The first time it happened, it was my mother. What perfect betrayal, like burning down the house where I was born. She grew tired in secret of the long, curved line of her belly, pendant in sweatpants and spreading over her lap when she sat. She hated huffing and puffing up the stairs, and she worried she’d become diabetic. So she underwent a radical form of weight loss surgery that eliminated over half of her gut — and taught me a powerful lesson in how intolerable it was to be like me.

Four kids and a minivan — nobody expected her to bother about her looks anymore. She didn’t tell anyone she was going to do it; she only told me I’d have to look after my younger siblings on the eve of the surgery. She made up her mind and didn’t want their judgments or their approval. The week before was an orgy of overeating that I recall as a conveyor belt of food. Carbonara thick as oil paint on piles of handmade noodles. Pot roast in flour-thickened gravy, potatoes enough to starve the Irish again, followed by bacon sandwiches that blurted mayonnaise from every side when she bit into them.

Even then, she barely cleared the insurance company’s weight requirement. Her doctor told her to make that last week count. Her best friend joked that she must be going in to get her tits done. She laughed and went under the knife at 4’11” and 285 pounds, nearly as wide as she was tall.

My mother was the first woman I knew who moved out of her own body.
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But what she really wanted was to not be like me anymore.

I went to support groups with her, in the year after the surgery. I didn’t go for the endless stories of these recovering fatties who had traded the feeling of being squeezed by the outside world for being strangled to thinness from within. I didn’t go for the stories of divorce so utterly rote and predictable that I struggled not to laugh. Men often marry fat women for very specific reasons. Conditions change and those men split like bananas. I went along because everyone there had once looked like me — and some of them had very nice clothes. They’d trade with one another, a 16 for a 14, a 12 for an 8. They shrunk before my eyes like icicles in spring. The tables marked 26/24/22 filled up and there was no one else to take those elastic dresses and 3X yoga pants. I showed up with a roll of garbage bags.

Why Don’t We Hear Fat Women’s #MeToo Stories?

More than once I inherited someone’s favorite outfit in its entirety, replete with the story of how it made her feel. I would wear that outfit later and remember that she wanted to stop being this so badly that she let someone cut out a large section of her intestines. She had an anchor-shaped scar across her entire abdomen. She vomited every day and shit herself at least once a week, but at least, thank god, it was all worth it because she wasn’t fat anymore.

There were other people I knew who moved out of their bodies, and I could understand why: They knew they had to go. They were being evicted anyway; blown knees and exhausted pancreas pushing them toward desperate measures. Weight loss surgery seemed a fair price if the alternative was death.

But in nearly every case, the alternative was my life.

I used to joke with people that I was my mother’s before picture, in the ubiquitous and devastating tradition of photos taken to reveal dramatic weight loss, the punchline for every ad that sells weight loss to women. Beforewe had shared a silhouette, titanic ass and olympian hips, a pear-shaped and pendulous swing we rode through the world. After I had trouble believing we were the same species, let alone iterations of the same bloodline. Long legs and short arms; freckles and the same crooked pinky finger. But disparity of scale suggested two different climates; two long-separated branches on the tree of life.

Before, my mother had dealt with the way people refuse to take fat women seriously. She had endured the infantilization and desexualization, and she was ready to trade it in. Two days after the surgery, she ignored her doctor’s orders and tried to chug a coke. I watched her stand over the kitchen sink with brown foam pouring from her nose and mouth, knowing herself chastened not by a paternalistic and fatphobic doctor for once, but by the physical reality that her new stomach was the size of a Dixie cup. A month later, I watched her black out after eating a Starburst; the sugar dumped into her bloodstream so fast that it acted like heroin when it hit her vitals. She traded the agony of perception for daily physical torment. After years of trying and failing at diets that never worked for anyone, she chose the nuclear option. She weighed her options and chose this over living a life like mine.

For me, it’s only the surgery that achieves the sharp sensation of abandonment, rejection, and betrayal. I’ve seen friends through every diet, every justification of denial, misery, and elimination. A friend or a cousin will one day lose the ability to converse about anything but carbs or sugar or whole foods or animal products. I’ll stop listening and start nodding. I know they’re trying to move out, move away. They cannot bear to be what we are anymore.

