by David Balashinsky
There are few things more offensive to one's sense of right and wrong than a double standard by which a harm is condemned in one case but a blind eye turned to a comparable (or worse) harm in another. And there are few instances of such a double standard more flagrant than the outrage currently being directed at Vagisil for its new OMV! product line by several prominent OB/GYNs.
For those unacquainted with OMV! and the controversy surrounding it, OMV! is a "personal care" product manufactured by Vagisil. The New York Times, The Washington Post and HuffPost have all reported on this within the past few weeks. The criticism of products that are marketed to women as palliatives for the pathological condition of having a vulva is not new. What is new is that Vagisil has recently launched a "feminine hygiene" product line - and an advertising campaign to promote it - that specifically targets teenagers. This is also the cause of the particular outrage about this product. As Dr. Jen Gunter (as quoted in WAPO) puts it,
Society's always looking for ways to make people with vaginas feel ashamed. I hate that industry with a passion because it capitalizes on vaginal and vulvar shame. But to see it marketed to teens? Not on my watch.
The objections to OMV! all sound similar themes and I agree with every one of them. "Feminine deodorant" wipes or sprays are unnecessary. The vagina, as Dr. Gunter is fond of saying, is "like a self-cleaning oven." (I love that simile, although I also think that anything that reinforces the link in people's minds between women, housework and especially kitchens is probably best avoided.) They are potentially and likely harmful. They do not so much address a problem as invent one by pathologizing the vagina and the vulva. In this respect, such products are the quintessential "solution in search of a problem" or (to put it more precisely) "cure in search of a disease." Worse, by pathologizing female genitalia, these products contribute to a culture of body-shaming that undoubtedly adversely affects women's and young women's self-esteem. There is even an argument to be made that such products represent an updated version of ancient, patriarchal notions of women as being essentially malignant and corrupting influences upon their male counterparts (think Eve and the apple). This peculiar, bipartite and contradictory concept regards women as temptresses with bodies ideally suited to that purpose yet, at the same time, regards that part of women's bodies that is most female and most tempting as the mephitic wellspring of so much pollution and evil that have been unleashed upon mankind. I don't think it's unreasonable to argue that products that exploit the concept of the vulva and the vagina as being inherently foul and malodorous are a contemporary manifestation of a very ancient, patriarchal view of women and of women's bodies, although this argument becomes a little harder (though not impossible) to make when the founders of two prominent companies that traffic in such garbage (Vagisil and Goop) are women.
So, whence my particular ire? It is this. In promoting an unnecessary product that shames female bodies and that has the potential to cause and in some cases does cause physical harm to female genitals, Vagisil is not doing anything worse than what the American College of Obstetricians and Gynecologists (ACOG) has done and continues to do in endorsing an unnecessary genital surgery that shames male bodies and that causes physical harm to male genitals. Yet four of the most vociferous critics of Vagisil's OMV!, including Jen Gunter, MD, Heather Irobunda, MD, Jennifer Lincoln, MD and Staci L. Tanouye, MD, are all Fellows of the American College of Obstetrics and Gynecology. My question for these FACOGs (which I posed, in vain, to several of them on Twitter and Instagram) is this: Why the double standard? I agree that vulvas don't need "fixing" in any way at all. Why won't ACOG agree that neither do penises?
