Abstract
Research on female genital cosmetic surgery usually comes from Anglophone countries. We investigated female genital cosmetic surgery in the predominantly Muslim South-East Asian country of Indonesia, aiming to identify the procedures offered by medical clinics on Instagram, how they are justified, and what they claim to achieve; and to understand what this means for women and their bodies. The 184 eligible posts from 19 clinics between 1 January to 31 March 2021 offered vaginoplasty, labiaplasty, hymenoplasty, and other procedures. Reflexive thematic analysis yielded three themes: Why you should have female genital cosmetic surgery, Indications for female genital cosmetic surgery, and What you will gain from female genital cosmetic surgery. Posts were similar to those identified in other countries, revealing implicit vulvar aesthetics, expectations that women choose to ‘improve’ their genitals, the need to please men, and that female genital cosmetic surgery is straightforward. Two differences from Anglophone advertising were the use of euphemisms to describe the vulva and an emphasis on physical ‘virginity’. Across countries, female genital cosmetic surgery advertising appears to arise from patriarchal constructs of women’s bodies and determination to control them. We contend that Indonesia shares with other countries the need for education—of medical practitioners and the general public—about sexuality and the vulva, and that the advertising of female genital cosmetic surgery should be regulated and rigorously monitored.
Female genital cosmetic surgery (FGCS) is defined as surgically changing the healthy vulva for non-medical reasons. The most common procedure is labiaplasty, but there are others including vaginoplasty and hymenoplasty (RCOG (Royal College of Obstetricians and Gynaecologists Ethics Committee) Citation2013).
There is a growing literature on the psychosocial aspects of FGCS (ACOG Committee on Gynecologic Practice Citation2020; Chibnall, McDonald, and Kirkman Citation2020; Dobson et al. Citation2017; Mowat et al. Citation2015, Citation2020; Simonis, Manocha, and Ong Citation2016) as well as on its problematic distinction from female genital cutting (e.g. Shahvisi Citation2023). Professional medical organisations have long expressed concern about FGCS, its potentially adverse outcomes, and the absence of consensus on acceptable clinical indications (ACOG Committee on Gynecologic Practice Citation2020; RANZCOG Women’s Health Committee Citation2019; RCOG (Royal College of Obstetricians and Gynaecologists Ethics Committee) Citation2013). Potential complications include scarring, adhesions, permanent disfigurement, infection, painful sexual intercourse, and altered sensation (ACOG Committee on Gynecologic Practice Citation2020; RANZCOG Women’s Health Committee Citation2019). Nevertheless, doctors advertise FGCS, particularly labiaplasty, in Australia (Chibnall, McDonald, and Kirkman Citation2020; Moran and Lee Citation2013) and elsewhere (Liao, Taghinejadi, and Creighton Citation2012; Zwier Citation2014). It has been found that advertisements for FGCS in Australia, for example, promoted FGCS as improving physical and mental health, hygiene, sexual function, and self-esteem, as well as appearance (Chibnall, McDonald, and Kirkman Citation2020). FGCS is even promoted and demonstrated on YouTube (Erdogan Citation2021). However, these advertisements are accompanied by others that offer to repair ‘botched’ labiaplasty (Learner et al. Citation2020).
Constructs of the body—the ‘normal’ and the ‘ideal’—are deeply embedded in culture (Bordo Citation2020; Laqueur Citation1990). Because research on FGCS tends to have taken place predominantly in high-income Anglophone countries, we set out to examine the phenomenon in the South-East Asian country of Indonesia. Indonesia maintains no official record of FGCS procedures and we were unable to locate any clinical guidelines.
Citizens of Indonesia are ethnically and linguistically diverse; the majority identify as Muslim. While FGCS is understood by many feminist scholars as an indicator of the widespread policing of women’s bodies (e.g. Rodrigues Citation2012) and a woman’s virginity is valued throughout the world, Indonesia has been notable in its explicit attempts to inscribe on the body cultural standards of feminine morality, signified by virginity in all unmarried women (Davies Citation2018). A virgin is commonly said to have a ‘tight’ vagina and an intact hymen (Davies Citation2018); it is expected that a virgin will bleed on first intercourse, despite evidence that bleeding might not occur (Lahlali et al. Citation2021; Shaw et al. Citation2022). The cultural significance of virginity is evident in the fact that women who applied to join the Indonesian military or police force were required to pass a ‘virginity test’ – an internal examination – before recruitment. This practice ended only in 2021 after sustained advocacy by women’s groups (White Citation2021). Male applicants were not subject to tests of their virginity, notwithstanding the expectation that men should conform to the same moral code (Davies Citation2018). Only women, not men, experience reduced social status and value from sexual activity and bring shame to their families (Frenzia Citation2020; Platt Citation2012).
