Mr Paul Philip,
Deputy Chief Executive & Director of Standards and Fitness to Practise
General Medical Council
St James’s Buildings
79 Oxford Street
Manchester M1 6FQ
February 2009
Dear Mr Philip
Labiaplasty – are we sleepwalking to a society in which doctors encourage FGM type IIa?
Complaint against doctors Pixie McKenna and Angela Kavouni
I write with a complaint about medical advice given in Series 2 of one of Channel 4’s popular body-focused TV shows, Embarrassing Bodies, transmitted on 28/4/2008. The Doctors concerned are Pixie McKenna and Angela Kavouni. You may wonder why I have taken this long to write to the GMC about this, which I will explain.
I was so shocked at the disparaging attitude of Dr Pixie McKenna to a pair of normal functioning labia that after viewing the programme I made a formal complaint to Offcom. Their reply is enclosed. I was unhappy with the reply as I distinctly remembered the show giving the message that larger labia are in some way not normal, but believed myself unable to take this any further as I had no way to re-view the programme and to confirm what was actually said.
Subsequently, late in 2008 I found myself looking up Channel 4’s website after again becoming upset about the misleading presentation of labiaplasty in other programmes. I found then that I could access and view the programme which was the subject of my original complaint, and I saw also the subsequent episode (which I had missed) covering the surgery itself and additional commentary. On this website I also found posts from the public which revealed that the programme had served to upset a large number of quite young women by convincing them that their vulva was abnormal.
I am now even more disturbed than when I made my original complaint. I write to you to ask that you admonish both doctors involved in this show for giving limited, misleading and inappropriate advice. Secondly I would like the GMC to inform doctors that encouraging patients to believe protuberant labia are ugly or unacceptable and require surgical reduction is a travesty of ethical evidence-based medicine, and arguably represents a breach of the FGM Act 2003. Excision of part or all of the labia is defined by the UN and the WHO as a type IIa female genital mutilation[1] and ignorance about the risks combined with social pressure to conform are considered to invalidate any adult consent with regards FGM.
The programme which is the subject of my complaint can be viewed at: http://www.channel4embarrassingillnesses.com/video/embarrassing-bodies/
Here is my summary of the content.
Dr Pixie McKenna looks at the labia of patient Alyson who is 45 and suffering from low self esteem which she ascribes to her genital size and shape. Alison has normal genital tissue, in fact her labia are smaller and less protuberant than many other British women, myself included, but since the age of sixteen she has believed herself to have an issue with excess skin. This she admits is psychological, and prevents her from undressing easily or being involved in ‘certain acts of sex’.
Dr McKenna then examines the patient’s vulva and immediately pronounces there to be “quite a lot of excess skin”. She notes the tissue seems healthy but proceeds to an assessment of its normality by asking the patient to stand with her legs apart. This results in the pronouncement that, “they’re sticking right down and normally you wouldn’t get that appearance.” This test, which appears to be entirely of Dr McKenna’s own creation, is rather ridiculous considering that in many - if not most - British women the labia minora are visible on standing with the legs apart. But Dr McKenna, and therefore by extension the patient, takes it very seriously. She eventually offers Alyson grudging reassurance in saying that her vulva is a ‘normal variant’ (how about just, very common, in fact smaller than many others?) but undermines this by repeating the term ‘excess skin’ and commenting that although some women put up with the situation (here she has a serious face), surgery can fix it.
Never does Dr McKenna attempt to explain the role of the labia, nor the fact that large ones are common, highly sensitive[2] and appreciated by many men. She does not suggest that Alison try the sexual acts she has denied herself – although this might help her to appreciate the role of labia. Neither is there is any attempt to offer Alyson counselling to investigate an underlying source of her psychological vulnerability. Naturally the patient, who arrived with a tendency to body dysmorphia and associated low self esteem, is easily convinced that her body requires surgical correction.
It’s worth noting here that the surgical sequence which follows is for Channel 4 what’s known as a money shot. This may serve to explain why the patient’s decision to seek an amputation of healthy flesh makes the doctor/presenter smile broadly – not a ‘normal’ medical response I would suggest!
We switch to the premises of Plastic Surgeon Angela Kavouni, who makes it clear she believes Alyson’s normal vulva is pathological: “definitely there is too much tissue there”. Dr Kavouni apparently performs 250 such amputations each year – at a cost of at least £3,100 for each operation - a rather lucrative trade it would seem. Although she finds time to express her distaste for the parts she makes money amputating, no information is forthcoming about the risks of the surgery, which include infection and unpredictable sensory outcomes, such as numbness or a neuroma which mediates pain rather than pleasure[3].
Alyson returns to Dr McKenna’s TV consulting room and shows off genitals which have lost an inch and a half of plump nerve-rich tissue. We’re shown the bloody amputated labia lying on gauze, and the voice over expresses that Alyson must be satisfied to have lost this encumbrance, which has been referred to as her ‘secret’ as if it were something shameful.
