Female Genital Cosmetic Surgery: Deviance, Desire and the Pursuit of Perfection

Text of a lecture given by Camille Nurka at the Women in Time Symposium, 30 November 2018, UTAS, Hobart, in association with the Australian Women’s History Network

I would like to say thank you to Paige Gleeson, Honey Dower, Frieda Moran and Penny Edmonds for very kindly inviting me to speak about my book, Female Genital Cosmetic Surgery: Deviance, Desire and the Pursuit of Perfection (Palgrave 2019). The book seeks to historicise the contemporary phenomenon of cosmetic labiaplasty, which is a surgical procedure that involves cutting back protuberant labia minora so that they are either entirely hidden by or sit flush with the lips of the labia majora. The main factors that prompt women to seek labiaplasty are fears of abnormality and concerns about aesthetic appearance, and problems with physical comfort, hygiene and sexual function. According to Australian cosmetic surgery chain Esteem Cosmetic Studio, the best candidates for labiaplasty ‘are women who are either experiencing sexual dysfunction or embarrassment because their labia (labia minora) are over-sized or asymmetrical’. In the clinical literature, labia minora that dangle below the labia majora are called ‘hypertrophic’, which simply means that the labia are large in size. As a diagnostic category, ‘hypertrophy’ is misleading because it is a denotative description of a structure and not a clinical pathology, even though it is presented as a medical diagnosis.

My book charts the history of this diagnosis of ‘labial hypertrophy’. It is not a sociological analysis of how women think about and respond to female genital cosmetic surgery (FGCS), nor does it attempt to provide a theory of female agency that is able to show how contemporary women navigate the pleasures and pains of genital cosmetic surgery. Rather, the book came about because I felt that the development of medical knowledge of the female genitals could provide some answers to the vexing question of where the idea of genital normality comes from. Medicine is not the only source of sexual knowledge, but it has been overlooked in accounts in the popular media and in academic articles that put the blame for cosmetic labiaplasty primarily on internet pornography. My book sets out the argument that we need to situate contemporary labiaplasty within the broader history of medical gynaecology because of medicine’s important role in laying the discursive groundwork for the expression of female genital anxiety—both among the doctors who treat ‘hypertrophy’ as a clinical problem and among ordinary women who worry that their vulva does not look normal. Although the current phenomenon of FGCS is embedded in contemporary late-capitalist Western culture, the questions that motivate this book are historical ones: To what extent is the genital shame driving female uptake of labiaplasty surgery strictly contemporary? How far back does the diagnosis of labial hypertrophy go? And where do our ideas about genital normality come from?

As a work of feminist history, my book subjects FGCS to a gendered analysis in showing how female genital sex has been represented and understood within white Western male-dominated medical imaginaries of sexual difference. Historian Joan Scott argued in 1986 that the analytic category of ‘gender’ was crucial not just for the project of writing women into history, but also for revealing the very concept of sexual difference itself as a historical entity. That is, the concept of ‘gender’ draws our attention to the male/female opposition as a political power relation, rather than a matter of biological nature that exists outside of human construction. For Scott, ‘gender’ is a crucial category of analysis that enables us to refer to ‘the social organization of the relationship between the sexes’. We can view the medical corpus that composes the book as contributing to the historical construction of gender because it has a stake in the binary positioning of man and woman as being of unequal biological constitution and social value. Such a project requires paying attention to how gender—or ‘the social organization of the relationship between the sexes’—intersects with other relationships of race, class and sexuality. Although it is a feminist history, my book does not do the work of recuperating or rescuing women as a missing people. It is less concerned with actual women and their experiences with doctors than it is with the abundant, though not always unified or coherent, gynaecological discourses that have worked tirelessly to define and redefine the boundaries of female sexual normality and abnormality.

In the lecture today, I want to contextualise the book as the outcome of a fruitful interdisciplinary intersection between gender studies, cultural studies and history. My disciplinary background is actually in gender and cultural studies, not history, so this book was an amazing learning experience for me in terms of the process of becoming a historian. I am ashamed to say that the budding feminist theorist that I was fifteen years ago would never have approached FGCS from the perspective of history. I read Foucault as a philosopher, rather than as a historian; I used Deleuze and Guattari without fully understanding their historical relationship to Freud and psychiatry; and my work on postfeminism largely failed to interrogate the ‘post’ as a signifier of time. My friend and intellectual mentor Zora Simic had politely suggested that my work needed more historical context, while I thought, rather impolitely, that historians lacked theoretical rigour. I was quite wrong, not to mention arrogant, and I’m proud to have finally come out of the closet as a historian. History came to me stealthily, through my undergraduate teaching in gender studies, especially in Zora’s History of Sexuality subject at UNSW, and in my work as a copyeditor with excellent historians of settler colonialism like Penny Edmonds, Jane Lydon and Jane Carey. My book is therefore the product of personal, professional and critical engagement with feminist history scholars from whom I learned how to situate women in time.

