This is not an operating room. It’s a solarium. The glass windows connect to a metal frame that connects to the concrete floor, the floor of this enclosed balcony three storeys up. The concrete is coated with sealant to keep it non-porous. The less porous a surface, the less chance bacteria will take root and grow and contaminate the area. When you’re dealing with skin and blood, you try to avoid contaminants. They cause irritations and infection and other disturbances that can lead to hospital visits. You don’t want someone to leave here and go to the hospital. The fewer people who know someone was here, the better.

Andy Niland knows this. It’s his apartment, his space, though he shares it with his girlfriend, Adrianne, who’s been living here for a few months. He put in the work to make sure it was as close to sterile as possible. But “almost sterile” doesn’t mean anything. Sterile is absolute. A crack, a cleft, a weak stitch—any imperfection, anything overlooked can lead to trauma.

A blue massage table sits inside the solarium’s sliding glass doors. One corner holds an autoclave. There are plastic drawers housing Andy’s tools: scalpel blades; surgical sutures and suture needles; silver nitrate in the form of lunar caustic; bottles of the local anaesthetic lidocaine and syringes with which to inject it. There are also piercing needles and body jewellery—by trade, he’s a body piercer, and sometimes he’ll do piercings here, too—but he has no use for them tonight. He bought all of these items legally; being in possession of them is not against the law. What he plans to do with them, however, will make him a criminal. He knows this.

It’s Sunday, January 18, 2009, and just after 5 p.m., the party arrives. Twenty-four-year-old Danielle leads the way. She’s pretty, with dark dyed hair, crimson streaks in the front, some piercings, and some tattoos—most of the former done by Andy—and she’s accompanied by a couple of girlfriends and her cousin. Maybe they’re here for support, maybe to gawk, or maybe there’s just not much to do in North Bay, Ontario, on a frozen Sunday night in the middle of winter. By 9:30, Danielle is lying on the massage table, naked from the waist down except for a pair of leg warmers that Adrianne, playing the role of nurse, gave her to wear. Andy, wearing a surgical mask and white nitrile gloves, injects three half-full syringes of lidocaine into separate points in Danielle’s inner labia, numbing the area. Then he marks with a surgical pen where exactly on her labia he’s going to cut. He’ll draw a pair of lines, let Danielle take a look with a handheld mirror, then wipe them off and try again. “You’re not going to have one bigger than the other,” Andy tells her. It’s an easy, friendly atmosphere. Danielle, Andy, and Adrianne know each other well, and all three are cracking jokes to keep it loose. “Oh, look,” Danielle says, “I’ve had both of you separately between my legs, and now I’ve got both of you together between my legs.”

This is not an operating room, and that’s part of the reason she wants to be here. In this solarium, subzero North Bay blissfully unaware just beyond the glass, she knows Andy will take care of her.

It’s not hard to find a cosmetic surgeon who will perform a labia reduction. Pick one at random in a major city and there’s a good chance he or she will offer some variation of the procedure. In Toronto, clinics take different approaches to selling it. Some go for the technical “labiaplasty,” while others soften the operation by calling it something like “vaginal beautification.” But for between $3,000 and $8,000, a licensed surgeon will use a laser to safely and quickly trim or reshape distended, uneven, discoloured, or painful labia.

These are the only circumstances under which a woman in Canada can consent to a labia reduction. The Ontario Human Rights Commission folds labia excision into its policy on female genital mutilation, if performed alongside removal of the clitoris and suturing shut the vaginal opening, called infibulation. The OHRC takes a stand on the issue to protect women from certain cultural backgrounds in Africa, the Arabian Peninsula, Asia and South America from being coerced or otherwise forced into “consenting” to such operations. It’s a difficult phenomenon to track reliably, however. “There is some evidence that FGM is practised in Ontario and across Canada,” notes the OHRC policy on the matter, adding that in some cases girls are likely sent out of the country for the procedure. These surgeries are unsafe and painful, in some cases performed with instruments as crude as shards of glass or cactus spines.