The saddest piece of this programme, for anyone with even a minimal understanding of the persistence of psychological issues, is single 45 year old Alyson’s statement at the end: “I’m hoping that with the next relationship I have, all of my insecurities will have gone”.
I’m also especially disturbed – and you should be too – by the number of anguished teenagers who have posted comments in responses to the programme and the ‘enlarged labia’ section of Channel 4’s website. Here are a selection of the comments, representing only some of those who have viewed the material, this year alone….
“ I have the same problem, I'm fifteen and very self-concious about it. I went to see my doctor and now she is referring me to a gynaecologist.”
“I have never had sex neither and I'm worried if my boyfriend will think that it's strange.”
“it makes me sick everytime i look at it. …. i too have heard boys talkin about how if a girl has them hangin down then it means she has been round the block.”
“i have enlarge labia since i was about 13! i cant stand the thought of seeing it and i wont let my partner of 4 years touch it if i can help it.”
“im 15 years old and its just like i will never be able do do anything.”
“hey im 14 and i also have this problem it really gets me down and i never want to do anything with a boy until i get it sorted out mine doesn't hang down that low but its so noticeable it all started when i was on the toilet and i shouted my friend ,is my vagina normal i asked she said i dont know so i shouted my older sister and she just laughed and said you have labia and i cried because its not nice.”
“im 16 and have this problem … im petrified how guys will respond to it. ive put of any contact down there with guys untill now and just wanted 2 know if any1 out there has this "problem" and can tell me how guys reacted when they saw…will i ever be able 2 have a normal sex life?”
“im 14 and i have enlarged labia .......its really started to upset me the more i think about it.”
The background issues
The labia minora and the contiguous clitoral prepuce represent a functioning part of the body. Their tissue type is similar to male foreskin, containing a dense concentration of nerve endings including those which respond to light stimulus including gentle nibbling, stroking and stretching. Thus they are highly prized as a means to enhance sexual foreplay by many women and men. Like foreskin they also have a protective role. This is expressed in the slang term for the labia as ‘curtains’ – when unstimulated they close together, protecting their inner mucous membrane as well as that of the vaginal entrance. This membrane is itself important – it secretes antibacterial substances as first line of defence against infection and may also produce pheromones.
There is no objective evidence to suggest that labial functions are reduced in larger ‘variants’, and in fact it’s logical to suggest that larger labia may actually perform the above functions better. Backing up this theory, Malinovský et al (see above) found a significantly larger number of nerve endings in so-called ‘hypertrophic’ labia…. Surely this finding, over 40 years ago, should have led us to question the very diagnosis of ‘hypertrophic’ and ask whether it isn’t actually entirely based on cultural prejudice?
This prejudice even has the whiff of racism about it. Labial variation tends to be genetically determined – in my family three generations of women (and probably many many more) have been born with abundant labia. It’s likely that certain ethnic groupings may be more likely to have labia of a particular size and shape, just as some communities are more likely to have bigger eyelids, thicker hair or larger bottoms.
The “Hottentot Venus” for example, that unfortunate object of 19th century prurience otherwise known as Saartjie Baartman, was observed to have ‘hypertrophic labia’ as well her other more well known ethnic features[4]. This feature came to be associated in the Victorian mindset with racial inferiority and sexual indulgence – even more so when it was realised that some African women actually stretched their labia further to increase their sexual sensitivity. It may be that our whole characterisation of what is normal and abnormal in relation to labia has its origins in this period of sexual and racial hysteria …
I hope you will look into these issues further, as well as admonishing the individual doctors. Although it may be hard to prevent a degree of cultural body dysmorphia, we can and should expect doctors to resist a social trend which demonises any part of the body. To do otherwise – and especially to ride such trends in order to make money or express personal prejudices - is deeply unethical.
Yours sincerely
[1] Eliminating Female Genital Mutilation, an interagency statement 2008 (Annex 2)
[2] Malinovský L, Sommerová J, Martiník J: Quantitative evaluation of sensory nerve endings in hypertrophy of labia minora pudendi in women. Acta Anatomica 1975;92:129-144 (DOI: 10.1159/000144435)
[3] Labiaplasty and Labia Minora Reduction: Treatment
(http://emedicine.medscape.com/article/1372175-treatment)
Steven P Davison, DDS, MD, Assistant Professor, Department of Surgery, Division of Plastic Surgery, Georgetown University Medical Center
Dr Davidson comments that the both amputation and the central wedge resection technique can damage nerve endings – of the central wedge resection he comments, “the procedure does have the potential to cause nerve damage, which can result in painful neuromas or numbness.”
[4] McNamara K.R. Genital Plastic Surgery and the Production of the Sexed Female Subject accessed at http://gnovisjournal.org/files/Karen-Roberts-McNamara-Pretty-Woman.pdf
