What social and ethical challenges are presented by female cosmetic genital surgery?

bbag-blog-image-logoFemale Cosmetic Genital Surgery: Social and Ethical Considerations

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In recent years, there has been an upsurge in plastic surgery for women who wish to alter the look and feel of their genitalia. The women who undergo these procedures claim they are empowering, but critics worry such surgeries pathologize normal genital appearance. Several surgeons are also using social media to document these surgeries, granting them greater visibility and legitimacy. This talk will discuss the latest innovations in female cosmetic genital surgery, the history behind the medical community’s involvement in defining women’s sexuality, and the ethical and social challenges these surgeries present.

March 13 calendar iconJoin us for Dr. Stahl’s lecture on Wednesday, March 13, 2019 from noon until 1 pm in person or online.

Dr. Devan Stahl is an Assistant Professor of Clinical Ethics in the Center for Ethics and Humanities in the Life Sciences at Michigan State University. She received her Ph.D. in Health Care Ethics from St. Louis University. Dr. Stahl teaches medical students and residents in the College of Human Medicine and performs ethics consultation services at hospitals in Lansing, Michigan. Her research interests include medicine and the visual arts, theological bioethics, and disability studies. Dr. Stahl’s recent book, Imaging and Imagining Illness: Becoming Whole in a Broken Body, examines the power of medical images and their impact on patients and the wider culture.

In person: This lecture will take place in C102 Patenge Room in East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

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Botox for Millennials?

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Devan Stahl, PhD

When I was in my mid-twenties I went to my physician to have a mole on my face removed. Before my dermatologist began the procedure, however, she suggested I consider another procedure: Botox. Botox for someone my age was “preventative,” she explained; if I could not move my facial muscles, I was less likely to develop wrinkles. To add insult to injury, she held up a mirror and pointed out all the lines on my face when I frowned (which I was doing at that moment, irked that my doctor was trying to push Botox on me). The experience was unsettling. Our culture is saturated with impossible beauty standards for women, but I did not expect my doctor to perpetuate these standards or to try to make money off of my potential insecurities.

I had nearly forgotten about this experience until last month, when my social media and online streaming services were inundated with advertisements for Botox® and Juvéderm® fillers that smooth wrinkles and plump lips. The advertisements were clearly geared toward millennial women such as myself. The ads push messages of personal empowerment. “My lips are my vocal advocates for self-acceptance,” one model says. “Command it, boss it, #juvedermit,” reads the tagline.

The drug company Allergan produces both Botox and Juvéderm, which some have deemed “cosmeceuticals” or cosmetic pharmaceuticals. According to news reports, Allergan’s aim over the next year is to increase sales to millennials as more products come on the market. According to a spokesperson for the company, they aim to “educate and empower consumers to do what is right for them when it comes to aesthetic treatments.” This push means that millennials are likely to see an increasing number of targeted ads that play upon social norms of beauty and youth to sell injectable toxins that have unknown long-term side effects. And although the short term risks might be seen as minimal (including pain at injection site, trouble breathing or swallowing, double vision, drooping eyelids, and more), studies have shown that when advertisements rely upon idealized forms of beauty to market cosmeceuticals, the social and psychological risks of not using the product detract from its known physical risks.

Botox and fillers are part of a multibillion dollar beauty and anti-aging industry in the U.S. According to a 2017 report by the American Society of Plastic Surgeons, 7.2 million Botulinum Toxin Type A procedures are performed in the U.S., which is up almost 800% since 2000. Although Botox and fillers have traditionally been used by an older demographic, millennials (ages 20-34) make up a fast growing demographic of Botulinum users. This means big money for companies like Allergan. The effects of Botox only last 4-6 months and cost around $300 to $400 a session. Their consumer potential means millennials are now being aggressively targeted by doctors (both dermatologists and dentists) as well as pharmaceutical companies. The pitch to these mostly wrinkle-free patients is that Botox will prevent wrinkles from forming, “it is best to clean your room before it gets dirty,” claims one dermatologist.

juvederm capture
Image description: A still from a Juvéderm® video advertisement shows a young woman touching her face with two fingers; text reads “SMOOTH IT Juvéderm® XC.” Source: JUVÉDERM IT : JUVÉDERM®/YouTube.

