Defining Normal Genitalia: A Review of Camille Nurka’s Female Genital Cosmetic Surgery

Everything, of course, has a history, and in her book, Female Genital Cosmetic Surgery: Deviance, Desire and the Pursuit of Perfection, Camille Nurka seeks to find the historical path leading up to what have been popularly (and not entirely accurately) called “designer vaginas.” These surgeries are often performed, and requested, with the intention of surgically altering the genitals to make them appear more “normal” – meaning, for the most part, labia that are small, evenly shaped, and non-protruding. Think Barbie. While some have placed the recent rise in popularity of female genital cosmetic surgeries (FGCS) to the advent of internet pornography, here Nurka sets out to uncover the longer history of the basis for FGCS, looking to find where ideas about normal female genitals arose. And, more specifically, where the idea of genital normality as being so scarily close to Barbie’s anatomy originated. To discover this, Nurka focuses on the role medicine, especially gynecology, historically played in creating this narrow idea of normal female genitals.

In an effort to ground the rise of FGCS in a longer history of (mostly Western) medical ideas regarding what are considered normal genitals, Nurka largely focuses on one of the surgeries that falls under this grouping, labiaplasty (the removal or reduction of protruding labia). As often the need for and use of labiaplasty is based on perceptions (from both clinicians as well as women) that labia are larger or more pronounced than is typical, she asks: “where did the diagnosis of labial hypertrophy come from?”¹ Nurka seeks answers in a series of chapters that each focus on a different era, starting with Hippocratic medicine, then turning to early Roman physicians through Vesalius to the seventeenth century, before moving to the nineteenth century and Western European colonial interest in Indigenous Khoi women’s genitalia. She then spends a chapter considering the work of the early twentieth-century French clinician Félix Jayle, who she believes to be “the first medical author to attempt to catalogue the range of dimensions of the labia and to sort them into types.”² There were four types of labia for Jayle, types he categorized in various degrees of normality. Nurka then turns to the American physician Robert Latou Dickinson and his work in the first half of the twentieth century regarding female sexual behavior and linking such behavior to genital appearances.

In her last chapter, Nurka speculates about ways to collectively consider labiaplasty and heteronormativity alongside two practices that often are not considered part of FGCS: what the WHO labels as female genital mutilation and surgery on babies born with atypical genitals. By giving discrete examples across long periods of time, Nurka seeks to lengthen the history of FGCS, showing how the idea of normal genitals and labial hypertrophy have been matters of medical discussion and diagnosis for centuries. She does so by essentially taking historical snapshots of moments she sees as pivotal to the framing of contemporary labiaplasty, and she clearly outlines a longer historical narrative regarding a medical discussion concerning female genitals and what has constituted normal female genitals.

That said, her argument could have been stronger had she considered the historical contexts of medical practice, the role of patients, and the practice of surgery. First, medical practice: did doctors use the categories of normal genitals and hypertrophy provided by Jayle and Dickinson? And if their peers did use their categories, how did they use them? What did it mean to diagnose someone with labia hypertrophy, in terms of the therapy offered, how the doctor saw his (more rarely her) patient, and how the patient responded to this diagnosis? Nurka does not answer how physicians used the diagnosis of labia hypertrophy, or indeed even if they used Jayle’s and Dickinson’s categories. So we are left wondering: are these categories intriguing examples of a few physicians’ interest in female genitals or are they illustrative of larger clinical practices in the diagnosing and treating of patients? Were these categories esoteric or were they used in the clinic? Nurka’s argument that FGCS has a long medical history could have been stronger had she considered these questions.

Secondly, though medicine is a powerful entity in determining ideas of bodily normality, physicians are not the only ones involved; patients are also part of this determination. While finding historical records from the perspective of patients concerning medical practice and clinical encounters can be challenging, Nurka could have at least speculated regarding how patients – and their anxious mothers – engaged with physicians in creating medical ideas of genital normality, what constituted labia hypertrophy, and why patients (or their mothers) saw the latter as a medical concern, leading them to seek a doctor.

Finally, and, I think, most importantly, Nurka did not grapple sufficiently with the concept of normality – and the restoration of the body to what is seen as normal, and thus to what is regarded as healthy – as a driving force within medicine. This is perhaps, in particular, true for surgery, an intervention predicated on the restoration of the body to normality. To restore a body to normality necessitates an understanding of what is not normal, of what is pathological. The one necessitates the other in medicine, very visibly in surgery. In addition to not grappling enough with medical and surgical concepts of normality and pathology and how they play out in practice, Nurka’s argument could have been stronger had she contextualized her subject within the history of surgery. Surgery in general, but especially elective (meaning non-emergency) surgery – and, even more to the story of the rise of FGCS, elective cosmetic surgery – rose in both availability as well as acceptability by the late twentieth century: elective cosmetic surgery moved from a marginal part of surgical practice to a more mainstream one.³ The medical and cultural acceptance of elective cosmetic surgery as normative by the late twentieth century is an important context that enabled the growth of FGCS.

Despite these reservations, Female Genital Cosmetic Surgery is largely accessible and clearly written, and her organization of chapters into discrete periods would make for easy separation as individually assigned readings for undergraduate students. Moreover, she makes effective use of a prolific number of images. Nurka is a gender studies scholar and, at times, her writing draws upon theories from this field. However, for the most part, she avoids jargon, making her voice in the growing critical discussion about the increasing market for FGCS accessible for those fascinated in – or outraged about – this topic.

Sarah B. Rodriguez

Sarah B. Rodriguez is a historian who teaches and writes about historical and contemporary issues in women’s reproductive and sexual health. She is also interested in the history of clinical practice and in the history of the ethics of clinical research. She published Female Circumcision and Clitoridectomy in the United States: A History of a Medical Therapy in 2014 and The Love Surgeon: A Story of Trust, Harm, and the Limits of Medical Regulation in 2020. She teaches at Northwestern University in the Global Health Studies Program in the Weinberg College of Arts and Sciences, in the Department of Medical Education in the Feinberg School of Medicine, and is a core faculty member in the Graduate Program in Medical Humanities and Bioethics.

• Sarah B. Rodriguez

  https://nursingclio.org/author/sarah-b-rodriguez/

  Female Circumcision, Clitoridectomy, and American Culture