The setting is certainly nice: a five-star golf resort high in the Tortolita mountains outside Tucson in Arizona. In spite of being in the middle of the desert, water is all around: two golf courses, three pools, a water park, plus three outdoor lawns raked by sprinklers. Inside, conventioneers are unloading displays of surgical instruments, orthopaedic furniture and clear plastic canisters designed to store human fat.
I’ve come to the Congress on Aesthetic Vaginal Surgery because I want to learn more about one of the fastest-growing cosmetic procedures in the United States. This newish industry consists of doctors and their clients (clients, not patients, because these surgeries are cash-only elective procedures) who believe the female nether area can be improved upon or remediated. Procedures offered include labiaplasty (trimming or completely removing labia), vaginal rejuvenation (tightening), hymenoplasty (“revirgination”) and clitoral “unhooding”, among others.
Designer vagina surgery is big business. According to the American Society for Aesthetic Plastic Surgery, in 2009, female consumers spent an estimated $6.8-million on these procedures (the figure counts only plastic surgeons, not gynaecologists). Its popularity is rising in the United Kingdom, too. In 2008, the British health service (NHS) carried out 1 118 labiaplasty operations, an increase of 70% on the previous year. And figures released this year show that the plastic surgery company Harley Medical Group received more than 5 000 inquiries about cosmetic gynaecology in 2010, 65% of them for labial reduction, the rest for tightening and reshaping.
The only reason I know about cosmetic vaginal surgery is that, while researching my latest book, I was given temporary faculty status at the medical school of the university where I teach creative writing, so I could observe obstetrics and gynaecology students. Somehow, I began to get spam emails addressed to “Dr Lee”, extolling the “revenue expanding” virtues of learning vaginal rejuvenation. And it’s clear at this conference that the bulk of participants are indeed not plastic surgeons but run-of-the-mill obstetricians and gynaecologists who see this as their passport out of traditional practice.
The irrefutable fact of the matter is that these cosmetic procedures can make you rich.
As one speaker makes a presentation about his successful cosmetic-gynaecology practice, the wallpaper from his laptop appears on screen. It is various shots of him with his Porsche.
The message is simple. A straightforward labiaplasty, done in-office, in a few hours, nets about $5 000. Enough customers and you too can live the good life. In what feels almost like a mini-masters in business administration programme, we sit through presentations on search-engine optimisation, burnishing one’s online reputation and marketing. Practitioners trade ideas on how to increase revenue by cutting costs: finding ways to do procedures using local anaesthesia, for instance, to avoid the expense of having to rent an operating room at a hospital and pay an anaesthetist. In surgery, assistants are needed to hold retractors, instruments that keep the incision open. One enterprising doctor displays a special clamp he has invented, patented and will be selling: a U-shaped gizmo that will make surgical assistants unnecessary.
Sanction of reality TV
In the US, cosmetic gynaecology may have the official sanction of reality TV (doctors have performed it on the wildly popular plastic-surgery makeover show Dr 90210) but the same cannot be said of the peer organisations. The American Congress of Obstetricians and Gynaecologists deems such procedures medically unnecessary, possibly unsafe and is “concerned with the ethical issues”, whereas the accrediting body, the American Board of Obstetrics and Gynaecology, refuses to recognise cosmetic gynaecology as a legitimate sub-speciality. This means there are no entry barriers for the physicians, as there are no board-certification requirements.
Consumers may not realise that it’s a bit of a Wild West out there, with doctors working out the kinks, as it were, as they go. Some here are presenting “how-to” videos on their methods to beautify the labia, arguing with other presenters about whether the “wedge” or “rim” technique is better, cautioning attendees not to pull the sutures too tight, or they will produce “scalloped” edges. And the body, as it heals, always has its surprises: “I get the lumpy-bumpies just like anyone else,” says one, showing his solution of shaving off bead-like skin tags that form around an incision, much in the way your grandmother might depill a sweater.
Because many of the obstetricians and gynaecologists at the conference are untrained in plastic surgery, one big question begins to bother me: On what/whom will they practise? The answer is, they don’t, or often not much. A number of those here plan to watch the videos and start operating.
Indeed, in one session, a doctor asks how to overcome beginner’s nerves and what the obligations are to let the patient know. “Do it on a 60-year old — it won’t matter!” comes one helpful suggestion from the audience.
Sherie, a 36-year-old from Oregon, spent $18 000 on vaginal surgery last year. “In my mid-20s, I noticed that my inner labia were larger than my outer labia,” she tells me, “but at that point I wasn’t overly concerned by it. Then I had laser hair removal for my bikini line and realised that not everyone might be like me. I browsed through one of my brother’s Playboys to see what the girls looked like. Some seemed to have very small or almost no labia. It was around that time that I began to wish mine were smaller, but I still had no intention of doing anything about it.”
Then she had three children in three years. “It seemed that all I did was work, have babies and take care of them.” It was around that time that she started to think “about the improvements that I wanted to make after the tolls of childbirth”. She contacted a plastic surgeon she knew and trusted and arranged to have the labiaplasty in his office.
“I was shocked when he handed me the mirror after he was done,” she says, “because the cuts and stitches were going the complete opposite way from how I had thought they would and I didn’t see how I would heal looking better and without very obvious scars.
“I went into freak-out mode and couldn’t believe what I had done.”
She went back to work for 10 hours and by the end of the day was in “excruciating pain”. Rather than waiting for her botched surgery to heal, Sherie decided to get it corrected straight away. After talking to other doctors and surgeons, she phoned a Red Alinsod.