However, virginity testing is not confined to Indonesia. Clinics have been found to offer virginity testing and hymen reconstruction in the UK, for example, even though the practice is illegal (UK Government Department of Health and Social Care Citation2022). This UK guidance document states that, ‘Any woman or girl, of any age, ethnicity, race, sexual orientation, religion, disability or socioeconomic status could be subjected to a virginity test or hymenoplasty’. It has also been reported that gynaecologists in Belgium have received requests for hymen reconstruction (Leye, Ogbe, and Heyerick Citation2018). Researchers report data from Morocco indicating that two kinds of hymen reconstruction performed on more than 500 women resulted in the desired bleeding after first subsequent intercourse (Lahlali et al. Citation2021). In contrast, an investigation conducted in two centres in the Netherlands found that only two of the 19 women who underwent hymen ‘repair’ (hymenoplasty) bled at the first subsequent intercourse (van Moorst et al. Citation2012). There have been efforts to make medical practitioners aware that virginity is a social construct, and that attempts to create a hymen that bleeds on first intercourse can be damaging to girls and women (e.g. Moussaoui, Abdulcadir, and Yaron Citation2022). We note that the Royal College of Obstetricians and Gynaecologists (RCOG) includes hymenoplasty in its definition of FGCS (RCOG (Royal College of Obstetricians and Gynaecologists Ethics Committee) Citation2013).
We conducted a comprehensive search of the literature to identify scholarly work on FGCS in Indonesia, expanding the usual search terms to take account of the cultural significance of the hymen: labiaplasty, vaginoplasty, hymenoplasty, labia majora augmentation, labia minora reduction, vulval lipoplasty, G-spot augmentation/amplification, clitoral hood reduction, and hoodectomy, all with the term Indonesia. Nine databases (SpringerLink, Scopus, Wiley Online Library, Taylor and Francis Online, SAGE Journals, ProQuest, Science Direct, JSTOR) yielded no relevant publications in English or Indonesian. There was a small literature referring to genital reconstruction after disease or accident.
There have been occasional newspaper mentions of hymenoplasty in Indonesia. For example, a celebrity was reported as having her hymen reconstructed to please her third husband (The Jakarta Post Citation2011). Since 2011, various media outlets have reported several kinds of FGCS, predominantly hymenoplasty, vaginoplasty, and labiaplasty (e.g. Arfin Citation2014). In public discussion, procedures tend to be grouped as means of ‘restoring’ virginity as part of a woman’s duty to serve her husband’s sexual needs and thus to maintain family harmony (Hilber et al. Citation2010). The Arfin (Citation2014) blog post, for example, defines hymenoplasty as returning the hymen to its ‘original condition … before pre-marital intercourse’, specifying that it is most useful to ‘victims of abuse’ by restoring their ‘psychological state’. Arfin, who identifies himself as ‘a pharmacy graduate’, defines vaginoplasty as tightening loose muscles, citing as his source ‘surgery experts that restore virginity’. According to him, labiaplasty is applied to ‘abnormal female organs so that their condition becomes normal’; no definition of normal or abnormal is given. Arfin advises interested women to consult an obstetrician-gynaecologist, adding, ‘don’t forget to ask for approval from your family beforehand if you want to undergo procedures to restore virginity, especially permission from your husband if you are married’ (translation by the first author).
Despite the limited peer-reviewed investigations of FGCS, it became apparent after a search on social media that FGCS was being advertised on the Internet by Indonesian clinics, most notably on Instagram. Internationally, the Internet is a common resource for health information; searches prompt targeted advertising (Choi et al. Citation2020). A systematic review of research published in English on the role of Internet content in the distribution of knowledge of FGCS found that the Internet promoted FGCS by identifying genital appearance beyond a narrow range as pathological, constructing genital aesthetics as contributing to women’s wellbeing and sex life, and identifying FGCS as safe, easy, and effective (Mowat at al. 2015).
We therefore aimed to determine what procedures were being offered by medical clinics in Indonesia, how they were justified, and what they were claiming to achieve, as well as to understand the meaning of these social media posts in relation to women and their bodies in Indonesia.
Method
Because this research was fundamentally concerned with meaning rather than quantification, a qualitative method was adopted (Hammarberg, Kirkman, and de Lacey Citation2016). Our theoretical perspective was social constructivist and we chose reflexive thematic analysis to achieve our aims (Braun and Clarke Citation2006, Citation2021, Citation2022).
We sought all Instagram posts associated with Indonesian-based clinics that offer FGCS, searching from 1 January to 31 March 2021. Using the ‘Most recent’ tab, we tracked hashtags related to FGCS procedures (in both English and Indonesian), all with ‘Indonesia’ or ‘Jakarta’: #labiaplasty, #vaginoplasty, #hymenoplasty, #aestheticgynecology, #operasibibirvagina (surgery of vaginal lips), #operasivagina (vaginal surgery), and #operasivaginajakarta (vaginal surgeries in Jakarta). We took and saved screen shots of all eligible posts and their linked pages. We allocated a letter to every associated clinic and a number to each post. For example, A1 is the first (by date) post of clinic A and A2 is the second.
The first author, who is bilingual and bicultural, translated into English all the posts and relevant material on the linked pages. Details were tabulated by clinic: number of posts, procedures offered, and the stated qualifications held by clinicians performing the procedures.
The researchers performed reflexive thematic analysis as a team during frequent meetings. Analysis was an iterative process in which a potential interpretation of one post prompted a search of other posts for similarities and differences. Themes were assessed, reassessed, and finalised through extensive discussion.