Beauty expectations for women have always been high, but some have speculated the turn to cosmeceuticals by young women has likely increased as a result of celebrity endorsements (Kylie Jenner famously announced she is a frequent user of lip fillers) and social media platforms such as Instagram that allow users to filter pictures. As Botox and other cosmeceuticals become more mainstream (and Allergan hopes they will by producing not only advertisements, but also blogs and podcasts), social norms are beginning to change such that young women are feeling increasing pressure to use biomedical technologies to preserve and enhance their youth. Cosmeceuticals increase the pressure on women to look young and cultivate feelings of inadequacy, according to Dana Berkowitz, author of Botox Nation: Changing the Face of America. Young women begin Botox because of their fear of looking older, even before they begin seeing major age-related changes in their faces.

The appeal of the technological fix is powerful to both men and women, young and old, in a culture that prizes youth and attractiveness. The reasons people use Botox and other anti-aging procedures are multi-faceted and should not simply be reduced to mere vanity. According to Berkowitz, young women claim Botox helps them get ahead in the workforce, helps them to feel good about themselves, and is common place in certain sectors of society. Whatever the reasons, however, the result of the normalization of cosmeceuticals is that aging is becoming increasingly pathologized, and our anxieties surrounding the natural aging process are likely to increase. “It is really up to you,” one Botox ad proclaims: “You can choose to live with wrinkles. Or you can choose to live without them.” Those who refuse to use cosmeceuticals are thus complicit in the dreadful aging process. Pharmaceutical companies and even some doctors are keen to encourage and capitalize on our aging insecurities.

Devan Stahl photoDevan Stahl, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Pediatrics and Human Development in the Michigan State University College of Human Medicine.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, February 7, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Stahl: Making Martyrs of Our Children: Religious Exemptions in Child Abuse and Neglect CasesMass Shootings, Mental Illness and StigmaDisability and the Decisional Capacity to Vote

Click through to view references

Would you ever consent to have your medical procedure broadcast on social media?

No Easy Answers in Bioethics logoEpisode 10 of No Easy Answers in Bioethics is now available! This episode features Dr. Devan Stahl, Assistant Professor in the Center for Ethics and the Department of Pediatrics and Human Development, and Dr. Christian Vercler, Clinical Associate Professor of Plastic Surgery in the Department of Surgery at the University of Michigan and Co-Chief of the Clinical Ethics Service in the Center for Bioethics and Social Sciences in Medicine. Drs. Stahl and Vercler address a trend known as Snapchat surgeons – plastic surgeons who amass sometimes millions of followers on the social media platform Snapchat by posting uncensored videos of operations they are performing. Together they offer their insight and expertise on the issue, and discuss whether these Snapchat performances are ethical. They also delve into the societal norms and power dynamics at play, and address how to move forward within the profession of plastic surgery in a world where social media seems to be here to stay.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics—clinical ethics, evidence-based medicine, health policy, medical education, neuroethics, shared decision-making, and more. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

Article from Dr. Stahl in April ‘AMA Journal of Ethics’

Devan Stahl photoCenter Assistant Professor Dr. Devan Stahl and co-author Christian J. Vercler (University of Michigan) have an article in the April 2018 issue of the AMA Journal of Ethics. Their article, “What Should Be the Surgeon’s Role in Defining “Normal” Genital Appearance?,” appears in the journal’s issue on ethical considerations in plastic and reconstructive surgery.