But while female genital mutilation might be widely recognized as a serious violation of human rights, legal labiaplasties happen every day—within limits. In Ontario, legislation has specified it as a “controlled act”—that is, one that only members of certain medical professions may perform. The 13 (soon to be 14) specified acts range from performing any operation below the dermis layer of tissue to even inserting an instrument (or finger) beyond certain thresholds (including the outer labia). Dentists, surgeons, nurses, and even acupuncturists are authorized to perform some of the acts, depending on the nature of their work. To operate without an authorization is, in the law’s eyes, illegal and potentially criminal. The Criminal Code of Canada, after all, explicitly mentions excising, infibulating, or mutilating the labia minora as acts deserving of an aggravated assault charge—unless, of course, they were performed by surgeons as parts of legitimate medical procedures. The Code also offers an allowance provided the patient is at least 18 and the procedure doesn’t result in permanent damage.

These are sensible, obvious precautions. They guarantee that the people performing these procedures have a certain level of skill. And yet, some see a trade-off: as legislation piles up in the interest of safety and security, people’s autonomy over their own bodies decreases.

Perhaps ironically, though, the medical community is more invested in patient autonomy now than ever before, except the focus is now on the patient’s refusal of treatment. “There’s a famous phrase in medicine,” says Dr. Philip Hébert, chair of the Research Ethics Board at Sunnybrook Health Sciences Centre in Toronto. “The doctor proposes and the patient disposes.” It’s simplistic, he admits, but the point is to avoid wading into territory where clinicians end up assaulting clients by performing unwanted or improperly explained procedures. Over the past 50 years, he says, bioethicists have occupied themselves with the robustness of the consent process to ensure patient autonomy is unimpeachable.

Patients’ wishes, however, only go so far. “Just because you have a right to your body,” Hébert says, “doesn’t mean there’s an obligation on the part of the health professional to help you do those things,” at least when it comes to experimental and dangerous procedures. There are limits to consent. For example, he says, people cannot consent to their own murders. “That will remain murder—it doesn’t exculpate the person from the responsibility of carrying out the act you ‘consented’ to.” Grievous bodily harm, no matter the circumstances, cannot be a consensual act.

This has been tested. In 1991, the Supreme Court of Canada decided, in the case of R. v. Jobidon, that a man who killed another man in a consensual fist fight in a bar parking lot was guilty of manslaughter. The verdict hinged on the belief that even though it was a fair and mutually desired fight, a person cannot consent to assault, and even if it was consensual, it’s hard to argue that two men brawling outside a pub are doing anything but assaulting each other.

Except, what if the assault doesn’t end with a death in a parking lot? What if the victim is a vocal and willing participant, one who makes it out alive, one who laughs at the idea that her rights have been violated in any way and is her alleged assaulter’s most vociferous defender? What then?

Danielle’s a bleeder, but at least the anesthetic is doing its job. It’s like being at the dentist, she says—someone’s obviously poking around, but she doesn’t feel much. While Andy nicks away with his scalpel blade, one of the friends snaps photos of Danielle’s bloodstained buttocks, complete with freshly formed clots, and Adrianne jokes about frying and eating the pieces of labia that Andy has removed.

It’s a fix for a problem Danielle has felt she had since she was 16. “I thought it was saggy and gross,” she says of her labia, “and I figured it was only going to get worse as I got older.” She called cosmetic surgery clinics, but either couldn’t afford the thousands of dollars it would cost or wasn’t able to convince a surgeon in either Toronto or Sudbury to take her without going through a psychological evaluation. One night at Andy’s apartment, she told him she’d been seeking out a surgeon, and he chided her gently for it—he’d done the procedure before, he said, and would do it for her at a fraction of the price.

“Really?” she asked. “You’d do that?”

He said it wasn’t complicated—just cutting off some extra skin. This was appealing: they knew each other well, the money would be easier to come by, and he’d use a scalpel instead of a laser. Based on photos she’d seen, the laser method removed the tissue in an unnatural looking straight line, whereas with a scalpel, it looked more organic. He quoted her a price of $250—far from the thousands of dollars she’d pay at a clinic, and based less on profit than on covering costs for the supplies he’d need.

