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A Female Plastic Surgeon's Thoughts on Bodily Autonomy

A few years ago, I attended the American Society of Plastic Surgeons meeting in New York City. This is a huge meeting with Plastic Surgeons in attendance from all over the world. It's an excellent opportunity for lectures, workshops, presentations and informal discussions with colleagues on the latest innovations.

This particular year I decided to attend a workshop on labiaplasty. A procedure that until recently existed only on the fringe of plastic surgery procedures, a niche procedure performed almost exclusively in the adult-entertainment industry. At that point, in the early '10s it was fast becoming a sought after procedure so I decided I needed to

learn more, little did I know it would spark a new path in my career. The workshop started off as all surgical workshops do: review of anatomy, review of techniques, tips/pearls, post-care, complication management, slideshow of before and after - fairly standard for a bunch of surgeons. But during the discussion, a colleague approached the microphone an asserted we should be offering these procedures to teenage girls before a partner had the opportunity to make a disparaging remark about the appearance of their external genitalia. I could feel my rage welling up. Clearly it would be easier to teach boys to be respectful, kind, generous lovers than to cut the normal genitalia of teenage girls to avoid offending the boys delicate sensibilities. Shouldn't they be happy/thankful to even be in that region after all? The suggestion was and remains outrageous to me.

I left the session while my mostly-male colleagues debated the merits of this idea.

Something was sitting very uncomfortably with me about the entire procedure and I needed to tease it out (to the point that I enrolled in my Masters of Science in Bioethics).

Here I was, a cosmetic plastic surgeon with my own private operating room routinely completing breast augmentation, liposuction, tummy tucks, facelifts with no ethical concerns but this one workshop and one colleague had made me start to ask questions about the entire industry.

While I was completing my MSc in Bioethics I started to ask my patients, not just about labiaplasty, but about all cosmetic procedures:

"why now?"

"What prompted you to seek this surgery at this time?"

"what do you hope to achieve through this surgery?"

"what do you think/hope will change in your life by having this surgery?"

"has anyone asked you to get this surgery?"

And for the most part the answers were as expected, variations of:

"I've had my babies, I'm done, I just don't like what the pregnancies have done to my body and I want to look more like me"

or "I feel young + great but what I see in the mirror doesn't match how I feel on the inside or "my kids have moved out, I've spent 18/20/25 years focusing on them + its time to do something for me"

or "it's always bothered me + now I have the time/resources to fix it".

I had very few patents with unrealistic expectations, or body dysmorphia and none that fit the exaggerated media caricature of plastic surgery patients.

But every so often I got an answer that threw me off, made me feel sad or even angry and really made me question not just my industry but our entire societal framework:

"my husband won't let me wear shorts in public because of my thighs"

"my husband won't be seen in public with me because my neck is "disgusting"

"my husband won't touch me anymore because of my post baby belly!

"my husband was attracted to my large breasts + now my marriage is falling apart

there have been so deflated by the babies".

The raging misogyny in these statements I will never forget.

I decided I needed to dive deeper into the concept of bodily autonomy and the ideas of authentic and nonauthentic consent. Of course I support bodily autonomy - all people should have full control over what they do with and to their bodies at all times (stopping short of doing something that harms others like not getting vaccinated during a world pandemic). So clearly I support all women to choose how they want to dress, wear their hair or makeup/no makeup, lip filler, breast augmentation, tummy tuck, butt lift or hair extensions. It's one of the best things about being a Canadian woman - we have full control to make those choices for ourselves. But, how many of us are fully in control of those choices, how many of us have been subtly or not subtly influenced into changes.

I struggle with authentic vs nonauthentic consent. Authentic consent is what we generally think of when we consider consent - we listen to the options, weight the pros and cons and make the best decision for ourselves. Nonauthentic consent can seem very similar on the surface but the final decision is overtly or covertly influenced by external forces - like a partner or even media messages. Clearly a proportion of my patients were not giving authentic consent to their procedures, even though they came willingly to the office, asked questions, understood the pros and cons and signed the consent forms, they were being overtly or covertly manipulated into presenting for their procedures. I saw repeatedly the concept of being worthy of love tied to their physical appearance. And that's it- that is what threw me off about the statement made by my colleague regarding labiaplasty on teenage girls-that deeply ingrained idea that our worthiness of physical and emotion love as women is tied to our external appearance.

This expression of benevolent misogyny-that girls are delicate, weak flower who must be protected, coddled and told what to do with their bodies for their own good (we will cut your labia to save you from the insults) is tied to hostile misogyny-women are only worthy of continued "love" if you change your body to suit my preferences (cut your genitalia to be pleasing to the ideal of men). As women we are constantly bombarded with these belittling messages - be a boss babe, girl power, girl boss, She-E-O, these all seem to be messages of empowerment but are subtly telling us we can't just be the boss, have power, be the CEO. Misogyny wrapped up as empowerment - we are only something relative to men, not enough on on our own, be must modify our own space and body to the comfort of men. These subtle messages pervade our existence.

I'm more than 20 years into my career of trying to find facilitate women's bodily autonomy through authentic consent. I try daily to amplify the empowerment signal above the misogynistic noise. So be the woman you want to be - for you, your goals and your choices. Before making a major decision stop and consider the potential sources of influence around you. Try to find the true empowerment signal in the midst of the misogyny.

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