Creating,maintaining and questioning (hetero)relational normality in narratives about vaginal reconstruction

Genital surgeries and normative heterosexuality: Feminist perspectives

Women’s bodies and subjectivities, bodily modification and heterosexuality are recurrent topics in feminist research. For example, there has been vigorous feminist debate concerning the beauty industry in general and cosmetic surgery in particular, and many scholars have examined women’s narratives about these practices (see for example Bordo, 1997; Davis, 1995; Edmonds, 2013; Gagné and McGaughey, 2002; Gimlin, 2007; Heyes, 2007; Morgan, 1991). In recent years there has also been an increased interest in female genital cosmetic surgery (FGCS), which involves procedures ‘that aim to change aesthetic (or functional) aspects of women’s genitalia but that are not medically indicated’ (Braun, 2010: 1393). ³ Critical examinations of these practices have indicated that they design bodies to fit normative sexual practices (Braun, 2005).

Closely connected to the above is feminist work on normative heterosexuality (Jackson, M., 1984; Jackson, S., 2006; Rubin, 1984; Seidman, 2005; Smart, 1996) which has highlighted the hierarchical organisation of sexuality in Western societies. Institutionalised normative heterosexuality is double-sided: it ‘regulates those kept within its boundaries as well as marginalizing and sanctioning those outside them’ (Jackson, S., 2006: 105). Along the same lines, empirical studies have shown that while young women attempt to negotiate meanings of traditional heterosexual patterns and practices, they nevertheless seem to uphold traditional views of femininity and sexuality (Allen, 2003; Harris et al., 2000; Maxwell, 2007; Stewart, 1999). Moreover, sexual hierarchies regulate sexual practice telling us that there is ‘one best way to do it, and […] everyone should do it that way’ (Rubin, 1984: 283), and that marital, reproductive sex acts are at the top of the hierarchy. Although alternative discourses do exist, this ‘coital imperative’ is strong and dismisses sexual practices such as kissing, touching, oral and anal sex (and all other non-heterosexual practices) as preliminary, optional extras or second-best substitutes for penile–vaginal intercourse (Gavey et al., 1999; Jackson, 1984; McPhillips et al., 2001). In this way, the coital imperative limits understandings of sexual practice in a manner that may stabilise certain sexual desires and behaviours (Gavey et al., 1999; Karkazis, 2008). Furthermore, it may strengthen links between gender identity, heterosexual practice and genitals (Braun and Wilkinson, 2005; Kaler, 2006; Kraus, 2013). Critical assessments of how success is defined in vaginal reconstructions for people with intersex conditions indicate, for example, that a ‘good’ sized vagina is defined as one able to accommodate a ‘normal’ sized penis (Karkazis, 2008; Kessler, 1998).

Scholars have also remarked on feminists’ focus on discussions of heterosexuality. Carol Smart (1996) suggests that instead of being concerned with bad heterosex and with constituting the heterosexual woman as a victim, feminists should acknowledge that women might enjoy or want better heterosex. She argues that ‘it is quite possible to acknowledge some of the benefits of living the heterosexual life-style and still seek to problematise the concept and category of heterosexuality’ (Smart, 1996: 234). What is required is a transgression of heterosexuality, not a denial of it. Stevi Jackson (2008: 34) similarly argues that the ‘ongoing negotiation of everyday, mundane, conventional sexual lives’ has been left out of the ‘polarized priorities between those pursuing anti-violence and exploitation agendas and those defending pleasure and diversity’. She suggests that by understanding the patterns of sexual relations in people’s everyday lives we can clarify the taken-for-granted and habitual, as well as gain an understanding of the celebration or devaluation of certain forms of sexual diversity.

Vaginal agenesis: Characteristics and treatment

Vaginal agenesis (absence of the vagina) due to Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome is found in about 1/4000–1/10,000 females (ACOG, 2002). Women diagnosed with this condition are genetically female, and, since neither the structure nor the function of the ovaries is affected, undergo ‘normal’ pubertal development as regards secondary sex characteristics (i.e. breast development, hair growth and external genitalia). However, having no uterus or vagina they do not menstruate, are unable to conceive, and may have difficulty in performing vaginal intercourse (Morgan and Quint, 2006).

