Content warning for genital mutilation, medical trauma

When Jessica Pin got a labiaplasty at age 18, her consent form read, “excision of redundant labia.” Instead, the doctor cut off the entirety of her labia minora and performed a clitoral hood reduction she never agreed to.

Afterward, when she touched her clitoris, there was no sensation. Since then, she hasn’t been able to orgasm, or feel much of anything at all, without a vibrator—something therapists and doctors dismissed as normal or a consequence of her “not being in love.”

When she wrote to her surgeon about what happened, he said he’d given her what she asked for. But an examination from his colleague confirmed that the dorsal nerve of her clitoris had been cut, leaving scars.

She wanted to report her surgeon, but her psychiatrist warned her that the board would defend him and attack her. Plus, the loss of her sexual functioning combined with the backlash she’d received for talking about it had left her suicidal. By the time she felt mentally healthy enough to speak out, the statute of limitations had passed. The doctor went on to win awards and become president of the state medical association. And even after she got yet another examination from his colleague, her surgeon said the scars must have been from a different surgery (which she never got) or that she must have done it herself (which she didn’t).

The loss of her sexual functioning combined with the backlash she’d received for talking about it left her suicidal.
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When another woman, who wishes to remain anonymous until her case goes to trial, got surgery to repair a tear to her labia after a sexual assault, she told the doctor not to go anywhere near her clitoris. “The doctor decided they needed to remodel my entire vulva, without discussing with me or asking for my consent, thinking this was best and would improve the ‘appearance,’” she remembers.

Instead of the minor repair she requested, her inner labia were completely cut off, and the skin of her outer labia and clitoral hood were pulled inward, causing nerve damage. In addition to losing all sexual sensation and ability to orgasm, she developed “extreme burning sensations, sharp pains in my clitoris glans, shaft, up the inguinal nerves and into my cervix.” She now finds it difficult to walk due to the pain. She had several consultations with doctors who do reconstructive surgery for botched labiaplasties. “They told me it looks like FGM,” she says.

A study she conducted that is currently awaiting publication has identified hundreds of women who have been victims of botched labiaplasties. Their complaints include complete amputation of the labia, inability to orgasm, clitoral injuries, and labia minora stitched to their labia majora, clitoral hood, or vagina.

It’s unclear how common incidents like these are, but they’re common enough that there are discussions on online forums dedicated to botched labiaplasties, as well as doctors who specialize in correcting them. One of them is Michael Goodman, MD, Clinical Assistant Professor in the Department of Obstetrics and Gynecology at the California Northstate University School of Medicine, who estimates that “well over a thousand” women suffer from botched labiaplasties each year. This number will likely grow, as labiaplasty is the world’s fastest-growing cosmetic surgery, seeing a 45% increase in 2016 alone.

They told me it looks like FGM.
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Pin thinks this problem is more common than we realize because many victims are afraid to speak out. “Things got a lot worse for me when I started trying to talk about it and decided I needed to stand up for myself,” she says. “That’s why I suspect women who are harmed stay silent. The worst part was the gaslighting, victim-blaming, lying, and minimization.”

One reason labiaplasties get botched is that OB-GYNs don’t have an adequate understanding of the labia or clitoris, says Goodman. “OB-GYNs are both ’women’s surgeons’ and supposedly experts in vulvar and vaginal anatomy. They are trained to perform ulvovaginal procedures but receive absolutely no training in plastic procedures on the vulva,” he explains.

“While a board-certified plastic surgeon will not dare to perform a labiaplasty unless his or her residency program includes labiaplasty and genital anatomy in their training program, an (untrained in plastics) OB-GYN will think, ‘Well . . . how hard can it be? I am an expert in the vulva! Just cut it off and sew it up.’” Much of the issue could be solved through proper training in medical school and residencies, he says.

The Sexist Science Of Female Sexual Dysfunction

Paul Pin, MD, Chief of the Division of Plastic Surgery at Baylor University Medical Center, often trains residents who’ve been taught nothing about clitoral anatomy, and he’s never seen clitoral anatomy in plastic surgery journals. This means that many doctors who perform labiaplasties don’t even understand the body parts they’re operating on. Jessica’s doctor had only performed two labiaplasties and received no training in them.

