this internalisation is that the appearance of feminine perfection is an artificial creation, aided by air-brushing, make-up, depilation and cosmetic surgery. It is ultimately unobtainable (or at any rate unsustainable). A strange aspect of the cultural subjection of women to value judgements based on unobtainable perfection is that any number of individual men and women may disagree with the judgement, but at a broad cultural level, it remains. Cosmetic genital surgery vividly feeds the myth of female bodily perfection, under the guise of ‘normality’. If the debate about cosmetic surgery focussed around teeth or ears, the underlying issue of cultural misogyny would be less apparent.

Finally the tension between autonomy, consent and non-malificence is pertinent for the medical profession. In general if a competent adult fully understands the risks and benefits of a procedure, consents to it, (and is able to pay for it), then respect for his or her autonomy would indicate that the procedure should be carried out. This is not always so straightforward. If an adult makes a request for surgery which seems to be against his or her best interest, we may question whether he or she is competent to consent. An example might be the refusal to operate on someone who requests extreme surgery because of underlying body dysmorphic disorder. We might also question whether the person has come under undue pressure to request the procedure, which is close to the stance the profession takes on requests for FGM, even if requested by the woman herself. Arguably a request for cosmetic genito-plasty could fall into this category, with the undue pressure arising from cultural expectation, interpreted by someone especially vulnerable. The problem with this approach is that it quickly slides into medical paternalism (or maternalism) and a rejection of women’s autonomy and capacity to consent. Any blanket diminution of female autonomy by the medical profession must be treated with the utmost caution.

As a woman and a doctor my gut instinct is to reject cosmetic genito-plasty and support measures which lead to it being restricted or banned. Nonetheless there are complex issues involved which deserve to be debated more fully, and which may lead to a greater understanding of the cultural context in which female cosmetic genital surgery occurs.

Competing interests: No competing interests

20 November 2012
Susan H Walker
Senior Lecturer in Sexual Health
Anglia Ruskin University
Rivermead Campus, Bishop Hall Lane, Chelmsford, CM1 1SQ
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