The research was approved by the Monash University Human Research Ethics Committee, (Reference: 27660).
Reflexive statement
All the authors are women. The first author is an Indonesian medical student whose first language is Bahasa Indonesia and who is also fluent in English; the second and third authors are Anglo-Australian university academics with long-standing interests and research records in women’s health. Cross-cultural discussion within the team was fundamental to the interpretation of meaning in the data.
Findings
We identified 19 clinics that contributed a total of 184 Instagram posts, 69 of which were original; the remainder were repeats. Numbers and percentages of posts throughout the presentation of results refer to the 69 original posts, not to repetitions, unless otherwise stated. Clinics posted 1-18 original posts (mean 4.8) (1-64 including repeats). Details are shown in .
Table 1. Clinics and instagram posts.
Eighteen clinics stated that they were in Greater Jakarta, one was in Central Java, and one had a branch in North Sumatra as well as Jakarta. Vaginoplasty and labiaplasty were each offered by 15 clinics, and hymenoplasty by 7. Clinics offering hymenoplasty were associated with 51 of the 184 posts. Other procedures were vaginal cleansing/bleaching (2 clinics), clitoral hood reduction, labial fat transfer, and vaginal tightening (1 clinic each) and generic genital procedures (2). Only 8 clinics stated the surgical qualifications of the doctors performing the procedures; these were obstetrics and gynaecology (5 clinics) and plastic surgery (3).
Most text (66.2%) was unattributed. Content attributed to doctors took the form of promotional videos (8.4%), written statements (2.8%), and webinars (2.8%); 5 doctors posted about FGCS in their personal accounts in which their clinics were identified. There were also patients’ testimonies in text and video format (7%).
Although posts often used the English words for procedures, it is notable that few named the vulva or its components, such as labia and vagina. Most used euphemisms instead, including ‘womanhood’ (‘kewanitaan’), ‘the intimate organ’ (‘organ intim’), ‘Miss V’ (‘Miss V’), and ‘the strong one’ (‘si Kuat’).
Images in the posts were of smiling women or their draped, headless bodies; female doctors in surgical garb or at conferences; diagrams of the vulva or the female reproductive system; a woman with a man; or images suggestive of the vulva (such as fruit) or the ‘ideal’ vulva (such as a slit in a sheet of white paper).
Themes
We identified three main themes, each with sub-themes: Why you should have FGCS; Indications for FGCS; and What you will gain from FGCS (see ).
Why you should have FGCS
Reasons for FGCS promoted in the posts were to achieve an aesthetic ideal, to establish or restore virginity, and to please one’s husband (which was implied by the other two). In each of these, women’s responsibility for genital care was emphasised. For example, one post exhorted, ‘as smart women, let’s invest in our own health!’ (B4), and another urged, ‘We have the option to do something and ask our doctors to help in repairing our organs’ (R2). A third clinic asserted that, ‘taking care of Miss V post-childbirth is important to ensure maximal recovery and to return to your initial girlhood state’ (A4). Women are said to be responsible not only to ‘care about face and skin, but … to rejuvenate the intimate area too’ (G1), a duty emphasised in other posts (e.g. D1, S1,4). The emphasis on responsibility implied that women can choose to take advantage of the procedures offered to them; choosing not to do so is an abrogation of responsibility.
Genital diversity was occasionally acknowledged (in 9 posts from 5 clinics) but not endorsed as aesthetically acceptable. Diversity comments included ‘The labia of every woman are different’ (B7,8, E3) and versions of the statement ‘No two bodies are the same’ (A5, B10,11, C14,15,18).
The preferred aesthetic ideal was identifiable from the descriptions of what would be surgically altered: labia that are ‘loose’, ‘elongated’, ‘visible’, ‘sagging’, ‘asymmetrical’, ‘hypertrophic’, ‘enlarged’, ‘excessive’, ‘irregular’, and ‘abnormal-looking’ (31 posts from 12 clinics). These ‘undesirable’ characteristics were attributed to ‘congenital deformities’ (e.g. A3, F2, H2), childbirth (e.g. A2, B9, D3), ageing (e.g. B9, C18, H2), and ‘excessive sexual activity’ (A5). FGCS was often said to be aesthetically desirable without specifying how attractiveness would be improved (e.g. C2, E1, F1, H5, O1). Clinic C claimed in several posts that even hymenoplasty was performed for aesthetic reasons.
Because a woman’s virginity has religious and cultural significance in Indonesia—a ‘sacred, holy, and important thing for women’ (A5) and ‘crucial for [her] social status’ (C6)—hymenoplasty is included among FGCS procedures advertised by 7 clinics in 28% of all posts. It was claimed to be a form of ‘premarital preparation’ (A4) for women to overcome the ‘fear of their future husbands finding out that their hymens are no longer intact’ (C13). The procedure was advertised as enabling women to ‘regain [their] virginity’ (C9) by ‘tighten[ing] or repair[ing] the ruptured hymen’ (C12), thus ‘return[ing] it to its original state’ (H1), ‘girlhood state’ (A4), or ‘teenage years’ (P1, R2).