The cuts themselves take an hour and a half, after which he stitches her wounds and applies the lunar caustic to cauterize the area and stop the bleeding. He gives her 10 sticks of her own and shows her how to use them: dip the head of the matchstick in distilled water to activate the silver nitrate, then apply it wherever she might be bleeding. It’ll burn, but it’ll work. He packs the area with gauze and puts a menstrual pad over top. She and her friends head out, around midnight.

When she wakes up at 3 a.m., the anaesthetic is long gone. Her body is screaming, racked with pain, and if a doctor were there, he’d probably tell her she was going into shock. She shakes violently but manages to toss herself into the bathroom to inspect the damage, where she finds the pad has stuck to the seeping blood from her stitches. Either out of fear or instinct, she pulls the pad down, which inadvertently tears off the scabs, causing a surge of bleeding. For the second time in a few hours she’s covered in blood, her blood, but now she’s alone in the middle of the night and she doesn’t know what to do. She tries to stop the bleeding but can’t. She’s panicking. So she calls Andy.

He’s a calming presence. He’s been in Canada almost 10 years after meeting and marrying a Canadian girl. The marriage didn’t last and Andy fell into one in a series of depressive periods, but he stuck it out in Canada, made a decent living as a body piercer and, finally, on July 25, 2008, officially became a Canadian citizen. His Irish brogue became so fine you could easily miss it—Adrianne says it would come out when he was grocery shopping and couldn’t find vegan-friendly foods—but now, with an agitated friend and client on the line, he summons whatever softness he can to put her at ease.

She tells him there’s so much blood she barely even knows where to look to apply the silver nitrate, so he instructs her to rinse the area, gently but fully, and try to catch where the bleeding starts. He offers to pay for a cab over to his place so he can do it for her, but, no, she’s able to figure it out. Yes, she’s comfortable. No, she doesn’t need to see him. He tells her if it gets worse to go to the hospital. They hang up, Danielle calms herself down and manages to stop the bleeding.

Neither one of them knows this will be the last time they’ll ever speak to each other.

Not long before Danielle came over for the procedure, Andy called Simon for advice. Simon has been operating at the heavier end of the body-modification spectrum before some of the younger practitioners had gotten their first piercings, and has knowledge to share if he thinks you’ll use it safely. “The longer I’m in this industry,” he’ll later say of this unsanctioned pseudo-surgical offshoot of body piercing, “I see there’s a point where things can be done safely, and there are certain things where we don’t have the right equipment.” For Simon, labiaplasty falls into the latter category.

But he thought highly of Andy and his work and was happy to give him some tips. For one, he told him to use taper-point needles to stitch in sutures rather than reverse-cutting needles—the former look like regular sewing needles and help prevent tearing after the fact. Simon won’t do labia removals anymore, though. If it’s available legally, he’s more inclined to leave it alone.

“Body-modification artist” is a handy, albeit recent, catch-all title for Simon and practitioners like him. But 30 or 40 years ago, when people started performing these procedures— largely in the gay S&M community—they were called cutters. You’d seek out a cutter for an extreme procedure like a subincision (a bisection of the underside of the penis from the urethra towards the scrotum) or a castration. Cutters typically didn’t advertise their services, which were, at best, legally dubious, but if you wanted to find a cutter, you’d find a cutter. It might have taken some time hanging out at piercing studios or leather shops, but the channels existed.

For better or worse, that process has been simplified over the years, due in large part to the internet. Russ Foxx doesn’t hide the procedures he offers; nor has he been to medical school. Working out of The FALL body piercing and tattoo studio in Vancouver, he has split people’s tongues, pointed their ears, and implanted silicone designs under their skin. Some fellow artists—and there are thousands performing these and other procedures around the world—worry that he shows off his work too readily and maintains too high-profile an online presence. He argues, though, that he’s offering services surgeons won’t. “I believe people should have the right to do these things,” he says, “and I have the right to do them safely for another consenting adult.”

