Upholding “First, Do No Harm”: A Review of Sarah B. Rodriguez’s The Love Surgeon

James Burt, an OB/GYN in Dayton, Ohio, spent years developing and perfecting his “love surgery.” He designed it to increase men’s pleasure during sex by “fixing” women’s anatomies so they would get better clitoral stimulation during missionary postion sex. The procedure involved radically altering womens’ genitalia: making the vaginal opening smaller, moving the vaginal opening closer to the clitoris, circumcising the clitoris, and cutting the pubococcygeus muscle. Although there were attempts to limit Burt’s medical practice, it ultimately took the national exposure of a CBS news show to completely shut his practice down.

I was drawn to Sarah B. Rodriguez’s telling of this story, The Love Surgeon: A Story of Trust, Harm, and the Limits of Medical Regulation, because of both its focus on women’s history and healthcare and its Ohio setting. How could I turn down an opportunity to review a book with a story I’d never heard of in my beloved Buckeye state? Rodriguez’s exploration of Burt’s horrific “love surgery” and the attempts by the medical establishment to limit and regulate his practice hit even closer to home than I could have imagined. I was shocked to read that Burt was practicing medicine at the same hospital I was born in and at the time I was born – the 1980s. Suddenly, an interesting book became one with a very personal connection. How did the medical community in my hometown let this happen?

Book jacket, red and white
Book cover of The Love Surgeon. (©Rutgers University Press)

Rodriguez charts James Burt’s development of “love surgery” as it evolved from its beginnings in the 1950s as a modified episiotomy repair to the final version, described above, which he offered as a separate, elective surgery from 1975-1987. Burt developed the procedure by operating on thousands of women without their consent, tacking on “love surgery” after he had delivered their babies or performed hysterectomies. Even after offering “love surgery” as an elective surgery, Burt continued to perform it on unsuspecting women who turned to him for other healthcare issues.

Rodriguez does a commendable job of not just showing the development of the surgery, but how Burt’s views on sex influenced the procedure. She quotes the book Burt wrote with his wife promoting his procedure to show that Burt believed the only acceptable sexual position was the missionary position and that women’s bodies were anatomically unsuitable for it. He wrote that “women were structurally inadequate for missionary position intercourse and he developed love surgery to correct this ‘pathological anatomy of the female coital area.’”[1] By changing women’s anatomy, Burt believed he would maximize women’s pleasure, which would maximize men’s pleasure, which would keep men happy in their marriages.

After describing Burt’s development of “love surgery,” Rodriguez takes a step back to put it in context. She uses the episiotomy repair procedure that Burt initially modified to explore two issues fundamental to the question of why and how Burt could develop “love surgery” on unsuspecting women. First, she tackles the development of informed consent in surgery. She shows that Burt was not necessarily operating outside the bounds of medical practice when he first began to perform his surgery. Through the 1970s, physicians regularly didn’t obtain consent for treatment for procedures that were considered routine (like an episiotomy repair) or were low risk. It was also considered a standard practice for physicians to decide what information they disclosed to or withheld from patients about a procedure. These practices slowly began to change throughout the decade. By the late 1970s, states required doctors to obtain informed consent from patients as a way to deal with the rise of malpractice cases.

Rodriguez then turns to an issue that continues to be a problem in medical regulation: the gray area between surgical innovation and experimental surgery. A surgical innovation can also be thought of as a variation on an accepted procedure. Rodriguez shows that surgeons have wide latitude to perform variations, as long as it’s in the best interest of the patient and the outcome is the same. A surgery becomes experimental when the outcome of the innovation is unknown. Once this happens, the procedure should be subjected to a clinical trial and consent becomes even more important. The decision on when an innovation becomes an experimental surgery is left up to individual doctors. In this area at least, Burt said he was operating within the expected practices of a physician. He claimed to have told the women who came to him for elective “love surgery” that it was not a standard procedure, but this cannot be verified. He also tried multiple times to have “love surgery” subjected to research trials. Here he was ahead of the curve for physicians by twenty years. The American College of Surgeons didn’t issue voluntary guidelines for evaluating new surgeries until the 1990s.

Scissors, scalpel, other tools
Surgical tools. (Wikimedia Commons|Wellcome Collection)

Rodriguez also chronicles the medical community’s attempts to regulate both the surgery and Burt himself. All ways to regulate doctors depend on other doctors taking action to stop a bad actor. Although doctors are formally regulated through state licensing boards, Burt faced no discipline from Ohio’s board throughout the 1970s. Many doctors are hesitant to formally register complaints against others. It would be a breach of etiquette to publicly question another physician’s judgement. Only one local gynecologist filed a formal complaint about Burt with the county medical society and the hospital at which Burt had operating privileges. At the time, Ohio’s board was also notoriously bad at investigating and disciplining physicians. Cleveland Plain Dealer investigations in the 1980s unearthed numerous examples of the board’s failure to protect patients. Instead of investigating complaints about incompetent physicians or poor medical care, investigators referred 80% of cases back to local medical societies with no formal disciplinary power.

Despite the lack of formal discipline, Burt did face informal condemnation. Although Burt tried to publish his research in peer-reviewed journals, give talks, and garner support from such gynecological luminaries as William Masters, no one wanted to be associated with “love surgery.” Local doctors refused to refer patients to Burt or worked to deny him operating privileges at their hospitals, limiting his ability to practice to one medical center. The county medical society issued a statement criticizing “love surgery,” and the hospital Burt could operate at began requiring a special consent form and demanded to see proof the surgery had positive outcomes. Finally, insurance companies stopped paying for “love surgery” claims.

However, Rodriguez shows it was ultimately patients’ complaints and media attention that were responsible for ending Burt’s medical practice. These complaints also indirectly caused the closure of the hospital where he practiced. Women began to seek treatment from other doctors as a result of their complications from the surgery. They found a physician who was willing to testify against Burt in court as part of a malpractice suit. In October 1988, the CBS show West 57th featured an exposé of the surgery’s horrors, interviewing both Burt and some of his patients who had suffered devastating complications. The resulting national media attention forced a serious investigation of Burt’s practice that finally resulted in the voluntary surrender of his medical license. The malpractice suits found Burt liable; additionally, the hospital where he was allowed to practice was forced to settle with a large number of patients.

Although it’s not an explicit part of the book’s argument, Rodriguez also does an excellent job shining light on the problems women face when they must deal with a healthcare system dominated by men. As Rodriguez points out, women came to Burt initially because of his reputation for listening to women and taking their health concerns seriously. Some of those same women were ashamed and embarrassed about their resulting complications from Burt’s practices, so they did not seek further medical attention for years after their operations. Burt’s violation of the trust these women placed in him as their physician is just as egregious as his performance of surgery on them without their consent.

The book ends with the state of medical regulation now: not a lot has changed since the days of Burt’s case. Medicine is still a self-regulating profession, with doctors hesitating to report each other for fear of a variety of consequences. State boards of medicine, with the power over physicians’ licenses, are still acting on their own with no federal oversight or guidelines. There is little to no coordination among different states. As Rodriguez points out, although the vast majority of physicians are professional and ethical individuals, the systems that allow errant behavior to take place have largely not changed. While this book is a disturbing read, it is important for its valuable insights into how medical regulation really works. Like a lot of people, I’ve always assumed that the systems in place to protect patients work how they’re supposed to. But after finishing this book, I was struck by the fact that the system designed to protect patients ends up protecting doctors.

Notes

    1. Sarah B. Rodriguez, The Love Surgeon: A Story of Trust, Harm, and the Limits of Medical Regulation (Rutgers University Press, 2020), 15.

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