Although it was (rarely) acknowledged that a woman can be born without a hymen or with an incomplete hymen (H2,7), and that there are causes other than sexual intercourse for a perforated hymen—such as vigorous sport (H6) and ‘excessive masturbation’ (C6)—bleeding after first intercourse was accepted in the advertisements to be required by husbands as evidence of a woman’s virginity (e.g. C3,4, J7). Women are reminded that ‘the groom’s family has the right to return the bride to her family’ (C4) if she is found not to be a virgin. One advertisement warned men to establish that their ‘future wife is still a virgin’ (J1), although, in the context of surgical repair, these posts might be seen to challenge men’s confidence.
It was also stated that married women can undergo ‘revirginisation … as a gift for the husband or for themselves, … to re-experience the First Night’ (B11, C6) and ‘the pleasure of bleeding during intercourse again’ (C13). Those who do will ‘make your husband happy’ (C16), encourage him to ‘come home sooner and love you more’ (Q1), and ‘improve household harmony’ (E1). Household disharmony was attributed to ‘looseness’ after childbirth that would limit a husband’s sexual pleasure (R2), as well as by women who have ‘large labia’, who will be concerned that the condition will ‘reduce male arousal’ (B3,8). One clinic recommended vaginoplasty ‘before your husband can use it [the vagina] again’ (M1), although another said, ‘If your partner doesn’t have any complaints, no surgery is necessary’ (R2). A patient from the same clinic was quoted as saying. ‘My husband has good reviews for this’ (S4). Throughout, there was an emphasis on ensuring that women’s genitals conformed to men’s expectations.
Indications for FGCS
Indications for surgery conveyed in the posts could be classified predominantly as physical or psychosocial, although the categories were interrelated. Physical indications included discomfort during exercise and sexual intercourse or when wearing tight clothing (e.g. A3, B11, C17). There was a range of physical indications listed by clinic B (post 4): ‘urinary incontinence, lack of lubrication during sex, feeling ‘loose’ after multiple childbirth, vaginal infection’. It was not always apparent how surgery could improve the listed conditions or experiences.
Psychosocial indications for FGCS were ‘psychological trauma’ (A4) and ‘sexual assault’ (B11), ‘lack of confidence’ or ‘insecurity’ about the ‘feminine area’ (A3,6, B11, C1,16,18, H2, N1), ‘dislike’ of the labia (B7,8,10), ‘shame and anxiety during sexual intercourse’ (C1) or embarrassment when she is ‘with her partner’ (A4), ‘anxiety before marriage’, (J1), and fear of not being accepted as virginal (C13, J1).
In a few cases, it was difficult to discern whose psychological or social problems were identified as indications for FGCS. For example, it was said that ‘women’s difficulty of opening up to their future spouse makes some men feel confused and ignored’ (C10).
Having experienced childbirth appeared to be an indicator in itself, linked to physical and psychosocial (relationship) problems. Repairs are needed for ‘gaping, … bruises, and swelling’ (A2), ‘imperfect stitches’ (A3), tearing (B2), ‘looseness’ (B4,5,7,9,11, C16,18, D3, H3,7, L1, M1), and also to repair the hymen (D2). Post-childbirth problems requiring surgery were sometimes not specified but presented as generalised deteriorations to be rectified (C11, F2, K1, R2). FGCS was also represented as a ‘reward’ after childbirth (S3), ‘purely for women’ (S4).
Ageing was frequently associated with childbirth in deleterious effects on the vulva, including stretching and sagging (A4, A5, B2,9,11, C1,18, D3, H2, H3, K1, L1, R2). Ageing, too, was therefore an indication in itself, although FGCS was claimed to ‘avoid the adverse effects of ageing’ (R2).
What you will gain from FGCS
The advertised outcomes of FGCS were linked to the indications for surgery and fitted the interrelated categories of physical and psychosocial benefits.
Some posts claimed a wide range of physical benefits from vaginoplasty and other FGCS procedures, including that they will tighten the vagina, cure urinary incontinence, reduce vaginal dryness, prevent recurrent vaginal infection, and stabilise vaginal pH (B4, B6, C8). Four clinics claimed that their FGCS procedures will improve genital hygiene (B11, C5, F1, R1); only one specified how: by removing ‘excess tissue’ from the labia (F1).
The majority of posts (63) promised a return to genital youthfulness, both in appearance and in greater sexual pleasure—with penis-in-vagina intercourse implied and sexual pleasure for the man assumed or stated. Most posts did not specify how youthfulness would be achieved, with the procedures named only as ‘rejuvenation’ or ‘rejuvenation therapy’ (e.g. C17, D3, E2, G1, N1, O2, R2). A tighter vagina that will ‘grip the husband’s penis’ (Q1) was defined as a benefit of vaginoplasty and other unspecified procedures by ten clinics, each in several posts (A, B, C, E, H, L, M, O, Q, R). One clinic (B11) claimed that clitoral hood reduction will ‘increase clitoral sensitivity’, without addressing the potential neural damage likely to decrease sensitivity. Clinic B made the same claim for vaginoplasty (B5,9), as do A(4), C (8,11,16), and S(4).