Commonly, the condition is detected as a result of absent menstruation, with most women undergoing treatment in late adolescence (ACOG, 2002). This is either in the form of surgery, where a neo-vaginal space is created by using skin grafts or a section of intestine, or through dilation, whereby the vaginal dimple is stretched with dilators graduating in size (Edmonds, 2003). In the European as well as in the North American context, surgical procedures have in recent years been criticised as inflicting unnecessary pain and scarring and it has become more common to only use dilators (Ismail-Pratt et al., 2007; Liao et al., 2006; Roberts et al., 2001).

Material and methods

This article presents data from ten in-depth interviews with women who, in their teens, became aware that they did not have a vagina or that they only had parts of a vagina. ⁴ The interviewees were all of Swedish origin and within the age range of eighteen to twenty-six years at the time of interview. Seven of them had undergone surgery and had been advised to undertake post-operative dilation. Two were advised to use dilators, and the third was offered surgery but turned it down and was not offered dilators. All interviewees had been told that the vagina could be enlarged by penetrative intercourse and eight said they had had intercourse. The interviews were conducted in Swedish. They followed a semi-structured interview guide designed to encourage the women to talk about their bodies and situation, their everyday interaction with others and their medical encounters. ⁵ All interviews were recorded, transcribed verbatim and all names of interviewees, doctors and others mentioned were replaced with pseudonyms.

When analysing the interviews I used narrative analysis. I understand narratives as sequential and meaningful stories of personal experiences (Squire, 2008: 43) which may include oneself and others and describe past, present or imagined events or experiences (Squire, 2008). Through narration people make sense of their experiences, but also present themselves, their point of view, their perspective and their knowledge of the world in particular ways (Bruner, 2003). Narratives are thus understood as created in a process of co-construction, in which the teller and the audience, whether real or imagined, explicitly or implicitly take part (Riessman, 2008). In other words, their contents and the ways in which they are told are shaped by the socio-cultural context.

In my analysis I focused not only on how women accounted for their actions and decisions, but also on the content of their narratives. I attended to how they positioned themselves and others as characters ordered in space and time in order to endow their narratives with meaning (Bamberg, 2004). This led me to explore how the interviewees juggled sometimes juxtaposed narratives (Bamberg, 2004) and the assumptions about bodies, (hetero)sexual practice and relationships that were drawn on to make narratives coherent (Adelswärd, 1997; Linde, 1986).

Creating a body that works: Intertwining treatment and (hetero)relational normality

In the first narrative, the interviewees present and account for their treatment decisions. They underscore their dissatisfaction with the present state of affairs (i.e. not having a vagina or having one considered too small), and present their wish to be ‘normal’ in the sense of being more like everyone else and having a body that ‘works’. Linda says she chose surgery because she wanted everything to become as normal as possible: she remembers thinking ‘normal is good!’ and ‘now it’s not normal and it’s not good!’ Jenny, on the other hand, says that ‘I totally do not mind being different in some way, but I do want it all to work as normally as possible’. This focus on a ‘working’ body is further underscored as the women describe medical encounters. Jenny says that her doctor talked about sex and relationships and explained that ‘there are ways to make it work’. Veronica also exemplifies this focus by stating that her doctor ‘gave the impression that everything wasn’t completely screwed’ and that ‘it could work anyway’. While she acknowledges that decisions about surgery are based primarily on how interested you are ‘in that kind of sex’, she says that she definitely did not consider not having surgery: ‘You still want to be as normal as possible’ and ‘you think about future sex’, she explains. ⁶