While the book is very much a medical, rather than a ‘cultural’ history, it has a sort of cultural studies sensibility in being a story about a phenomenon that has entered into popular discourse under the term ‘designer vagina’. A cultural studies perspective enables us to view medical literature as a product of culture, rather than simply the outcome of the scientific search for truth. While science gives us access to vital facts about our biology and the world we live in, we must also remember that scientific knowledge draws on the representational devices of language and imagery, and that it has a history. One of the things I sought to do in this book was to situate scientific texts as participating in the making of narrative and visual cultures of the body, following the influential and illuminating work of scholars of the sciences such as Anne Fausto-Sterling, Londa Schiebinger, Thomas Laqueur and Sander Gilman. In the discipline of cultural studies, it is tempting to place under the banner of ‘culture’ narrative genres found, for example, in literature, religion, art, and the mass media. It is not quite so easy to place Western science wholly within these cultural traditions due to the distinct and special nature of its empiricist inquiry. And yet the sciences are no less visual or richly descriptive as the arts. Visual representations such as illustrations and photographs are embedded in the scientific process of elaborating genital typologies and topographies; and denotative names for the genitals have been formed through the poetic intersections of vision and language, where a part of the human anatomy gains its name from some other part of nature like a myrtle berry, a lily or a moth’s wing. A cultural studies perspective appreciates the literariness of scientific description, and its use, particularly among nineteenth-century naturalists, of literary allusions and simile. It understands science as an institution that carries cultural weight and reproduces, in its own empiricist way, certain culturally specific ideas about gender, race and sexuality. And it gives us license to take sites of consumer fantasy, such as cosmetic surgery, seriously as an object of study.

When I first started thinking about contemporary cosmetic labiaplasty, I wasn’t at all convinced that it was driven largely by pornography. And when I sat down to read the plastic surgery literature, I realised that it was actually medicine that needed interrogation. That’s what led me to start investigating the history of medical knowledge about the vulva. It was in writing this book that I finally understood the thrill and allure of the archive: I felt like a detective tracking down significant historical moments because I had specific chronological questions that needed answering. I knew I wanted to go back as far as Hippocrates, who is considered the founding figure of modern Western medicine. The most important initial question for me was: When were the labia minora first identified as a specific biological structure? I wanted to know what naming conventions the ancient Greeks and Romans applied to the female genitals, because there can be no diagnosis of ‘hypertrophy’ or ‘enlargement’ without a name for the part of the body that is affected by it.

Interestingly, it turned out that the Greeks didn’t care that much about anatomical precision in their naming conventions. Mostly, male and female genitals were just called aidoion, or the ‘shameful parts’. Hippocrates (born around 450 BCE) called the labia ‘overhanging banks’, but didn’t bother to distinguish between inner and outer. Rufus of Ephesus (born around 80 CE) said they were also known as ‘myrtle lips’, and he renamed them ‘wings’. Soranus (born around 100 CE) was the first to clearly distinguish between the wings (for the labia majora), the lips (for the labia minora) and the nymphe (for the clitoris). But later, Soranus’s taxonomy would be forgotten. The labia minora never acquired a stable identity until anatomist Andreas Vesalius relabelled them as ‘nymphae’ in the sixteenth century. This name was generally used until around the mid-nineteenth century, when the term ‘labia minora’ gained currency.

Figure 1. Illustration of the ‘Tablier des femmes Hotentotes’. François Péron and Charles Alexandre Lesueur, ‘Observations sur le tablier des femmes hottentotes’ [Observations on the Hottentot Apron], Bulletin de la Société Zoölogique de France 8 (1883). Courtesy Biodiversity Heritage Library. Digitised by Smithsonian Libraries

The second most important question was: When did hypertrophy or enlargement of the labia minora become a recognisable diagnosis among medical authorities? What I found was that when this diagnosis began to appear in the medical literature in the sixteenth century, it was associated first with Egyptian women and then, in the seventeenth century—when the Dutch colonised southern Africa—it shifted to become attached almost exclusively to Khoi women whom the Dutch settlers called ‘Hottentots’. It was then that labial hypertrophy became synonymous with what white anthropologists and gynaecologists came to call the ‘Hottentot apron’. The discussion of the Hottentot Apron in Chapter 4 is pivotal to the book, as this is how the image of pathological labial hypertrophy gained traction in the European medical community. The colonial invention of the ‘Hottentot apron’ is also important because it was part of the invention of race as a biological signifier of an unbridgeable gap between black women and white women. Early nineteenth-century scientific drawings of this appendage would be revived in medical descriptions and discussions of labial hypertrophy into the twentieth century.

When I was writing Chapter 4, I was excited to have solved the mystery of who authored the drawing that cropped up repeatedly in medical textbooks as the archetypal example of the ‘Hottentot apron’. It was a French naturalist called Alexander Leseuer, who had visited the Cape of Good Hope in 1804. I was even more excited to find a digitised copy of Leseuer’s original drawing buried in a copy of the 1883 edition of the Bulletin of the French Zoological Society. He was a difficult man to track down! Luckily, I was able to reproduce the image for free with permission from the Biodiversity Heritage Library (Figure 1).