Vulvar anatomy is also woefully absent in textbooks. After poring through medical books, Jessica has only been able to find the nerves and vasculature of the clitoris illustrated in two—Williams Gynecology and Williams Obstetrics—and even these didn’t have accompanying descriptions. Anatomy books include “very little detail about clitoral anatomy—certainly less than the penis,” confirms Paul Pin. “The real nerve supply to the clitoris is almost universally absent in textbooks.”

No one even knows how many of these procedures are done, much less what the outcomes are.
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Another problem is that doctors who offer labiaplasties are not held accountable for providing the procedure safely, he adds.

“Most labiaplasties are done in doctor’s offices under local anesthesia, in non-certified operating rooms. No one even knows how many of these procedures are done, much less what the outcomes are. Professional societies should demand their members report their numbers and their outcomes to insure patient outcomes.”

But the issue goes deeper than lack of training or oversight. Underlying the erasure of vulvar genitalia from textbooks, journals, and medical schools is a societal neglect for female sexual pleasure and health. Many people still describe vulvar genitalia as the “vagina,” neglecting the clitoris and other sensitive external parts. In sex ed and biology classes, people learn about the role of vulvar anatomy in reproduction, not its potential for pleasure. As feminist author Peggy Orenstein put it in her TED Talk, kids “learn that boys have erections and ejaculations, and girls have periods and unwanted pregnancy.”

It’s this view of women as baby-making or man-pleasing machines, rather than human beings with their own desires and needs, that colors medical education. “For most medical students, the great majority of sex-ed-related learning has to do with reproductive anatomy and functioning, not pleasure,” explains sexologist Carol Queen, PhD. “The clitoris isn’t really directly relevant to this, and so the ‘inner workings’ (uterus, ovaries, fallopian tubes, etc.) often get more attention.”

As such, many women and gender variant folks themselves don’t learn the importance of the clitoris—or that the labia can also be sources of sexual pleasure. “I didn’t know my body or understand the significance of lost external sensation because I thought the magic was supposed to be inside the vagina,” says Jessica.

What A Fake ‘Female Orgasm’ Statistic Says About Gender Bias

In a society that considers women’s primary role in sex to be pleasing men, injuries that do not affect their ability to have penis-in-vagina intercourse are trivialized. “Female sexuality is objectified in the way it is approached. The vulva isn’t well described as an actively functional apparatus, which it is,” says Jessica.

“Do you think men would go to urologists who didn’t know the nerves and vasculature of the penis? Obviously not in a million years. But for some reason, women are comfortable with doctors who approach their vulvas as if they are non-functional, inanimate objects. ‘How vulvas work’ is not a subject of much consideration because women are ‘complicated’ and ‘emotional,’ not sexual.”

Compounding this problem is an overall neglect for sexual pleasure in the medical field, and a denial of the fact that pleasure is part of health. For example, women who don’t experience adequate sexual arousal may suffer from painful sex, which could lead to medical problems, Queen explains.

Queen believes surgeons should be required to inform their patients that, even when they’re performed properly, labiaplasties remove sensitive tissue and could result in some loss of sexual sensation. The same goes for hysterectomies, she adds. “While it can absolutely be medically necessary, it is often the case that patients aren’t informed that sexual sensations may change, and historically, doctors didn’t focus on retaining fully functional neurology when they removed a uterus.”

If vulvas got the same standard of care as noses, I’d be happy.
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When Jessica has written about her botched surgery, some have questioned why she got a labiaplasty in the first place, and implied that she was asking for it by going under the scalpel. But while she acknowledges that unrealistic beauty standards led her to get the surgery, she points out that other forms of surgery are held to higher standards, regardless of the patient’s motives. “If vulvas got the same standard of care as noses, I’d be happy,” she says.

Ultimately, if people learned about and valued women’s sexual anatomy and pleasure, fewer people would be getting labiaplasties, and those who did would be able to get them more safely, says Queen. “It’s not just that doctors need pleasure-inclusive sex education as part of the medical curriculum,” she says. “Everyone needs sex education that honors the fact that most people want sex that is pleasurable.”

