"Ladies, get out your hand mirrors," begins a curious press release I find on my desk one Monday morning. "Yes, it is true ... the newest trend in surgically enhanced body beautification: Female Genital Cosmetic Surgery." Many patients of Gary Alter, M.D., an aptly named Los Angeles plastic surgeon, "had been troubled for years about the appearance of their inner vaginal lips (labia minora)," the pitch goes on. But thanks to "surgical procedures designed to improve the appearance of female genitalia," Alter has found "perfect solutions to common problems; the ultimate way for women to be gorgeous absolutely everywhere."
I laugh out loud: What a joke! But then I wonder, are women really worrying about the size and shape of their labia like they do about every other body part they've cut, stretched and sculpted with plastic surgery? Although I'm assuming the letter is mostly hype, I have a niggling fear that not a few women might actually be lining up for labiaplasty. (Around my office, at least, the reaction was, "You're kidding," followed quickly by, "Wait, how do I rate?")
With increasingly baroque cosmetic surgeries becoming available every other week (cleavoplasty, for instance, plumps up the deep crevasse that can result from breast-implant surgery, using fat transplanted from the butt and elsewhere), it seems fair to ask: Who is driving this craze for ever-more-exotic plastic procedures -- feverishly insecure patients, profit-hungry doctors or some combination thereof?
At Alter's office, in the heart of the glittery Rodeo Drive shopping district in Beverly Hills, I'm leafing through People when a young man emerges from the back, waves a cheery good-bye to the nurses and walks slowly, gingerly, to the door, like an extremely saddle sore cowboy. I don't know whether Alter will give me answers, but I'm definitely in the right place to ask questions: This has to be the epicenter of the total -- and I mean total -- body overhaul.
When I take a seat across from Alter at his desk, he confesses that he's a little beat. This morning he performed five hours of liposuction in hopes of giving a male-to-female transsexual patient "a better curve to her waistline." And indeed, as he contemplates the trajectory of his career, the doctor looks weary. Because he's board certified as a plastic surgeon and as a urologist, he says patients with -- he pauses before finding the right delicate phrase -- "certain genital abnormalities" are frequently referred to him. In addition to the traditional menu of cosmetic surgeries, he reconstructs congenital defects and performs common vaginal operations, such as repairing bad episiotomies. He also does more controversial procedures such as pubic vaginal lifts -- nip-and-tuck excisions of skin from above the pubic hair said to give women's groins a more youthful, "elevated" appearance -- and penis enlargements, which other doctors say can leave men impotent.
While most gynecologists and plastic surgeons say requests for labiaplasties are rare, a few admit to performing the procedure for women whose large labia minora cause serious discomfort in tight clothing or during sex. Alter and a small but growing number of his colleagues are enthusiastic about the operation's cosmetic future. Alter tells me the technique he has invented doesn't leave much scarring on the exposed edge of the labia. He slides before-and-after Polaroids across the desk. I frown in an effort to appear serious, like some kind of crotch scholar. To me, the pre-op shots don't look markedly abnormal, considering that vulvae come in a snowflakelike spectrum (or at least they do at the "free body" beaches I've visited in Europe). Yet Alter seems convinced there's something freakish about the women. "You see how this is real large?" he says, pointing to slightly asymmetrical labia. "Her sister even made fun of her, OK?" The labia of the woman in the next photo are more elongated, but by no means strange. What strikes me in the "after" shots is the eerie similarity between the women. Pre-op, you could have picked their labia out of a lineup; now, their genitalia are carbon copies of each other.
Alter says his new service is giving women relief from what might be called "labia envy." "Some women have this feeling they're not that pretty down there," he says. "If you really think you're deformed, you're going to be less open to a sexual relationship. Before, it was the dark ages, because nobody really cared, or knew, what it looked like. But now, with Penthouse and all these magazines that show vaginas -- I mean, they really show it -- you have women, not just men, looking. And they start making aesthetic judgments." From Alter's "after" shots, it would appear that the in-look for labia is slim and straight.
- - - - - - - - - - - - - - - - - - - - -
In my admittedly limited circles, I may have missed the outcry for cosmetic labia reduction. After all, other doctors say that the inauguration of Playboy in the '50s helped spawn the craze for breast enlargements in the '60s and '70s. More recently, the bodybuilding movement has inspired men to get calf and pectoral implants. Perhaps Alter is right about the Penthouse effect. I ask him how many of the procedures he's done, expecting big numbers. "Ah, five or six," he mumbles, shuffling papers on his desk.
