The harms of medicoplastyBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1983 (Published 07 October 2008) Cite this as: BMJ 2008;337:a1983
- Daniel K Sokol, lecturer in medical ethics and law, St George’s, University of London
The 16th century French author and physician Rabelais was obsessed with vaginas. In one of his stories an old lady drives the devil away by showing him her vagina.1 Today the devil might recommend she go to the nearest aesthetic surgeon for vaginal rejuvenation. A touch off the labia (labioplasty), a bit of tightening here (vaginoplasty), and voilà: a designer vagina.
The number of cosmetic genital operations is seemingly on the rise.2 3 4 The British Association of Aesthetic Plastic Surgeons, in its section on genital surgery, notes: “With a growing acceptance of surgery designed to alter appearance, and the increasing availability of explicit images of naked women, a number of women are requesting surgery to alter their intimate appearance, feeling that they compare unfavourably.”5
Here is my paternalistic view: medical professionals, whether working in the private or public sector, should not succumb to these requests. Although it would be hard to argue that anyone seeking aesthetic genital surgery is unable to make an informed decision, it is plausible to argue that patients’ autonomy is often diminished by strong social or peer pressures. A female friend once told me how fat and ugly she felt after reading a popular woman’s magazine. She was neither fat nor ugly. A drug company promoting a drug for hair loss—an issue close to my heart—urged balding men to consult their doctor. In a leading website on hair loss, sponsored by a drug company, a poll asks: “Have you felt less attractive since you started losing your hair?” Women seeking cosmetic genital surgery often bring pictures of their ideal vagina from advertisements or pornography.4 Creating or exploiting insecurities is a lucrative business.
Advertisements for cosmetic surgery are also manipulative, if not downright deceptive. How radiant and stunning the (digitally enhanced) models look! How easy and stress free the procedure is! The sheer number of advertisements and their wide exposure in public spaces suggest to passers-by that cosmetic surgery is not much different from a trip to the hairdresser.
In the eyes of the public, doctors are doctors, whether they practise in Harley Street or in an NHS hospital. Although aesthetic surgeons are a minority, their actions affect the image of the entire profession. Some genital operations, such as in vaginal prolapse or the reduction of grossly enlarged labia, are medically indicated; but if we extend the remit of medicine to capture requests for treatment on anatomically normal structures that has clear harms and uncertain benefit, the public’s perception of doctors may suffer—all the more so if financial gain is involved.
The public may lose trust because such procedures deviate from the spirit of the Hippocratic oath. As medical science progresses, the oath retracts further into the communal consciousness of medicine, a distant star whose brightness is fading. Many medical students now only know its name. We should not let it fade, for it is the medical profession’s guiding star. Although some parts of the oath are out of date, others contain unchanging truths: “I will use treatments for the benefit of the ill in accordance with my ability and my judgment, but from what is to their harm or injustice I will keep them.”6
The key phrase is “for the benefit of the ill.” What constitutes an illness is not always easy to define (the philosopher Georges Canguilhem reflected on the changeable nature of the normal and the pathological decades ago7), and grey areas exist, but a vagina that is not sufficiently tight according to the opinion of a partner or some pornographic ideal is no illness. The acquiescence of aesthetic surgeons, however, may help create a new illness.
In the transition from NHS to private doctor it is easy to slip, quite imperceptibly, into a more business minded mode. The patient becomes a client, and the provider-client partnership may seem to differ from the doctor-patient relationship. In an act of self deception we can lose sight of our conflict of interest and accede to the ill thought out wishes of patients, dismissing the lure of money and hiding behind the convenient belief that it is the patient’s autonomous choice: “If that’s what they really want, and they understand the risks, then who am I to question it?” The answer is: you are a doctor, not a tattoo artist. Committed to the Hippocratic ideal of treating the sick, doctors should not be complicit in the medicalisation of the normal by fulfilling the aesthetic desires of the worried well. Far from doing them good, they may let them down. Protecting patients—or keeping them from harm, in the words of the oath—may require persuading them that surgery is not the answer.
Today’s doctors, like the Rabelaisian devil, should walk away from patients who ask for aesthetic genital surgery. Their wallets will be less full, but their integrity will remain. By altering the shape of women’s normal labia and other similar procedures, doctors are altering the character of medicine. Such medicoplasty has many risks and few benefits. Clinicians of all stripes, not just surgeons in the Hippocratic tradition, should speak out against “Hollywood” practitioners. The reputation of the medical profession, laboriously built up since physicians began to be university trained around the 13th century, is under threat.
Cite this as: BMJ 2008;337:a1983
Thanks to Janice Rymer, Ronald Sokol, Anna Smajdor, David Hobson, and Thomas Palser for their helpful comments.