For context, here is some background. Most neonatal circumcisions are performed by obstetricians (section 4.2, p. 22 in the linked United Nations report). As for ACOG, it is a professional organization consisting of obstetricians and gynecologists (obstetricians are generally trained in gynecology and gynecologists are generally trained in obstetrics, hence the acronym OB/GYN). ACOG has officially endorsed the American Academy of Pediatrics' 2012 Technical Report on neonatal male circumcision. The AAP concedes that "existing scientific evidence is not sufficient to recommend routine circumcision" and that "the procedure is not essential to the child's current well-being. . . . " Nevertheless (and possibly because neonatal circumcision generates hundreds of millions of dollars in revenue annually) the authors of the AAP's 2012 Technical Report argued that "it is legitimate for . . . parents to take into account their own cultural, religious and ethnic traditions, in addition to medical factors" when opting to subject their sons to circumcision (note that "medical factors" is listed last) and it concluded, therefore, that "the benefits of newborn male circumcision justify access to this procedure for those families who choose it." The Technical Report acknowledged, incidentally (or not so incidentally), that among the reasons often cited by parents in the U.S.A. for making this "choice" are "hygiene and cleanliness of the penis" and "[s]ocial concerns." Hence, when they referred to the "benefits" of neonatal circumcision, the authors of the AAP Technical Report were not referring to medical benefits so much as to what they believed were benefits as broadly construed to include social benefits. This distinction was further clarified in a commentary written by Andrew Freedman, MD (one of the members of the Task Force that prepared the AAP's Technical report) that was subsequently published in Pediatrics. As Dr. Freedman explained,
To understand the recommendations, one has to acknowledge that when parents decide on circumcision, the health issues are only one small piece of the puzzle. In much of the world, newborn circumcision is not primarily a medical decision. Most circumcisions are done due to religious and cultural tradition. In the West, although parents may use the conflicting medical literature to buttress their own beliefs and desires, for the most part parents choose what they want for a wide variety of nonmedical reasons. There can be no doubt that religion, culture, aesthetic preference, familial identity, and personal experience all factor into their decision. Few parents when really questioned are doing it solely to lower the risk of urinary tract infections or ulcerative sexually transmitted infections. Given the role of the phallus in our culture, it is not illegitimate to consider these realms of a person's life in making this nontherapeutic, only partially medical decision.
The upshot of all this is that ACOG has formally adopted a position supporting a parent's right to subject her or his child to circumcision for cultural reasons, for aesthetic reasons, for religious reasons, for reasons of "hygiene" and "cleanliness," for any reason or for no reason. In the United States, "just because" is a sufficient justification for performing an irreversible and medically-unnecessary genital surgery on an infant male. ACOG Fellows are, of course, physicians who presumably have taken an oath to abide by a code of ethics. Among other things, that code prohibits the use of surgery when less invasive, more conservative treatment options are available. The Code of Professional Ethics of the American College of Obstetricians and Gynecologists also enshrines the principle of autonomy: the right of the individual to make informed choices about her or his own body. Yet, with its endorsement of the 2012 AAP Technical Report on infant male circumcision, ACOG invites its Fellows to violate these same ethical guidelines. That is why I have singled out the four FACOGs mentioned above. While none of them performs non-therapeutic infant circumcisions as far as I am aware (Dr. Lincoln explicitly informed me on Twitter - before she blocked me - that she doesn't), all of them are dues-paying members of ACOG who proudly include FACOG among their post-nominal letters. That (along with their failure to publicly and energetically repudiate ACOG's endorsement of unnecessary genital surgery) not only makes their implicit support for ACOG's position a reasonable inference but makes criticism of them for it valid. More to the point, it makes their inconsistency - the double standard of criticizing OMV! while implicitly endorsing forced non-therapeutic circumcision - fair game.
The parallels between "feminine hygiene" products and non-therapeutic circumcision are several and striking, starting from the simple fact that both target genitals: female and male, respectively. (It goes without saying that, throughout this essay, when I refer to "feminine hygiene" products, I am not referring to menstrual products but only to unnecessary "cleansing" and deodorant products such as OMV!.)