"I think somebody could send a note to our ethics committee and say, 'That's fraudulent,' and that would be legitimate," says Dr. Dennis Lynch, president of the American Society of Plastic and Reconstructive Surgeons, when I told him that Alter's press release asserted that "many" patients had sought labiaplasty, then gave him the surgeon's actual, uh, head count. Lynch says the ethics committee could give him what amounts to a slap on the wrist: It could recommend that he tone down the language of his promotional material. Since cosmetic plastic surgery is, by design, innovative -- it's been pushing the boundaries of medicine and, in turn, culture for decades now -- it seems a bit hypocritical for the surgeons who made "boob job" a household term to be schoolmarmishly complaining about the next generation's marketing strategies, much less their latest operation. But Lynch and other doctors say they're legitimately concerned about fringe plastic surgeries pushing into the mainstream. They charge that some doctors get so caught up in expanding their repertoire of lucrative elective procedures, they forget their do-no-harm Hippocratic oath. (Patients pay out of pocket, in full, for most cosmetic surgery, while insurers are forever tightening reimbursement for nonelective treatments.) So while Alter sees penis enlargements as a victory for men demoralized by small-penis jokes, other doctors say they won't perform the operation because it can cause infection and loss of sensitivity.
Alter insists labiaplasty hasn't changed his patients' sexual sensation; his technique is relatively safe, he adds, since he avoids cutting near the clitoris. But Dr. Norman Schulman, chief of plastic and reconstructive surgery at Lenox Hill Hospital in New York, says that's impossible because the female anatomy is too unpredictable: "There are women whose nerve centers are collected at the clitoris, women whose nerve centers are collected at the labia, women whose nerve centers aren't even in the genitalia." The change in appearance is slight, he says, "and yet the consequences -- whew."
Schulman says he is already aware of lawsuits against surgeons by women who claim labiaplasty impaired their sexual responses. It's impossible to predict, but such cases could become the quintessential "he said/she said" litigation of the medical-malpractice world. If a woman says that labiaplasty took away her ability to have an orgasm, who could prove her wrong?
Every time a new procedure is invented for an as-yet-untouched region of the body, the essential conundrum of plastic surgery is pointed up: While doctors may sometimes push surgery on patients, it's also true that patients clamor for certain operations because they make them feel better about themselves. "We've accepted that having body parts that are way off the charts is painful for a person," says Dr. Nada Stotland, president of the Association of Women Psychiatrists. "Yet the question is, then, where do you draw the line? I think most of our energy should be used to help people feel proud of their bodies. But at the same time, you can't entirely denigrate the idea that a body feature could cause a person enough psychic pain to warrant surgery."
When I call one of Alter's patients (who asked not to be named), she says the surgery has made "a world of difference" to her sex life. "If you see something affecting your relationship, then, yeah, save yourself the head trauma and get it done," she says. "I'm a lot happier." She also seems aware that the procedure may not have changed her anatomy as much as her attitude toward it: "Once you get a hang-up, it just grows and grows. It's all mental, and women tend to do that in our society." Alter's patient sounds pretty well-adjusted, and the doctor, for his part, says he avoids plastic-surgery junkies who undergo serial operations desperately trying to achieve perfection. "You decide whether or not you think a patient is crazy," he says.
When it comes to cosmetic labiaplasty, however, Dr. Katharine Phillips, a psychiatrist who is the director of the body dysmorphic disorder (BDD) program at Butler Hospital in Providence, R.I., says no doctor should make a quick assessment. Although, so far, she's only treated men who are so anxious about their "deformed" genitals that they stop socializing and spend hours in front of the mirror, she says any woman who did the same would be a candidate for a BDD diagnosis. "We know that people with BDD tend not to do well with surgery and are often very unhappy with the procedure," she says. Phillips says she has also seen cases of plastic surgery-induced BDD. "We don't know how many people we're talking about, but there is some risk that this will trigger a very tormenting, very painful obsession."
If breast implants and nose jobs are acceptable, if only because we've grown accustomed to them, it's hard to argue that injecting bacteria toxins (Botox) into the forehead or implanting butt fat between the breasts is categorically wrong or too extreme. Still, the idea that women should pretty up such highly personal territory as the labia seems like a low blow. "Barbie may be plastic, pink and totally smooth down there," Stotland says, "but the fact is, people's bodies are not like that; they're not uniform, and they're not supposed to be." Even Alter seems to realize that labia reduction might not be his profession's nicest invention. "It's another pain in the ass," he says, with a whatta-ya-gonna-do shrug. "It's another insecurity to throw out there," he concludes, as if he weren't one of the guys doing the throwing. So maybe, knowing that the doctor himself admits to helping manufacture the problem he seeks to treat, women shouldn't catch the pitch.