This first narrative shows that, against a backdrop of norms and beliefs about heterosexual relationships and sexual practice, certain bodies are categorised as calling for modification, which creates a need for intervention. Moreover, in the light of medical progress and belief in medicine’s capacity to create a body that ‘works’ in taken-for-granted heterosexual practices, treatment is positioned as the self-evident option. ⁷ Jessica, for example, describes that when she found out about her condition she had recently met a man and explains that ‘I couldn’t have sex at that time and I felt “Why would he ever want me?”’ She says that she wanted surgery since she wanted to ‘at least appear like everyone else’ and that ‘it was self-evident to want to be like everyone else’. In the following this is further exemplified as she tells of her appointments with the gynaecologist and the plastic surgeon:

Interviewer: And then you saw Doctor Svensson?

Jessica: Yes.

Int: And what happened?

J: Gosh, I’ve seen Doctor Svensson so many times I mix it all up.

Int: Oh you do? That doesn’t really matter. But these first visits, before the surgery, do you remember what you talked about or what …? ⁸

J: She examined me, of course, and Doctor Andersson [the plastic surgeon] was there too and they explained how the surgery would be performed and I could decide whether I wanted to use skin from the thighs or the buttocks.

[Omission of speech. The interviewer mentions that the doctors will not be able to identify Jessica and the focus shifts somewhat until the researcher asks the following question]

Int: Did you talk about any other treatments or was surgery …?

J: No …

Int: Was it the only option? Kind of?

J: Yeah … Of course I wasn’t forced to do it. But of course I wanted to. So we didn’t talk about any options. That was probably … that was about it.

Int: What was it that felt so self-evident about it?

J: About surgery?

Int: Wanting to have … – choosing surgery?

J: Yes but the thing is, you want to be like everyone else … It’s really all about that. And you do want to have … like, get the chance to have a normal life. If you want to … Something like that.

Moreover, as the interviewees account for their treatment decisions they connect their focus on a ‘working’ body and a ‘working’ sex life to present or future relationships. Anna says that ‘sex … it didn’t work. Not to do it the normal way anyhow.’ She and her first boyfriend talked a lot about what to do but it was not until she met her second boyfriend that she saw a gynaecologist.

Interviewer: So that was about two years after you found out about it [not having a uterus]?

Anna: Yes … because then I felt, kind of, that something had to happen. Because it’s really not possible to have a boyfriend in the long run without, like, having sex at all. (Int: No … ?) Not with the ones I met anyhow [laughs].

Int: Did it seem like an alternative to you?

A: It was more like ‘well, whatever … ’, it wasn’t vital or anything … to me. But they felt … – so then I felt ‘I can check it out, at least’. Because I really would like to know what it was that  …  why it didn’t work. So then I went there and they [the doctors] did the first surgery.

The first narrative corresponds to the idea that normative heterosexuality may regulate those within its boundaries (Jackson, 2006), reinforcing a ‘coital imperative’ (Jackson, 1984). Here the women draw on a set of socio-cultural norms and beliefs in light of which treatment is presented as the obvious choice – not only because it can make your body more like everyone else’s, but also, and indeed chiefly, because it enables long-term relationships with male partners, i.e. provides (hetero)relational normality. Importantly, this notion of (hetero)relational normality has a corporeal dimension. It reflects certain assumptions about ‘normal’ female genitals – and about the possibilities of creating such genitals through treatment – that shape these women’s corporeal subjectivities. But this entanglement of ideal (hetero)relational normality and medical intervention, which results in specific surgical and bodily shapings, not only informs understandings of female ‘corporeal requirements’, it also involves narrow views of male partners’ bodies, expectations and desires, as becomes clearer in the analysis of the second narrative.

