AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. April 2018, Volume 20, Number 4: 384-391.
doi: 10.1001/journalofethics.2018.20.4.msoc4-1804.

Medicine and Society

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What Should Be the Surgeon’s Role in Defining “Normal” Genital Appearance?

The Hottentot Venus’s exploitation for “education” can teach plastic surgeons to avoid using social media to sexualize or objectify patients’ bodies.

Devan Stahl, PhD, MDiv, and Christian J. Vercler, MD, MA

Abstract

The recent rise in women seeking cosmetic surgery of their genitalia (labiaplasty) coincides with the increasing number of surgeons posting videos of these operations on social media accounts and websites. Sociocultural influences significantly contribute to our ideas of what constitutes healthy and pathologic, and surgeons have historically played a role in defining “normal” and “abnormal” anatomy. In the nineteenth century, Saartjie Baartman—a woman with a large posterior and unusually long labia minora—was used by physicians to “educate” the public about these differences. We examine the parallels with the twenty-first century practice of surgeons using social media to educate patients about the operations they perform and discuss ethical and professional hazards associated with this practice.

Introduction

Over the past few years, a growing number of plastic surgeons have begun publically broadcasting their surgeries on Snapchat [1], a social media platform that allows users to post pictures and video “stories” that can last up to 24 hours before they vanish from the app. Unlike many other social media platforms, Snapchat allows users to post nude content as long as it is not “pornographic” or “sexual” [2], which allows surgeons using Snapchat (who are mostly men) to post images and videos of breasts, buttocks, and genitals of their patients (almost all women) before, during, and after surgery [3, 4]. Daily, viewers “tune in” to watch various women receive breast augmentations, “butt lifts,” “tummy tucks,” and even labiaplasties, which one surgeon using Snapchat claims are one of the most common procedures he performs [5]. The platform allows plastic surgeons to document their patients in what is perhaps their most vulnerable state, revealing the most intimate parts of their bodies in a casual, entertaining, uncensored environment.

Even the most intimate and hidden parts of a woman’s body, including her genitalia, are not immune from the plastic surgeon’s “gaze,” which, as Michel Foucault describes, depersonalizes the patient, making her an object of knowledge [6]. During procedures, the expert surgeon points out what is “abnormal” about the woman’s vagina to the Snapchat viewer, including various points of asymmetry, an excess of skin or folds, or looseness. He then explains what he can do to help her achieve a more “natural,” “beautiful,” “smooth,” “tight,” or “tucked in” appearance. Although these surgeons receive consent from their patients to use the patients’ images on Snapchat, the ways in which they depict, speak about, and handle their female patients’ bodies on Snapchat is often vulgar, sexist, and gender normative [7]. The surgeon’s actions thus help to define and constrain “normal” genitalia for women. In turn, women might learn to internalize and accept damaged self-conceptions because they regard features that deviate from normal as being important to their own gendered identity [7]. Surgeons further reify normal genitalia by having their patients participate in a public performance of the correction of their “deformity.” By pathologizing certain characteristics of female genitalia, surgeons contribute to the notion that women’s bodies need “fixing,” which can be damaging to women’s identities. Plastic surgeons must follow ethical guidelines when using social media platforms such as Snapchat to avoid sexualizing, objectifying, and exploiting their patients as well as demeaning their profession and reinscribing hegemonic gender norms.

Historical Precedents

The surgeon Snapchat phenomenon is hardly the first collision between a voyeuristic public fascinated with women’s genitalia and a medical community willing to exploit women’s bodies for personal and professional gain. In 1810, British surgeon Alexander Dunlop met Saartjie Baartman, a Khoisan woman working as a servant in the British-controlled Cape Colony. Fascinated with the steatopygia of her buttocks and unusually long labia minora, Dunlop convinced Baartman to come to England with him to exhibit herself as a freak show act [8]. Baartman became the “Hottentot Venus,” a crude joke referencing her Khoisan heritage and unusual anatomy that strayed far from European notions of classic beauty. Baartman was cast as an ethnopornographic freak show: a strange, sexual, and wild creature who bordered on the subhuman [9]. Spectators were invited to stare at Baartman and, for an extra fee, they could touch her buttocks to prove it was authentic [10]. The show was one of the most famous attractions of Georgian London, but many found Baartman’s display degrading and indecent, as well as immoral and possibly illegal after slavery was abolished in Britain [10]. Members of the African Association took the matter to court, but the case was dismissed after Baartman testified she came willingly to England to make money and was under no restraint to remain [11]. Baartman later wound up in Paris, where she continued to be exhibited and examined by Georges Cuvier, a naturalist whose 16-page report on Baartman dealt mostly with Baartman’s genitalia, breasts, buttocks, and pelvis [11]. After her death in 1815 [8], Cuvier made a cast of Baartman’s body and preserved her brain and genitals, which remained on display in the Museum National d’Histoire Naturelle in Paris until 1955 and were only returned to South Africa in 2002 [11]. Today, Baartman’s biographers agree her display was exploitative and unethical, despite the fact that she was a willing participant [8, 10].