Dr. Hébert’s views are in line with Foxx’s, at least as far as an attitude towards openness. Legitimizing and regulating these procedures would open them up to the public in a way that would, in the end, make them safer, he says. “The evidence that something’s wrong,” says the bioethicist, “is if people aren’t willing to talk about it, bring it into the public eye. It suggests they themselves think something’s wrong with it.” In his experience, when such ideas and practices are concealed, whether in a professional setting or otherwise, the general public only finds out about them when there’s an egregious, tragic misstep.

Simon’s had his share of close calls. The first labia removal he ever did, he clamped down on and crushed the labial tissue with forceps under the misguided impression it would make the cuts easier. Once the cuts were made, though, a rim of damaged tissue remained, not nearly strong enough to hold even well-stitched sutures. Blood pooled until it welled up and burst, a projectile stream of red geysering three feet out of the tissue. He quieted the squirting with pressure, but with so much blood, a hospital visit could have been in order. “Some practitioners,” he says, “are not willing to make that call. There’s a point where you’re not there anymore, and it’s all about the client.”

Police arrested Andy and Adrianne on charges of aggravated assault on Wednesday, January 21—a few days after he removed parts of Danielle’s labia—and gave Andy unrelated weapons charges for a collector’s gun found in his apartment as well. The mother of one of Danielle’s friends who’d been present for the procedure found out what had happened and wasted no time getting in touch with the North Bay Parry Sound District Health Unit. Dr. Jim Chirico, the medical officer of health with the health unit, says his team had reason to believe there had been “significant complications” from the procedure and turned the matter over to the police. Detective Constable Jim Kilroy took the lead on the case, first visiting Danielle with another officer earlier that day.

They seemed amazed that she was mobile, but she made it clear she felt fine. Kilroy, a tall man who had to duck down slightly to fit under Danielle’s six-foot-high ceilings, told her that they’d still prefer she go to the hospital for an examination. But this visit, which implied something wrong had been done to her, felt like more of a violation than anything Andy had done. Andy had given her the remnants of her excised labia in a jar of alcohol, which Kilroy told her he’d have to confiscate as evidence. (Kilroy declined to comment on this story, citing privacy laws.) She argued, but he told her that once it left her body, it was no longer her property.

A doctor who saw her at North Bay General Hospital told her that Andy’s work wasn’t all that bad—maybe not enough stitches, but generally well done. Of course, Andy wouldn’t have been able to prescribe antibiotics or anti-inflammatories, but from a technical standpoint, he seemed to know what he was doing. An infection was developing, though, and Danielle was given a portable IV to carry with her to fight it off.

She and some friends went to the courthouse on Friday for Andy and Adrianne’s arraignment. The justice of the peace singled her out in the crowd, telling her that the conditions of the bail meant she was to have no contact whatsoever with the two defendants. Adrianne was released on her own recognizance, but Andy’s bail was eventually set, after an appeal, at $2,500 and one surety, and by February 27, he was out of jail and back to work, albeit restricted to body piercing. The trial would follow later in the year. “I’m confident that I can win this,” he wrote in an online journal, “though it will take no small measure of effort.”

Danielle was livid. She visited Kilroy at the station to vent, only to be told to calm down, to look up the law—she was not allowed to consent to what had happened, he told her. Legally, this was true. She may have agreed to the procedure, but that assent was not the same as true consent, which goes far beyond a signature on a waiver. Andy wasn’t trained to assess her capacity to make an informed decision; nor was he qualified to disclose the necessary information to allow her to make that informed decision. And disclosure doesn’t just mean giving a patient a pamphlet to read; the clinician must ensure all alternative medical measures have been discussed, including the option of doing nothing, and the likely outcomes from those paths. Andy may have been a good friend and handier with a scalpel than the average citizen, but he was not a physician, nor, in the law’s eyes, was he in any position to receive consent for the procedure.