Maintaining vaginal size: Endurance and the conflation of sex and maintenance

In the second narrative the interviewees tell of the maintenance work required to increase and preserve the size of the vagina, either by use of dilators or by having intercourse. ⁹ Drawing on the same socio-cultural norms and beliefs as the first narrative, the main point here is that, despite pain and emotional effort, maintenance is endured because it gets better over time and because maintenance will make ‘sex’ work. Jessica describes what it was like to use the dilators after having had surgery:

Jessica: And then I had to … Since they’d created a vagina I had to use, like, dilators. And I had to use them several times a day, and it felt very difficult and it hurt. And I felt that you had to force it [the dilator]. Yeah, in the beginning it was really tough, I remember. And I was really upset and cried because … – yeah, because it hurt and it was hard and I thought, kind of, ‘Is it going to go on like this forever?’ But then again you do it more often in the beginning, to stretch it.

Interviewer: So how did you feel about this treatment? What was it like to use the dilators? Could you describe it?

J: Yeah … in the beginning it was tough and it felt … strange. (Int: Mmm) But it did get better and better all the time.

Int: So how long did you use them for?

J: Well, … I’ll be using them for the rest of my life.

However, maintenance does not only involve dilators. All the women indicate that they have been told by their doctors that dilation is not necessary if they have sex (i.e. penile–vaginal intercourse). Elsa, for example, says that she has been told that ‘if you meet a man, you don’t have to use them’. But if the relationship ends, Elsa explains, you have to use them again because ‘otherwise it’ll grow back together. It will. And then there’s nothing more you can do about it, they’ve said.’ Patricia touches upon the same topic as she describes how she sometimes felt that she had to have sex although she did not feel like it, and remembers thinking ‘OK, I suppose I might as well do it [have intercourse] so as to do something about it [vaginal size].’

In presenting the use of dilators as unnecessary if one enters into a relationship, the women indicate that penetrative intercourse is the assumed sexual practice in (heterosexual) relationships, and how sex in the sense of vaginal penetration becomes a part of maintenance. Hence the second narrative reveals not only how a notion of ideal (hetero)relational normality forms the women’s corporeal experiences of, and interactions with, their own bodies as they undertake sometimes painful dilation, but also how this notion shapes their physical interactions with partners, where intercourse is presented as the only substitute for the use of dilators. That is, treatments are directed towards ‘sex’, but sex also becomes treatment. Maintenance becomes a part of the ‘ongoing negotiation of everyday, mundane, conventional sexual lives’ (Jackson, 2008: 34), and positions these women’s bodies as sites for the maintenance of (hetero)relational normality and their male partners’ bodies as instruments for this. Hence maintenance may not only strengthen norms and beliefs about vaginal size and assumed sexual practice, but likewise reinforce socio-cultural norms about the size and function of male genitals and assumptions about male partners’ sexual desires and expectations.

Refusing maintenance and questioning results: Re-negotiations of (hetero)relational normality

The third narrative has a different tone than that of the previous two. Although it takes its starting point in the same assumptions, the women here present a different view of treatment. This becomes clear as they tell of how they have ceased to dilate, and articulate their doubts concerning the results of treatment. This narrative contains a certain questioning as the interviewees point out that, although they wanted a larger vagina, they did not by any means like the maintenance work required and ‘wanted it to be over with right away’, as Anna said. The majority also say that they have not dilated as much as ‘you should’ because of the pain and effort it involves. Anna also says that she knows she is supposed to use the dilators regularly, but because of the pain she only uses them when she ‘has to’, i.e. the days before she has a doctor’s appointment. Maria likewise says that she hardly ever used the dilator. She was told that ‘you were supposed to do it 20 minutes every day for about 10 months, or something like that’ and she found this very ‘difficult to deal with’ – both psychologically and physically because of the pain. Especially, she says, she finds it hard that she ‘has to create something others already have got’, adding that ‘it hurts a lot too’. An excerpt from Linda’s interview further exemplifies how the women question whether maintenance is really worth the effort.