Two posts claimed physical and psychological healing from sexual assault (A4, B11), although one post pointed out that ‘medically, [hymenoplasty] does not have any benefits’ (C12).
The main psychological benefit was claimed to be an increase in confidence, apparently because of aesthetic or functional improvement; the source of improved self-confidence was not always specified. For example, generic claims that women will ‘feel more confident’ (H3) after FGCS were made by clinics A, C, E, G, H, and R. It was asserted that FGCS would ‘restore her confidence when she is with her partner’ (A4) and that ‘restoring your self-confidence’ would allow women ‘to prepare for a better future’ (C9). Women who are ‘insecure’ when ‘serving their husband’ (A1) will be more confident; as one patient testimony reported, ‘my husband is more affectionate and loving [after the treatment]’ (A1). In sum, FGCS would make women ‘feel more beautiful, feminine, sexy, attractive, confident’ (S3).
These benefits were advertised to flow from procedures that were described in 14 posts from 7 clinics as straightforward: ‘minor surgery’ (A3, H1), ‘simple’ (B5), ‘safe’ (A3, C8), rapid (A4, B5, C2, H1, I1), with minimal bleeding (A5), and not requiring hospitalisation (C1,5; F1,2). It was claimed that women ‘won’t feel any pain or discomfort’ (C3) and will have no scars (J1).
Discussion
Our analysis of Indonesian Instagram posts advertising female genital cosmetic surgery (FGCS) yielded themes that were similar to those found in previous research in Anglophone countries, apart from the prominence given to ‘restoration’ of virginity and the extensive use of euphemism.
The three main themes found in Indonesian posts encompass aspects of what can be found (for example) on websites from the USA, the UK and Australia, including implicit vulvar aesthetics (minimal visible genitalia), the expectation that women will take responsibility for choosing to ‘improve’ their genitals, the need to please men, and that FGCS is straightforward (Chibnall, McDonald, and Kirkman Citation2020; Liao, Taghinejadi, and Creighton Citation2012; Moran and Lee Citation2013). A commercial imperative was evident in all cases.
This is the first investigation of medical advertisements for FGCS in Indonesia. Its originality is a strength, but also a limitation in that, since there was no local research on which to build, it is inevitably incomplete. Among other things, Indonesian research is needed on other platforms and directly with women who have had or are considering FGCS. Close investigation of medical education and advertising regulations is also desirable, signifying other topics for research.
For all the perceived cultural differences between Indonesia and Anglophone countries, the invitation to women in Indonesian posts to amend the vulva in conformity with an arbitrary aesthetic standard differs little from advertisements identified in other countries. The similarities are not, perhaps, surprising. It has been found that women seeking labiaplasty express emotional, psychosexual, and functional distress about their genitals, regardless of age or nationality (Zwier Citation2014).
Of the two major differences, the tendency to use euphemisms for components of the genitals, which appears not to have been found to the same extent in Anglophone advertisements, might arise from the enshrouding of women’s sexual practices in ideals of beauty and politeness (Hilber et al. Citation2010). The bodily demands placed on women in the Indonesian police force and the requirement to be virginal, pure, and beautiful (Davies Citation2018) are also consistent with euphemistic reference to the vulva.
The more notable difference in the Indonesian Instagram advertisements is the encouragement to establish physical ‘virginity’. This might arise from a culture that places value on the purity of a woman’s body which is the property of her (current or future) husband, who has the right to expect that she has ‘saved’ herself for him. Establishing a hymen after childbirth plays into a continuing fantasy of the virginal women who gives her virginity anew to her husband (Davies Citation2018; Frenzia Citation2020).
As Bordo (Citation2020) has claimed, the body may operate as a metaphor for culture. In this model, cosmetic surgery on the vulva can be understood as shaping the body to suit cultural constructs of femininity. In a patriarchal culture that demands virginity of women, FGCS is an instrument of conformity. In many (but not all) cultures throughout the world, the goal has been to achieve what has been called the Barbie Doll ideal (Schick, Rima, and Calabrese Citation2012), in which the vulva is shaped to minimise visible female sex organs so that masculine sexuality dominates and female sexuality is subdued.
It is beyond the scope of this paper to extend discussion to female genital mutilation (or cutting) (FGM/C), of which there is a long history in Indonesia (e.g. Fisher Citation2009; Fisher and Cabral de Mello Citation2015). According to UNICEF (Citation2019) almost half of girls under 12 years of age in Indonesia have undergone some form of FGM/C, usually of the least invasive kind, and mostly when they were less than a few months old. The authors of a report on a large multi-method study conducted in Indonesia (and two other countries) concluded that FGM/C arose from the confluence of religion (which was predominantly Muslim in Indonesia, Christian in Ethiopia and Kenya), tradition, and the control of women’s bodies (Kakal et al. Citation2023). Establishing any clear-cut distinction between FGM/C and FGCS is problematic; both could be considered by some to be a matter of personal choice, while at the same time both are impelled by society and culture. FGCS and FGM/C are each designed to reshape the vulva to suit culturally normative constructs of women’s bodies and sexuality.