Let’s imagine this story isn’t about the pill, its about beer. Imagine that every three months you have to pay to see a doctor to get their permission to drink it. Or, maybe you don’t like it — for taste or health risk concerns. But whether you want to drink it or not, you’d be bothered that a person’s own judgment wasn’t enough. You’d be bothered by how hard it was to get.

Welcome to the world of acquiring the pill, with one important difference: The pill ain’t for fun.

While it obviously isn’t for everyone, many people use the pill or other hormonal birth control methods to decide when or if they’ll have children, to prevent being in pain for one week in every four, to control when or if they’ll bleed, and more.

The health risks of beer can be severe, and people are welcome to see a doctor if they are concerned. Likewise, the pill can also have side effects (most medicine does) and people can also see a doctor about that if they choose to.

The strange thing is that people in most “first world” countries are obliged to see a doctor every three months to a year (depending on local regulations), for 35 years or so. Even if they stay on the same pill and have no new symptoms or concerns.

Jen Billock Young told me she spent three years trying to get access to the pill. She said she felt “defeated” at every turn, after she had to wait a year and a half just to get a new patient exam, then was told she had to get a pap smear … and so it went on.

Meanwhile, cigarettes, responsible for more than 480,000 deaths a year in the United States, are easy to buy. Caffeinated drinks taken in excess can cause palpitations, high blood pressure, vomiting, convulsions, and in a few cases death, according to the NHS. But they too are easy to get. Dietary supplements have accounted for over 8,000 people needing treatment in health care facilities. And then there are guns, available just by walking into a shop in many parts of the country.

The point isn’t that things like beer should be regulated or prescribed, but rather that we should question why women aren’t trusted to make decisions about what is best for them, and consumers of beer or cigarettes are?

After putting out a call, many women told me about the ordeals they have had to go through to get the pill.

Billock Young told me she finally got her prescription six months ago. She had been on Wisconsin state insurance, and was required to see a gynecologist before she could get a prescription. The wait for that was 1.5 years. She then had to get a pap smear before they would prescribe the pill, and that took several months more.

“Meanwhile, I tried to go to Planned Parenthood. They refused to give me a prescription because my blood pressure was slightly elevated because I was nervous … They said they could only offer me a shot that I had to come in for every three weeks.”

When Billock Young finally got to see a doctor and get the prescription, she encountered more hurdles. “The state insurance filled the prescription for three months at a time, but I got kicked off (of that). So I bought a marketplace plan … and they’ll only refill it one month at a time.”

Emily Popek said she was “shocked and disappointed” to discover that her insurance company didn’t offer coverage for contraceptives. She said customers had to use a third-party company, and even then there were no providers offered within a 60-mile radius of her home.

For me, there was that time a doctor drew a diagram to show me how the pill would decrease my fertility. I told her that wasn’t true, and even so I didn’t mind, but she persisted in discouraging me. Other doctors have told me it is bad to take it for a long time (also not true), and it’s gotten to the point where I lie to doctors in order to avoid the lectures and the small bits of trauma that come with constantly having to justify my private choices to strangers.

Others told me their stories anonymously through Reddit. One woman described how an “old white doctor” berated her when she was 18, implying she was “young, frivolous, and rash with boys,” and would regret her decisions. He refused to prescribe her the pill, claiming it caused breast cancer.

Another woman also had an “old white man” doctor who refused to write a pill prescription for her, saying young people forget to take the pill. She said she was already taking other daily medications.

Another person told me anonymously in an interview about how she saw an endocrinologist while taking the pill for Polycystic Ovary Syndrome (PCOS) symptoms. “The doctor told me that the pill increases the risk of diabetes and in general isn’t good for women with PCOS. He then looked at me sternly and asked if I was using the pill as a contraceptive as well and I said I wasn’t. He replied ‘good girl’ in a patronizing but sincere tone.”

There were more stories of all the irrelevant and judgmental questions doctors asked — most commonly, the number of previous sexual partners. But doctors rarely ask the few questions that could be useful, about side effects.

Even then, the main concern — blood clotting — has a risk of 12 in 10,000. The risk is the same for pregnant women, but we don’t need permission for that (and shouldn’t, of course). For our beer (alcohol) drinking friends, the odds are higher of getting cancer. A male who drinks two pints of lager a day doubles his risk of esophageal cancer from one in 75 to one in 38.