“We talked about not only labial reduction but other possible procedures I might want to get done since I was going to endure some pain and downtime anyway. This made sense to me, to just get any and all done down there while I had the chance. Together, they decided on an ablation (for bleeding), haemorrhoidectomy, labia reduction, hood reduction (to match her new labia), vaginal tightening and repair of her perineum. “The next few weeks and months were a little painful at times, but it all healed beautifully,” she says.
Labiaplasty
One doctor’s sales pitch invites clients to “get double-D labia to go with those double-D implants!” I am unsure of what attractive vaginas are supposed to look like but, after a few presentations, a clear surgical ideal emerges: labia inflated to banana-like pontoon proportions, a look that I can only describe as pure mammalian oestrus. The aesthetic ideal goes one step further when Alinsod, who practises in body-conscious southern California, tells us that his most popular labiaplasty procedure is one he invented, a “smooth” look, called the Barbie (after the doll), that involves shearing off the entire labia minora, the inner lips, to leave a “clamshell” look.
It should be noted that labiaplasties done for purely functional reasons, such as dyspareunia (pain during sex), may be categorised as medically necessary and therefore eligible to be covered by insurance.
However, when I speak to practitioners at the conference, they wave away the idea that either they or the client would want to take that route. “It’ll take me 10 minutes, but I’ll get only $300,” one said. “And it will look like I spent 10 minutes on it.” Another agrees, explaining that much of the elective fee he charged had to do with the two hours he’d spend “making it look pretty”.
There are few female surgeons at the conference in Tucson and, between the endless pictures of labia and the macho patter, it is invariably awkward reporting it as a female journalist. Alinsod has been generous in granting me full access, but the others here are wary about how their field might be portrayed. Indeed, a good portion of the seminars are devoted to how to counter criticism both from feminists accusing “disease mongering” doctors of preying upon women’s insecurities to create a demand for procedures that they didn’t need, such as the story that ran in Cosmopolitan magazine last year headlined: “Vaginas Under Attack: Don’t Let Your Greedy Gyno Talk You Into This Horrible Mistake”.
That evening, during pre-dinner drinks, I try to take advantage of the more casual atmosphere to canvass the doctors: Did they really expect to go home and start doing the surgeries after just watching a few videos?
Apparently, one can take a training course from a more established doctor but, as with everything in this for-profit business, that comes at a price. Some grumble about “tuition fees”. Studying for a few weeks with the surgeon who’s been on Dr 90210, for instance, apparently costs $75 000, so many cost-conscious doctors prefer to skip this step.
I must look incredulous, because another doctor assures me that one always has the option to buy an additional “cadaver lab” workshop in which to practise. “Do they hold the cadaver labs at fancy golf resorts like this one?” I joke, imagining the Ritz trying discreetly to wheel in covered gurneys with the fresh flowers.
But nobody laughs because, apparently, they do sometimes conduct cadaver labs at luxury convention hotels (though not at this particular conference) and some are very touchy about the doctor stereotype that they like to play golf.
The most offended doctor — whose presentation is all about how to persuade a patient to add a cosmetic-gynaecology procedure to an incontinence surgery in which Gore-Tex mesh is implanted as a kind of sling to hold up the organs (a procedure currently being questioned by the Food and Drug Administration for severe side effects and frequent failure) — tells me to get lost and drags his colleagues away.
On Sunday evening, the conference comes to an end. Laid on a table are a bunch of framed, official-looking certificates made on the organiser’s computer, certifying that doctors have physically been here for the presentations. I’m still haunted by the idea that some are going to go home, hang them on the wall and begin cutting.
Perhaps in recognition of this, one of the last sessions is on the new-new market for “revision surgery”. A PowerÂPoint slide is labelled “Labiaplasty Disasters” and what I see resembles crushed vegetables more than female genitalia.
A common problem, I learn, is when doctors don’t take into consideration that labia can retract, which can turn a simple trimming job into an inadvertent Barbie. Luckily, Alinsod, the inventor of the Barbie, has also come up with a reparation surgery: flaps of skin grafted to create the trompe l’oeil of resurrected labia. I’m impressed by the man’s constant inventiveness. He also clearly enjoys what he does — “I could do labiaplasties all day!” — and has satisfied patients, judging from his busy practice. So why do I feel a continuing sense of unease?
Alinsod, in fact, is responsibly working towards using conferences such as this to help set professional standards that will perhaps assist in fostering the legitimacy of cosmetic gynaecology and lead to safety standards and clinical trials. Indeed, in an unpoliced medico-industry, without the doctors organising themselves and sharing their data, safety questions and adverse effects might go unaddressed (what impact these procedures might have on childbirth, for instance, is still unknown).
I realise that my disquiet is not so much to do with individual doctors but with whether, in an age in which a good portion of Americans are uninsured and don’t have access to healthcare, this is the best use of limited medical resources. In an odd coincidence, at the same time as the Congress on Aesthetic Vaginal Surgery was taking place, new legislation was being enacted in Arizona that cut off state funding for organ and bone marrow transplants, life-saving but costly procedures that were being denied in the name of necessary healthcare rationing.
As Dr Porsche and the other tightly scheduled doctors run to catch planes back to their practices, a handful linger. As the Tortolita mountains redden in the dusk, they put their feet up by the outdoor chimney, shed their name badges and order drinks made with expensive tequilas. In the desert all around are the lush golf courses and artificial pools offering a kind of gleeful profligacy to those willing to pay. —