Consistent with Bordo, Laqueur (Citation1990) has persuasively demonstrated, using centuries of anatomical drawings, that sex—not just gender—is culturally defined. He has argued that understanding the physical female body is not a matter of biological questions about the difference of women’s bodies from men’s but political questions of the nature of women. Understood in this way, it can be argued that varieties of FGCS procedures that differ by country stem from the same source: namely, patriarchal constructs of women’s bodies. Whether the emphasis is on aesthetics, sexual exclusivity, or the erasure of female sexuality, the aim is to maintain strict control over women’s bodies. This applies to the rejection of the wide diversity of vulvar morphology as well as to the value attached to the fantasy of the intact hymen.
Research on advertisements for FGCS in all countries, including Indonesia, has found that they imply that women choose to make these changes to their genitals. Moran and Lee (Citation2013), for example, found that a neoliberal discourse of individual choice, self-improvement, and objectification was used as justification for FGCS in Australia. This problematic attribution of free will and choice to women who undergo FGCS in accordance with cultural expectations has been finely interrogated and discussed by Rodrigues (Citation2012), who argued that the claimed difference between FGCS (chosen) and female genital mutilation (FGM) (imposed) can be seen as an artefact of cultural Othering, not a valid distinction. Choice is limited or non-existent in the face of cultural pressure, whether implicit or explicit.
Given the cultural underpinnings of FGCS, it is daunting to consider how the situation could be improved for women. A starting point could be the dictum of first doing no harm, addressed in medical school. Medical practitioners need to be aware of the lack of strong evidence for FGCS and the attendant risks (e.g. ACOG Committee on Gynecologic Practice Citation2020; Moussaoui, Abdulcadir, and Yaron Citation2022; RANZCOG Women’s Health Committee Citation2019). They may then need guidance to assist them to communicate this information to their patients (RCOG (Royal College of Obstetricians and Gynaecologists Ethics Committee) Citation2013). This guidance could be part of medical education and continued professional development. An Australian survey found that a majority of General Practitioners (75%) reported having inadequate knowledge of how to manage patients who request FGCS (Simonis, Manocha, and Ong Citation2016). It is possible that a similar finding might be made in Indonesia; this could be a worthy topic for future research.
Specifically considering hymenoplasty, after an extensive systematic review of systematic reviews, randomised controlled trials, and observational studies that had investigated FGCS, in one recent study the researchers recommend that women seeking the procedure should be given reassurance as well as accurate information that the procedure does not reliably result in the desired outcome of bleeding at first subsequent intercourse (Shaw et al. Citation2022). We recognise that reassurance and information might not be sufficient to counteract social and cultural pressure, but it is a start. A public health promotion campaign could draw on the internationally acclaimed resource provided by the Labia Library (www.labialibrary.org.au).
The final implication of our research is that advertising of FGCS should be regulated and rigorously monitored. This has also long been urged in other countries (e.g. ACOG Committee on Gynecologic Practice Citation2020; Chibnall, McDonald, and Kirkman Citation2020; RCOG (Royal College of Obstetricians and Gynaecologists Ethics Committee) Citation2013; Shaw et al. Citation2022), although any beneficial effects of regulation and monitoring are yet to be identified. Nevertheless, given the likelihood that advertisements for cosmetic surgery in Indonesia will exacerbate sociocultural pressure to police women’s bodies, such advertisements should be regulated so as to be medically accurate and supported by strong research evidence.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
- ACOG Committee on Gynecologic Practice. 2020. “Elective Female Genital Cosmetic Surgery: ACOG Committee Opinion, Number 795.” Obstetrics and Gynecology 135 (1): e36–e42. https://doi.org/10.1097/AOG.0000000000003616.
- Arfin, M. I. S. 2014. “Definisi dan Jenis-jenis Operasi Mengembalikan Keperawanan [Definitions and Types of Procedures to Restore Virginity].” Blog post. January 22. https://www.kompasiana.com/noteboll/551fde7181331151019dfe0d/definisi-dan-jenisjenis-operasi-mengembalikan-keperawanan.
- Bordo, S. R. 2020. “The Body and the Reproduction of Femininity: A Feminist Appropriation of Foucault.” In The New Social Theory Reader, 2nd ed., edited by S. Seidman and J.C. Alexander, 207–218. London: Routledge.
- Braun, V., and V. Clarke. 2006. “Using Thematic Analysis in Psychology.” Qualitative Research in Psychology 3 (2): 77–101. https://doi.org/10.1191/1478088706qp063oa.
- Braun, V., and V. Clarke. 2021. “One Size Fits All? What Counts as Quality Practice In (Reflexive) Thematic Analysis?” Qualitative Research in Psychology 18 (3): 328–352. https://doi.org/10.1080/14780887.2020.1769238.
- Braun, V., and V. Clarke. 2022. “Conceptual and Design Thinking for Thematic Analysis.” Qualitative Psychology 9 (1): 3–26. https://doi.org/10.1037/qup0000196.