Abstract: The recent rise in women seeking cosmetic surgery of their genitalia (labiaplasty) coincides with the increasing number of surgeons posting videos of these operations on social media accounts and websites. Sociocultural influences significantly contribute to our ideas of what constitutes healthy and pathologic, and surgeons have historically played a role in defining “normal” and “abnormal” anatomy. In the nineteenth century, Saartjie Baartman—a woman with a large posterior and unusually long labia minora—was used by physicians to “educate” the public about these differences. We examine the parallels with the twenty-first century practice of surgeons using social media to educate patients about the operations they perform and discuss ethical and professional hazards associated with this practice.

The full article text is available online via the American Medical Association.

Watch every lecture from the 2013-2014 Bioethics Brownbag & Webinar Series

Largent-slideReye’s Syndrome: A Medical Mystery and a Modern Dilemma
This talk from Mark A. Largent, PhD, examines the history of Reye’s syndrome, the hunt to uncover its cause, and the debates that have emerged over last twenty years about the role of aspirin in Reye’s syndrome. View Webinar

Bosk-slideMedical Sociology as Vocation
This presentation from Charles L. Bosk, PhD, discusses what it means to speak of ‘medical sociology as a vocation,’ using Weber’s classic essay ‘Science as a Vocation’ as its departure point. View Webinar


Fisch-slideThe Declining Provider: Refusal, Responsibility, and Reasonableness
This presentation from Deborah Fisch, JD, examines how we arrived at our current VBAC position, its implications for maternal and child health, and the connection to other instances of declining providers. View Webinar

Loup-slideAre Researchers Ever Obligated to Provide Individual Research Findings to Non-participant Third Parties?
This presentation from Allan Loup, JD, addresses an emerging consensus that, in some circumstances, researchers have obligations to return individual research results to research participants. View Webinar


“Enlightened” Breath: Breathing and Biomedicine
While much is known of the physiological importance of breathing in biomedicine, there is almost no appreciation of its possible therapeutic role. This presentation from Sebastian Normandin, PhD, argues for a new era – an age of enlightenment – in the use of breath and breathing as a healing tool. View Webinar

Vercler-slidePlastic Surgery Ethics: An Oxymoron?
In this lecture, Dr. Christian J. Vercler examines the distinctions made between cosmetic and reconstructive surgery, discusses how plastic surgeons think about those distinctions, and uncovers the different ethical frameworks that support these practices. View Webinar


Click here to watch more lectures dating back to 2010, and save the date for the first webinar of the 2014-2015 Series: September 17, 2014.

Learn the reality of ethics in plastic surgery — it’s not what you see on TV

bbag-iconPlastic Surgery Ethics: An Oxymoron?

Event flyer: Vercler Flyer

Most plastic surgeons portrayed in the media exhibit questionable moral judgment. After watching shows such as Nip/Tuck, Extreme Makeover, Dr. 90210, and The Swan, one could easily conclude that ethics plays no part in the practice of plastic surgery. Indeed, some have charged cosmetic surgery with being entirely outside the scope of medical practice. Dr. Vercler will examine the distinctions made between cosmetic and reconstructive surgery, discuss how plastic surgeons think about those distinctions, and uncover the different ethical frameworks that support these practices.

apr-23-bbagJoin us for Christian J. Vercler’s lecture on Wednesday, April 23, 2014 from noon till 1 pm in person or online:

In person: The lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? View this webinar and others as archived recordings.

Christian J. Vercler, MD, is Clinical Assistant Professor in the Division of Craniofacial Surgery in the Section of Plastic and Reconstructive Surgery at the University of Michigan. He serves on the faculty of the Center for Bioethics and Social Sciences at the University of Michigan. He completed a Fellowship in Clinical Ethics at the Emory University Center for Ethics and also has an MA in Bioethics. He has served on ethics committees since 1998, and has taught medical ethics to residents and medical students at Emory University, Harvard, and the University of Michigan. Dr. Vercler graduated from Wheaton College with a BS in Biology and an MA in Theological Studies. He went to medical school at the University of Illinois. He completed general surgery training at Emory University and plastic surgery at Harvard. He then did an additional fellowship in Craniofacial Surgery at the University of Michigan.