So why does this matter?

A 2013 U.S. study found that 30% of women who weren’t on the pill would take it if it were available over the counter (and it was still affordable).

Making the pill and other hormonal birth control methods difficult to access denies women, and others with wombs, total control over our lives. It perpetuates inequality, with those who work multiple jobs or who are poorer finding it harder to overcome the time, financial, and psychological obstacles.

Birth control impacts people’s access to education, to work, and to leisure time. A 2013 Guttmacher Institute review of 66 studies found that reliable contraception helps people be better parents. That is, parent(s) who experience unplanned childbirth are more likely to have depression and anxiety. Reliable contraception on the other hand, allows parent(s) to grow as people and have children when they are more prepared and their incomes are higher.

There have been small improvements in access to hormonal birth control. Next year, for example, people in California will be able to pick up one year’s worth of pills at a time. Apps are becoming available for virtual consultations, but the video chats still cost money, the apps are limited to a few states, and in order to receive more than a three-month supply, the patient needs to have recent blood pressure results ready to show during the consultation.

Still, these changes don’t involve more respect for women’s decision-making.

Beer is still easier.

This piece originally appeared on Role Reboot and is republished here with permission.

By Sarah Torna Roberts

After an almost too easy road toward adoption, California Assembly Bill 1306 died on the Assembly floor in the last hours of the last day of the most recent legislative session. Had it passed, the state of California would have allowed certified nurse midwives (CNMs) to fully utilize their education and training without the archaic requirement of physician oversight — and women’s medical care in California would have finally entered the 21st century.

That is because CNMs are experts. They are registered nurses with master’s degrees of science with a specialty in nurse midwifery. They are trained in providing women with excellent care from puberty to menopause, with an emphasis on pregnancy and birth in normal, healthy women.

So physician oversight is a requirement that serves more as bureaucratic red tape than actual protection for a patient. Part of that is because the definition of “oversight” remains vague, and the term has been interpreted in various ways by different entities. In most cases, CNMs are providing care directly to patients without the physical presence of a medical doctor, and “physician oversight” amounts to little more than a doctor who is technically held liable for the actions of that CNM. The overseeing physicians do not have to be in the room when care is being provided. They don’t even have to be on the premises. Even in the hospitals, the physicians aren’t looking over the shoulders of the CNMs as their patients give birth.

This is one distinction often misunderstood by those who hear the word midwife and assume a correlation with home birth. Actually, 95% of CNMs attend births in the hospital, not at home, and they care for women who are experiencing low-risk, normal pregnancies. Because this is the scope of their practice, they take seriously their responsibility to collaborate closely with OB/GYNs, especially regarding any patient who would benefit from a different type of care.

“Obstetricians and gynecologists are trained surgeons whose skills should be utilized for patients in dire need of intervention — not normal, healthy women,” stated Melissa Wilmarth, a recent graduate of Georgetown University’s nurse-midwifery program who moved her family to Visalia, California, to provide care to a community that has limited numbers of practicing CNMs.

Currently in California, there are only 2.44 OB/GYNs for every 10,000 women, so allowing CNMs to practice within their full scope would leave OB/GYNs free to tend to the patients who really need them. Had AB 1306 passed, the unnecessarily long patient lists of OB/GYNs could have been reduced, no doubt increasing the quality of care all women receive.

But instead of welcoming this monumental advancement of better quality health care for women, as well as increased access for women of all socioeconomic levels and geographic locations, the California Medical Association (CMA), a professional organization made up of California doctors, fought tooth and nail to keep this bill from passing into law. In their perspective, if CNMs became autonomous in the eyes of the law, physicians would experience competition for the first time — an end these doctors were unwilling to accept.

According to Rebecca Garrett-Brown, California Nurse-Midwives Association’s president-elect, the CMA had nearly a dozen lobbyists on the floor of the California state assembly during those final important hours, all of them insisting that passage of AB 1306 would leave patients unprotected in the hospital setting, a claim that Garrett-Brown says is “just not true.”

The CMA-hired lobbyists were, however vaguely, referring to the corporate practice of medicine that assembly member and author of AB 1306 Autumn Burke removed from the bill in order to acquire support from the California Hospital Association prior to the final vote.