- Chibnall, K., K. McDonald, and M. Kirkman. 2020. “Pathologising Diversity: Medical Websites Offering Female Genital Cosmetic Surgery in Australia.” Culture, Health & Sexuality 22 (1): 64–80. https://doi.org/10.1080/13691058.2019.1574029.
- Choi, H., C. Mela, S. Balseiro, and A. Leary. 2020. “Online Display Advertising Markets: A Literature Review and Future Directions.” Information Systems Research 31 (2): 556–575. https://doi.org/10.1287/isre.2019.0902.
- Davies, S. G. 2018. “Skins of Morality: Bio-Borders, Ephemeral Citizenship and Policing Women in Indonesia.” Asian Studies Review 42 (1): 69–88. https://doi.org/10.1080/10357823.2017.1407292.
- The Jakarta Post. 2011. “Dewi Persik Feels Like a Virgin.” The Jakarta Post, June 6. https://www.thejakartapost.com/news/2011/06/06/dewi-persik-feels-a-virgin.html
- Dobson, A. S., K. McDonald, M. Kirkman, K. Souter, and J. Fisher. 2017. “Invisible Labour? Tensions and Ambiguities of Modifying The ‘Private’ Body: The Case of Female Genital Cosmetic Surgery.” In Aesthetic Labour: Rethinking beauty politics in neoliberalism edited by A. S. Elias, R. Gill, and C. Scharff, 351–367. London: Palgrave Macmillan.
- Erdogan, G. 2021. “Female Genital Cosmetic Surgery (FGCS): Evaluation of YouTube Videos.” Journal of Gynecology Obstetrics and Human Reproduction 50 (4): 102102. https://doi.org/10.1016/j.jogoh.2021.102102.
- Fisher, J. 2009. “Female Genital Mutilation.” In Mental Health Aspects of Women’s Reproductive Health: A Global Review of the Literature, edited by the WHO Sexual and Reproductive Health and Research Team, 147–157. Geneva, Switzerland: World Health Organization.
- Fisher, J., and M. Cabral de Mello. 2015. “Mental Health Consequences of Violence Against Women.” In Violence and Mental Health edited by J. Lindert and I. Levav, 133–152. Dordrecht, Heidelberg, New York, London: Springer.
- Frenzia, A. F. 2020. “Kontrol Terhadap Tubuh Perempuan Pada Praktik Rejuvenasi Vagina [Control of Women’s Bodies On Vaginal Rejuvenation Practices].” Jurnal Kawistara 10 (2): 172. https://doi.org/10.22146/kawistara.55551.
- Hammarberg, K., M. Kirkman, and S. de Lacey. 2016. “Qualitative Research Methods: When to Use Them and How to Judge Them.” Human Reproduction 31 (3): 498–501. https://doi.org/10.1093/humrep/dev334.
- Hilber, M. A., T. H. Hull, E. Preston-Whyte, B. Bagnol, J. Smit, C. Wacharasin, and N. Widyantoro. and WHO GSVP Study Group. 2010. “A Cross Cultural Study of Vaginal Practices and Sexuality: Implications for Sexual Health.” Social Science & Medicine (1982) 70 (3): 392–400. https://doi.org/10.1016/j.socscimed.2009.10.023.
- Kakal, T., I. Hidayana, A. B. Kassegne, T. Gitau, M. Kok, and A. van der Kwaak. 2023. “What makes a woman? Understanding the Reasons for and Circumstances of Female Genital Mutilation/Cutting in Indonesia, Ethiopia and Kenya.” Culture, Health & Sexuality 25 (7): 897–913. https://doi.org/10.1080/13691058.2022.2106584.
- Lahlali, A., D. Sawan, M. SidAhmed-Mezi, J.-P. Meningaud, and B. Hersant. 2021. “Hymen Restoration: An Experience from a Moroccan center.” Aesthetic Surgery Journal 41 (12): NP2053–NP2059. https://doi.org/10.1093/asj/sjab276.
- Laqueur, T. 1990. Making sex: Body and Gender from the Greeks to Freud.” Cambridge, MA: Harvard University Press.
- Learner, H. I., C. Rundell, L.-M. Liao, and S. M. Creighton. 2020. “Botched Labiaplasty’: A Content Analysis of Online Advertising for Revision Labiaplasty.” Journal of Obstetrics and Gynaecology 40 (7): 1000–1005. https://doi.org/10.1080/01443615.2019.1679732.
- Leye, E., E. Ogbe, and M. Heyerick. 2018. “Doing Hymen Reconstruction’: An Analysis of Perceptions and Experiences of Flemish Gynaecologists.” BMC Women’s Health 18 (1): 91–91. https://doi.org/10.1186/s12905-018-0587-z.
- Liao, L.-M., N. Taghinejadi, and S. M. Creighton. 2012. “An Analysis of the Content and Clinical Implications of Online Advertisements for Female Genital Cosmetic Surgery.” BMJ Open 2 (6): e001908. https://doi.org/10.1136/bmjopen-2012-001908.
- Moran, C., and C. Lee. 2013. “Selling Genital Cosmetic Surgery to Healthy Women: A Multimodal Discourse Analysis of Australian Surgery Websites.” Critical Discourse Studies 10 (4): 373–391. https://doi.org/10.1080/17405904.2013.813772.