This likely didn’t faze Andy. At some point, he developed an ego about his work. When Craig Coupal met him, not long after Andy came to Canada and was piercing at a shop in Sudbury, Ontario, he said the Irish expat stood in stark contrast to the body-modification “rock stars” who took unnecessary risks just for the sake of an interesting and unique portfolio. Beyond that, Coupal says, he was opposed to the do-it-yourself types who would experiment on themselves and friends outside of a professional setting. Gradually, though, a competitive streak started building in Andy. He wanted to outdo—or, at least, keep pace with—the industry’s cutting-edge practitioners. “His work was never bad,” says Coupal, a piercer at Live Once Tattoo, where Andy was once employed, “he was just getting cockier, advertising on Facebook, doing stuff in the shop.” It was bad form to do heavier modifications at the studio, which was inspected by the health board, so he started doing them at home, stepping outside the strict client base of friends and staff he’d previously stuck to. If people want a cutter, they’ll find a cutter. Andy made himself easier to find.

In May, Danielle moved to the Ottawa area with her boyfriend. By then, Andy and Adrianne had broken up and she had left North Bay for Sudbury. They were still not allowed to speak to Danielle, but Andy’s online journal entries indicated that the case was moving in a positive direction. On July 23, he wrote that he was going to take a plea deal. He’d pay a fine of up to $5,000, be on probation for a year and likely be prohibited from doing any genital modifications beyond piercing. “Ultimately,” he wrote, “I’ll just be happy to give a deep breath and be able to say, ‘it’s over.’”

On Saturday, August 8, Coupal stopped by the shop to say hi. He didn’t work Saturdays, but the piercer on duty was happy to see him—they were swamped with customers and he asked Coupal if he could stick around and help out. “I don’t know what it is,” his co-worker said, “but apparently we’re the only piercers in town today.”

“Where’s Andy?” Coupal asked. Andy had been working at Sacred Art Skin Grafix, a shop a few kilometres south.

“I don’t know,” he told Coupal. “He’s missing.”

He’d actually been missing since August 4. Up and gone, left behind his identification and his cats, not a mention to anyone of where he was going. His friends were flummoxed— this wasn’t like him. Theories sprung up: he was camping to clear his head; new charges were coming down and he was on the run; someone had disapproved so strongly of what he’d done that they’d murdered him—one rumour was that his body was found with nine bullets in it. Without any inside knowledge, Coupal scoffed at this. “This is North Bay,” he says, “someone gets nine bullets in them—someone gets one bullet in them, accidentally, cleaning their gun—it makes the news.” But weeks went by with no new leads. Members of his family from Ireland came to North Bay to meet with police.

Danielle came back, too. She’d felt responsible for the trouble he’d been through all year, and this was almost too much to take. Still, it wasn’t a secret Andy had his issues. Years of depression, hard drinking—he once took two bottles of wine as payment for a more advanced body-modification procedure. Going missing, though, especially after seeming resigned to his fate, didn’t sit right with those who knew him.

On August 28, his body was found in the woods off Highway 63 in northeast North Bay. He’d hanged himself weeks earlier, leaving behind a mess of secrets. Danielle says that if she’d known it was going to come to this, she never would have had the procedure done—at least, not by him. She could have saved her money and found a licensed professional who would help her. She could have gone to Tijuana and had it done cheaper there. She could have lived with a part of her body that she found unattractive, too. For a brief window, though, she thought she had another option. “I trusted him,” she says. “I trusted him with my life. And I don’t see why he shouldn’t have been allowed to do what I wanted him to do.”

Sure, blame can be spread around. If the procedure hadn’t been reported, he never would have been arrested. If he hadn’t been arrested, he wouldn’t have had to deal with the stresses the year brought. If he hadn’t just recently become a Canadian citizen, he might have simply been deported. Hell, if he’d just been allowed to provide the service Danielle had given him permission to do in the first place—if the laws didn’t apply to him, as he appeared to believe they shouldn’t—maybe he’d still be alive. He made his choice, though, his final choice, just as he’d made the choices that led him to that point. He didn’t deserve to die, but it’s just not that simple, is it?