Going Under the Knife for Masculinity or Femininity

Our bodies come in all shapes and sizes. Hormones sculpt our bodies into their adult forms, mainly prenatally and during puberty. But a growing number of people seek cosmetic surgery, including genital and breast surgery, to make their bodies look either more masculine or more feminine.

Most who seek genital surgery are cisgender (i.e., not transgender) and have sex-typical genitals, but want hypermasculine or hyperfeminine genitals—men want larger genitals, and women want smaller genitals.

Pornographic images of men with unusually large penises, especially on the internet, have exacerbated men’s desires for a larger penis. A 2006 internet survey of about 50,000 heterosexual people found that 45 percent of the men wanted a larger penis, even though 85 percent of the women were satisfied with their partner’s penis size.

There is a large market for products, such as creams and pills, that are claimed to increase penis size. But these products are unregulated and have no effect on penis size, according to available evidence. This was reported to be a $320-million industry in 2019.

In the quest to increase penis size, some men apply an exercise to push blood toward the tip of the penis (called jelqing), fit a vacuum device over the penis to produce suction, or attach a traction device that stretches the penis for several hours each day. Reports suggest that only traction devices may have an effect on penis length, but only while it is flaccid.

There are also surgical approaches. To increase penis width, either hyaluronic acid or fat from elsewhere in the body is injected, or fat is grafted onto the penis, though some of this fat is typically reabsorbed later. To increase apparent penis length, the suspensory ligament linking the penis to the abdomen is cut, causing the (unchanged) penis to hang lower.

The American Urological Association currently states that these surgeries have “not been shown to be either safe or efficacious.” Penile surgeries can cause swelling or infection that occasionally requires penis removal and caused 167 deaths in 2018 in India and China alone.

Nonetheless, surgical approaches to penile enhancement are growing. According to the International Society of Aesthetic Plastic Surgery, over 45,000 penile enhancement surgeries were carried out between 2013 and 2017, and there are reports of dramatic increases just since 2018. The cost of the pair of penile surgeries is listed by a German center as about EUR 9,900.

While these surgeries may increase the apparent size of the flaccid penis, they do not increase the length of the erect penis. Cutting the ligament may also reduce the stability of the erect penis, which can cause difficulties during sex.

Thus, the goal of these surgeries is not to improve sex, but simply to have a penis that looks bigger when flaccid, as it might be seen while undressing or showering at a gym. This is more about the locker room than the bedroom. Having a penis that looks longer and/or thicker makes some feel more manly and confident. The 2006 internet survey reported a correlation between men’s satisfaction with their penis size and their self-rated body attractiveness and even facial attractiveness.

Women increasingly seek to reduce their genitals surgically, especially by labiaplasty, in which the labia minora (the inner labia) are cut back. (The clitoris is typically not cut, unlike surgeries performed on intersex infants to make them look more typically female.)

Some seeking labiaplasty bring their doctors pornographic images of genitals to illustrate their surgical goals. Some pornographic actresses, however, report that their own labia minora were digitally erased in images, effectively making their genitals look prepubescent. Thus, some pornographic images of genitals may themselves be inauthentic.

Though less common than other cosmetic surgeries, labiaplasty is increasing. According to the American Society for Aesthetic Plastic Surgery, there were 5,070 procedures reported in the U.S. in 2013 and 12,903 in 2019, a 154 percent increase. The average surgeon’s fee was $2,952.

During puberty, estrogens cause the growth of breasts and buttocks. Some women have long sought to enlarge their breasts and/or buttocks to look more feminine. In the 18th century, breasts were injected with olive oil, paraffin, or petroleum jelly, or surgically implanted with substances, including rubber, metal, ivory, or even glass. In the 1940s, fat from elsewhere in the body was injected into or grafted onto the breasts. In the 1950s and 1960s, liquid silicone was injected. Many of these procedures had serious health consequences.

In 1963, breast implants made of liquid or gel within a flexible silicone sac were introduced and quickly became by far the most common surgery to enhance feminine body shape. In 1992, the Food and Drug Administration imposed a moratorium on silicone-gel implants for cosmetic surgery, and only saline-filled implants were then available in the U.S. But no consistent evidence of undue risk was found (beyond usual risks of surgery), so silicone-gel implants were reintroduced in 2006 and are now 88 percent of U.S. breast implants.

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There have been at least 280,000 breast implants in the U.S. each year since 2003, with a high of 399,240 in 2007. In 2019, there were 280,692 such surgeries, more than any other kind of cosmetic surgery. In the U.S. in 2019, the average surgeon’s fee for a silicone-gel breast implant was $4,085, and the total spent on breast implants was over $1 billion.

If we include the 146,711 breast-lift surgeries, there were almost half a million surgeries to enhance breasts in 2019 in the U.S. alone. From 1997 to 2019 in the U.S., there were a total of over 6.3 million breast-implant and over 2.2 million breast-lift surgeries. (None of these numbers include breast reconstruction surgeries after mastectomy.)

Most women who obtain breast implants wish to increase their body image satisfaction. Many report having been teased about small breasts as adolescents. Although typically 80-90 percent say they are satisfied with the surgical results, breast-implant patients also commit suicide at two to three times the rate of control groups.

Buttock augmentation surgery has also become popular in recent years, growing from 614 procedures in the U.S. in 2002 to 35,880 procedures in 2019, an increase of 5,743 percent. The average surgeon’s fee for buttock implants was $4,795.

Some women and men have breast reduction surgery. For women, this can be motivated by pain, discomfort, and the inconvenience of large breasts.

For men, breast reduction surgery is typically motivated by a wish to avoid looking feminine. Men’s breasts (or what appear to be breasts) may be enlarged due to working out (building the pectoral muscles), being obese (accumulating fat in the breasts), or developing glandular tissue that could potentially secrete milk. The growth of such glandular tissue is typically caused by extra estrogen, which is made from testosterone in a single chemical step. In 2019 in the U.S., 21,407 men had breast reduction surgery due to the growth of glandular tissue, with an average surgeon’s fee of $4,107.

These surgeries to make our bodies appear more masculine or feminine are generally not covered by health insurance. The large investment that patients make and the large and growing industry that provides these services suggest that appearing more masculine or more feminine has taken on undue importance in contemporary Western societies.