Beyond this, one of the chief criticisms of OMV! and similar products is that they pathologize the vulva and the vagina. In order to sell a cure or a treatment, after all, one must first identify a problem that needs to be cured or treated. That is exactly what the medical profession (and others) did during the 19th century with the male prepuce (or foreskin). It is well known that male circumcision was introduced and popularized as a "cure" for masturbation (and its inevitable sequela, "masturbatory insanity") as well as for numerous other ailments that were attributed at the time to the presence of the male prepuce. The process by which the male foreskin became pathologized within the realms of medical practice and the culture at large (in England and in the United States) has been thoroughly documented. A concise summary was written by Jessica Wapner and published in 2015 in Mosaic. In The Troubled History of the Foreskin, Wapner writes,
One day in 1870, a New York orthopaedic surgeon named Lewis Sayre was asked to examine a five-year-old boy suffering from parallysis of both legs. . . .
After the boy's sore genitals were pointed out by his nanny, Sayre removed the foreskin. The boy recovered. Believing he was on to something big, Sayre conducted more procedures. His reputation was such that when he praised the benefits of circumcision . . . surgeons elsewhere followed suit. Among other ailments, Sayre discussed patients whose foreskins were tightened and could not retract, a condition known as phimosis. Sayre declared that the condition caused a general state of nervous irritation, and that circumcision was the cure.
His ideas found a receptive audience. To Victorian minds, many health issues originated with the sexual organs and masturbation. . . .
The circumcised penis came be seen as more hygienic, and cleanliness was a sign of moral standards. An 1890 journal identified smegma as "infectious material." A few years later, a book for mothers . . . described the foreskin as a "mark of Satan." Another author described parents who did not circumcise their sons at an early age as "almost criminally negligent."
By now, the circumcision torch had passed from Sayre to Peter Charles Remondino, a popular San Diego physician. . . . Remondino described the foreskin as a "malign influence" that could weaken a man "physically, mentally and morally; to land him, perchance, in jail or even in a lunatic asylum." Insurance companies, he advised, should classify uncircumcised men as "hazardous risks."
By the turn of the 20th century the Victorian fear of masturbation had waned, but by then circumcision had become a prudent precaution, and one increasingly implemented soon after birth. . . . By 1940, around 70% of male babies in the United States were circumcised.
. . . By the 1970s . . . more than 90% of U.S. men were circumcised. . . . The American foreskin had become a thing of the past.
Throughout its modern history, as one rationale after the other for neonatal circumcision has been discredited, one rationale after the other has arisen to take its place. Thus has neonatal circumcision - like vaginal douches and "feminine hygiene products" - become the quintessential "cure in search of a disease."
What makes the "feminine-hygiene-products" industry so particularly objectionable is that it not only reflects a culture of body-shaming of people with vulvas and vaginas (recall Gunter's comments, above) but that it contributes to and perpetuates that culture. But, here again, we see an identical phenomenon at work (except by proxy, because the social pressure is exerted on parents) with respect to non-therapeutic circumcision and penile anatomy. Non-therapeutic circumcision is performed primarily for cultural and "aesthetic" reasons. Social conformity - "so he will look like his father" and "so he won't be made fun of in the locker room" are among the most common rationalizations offered by parents for having their sons circumcised. "So his future sex partners [who, of course, are always assumed to be women] won't be turned off,'" is another. More broadly, because we live in a culture in which male genital cutting has been normalized, many if not a majority of Americans conceptualize a surgically-reduced penis as "normal." Thus, they tend to regard a healthy, intact penis as abnormal, ergo, deformed. It remains common, therefore, for intact boys and men to be mocked for the natural anatomical structure of their genitals (hence the concern about locker rooms). No one should pretend that this body-shaming doesn't adversely affect the body-image and self-esteem of intact boys and men. The problem, however, for such boys and men is not that their penises are intact but that their prepuces have been stigmatized by our society. It is the very act of routine circumcision - the normalization of circumcised penises - that contributes to and perpetuates this culture in which intact penises are stigmatized. As a result, every boy - whether circumcised or intact - grows up with the perception that he was born with a congenital deformity of his penis that either was "corrected" by circumcision or, if it wasn't, ought to have been. And every time an OB/GYN performs a medically-unnecessary circumcision, she or he perpetuates this body-shaming culture, just as ACOG perpetuates it with its endorsement of non-therapeutic circumcision.
