Shelby Quast: Is cosmetic labiaplasty in adolescents just FGM under a different name?

shelby quastLabiaplasty in girls younger than 18 has become increasingly popular in the US in recent years. According to the American Society for Aesthetic Plastic Surgery, the number of girls aged 18 and younger having cosmetic genital surgery increased by 80% between 2014 and 2015 (from 222 girls in 2014 to 400 girls in 2015).

While some surgeries are carried out for medical reasons, this huge increase appears to also be driven by non-medical reasons, including insecurity caused by higher levels of exposure to porn and a lack of understanding that there can be huge variation in healthy female genitalia.

Seemingly in response to the concern and uncertainty of medical professionals on how to deal with this phenomenon, the American College of Obstetricians and Gynecologists (ACOG) recently issued new guidelines for health personnel. These guidelines refer to surgeries that are carried out for medical reasons, but also “cosmetic procedures,” which are “performed to reshape normal structures.” In practice, this means operations on a girl’s labia when she is not experiencing any physical pain or discomfort.

The college recommends that doctors offer “education and reassurance regarding normal variation in anatomy, growth, and development,” and stresses that non-surgical treatment should be prioritised when somebody under 18 seeks treatment, such as labiaplasty. However, it suggests too that if “emotional discomfort” persists, then surgery can be considered.

In addition to the potentially harmful health and related consequences, there is also the concern that any labiaplasty carried out on a teenage girl in the US for “non-medical reasons” may be breaking US law. According to the 1996 anti-female genital mutilation (FGM) act, unless it is “necessary to the health of the person on whom it is performed,” cutting a girl’s labia is illegal and can mean up to five years in prison for the person who performs it. This reflects the World Health Organization guidelines too, which categorise such surgery as Type IV FGM.

Two questions arise from this. The first relates to what are considered “non medical reasons”—and, specifically, if emotional discomfort can be considered a medical reason to perform the surgery on adolescent girls. Health personnel have a duty to “do no harm” and to work towards what is best for their patient. Emotional discomfort, which may be caused largely by altered representations of women’s bodies in the media, is something that is not best addressed through surgery—a process that can cause further damage and which does not deal with the underlying causes.

While we appreciate the complexity of this issue, it is important to identify and address the reasons for such emotional discomfort. We do not fully know either how much physical, emotional, or psychological harm cutting away or trimming this sensitive area may cause for the girl during her life. The facilitation of surgery to change perfectly healthy genitalia can also be hugely damaging to a girl’s sense of herself and confidence in her own body.

Even ACOG agrees that such procedures may not be safe for adolescent girls and could have serious consequences. The potential harms seem to clearly outweigh the supposed benefits.

The second question for many—including health professionals—is whether labiaplasty on an adolescent girl for non-medical reasons can really be considered FGM. Legally, in the US, the answer is yes. It is sometimes argued that labiaplasty is for “cosmetic” or “social acceptance” reasons, but FGM is often performed for supposed “cosmetic” or “social acceptance” reasons too. We should be very careful about allowing loopholes in protection laws based on the perceived motivations of the adolescent girl undergoing the procedure.

Equality Now has worked for over 20 years on ending FGM in the US, on the African continent, and globally. We are finally making real progress in getting people to understand that FGM is violence against girls and an extreme human rights violation. It is vital that all labiaplasty for girls under 18 for non-medical reasons is clearly recognised as against the law and that ACOG guidelines reflect this.

Over 10 000 Americans have already joined Jaha Dukureh, FGM survivor activist and one of this year’s Time 100 most influential people, who is challenging the ACOG guidelines, with the support of Equality Now. This is the latest turn in a long standing campaign to ensure US health personnel become ambassadors for the health of girls and do not violate anti-FGM laws and policies.

In 2010 Equality Now successfully campaigned for the American Academy of Pediatrics (AAP) to retract portions of a statement, which instructed doctors that they could “nick” a girl’s genitals—a form of FGM. The surgery that ACOG is now referring to—albeit as a last option—is potentially even more invasive.

The US medical community could take a look at the United Kingdom, where health personnel are actively leading anti-FGM efforts. Equality Now worked with the UK based Royal Colleges of Obstetricians & GynaecologistsMidwives, and Nursing, as well as the union Unite, to issue a set of recommendations for health professionals and others to protect girls at risk of FGM and to support survivors. This directly informed UK policy and that country’s national health service now has a clear system for identifying, recording, and reporting instances of this abuse.

For several decades, momentum to end FGM has been growing. Despite difficult odds, we are finally making progress, but with over 200 million women and girls affected—and only a tiny funding pool available for activism from innovative foundations including the Wallace Global FundComic Relief, and the Human Dignity Foundation—there is much more to be done.

Against this backdrop, we urge ACOG to consider tweaking its guidelines, which have the potential to affect the health and wellbeing of American girls, and focus instead on empowering health personnel to be much needed ambassadors for the rights of all American girls.

Shelby Quast is Americas director of Equality Now, an international human rights organisation.

Competing interests: None declared.