Parallels between the Past and Present

While not to diminish the horrendous conditions under which Baartman found herself during her short life as a freak show exhibit or the obvious racism, sexism, and imperialism that undergirded her display, Baartman’s treatment bears some resemblances to the many women who participate in their surgeon’s Snapchat videos in at least four ways. First, the main impetus for the public display of these women is male surgeons. Beyond having the advantage of medical knowledge and skills that are revered in American society, the surgeons using Snapchat control how their female patients, who are unconscious and typically nameless as well as faceless, are displayed in their Snapchat videos and thus wield incredible power over them. The celebrity these surgeons are beginning to gain through their use of social media platforms exacerbates this power imbalance. By virtue of their power, surgeons are able to set the standards for what constitutes normal female genitalia, which, as mentioned previously, can be internalized by women exposed to new—and perhaps damaging—standards of genital comeliness [7]. Of course, simply because a patient (or freak show performer) agrees to be displayed by a medical professional does not rule out exploitation. As we will show, certain surgeons’ blatant sexualization and objectification of their patients’ bodies is indeed unprofessional and exploitative, even if patients themselves agree to this display.

Second, these Snapchats, like the freak show, purport to be a form of education for lay audiences; indeed, the claim is that the educational aspect is why most viewers tune in [12]. Just as the participation of scientists and physicians in the nineteenth-century freak show granted these experts legitimacy and (seemingly) prevented them from being seen purely as recreational [13], so, too, does the presence of a surgeon allow the display of women’s bodies on Snapchat to be seen by many as educational rather than exploitative. Surgeons in the nineteenth century, like plastic surgeons who use Snapchat today, used women’s bodies as a way to “educate” their profession and the public about the abnormal or displeasing female body and the power of medicine and science over such bodies. Like the showmen of the nineteenth century, surgeons and their social media staff act as the freak show lecturers, directing the audience toward what to look for and why it matters, all the while normalizing and legitimizing gazing at it. The mood is light, the surgeons and their staff members (usually young attractive women) crack jokes, make small talk, play music, and dance, all the while populating their shared images, emojis, memes, Bitmojis, and popular Snapchat filters. Some surgeons, keen to be the center of attention even when examining their patients’ naked bodies, create floating images of their own heads that they position carefully over women’s breasts and vaginas. Such practices do not educate anyone about the technical skills involved in surgery, the risks involved, or the possible complications. Moreover, it is hard to imagine how such practices benefit the patient, whose care is supposed to be primary. While there is as yet no evidence, one ethical, social, and cultural concern is that the focus on “entertaining” a virtual audience detracts from patient safety and efficiency.

Third, persons who object to surgeons’ Snapchats likely question women’s consent to being displayed, just as the African Institution questioned Baartman’s willing participation. Some Snapchat surgeons claim not only that all of the patients filmed give consent but also that most of their patients know them from social media and ask to be filmed [14]. Some patients want their faces and tattoos covered, but others request “shout-outs” to their friends and family during and after their procedures [14]. As one surgeon explains, millennials, who comprise the bulk of his patients, are unashamed of their bodies or voicing their insecurities, so they do not see plastic surgery as a private matter [14]. Presuming these patients do give their consent, surgeons are still obligated to speak about and handle their patients in respectful and professional ways. If they do not, patients themselves might be blamed for their own representations by Snapchat surgeons. After learning that Baartman consented to her exhibition, many felt justified in belittling her, and she became the subject of countless cruel cartoons, doggerels, and ballads [9]. Doubtless, some might similarly deride millennial women for the same credulity in willingly participating in their own exploitation. Surely, some women are doing so, particularly when they have internalized a prevailing construction of idealized femininity [7]. But consent does not end the moral problem a patient’s display might constitute. The nature of the patient-surgeon relationship is one particularly marked by an imbalance of power such that merely obtaining consent is insufficient for avoiding exploitation [15]. An overreliance on the bioethical principle of respect for autonomy has likely obscured other unethical behavior that can occur when physicians treat patients unprofessionally. Surgeons should continue to be aware of the power differentials that enable the exploitation of vulnerable patients, who are likely to internalize messages about “inadequacies” and “defects” that are perpetuated from inside and outside the medical community.

Finally, we ought to be concerned with how patients are portrayed and spoken about, as well as with how surgeons handle their bodies. Not only was Baartman portrayed as a subhuman animal, she was poked and prodded like one as well. Even in death, Baartman’s full cast was on display and her genitals preserved in a specimen jar, which was later stored and forgotten until South Africa requested her body to be repatriated [11]. Most surgical patients are naked, unconscious, and on display to the medical team, but surgeons should be careful not to exacerbate these vulnerabilities by overtly objectifying or sexualizing their patients. Male surgeons ought to refrain from behaviors the authors have observed on Snapchat—explicitly sexualizing their patients by referring to how sexually appealing or “hot” they will be postsurgery, asking viewers to rate the sexiness of a woman’s new body, or commenting on how sexually fulfilled their partners will be. Surgeons should also be careful to handle their patient’s bodies, whether intact or dissected, with professional care. Practices the authors have observed on Snapchat, such as dunking excess fat into basketball hoops, pretending to wear a woman’s skin, or groping newly reconstructed body parts while commenting on their sex appeal, must be avoided. Surgeons must be careful that their medical gaze is therapeutic in intention and not objectifying or sexualizing.