The corporate practice of medicine ban is a state doctrine that bars corporations, including hospitals, from directly hiring physicians and CNMs. The ban was originally intended to protect patients from the possible abuses a corporate entity can inflict if a physician or midwife ultimately answers to the corporation’s interests over the patient’s needs. But doctors have been worming their way around this law for years by joining together and presenting themselves for hire by a hospital as a “medical group,” not as individual physicians. And most other states have done away with the CPM ban in favor of other measures to protect the integrity of medical care, citing the antiquated language of the ban in light of the many exceptions and loopholes (ahem, those “medical groups”) already employed.

But California has refused to budge, interpreting the CPM ban as stringently as possible and also allowing powerful groups like the California Medical Association to use it as a scapegoat for their opposition to lifting the physician oversight requirement on skilled medical providers like CNMs.

When state representative Burke removed the CPM language from AB 1306, other language was added to support the intent of the ban. California Nurse-Midwives Association health policy chair Kim Dau stated, “Nurse midwives are on board with the concept of the ban on the CPM. We want to completely avoid conflicts of interest in patient care. Period. What we object to is how it is used to define the terms of our relationships to our employment, thus limiting access.”

To that end, AB 1306 was amended to read, “the bill would prohibit entities described in those specified settings from interfering with, controlling, or otherwise directing the professional judgment of such a certified nurse-midwife, as specified.” In light of this amendment, one would think the CMA would lift their objections, but they did not.

At this point, one must ask why a state known for its progressive ways is allowing the CMA to keep women’s access to medical care in the dark ages.

In the opinion of Linda Walsh, CNM and outgoing president of the CNMA, it’s all about the financial power of the CMA, the physicians’ professional organization. For years she has watched the CMA wield its power often in direct contrast with the will of the people. “Follow the money,” she said, noting that the CMA has given not insignificant amounts of money to various California senators and assembly members. “My own senator, Bill Monning, has never voted for a bill CMA opposed, even when his constituents have heavily supported the bill and shared that with him (as with AB 1306).”

Despite the fierce opposition of the CMA, Walsh says that the physicians she has worked with have always fully supported nurse-midwifery, but added, “That being said, I’m not sure how many felt safe enough to be vocal about support of the bill.”

Garrett-Brown has also enjoyed tremendous support from the physicians with whom she has collaborated with at University of California, San Diego for more than 20 years, naming Dr. Thomas Moore and Dr. Yvette LeCoursiere specifically. She stated that, contrary to Walsh’s experience, both physicians actively support midwives engaging in their full scope of practice and wrote letters on behalf of AB 1306 to share this perspective with the legislature.

In fact, physicians and nurse-midwives have long enjoyed a collaborative and mutually beneficial relationship, one that has been widely acknowledged on a national level. The American Congress of Obstetrics and Gynecology has put out several very strong position papers identifying nurse-midwifery as independent and autonomous. However, the CMA continues to insist that the relationship be hierarchical rather than collaborative, if only in law.

“For us, it’s all about access,” stated Garrett-Brown, who noted that California currently has nine counties that do not have OB/GYN care of any kind. With the passage of AB 1306, CNMs would have been free to establish practices and free-standing birth centers in some of these areas, increasing the number of providers available and the number of women with access to medical care.

Wilmarth, the recent graduate from Georgetown’s nurse-midwifery program who just passed her nationally accredited boards examination, will join an obstetrics practice alongside one other CNM. She’s thankful for a job with physicians who are supportive of her role in the practice, but she’s very aware that many newly-graduated CNMs in California are either forced to move to a more midwifery-friendly state or must continue to work as an RN until a CNM job opens up.

When Walsh moved to California from the east coast in 1990, she routinely asked her colleagues why California didn’t have more established midwifery practices. She says the answers were always the same: “powerful physician groups who didn’t want the competition, plus a declining birth rate.”

Considering the outcome of AB 1306, it’s not difficult to acknowledge the power of the CMA and the power of the almighty dollar. Unfortunately, what they are paying for isn’t better patient protection and care, which is the excuse they’d have you believe, but the autonomy of qualified medical personnel able to provide excellent care to thousands of women who deserve exactly that.

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Lead image: flickr/usarmyafrica