The fat people who become obsessed with counting calories and steps, the ones who try to vacate their bodies a little at a time . . . I don’t worry about them. They’ll never make it. Sooner or later they all come back.

The ones who follow in my mother’s footsteps are the ones that really leave. They get something cut up and cut out, they install new hardware to stop them from eating the world. They pack it in and they don’t return. I stay me.

I’ll be polite to my fellow fatties when they fall prey to the pressure; I understand what they’re going through. Thin people talking diets fill me up with liquid murder. I cannot abide their careful warding, hanging up knots of garlic and crossing themselves three times when they see me coming. I will not listen to their terrified superstition or their smug pseudoscience when they tell me again and again what they are willing to go through rather than become like me. When their talk rolls around to calories and their moral obligation to hate themselves, I typically spread out as wide as I can. I can expand like a jellyfish; it is a particular advantage of the very fat. I conform to the shape of my container like a water balloon. Displaying maximum width, I’ll eat anything I can get my hands on while they talk. On one notable occasion I shut down a discussion on the evils of white rice by calmly eating a trick-or-treating sized bag of mini Snickers while nodding my fat head to show I understood.

In outraged weariness of being seen as a cautionary whale, I seek out ways to weaponize my own image. I haunt thin people at the gym as the Ghost of Fatness Yet to Come. It started off as a demoralizing phenomenon; I began by refusing to shrink away from the pained glances and open hostility I receive for having the audacity to live in a fat body without making a constant apology for myself. My gym in San Francisco is a caricature of bodily obsession. Its ad campaigns are notorious, and lithe trainers cruise the floor like sharks sniffing for blood. There are no other fat people there. An orca among eels, I cast my shadow over their swimming and striving, and they look upon me in naked terror. I am the reason they get up at 5 a.m. and wear a monitor that counts their steps. I am the worst thing that can happen.

‘It’s Because You’re Fat’ — And Other Lies My Doctors Told Me

One after another, the fat people in my life have left me. Not through diet or exercise, not through the much-vaunted “lifestyle change.” They get the surgery and they cross over to the other side. Many of them have been self-accepting, even fat-positive. They came through hell to love themselves and live in their bodies without apologizing. But they’ve gotten tired of haunting the gym. They get tired of people lecturing and begging. They get tired of men at the bar shouting “man the harpoons.” They get tired of their seatmates on airplanes asking to be moved. They get tired of hearing they were too fat to fuck, or that this dress does not come in that size. They’ve done the impossible math: one set of humiliations they’re willing to trade for another. They come to agree with our thin friends; this life is the absolute worst fucking thing that can happen to a person.

I made new friends with a fat girl. She is beautiful and smart and holds an enviable position in my community. I tried several times to engage her in the casual sorority of fat girls, to talk brands and clothes and share a little eye roll at the way things are. She rebuffed me in a kind but cold way, and I didn’t know why. I thought spitefully that she might be one of them, in long recovery from the knife and not yet passing for thin. Months later, she published her own story of dysphoria in a lyrical cry that broke my heart. I adjusted. I took another step in the direction the conclusion toward which most of my life has been leading me: No matter how much they hurt, the actions of others are entirely for and about themselves. They aim those harpoons at their own hearts.

My mother did not opt for invasive surgery to leave me behind. She did it because was tired of the inescapable fight that is life in a fat body. I am not the victim here. I am only a casualty.

Yet another friend went in for the surgery, early this year. I tried to look at her life without judgment, without centering my own emotions, and figure out why she would choose this. We’re old enough now that vanity itself does not seem like enough. Maybe she’s lonely and thinks this is the answer. Maybe she wants to travel without being a spectacle and an inconvenience. Maybe she just wants to live in another body before she dies. In the end it doesn’t matter. She’s doing the thing that everyone but me will understand. It’s what they would do in her place.

The first day I knew she was home and recovering, I briefly considered having a dozen donuts delivered to her door.

But I didn’t. Because there are worse things a person can be than fat.

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.”