Figure 2. A pictorial example of racist evolutionary theory situating white women as the pinnacle of human development. Frontispiece from Edmond Perrier and René Verneau, La femme. Dans la nature, dans les moeurs, dans la légende, dans la société, book 1 (Paris: Bong & Cie, 1908). Courtesy BIU Santé, Paris.

As I suggested, the Hottentot apron became part of the scientific discourse of race, and it served to mark out evolutionary boundaries between not-quite-human black women and civilised white women. This white colonial conception of ‘women in time’ viewed female biology through the prism of evolutionary racism, in which black people were thought to evolve more slowly than white people. In the early twentieth century, the Hottentot apron was trotted out by European gynaecologists to stand in for evolutionary imperfection and biological abnormality (Figure 2).

With the rise of eugenic theory in France, Britain and America, elongated labia became a symbol of feminine imperfection and racial degeneration. Chapter 5 examines French gynaecologist Félix Jayle (La Gynécologie) to explore the ways in which medical eugenics in the early twentieth century sought to identify a bodily norm to which white women should aspire if the white race were to be healthy and robust, and, more importantly, ‘normal’. ‘Normality’ was an important word in Jayle’s lexicon because he felt that abnormal body shapes and types retarded white evolution, contributed to infant mortality, and needed to be eradicated through improving public health. To this end, Jayle was one among many eugenicists to ascribe to the theory that perfect female health depended upon perfect body proportions. In his view, health and beauty were mutually reinforcing. He looked at bodily elements like bone structure and distribution of fat, but what caught my particular interest was that he had divided the vulva into four types, ranging from completely abnormal, to kinda normal but kinda unhealthy, to completely normal and healthy (Figure 3).

Figure 3. Images from Félix Jayle, La Gynécologie. Tome 1: L’Anatomie Morphologique de la Femme (Paris: Masson & Cie., 1918), 105. Courtesy Matheson Library, Monash University, Melbourne.

The archival sources revealed a rich discursive field by which I was able to contextualise the technology and practice of labiaplasty within broader racialised frameworks of health and illness. By way of contrast, contemporary sociological and psychological approaches can tell us about what individual women, plastic surgeons and gynaecologists think about female genital surgery, but they cannot tell us very much about how their ideas have been historically transmitted and acquired. In other words, if we are restricting our enquiry to the contemporary scene of cosmetic genital surgery, gender and race are only meaningful as categories of identity in relation to the individuals who participate in the sociological research, rather than as epistemes that have shaped and continue to shape the medical discourse of labial hypertrophy itself.

This is not at all to say that archival research is superior to other kinds of research, but there is something quite exhilarating about digging into historical sources to try and get a sense of how we got here. One thing that history tells us very clearly is that the female genitals have never been a neutral body part, but have always been enmeshed in cultural ideas about what this phantasmagorical thing called ‘femininity’ is or should be. The medical archives can show us how ideas about female genital normality and abnormality constantly come into being, fade away, shift, or persist over time.

For instance, there is a persistent historical connection between genital abnormality and sexual morality. On the cosmetic surgery website RealSelf, women express fears that masturbation has caused their labia to become enlarged. One confesses that ‘Im 18 years old and I believe I have damaged my inner labia by over masturbation’, while another writes, ‘I’m still a virgin but worried that maybe labia is too big? I used to masturbate lots and think it may be stretched out’. These fears about masturbation causing perceived genital abnormality are not at all new. From the eighteenth century into the early twentieth century, enlarged genital organs were associated with deviant sexual practices and mental illness. In Chapter 6, I look at how large labia minora became associated with nymphomania, masturbation and lesbianism through the work of early twentieth-century American sexologist Robert Latou Dickinson. It was through reading Dickinson himself and also reading about Dickinson—via the excellent work of historian Jennifer Terry—that I finally understood that feeling of excitement historians get when they explore an archive. Dickinson became a really interesting figure to me, and I dearly wanted to go to the Kinsey Institute in the United States to find out more about him, but alas, I had no academic job, no grant, and no money.

When I talk about the archives that I consulted for this book, I am referring to the digital copies of medical treatises, dictionaries, atlases and textbooks that can be found online on sites like the Internet Archive, the Wellcome History of Medicine Collection, the National Library of Australia and the Hathi Trust Digital Library. We are fortunate to be able to do historical research in the digital age—it was quite incredible to be able to access from my home computer anatomist Andreas Vesalius’s original manuscript, De humani corporis fabrica, which was published in 1543 and written in Latin. The limitation of this research is, of course, that I only had access to books that had been digitised or that were available in local libraries near where I live, such as the Matheson Library at Monash University and the State Library of Victoria. Because I had no money, international travel was not an option, much as I would have liked to visit the Kinsey Institute in the States or the Bodleian Library in the UK. Nevertheless, I can attest to the wonderful wealth of freely available digital copies of historical books, documents and images on the internet, and in this respect, scholarly historical research—at least with regard to written records of European provenance—has never been more available to the curious researcher.

Camille Nurka is an independent gender studies scholar. She has taught as a sessional lecturer and tutor at a number of Australian universities and published widely on the politics of sexed embodiment. She is also a professional freelance copyeditor for academics in the humanities and social sciences.

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