But I think – or rather I know, because a while ago I read a note from my diary that I’d written after I’d had surgery – that I obviously found it more difficult afterwards than I’d ever imagined it could be. It hurt a lot more afterwards and it was more difficult and tricky to keep the dilator, which would keep it open, in place and everything. And I know that Doctor Johnson talked about this, but still I hadn’t at all expected it. You think more about the operation and that it’ll hurt right afterwards and that it’ll be quite all right after that, but it kept on and it was really difficult and it still is, kind of – not as bad but still a bit difficult, yeah …

In this narrative women also de-emphasise the significance of vaginal size. Some of them do so by underscoring that male partners do not seem to notice any difference. Jenny, for example, says that she only uses the dilators once in a while, perhaps not as often as she should. But she does not see anything ‘too dangerous’ in this, and says that her boyfriend, whom she has not yet told, does not seem to have noticed that her vagina has been surgically created. Joanna similarly says that to her knowledge no man has been able to tell that her vagina has been surgically created. Possibly, Joanna adds, the man could start to wonder about the scars on her thighs from the skin grafts, but so far she has made sure to turn the lights off and thus there has been no comment. Other women indicate that men do not seem to care as much about the vagina as they had expected. Maria explains that you might have to be careful when having sex and that you might need lubricants, but she has found that men are very accepting and understanding ‘when it comes to these things’, which she had not expected. As in the previous narratives, male partners have a central role – but, as these examples reveal, the third narrative presents a different view of male partners’ expectations and reactions. ¹⁰ And, it indicates that a ‘normal’ sized vagina is not so important for relational normality after all.

Finally, in this third narrative women also question the results of treatment. Patricia says that she found it hard to know how much she had to dilate in order to make her vagina ‘normal’ sized. Searching the Internet, she found out that a normal sized vagina is ten to fourteen centimetres long, and she says ‘I thought “Oh my god, I don’t have anything like that! Will this work?!” But it did’. ¹¹ Here, Patricia can be seen as implicitly questioning the results of dilation and the importance of vaginal length by underscoring that although she previously felt unsure whether her vagina would ‘work’, it all turned out okay. In contrast, Joanna questions whether treatment provides the desired results. She explains that she wanted to get the surgery over with as quickly as possible in order to be able to have sex, but after the surgery sex became difficult. At that point, she says, she did not feel like having sex any more but felt she had to ‘because otherwise it’ll just get smaller and then you’ll have done it all for nothing’. This ‘became somewhat of a dilemma’, Joanna explains. She also comments on her lack of sensation during sex: perhaps she ‘shouldn’t be able to feel anything’ because the vagina ‘isn’t real’. Hence treatment may create a ‘normal’ sized vagina, but sex may still be more difficult than expected. And although she now has a vagina, Joanna describes it as not being ‘real’, and indicates her uncertainty as to whether such a vagina is supposed to provide the sensations that she seems to have expected.

The interviewees who did not have surgery remark even more explicitly on the results of treatment. Esther explains that sex can be painful, especially if the man has a large penis, and says that she was considering surgery in the hope that it would make sex more pleasurable. Still, in the excerpt below she expresses her criticism of the way in which she was told that surgery would make everything fine.

Interviewer: What was it that was going to be fine?

Esther: It’d get really easy to have sex and then I’d be more like everyone else, that was kind of the way I understood it. When I look back on it now I say to myself: ‘Yeah, but why did they only tell me about that side of it?’ There was never anything about it not turning out that good. Because, I mean, when you read stuff on the Internet, you, like, find that it can go wrong and if you take skin from the thigh it might start to grow hair! I mean, then you’re certainly not like everyone else, are you?!? Things like that were never even mentioned, but at the same time – no, I don’t know, but at least they didn’t try to talk me into it. They told me to wait. And I felt that was good. Because if they’d … if they’d been more persistent, telling me to have it done, then I’d have had it done … without knowing what I was getting myself into.

In the third narrative, women present contrasting perspectives on the significance of the vagina and the meaning of sexual function. Here the body is not presented as a site for modification and maintenance, but as a site for resistance. In telling of refusing painful dilation and questioning the results of vaginal reconstruction, women pave the way for critical reflection about sexual practices, male partners’ expectations and medical prospects that can make possible a re-evaluated and expanded understanding of (hetero)relational normality.