The similarities do not end there. It goes without saying that special "cleansers" for the vulva (and the vagina) are unnecessary. And when washing the vulva is appropriate, water and maybe a mild soap are more than sufficient. But it turns out that soap and water work just as well on intact penises as they do on vulvas. Yet "improved hygiene" - "cleanliness of the penis"- is not only frequently offered by parents as a reason to have their child circumcised, this reason is cited specifically in the AAP Technical Report. To be sure, the AAP and ACOG do not themselves explicitly cite "hygiene" as a justification for circumcision. But both organizations do endorse the right of parents to impose circumcision on their children even when their reasons for doing so have no basis in rational thought or medical science. As noted, the AAP's Technical Report - endorsed by ACOG - asserts that it is perfectly "legitimate" for parents to take social, cultural and religious factors into consideration when deciding on whether to subject their male child to circumcision. But what is the concept of the vulva as something that is intrinsically unclean if not a social and cultural (and, to some extent, a religious) construct? What is the concept of the male foreskin as intrinsically unclean if not the same sort of social and cultural construct? By the same token, if a special "feminine wash" is unnecessary as a method for keeping the vulva clean, isn't surgery even more unnecessary, by orders of magnitude, as a method for keeping the penis clean?
Still another criticism of OMV! and similar products is that they are not just potentially but positively harmful to the vulva and the vagina. As the Times (which interviewed Dr. Tanouye and others for its coverage of this story) reports,
Any product that is scented can potentially damage the skin, Dr. Tanouye said. And while not everyone may experience a reaction, or react immediately, experts said that certain health issues can emerge after prolonged use. "Fragrance is the No. 1 cause of allergic contact dermatitis," Dr. Tanouye said, which is a condition in which the skin gets inflamed and becomes itchy, red and rashy after contact with an irritating substance.
HuffPost reports that "people who used these ["feminine hygiene"] products were up to three times more likely to get a vaginal infection." Of course introducing an irritant to the vulva, let alone into the vagina, is likely to be harmful. But what amount of willful blindness is required not to recognize that cutting off part of someone's genitals is even more harmful? There is a cure, after all, for contact dermatitis. In contrast, there is no cure for circumcision. It's irreversible.
Lastly, OMV!'s critics cite the "predatory" nature of this and similar products. They exist and are promoted for one reason: to make money. And that, I submit, is precisely the motivation behind ACOG's endorsement of the 2012 AAP Technical Report on infant circumcision. That hundreds of millions of dollars are spent annually on totally unnecessary "feminine hygiene" products is disgraceful. That companies like Vagisil and Goop profit to the tune of hundreds of millions of dollars annually by selling these products is unconscionable. How is it any less disgraceful that hundreds of millions of healthcare dollars are misdirected annually into a medically-unnecessary genital surgery? (This is money that could be spent on early childhood nutrition programs or providing access to the full range of reproductive healthcare services for uninsured or under-insured women, to offer just two examples.) And how is it any less unconscionable that ACOG's members directly profit from the performance of this medically-unnecessary genital surgery?
Vagisil exists only to make money. Its shareholders and most of its officers do not swear an oath of beneficence, nor are they obligated (even if we think they should be) to be guided by the precept primum non nocere. Every member of ACOG, in contrast, does swear such an oath and is under such an obligation. Subjecting unconsenting children (and the adults that they become) to a medically-unnecessary and irreversible genital surgery violates that oath and that obligation. Thus, while I salute Doctors Gunter, Irobunda, Lincoln and Tanouye for their criticism of OMV!, I respectfully suggest that they should also put their own house in order. Even though they, themselves, may not perform non-therapeutic circumcisions, they belong to an organization of OB/GYNs who do. Vagisal will probably never abandon its business model in order to do the right thing. Of ACOG, on the other hand, the public has a right to expect much, much more.
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