Contemporary Lessons

Saartjie Baartman’s body was a phenotypic anomaly in Western society, reinforcing her “otherness” and reifying normal sexual anatomy among European audiences by contrast. Ironically, the contemporary phenomenon of posting before and after photos of genitalia on Snapchat once a procedure is finished does the opposite. It pathologizes normal anatomy and induces emotional distress about one’s appearance [16]. The American Society of Plastic Surgeons has only been tracking the incidence of labiaplasties since 2015, and data from 2016 show a 39 percent increase in the number performed over the previous year [17]. What can explain the explosion in the popularity of this procedure? It is difficult to discount the effect of the medicalization of the sexualizing “male gaze.” Holding up the vulva as an object of aesthetic scrutiny and projecting postoperative images as the ideal reinforces the assumption that what is within a broad range of phenotypically normal anatomy is abnormal. Often labiaplasties are touted as “rejuvenation” of the external genitalia [18]. W. A. Marshall, an anatomist, and J. M. Tanner, an endocrinologist, classified the appearance of external genital development in four stages in which the fourth represents the postpubertal adult phenotype [19]. That the result of most labiaplasties is the achievement of a Tanner stage one appearance—that of an infant or prepubertal girl—should give us pause. Surgeons might be unwittingly perpetuating and exploiting pedophilic tendencies, which are problematic for adult women as well as children.

The advertising guidelines of the American Society of Plastic Surgeons (ASPS) [20] state that “photographs or images will not … falsely or deceptively portray a physical or medical condition, injury, disease, including obesity, or recovery or relief therefrom” [21] and prohibit “appealing to the layperson’s fears, anxieties, or emotional vulnerabilities” [22]. A significant number of women seeking labiaplasties cite negative self-perception regarding their genital appearance as a reason for having the operation [23, 24]; therefore, surgeons must consider the extent to which their social media accounts contribute to inducing these feelings of “pudendal self-loathing” [25].

Images labeled #thinspo and #thinspiration (among others) have been regulated by Instagram precisely because of the negative effects such postings on social media might have on certain people, specifically those with eating disorders [26]. While banning such images from social media does not solve the problem [26, 27], there should be a recognition and appropriate response from surgeons to take responsibility for their role in defining normal anatomy in a way that pathologizes a vast swath of normal anatomic variability. The fact that those responsible for defining or redefining what constitutes normal sexual anatomy for women are also those directly profiting from the content of those definitions is an inherent conflict of interest.

Above all else, plastic surgeons are medical professionals who must hold themselves to a higher standard of conduct than merchants peddling goods. The fiduciary responsibility the surgeon has to her patient demands that she put the best interests of her patient before her own profit [28, 29]. In the twenty-first century, it seems clear that Saartjie Baartman was exploited for “educational” purposes and that her “consent” cannot justify the way her body was used. The parallel to surgeons today who use their patients’ bodies to educate and entertain on social media is compelling. We believe that the majority of surgeons involved in these activities are merely intending to use every avenue to reach a wider audience, build their reputation, and attract more patients. They are likely unaware of the ramifications of these behaviors. We suggest that surgeons who are serious about their commitments to ethical and professional guidelines, such as the ASPS’s, refrain from using social media in ways that sexualize patients’ bodies, objectify women’s flesh for entertainment, exploit women and children, and market the surgeon at the expense of ensuring safety and efficiency during operations.



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Devan Stahl, PhD, MDiv, is an assistant professor of clinical ethics in the Center for Ethics and Humanities in the Life Sciences at Michigan State University in East Lansing, where she also teaches ethics and medical humanities in the College of Human Medicine and works as a clinical ethics consultant. Dr. Stahl’s research interests include medical fine art, disability studies, and theological bioethics.

Christian J. Vercler, MD, MA, serves as a clinical assistant professor in the Division of Craniofacial Surgery in the Section of Plastic and Reconstructive Surgery at the University of Michigan in Ann Arbor, where he is also co-chief of the Clinical Ethics Service of the Center for Bioethics and Social Sciences in Medicine. He completed a fellowship in clinical ethics at the Emory University Center for Ethics and earned a master of arts degree in bioethics from Trinity International University.

Are Cosmetic Surgeons Complicit in Promoting Suspect Norms of Beauty?, May 2010

Are Physicians Blameworthy for Iatrogenic Harm Resulting from Unnecessary Genital Surgeries?, August 2017

Can Plastic Surgeons Maintain Professionalism within Social Media?, April 2018

When Is Advertising a Plastic Surgeon’s Individual “Brand” Unethical?, April 2018

When Is Posting about Patients on Social Media Unethical “Medutainment”?, April 2018

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.