- Moussaoui, D., J. Abdulcadir, and M. Yaron. 2022. “Hymen and Virginity: What Every Paediatrician Should Know.” Journal of Paediatrics and Child Health 58 (3): 382–387. https://doi.org/10.1111/jpc.15887.
- Mowat, H., K. McDonald, A. Dobson, J. Fisher, and M. Kirkman. 2015. “The Contribution of Online Content to The Promotion and Normalisation of Female Genital Cosmetic Surgery: A Systematic Review of the Literature.” BMC Women’s Health 15 (1): 110. https://doi.org/10.1186/s12905-015-0271-5.
- Mowat, H., A. S. Dobson, K. McDonald, J. Fisher, and M. Kirkman. 2020. “For Myself and Others Like Me’: Women’s Contributions to Vulva-Positive Social Media.” Feminist Media Studies 20 (1): 35–52. https://doi.org/10.1080/14680777.2018.1546209.
- Platt, M. 2012. “It’s Already Gone Too Far’: Women and the Transition Into Marriage in Lombok, Indonesia.” The Asia Pacific Journal of Anthropology 13 (1): 76–90. https://doi.org/10.1080/14442213.2011.636063.
- RANZCOG Women’s Health Committee. 2019. “Vaginal ‘Rejuvenation’ and Cosmetic Vaginal Procedures.” Australian and New Zealand Journal of Obstetrics and Gynaecology 59 (6): E22–E23. https://doi.org/10.1111/ajo.12999.
- RCOG (Royal College of Obstetricians and Gynaecologists Ethics Committee). 2013. “Ethical Considerations in Relation to Female Genital Cosmetic Surgery (FGCS).” https://www.rcog.org.uk/globalassets/documents/guidelines/ethics-issues-and-resources/rcog-fgcs-ethical-opinion-paper.pdf
- Rodrigues, S. 2012. “From Vaginal Exception to Exceptional Vagina: The Biopolitics of Female Genital Cosmetic Surgery.” Sexualities 15 (7): 778–794. https://doi.org/10.1177/1363460712454.
- Schick, V. R., B. N. Rima, and S. K. Calabrese. 2012. “Evulvalution: The Portrayal of Women’s External Genitalia and Physique Across Time and the Current Barbie Doll ideals.” Journal of Sex Research 48 (1): 74–81. https://doi.org/10.1080/00224490903308404.
- Shahvisi, A. 2023. “FGM’ vs. Female ‘Cosmetic’ Surgeries: Why Do They Continue to Be Treated Separately?” International Journal of Impotence Research 35 (3): 187–191. https://doi.org/10.1038/s41443-021-00514-8.
- Shaw, D., L. Allen, C. Chan, S. Kives, C. Popadiuk, D. Robertson, and J. Shapiro. 2022. “Guideline No. 423: Female Genital Cosmetic Surgery and Procedures.” Journal of Obstetrics and Gynaecology Canada: JOGC = Journal D’obstetrique et Gynecologie du Canada: JOGC 44 (2): 204–214.e1. e201. https://doi.org/10.1016/j.jogc.2021.11.001.
- Simonis, M., R. Manocha, and J. J. Ong. 2016. “Female Genital Cosmetic Surgery: A Cross-Sectional Survey Exploring Knowledge, Attitude and Practice of General Practitioners.” BMJ Open 6 (9): e013010. https://doi.org/10.1136/bmjopen-2016-013010.
- UK Government Department of Health and Social Care. 2022. “Virginity Testing and Hymenoplasty: Multi-Agency Guidance.” July 1. https://www.gov.uk/government/publications/virginity-testing-and-hymenoplasty-multi-agency-guidance/virginity-testing-and-hymenoplasty-multi-agency-guidance
- UNICEF. 2019. “Statistical Profile on Female Genital Mutilation/Cutting in Indonesia.” Data and Analytics Section, Division of Data, Research and Policy. https://data.unicef.org/wp-content/uploads/country_profiles/Indonesia/FGMC_IDN.pdf
- van Moorst, B. R., R. H. W. van Lunsen, D. K. E. van Dijken, and C. M. Salvatore. 2012. “Backgrounds of Women Applying for Hymen Reconstruction, The Effects of Counselling on Myths and Misunderstandings About Virginity, and the Results of Hymen Reconstruction.” The European Journal of Contraception & Reproductive Health Care 17 (2): 93–105. https://doi.org/10.3109/13625187.2011.649866.
- White, S. 2021. “Indonesian Army Says Has Stopped ‘Virginity Tests’ on Female Cadets.” The Jakarta Post, August 11. https://www.thejakartapost.com/news/2021/08/11/indonesian-army-says-has-stopped-virginity-tests-on-female-cadets.html
- Zwier, S. 2014. “What Motivates Her’: Motivations for Considering Labial Reduction Surgery as Recounted on Women’s Online Communities and Surgeons’ Websites.” Sexual Medicine 2 (1): 16–23. https://doi.org/10.1002/sm2.20.