Why Women Request Labiaplasty

Sarah C. Sorice, M.D.; Alexander Y. Li, B.S., M.S.; Francisco L. Canales, M.D.; Heather J. Furnas, M.D.

Disclosures

Plast Reconstr Surg. 2017;139(4):856-863. 

In This Article

Abstract and Introduction

Abstract

Background: In recent years, labiaplasty has jumped in popularity, despite opposition to the procedure. In 2007, the American College of Obstetricians and Gynecologists declared the recommendation of cosmetic vaginal procedures to be "untenable," although in 2016 they allowed consideration of labiaplasty in adolescents if symptoms persist. The reasons for labiaplasty requests are not yet fully understood, and physician opposition limits patient access to surgical relief.

Methods: In this prospective study, 50 consecutive patients consulting about labiaplasty were given a questionnaire assessing 11 physical and appearance-related symptoms associated with elongated labia.

Results: The mean patient age was 33.5 years (range, 17 to 51 years). Fifty-eight percent of women had given birth, 52 percent noticed that their labia had become elongated as they got older, and 93 percent had bilateral elongation. When asked about physical symptoms, over half of patients experienced tugging during intercourse, found tight pants uncomfortable, experienced twisting of the labia, and noted labia visibility in yoga pants. Nearly half experienced pain during intercourse, and 40 percent said their labia could become exposed in bathing suits. Regarding appearance, almost all patients were self-conscious and over half felt less attractive to their partner, experienced restricted clothing choice, and noted a negative impact on self-esteem and intimacy. Nearly all patients experienced at least four symptoms.

Conclusions: Most patients requesting labiaplasty experience both physical and appearance-related symptoms. Understanding this patient perspective is crucial in assessing surgical outcomes. Furthermore, the better all physicians understand labia symptomatology, the better supported patients will be in seeking surgical relief.

Introduction

Why women seek labiaplasty has been steeped in controversy in recent years. Although several studies have established that patients with functional and appearance-related symptoms associated with long labia minora experience high levels of satisfaction after labiaplasty[1–8] with low complication rates,[3,6,7,9,10] many physicians have historically opposed the procedure.[11–16] In one study in which over half of 33 women (57 percent) seeking labiaplasty complained of pain and discomfort from their elongated labia, the authors expressed surprise that both the patients and their referring doctors felt surgery was indicated, citing a lack of evidence regarding the safety and efficacy of the procedure.[14]

Physicians' reluctance to accept labiaplasty as a beneficial procedure is based on several factors. Many doctors claim that women with normal anatomy are unduly influenced by Brazilian waxing, online images, pornography, and promotion of designer vaginas to socially vulnerable women.[11,13,14,17–23] In fact, Sharp et al. assert that surgery performed on normal anatomy such as labiaplasty and breast augmentation is a matter of ethics, politics, and philosophy, rather than being a matter of science.[24]

The influence of media images on women's interest in labiaplasty has been the subject of several studies. Sharp et al. found that, compared with women who had not undergone labiaplasty, women who had undergone the procedure had seen more images of the female genitalia in the media and had internalized their idealized form.[25] Placik and Arkins associated an increase in labiaplasty with a shift in Playboy magazine's focus from the breasts to the female genitalia over time.[17] Although several authors have stated that pornography influences women to have labiaplasty,[13,18,22,23,26,27] there is little evidence to confirm that it has a major impact. In a study of 33 women presenting for labiaplasty, Crouch et al. found that only 12 percent reported even viewing pornography, much less being influenced by it.[14] Rather than agreeing that women are manipulated by the media, Hunter proposed that women who are unhappy with the appearance of their genitalia may turn to the Internet to find out how to address their concerns, because it is the most accessible source of information.[28]

Although some authors have found that patients seek labiaplasty for functional concerns,[29,30] others suggest that patients mention physical complaints to "legitimize" a request for surgery.[29,31] Nonsurgical approaches recommended to appease these women include education about their normal anatomy, suggesting a different bike seat, promoting looser underwear, advising the use of emollients for physical symptoms, and referring patients for psychological counseling.[11,13,25,32,33]

Echoing these sentiments, in 2007, the Committee on Gynecological Practice under the American College of Obstetricians and Gynecologists published a formal position paper, which found the recommendation of vaginal rejuvenation and cosmetic vaginal procedures to be "untenable" in the absence of data on the safety and efficacy of the procedures.[15] Furthermore, they expressed ethical concerns about the marketing and franchising models associated with the procedure, charging that claims that such surgery is proven and accepted are deceptive. Instead, citing the procedure's risks, including infection, scarring, dyspareunia, and altered sensation, they emphasized the importance of reassuring women of the wide variability in female genital appearance.[15]

Indeed, the complications reported in the literature include those mentioned by the American College of Obstetricians and Gynecologists, along with hematoma, overresection, scalloped edges, scarring, dehiscence, bleeding, aesthetic concerns, shortened introitus, and discomfort,[3,6–10,18,34–37] with revision rates of nearly 3 percent.[3,7] Nonetheless, the documented complication rates are low (2.65 to 10 percent),[3,6,10,35–37] and the satisfaction rates are high (≥90 percent).[1–8] Specific benefits of the procedure include greater self-esteem; better sexual satisfaction; and improvement of discomfort associated with irritation, exercise, and sexual intercourse.[3,6,7,9,29] Indicating that the American College of Obstetricians and Gynecologists is shifting its attitude, a formal opinion published in 2016 by the Committee on Adolescent Health Care allowed for the consideration of labiaplasty with the persistence of symptoms or emotional discomfort.[38]

Physicians' own personal biases can influence their viewpoint on labiaplasty. Despite the procedure's reported favorable outcomes,[1–3,39] some physicians find female genital cosmetic surgery and female genital mutilation to be barely indistinguishable. One of the earliest articles on labiaplasty described the degrees of female circumcision, including excision of the entire genitalia with infundibulation, and conjectured that patients may feel more feminine after a "partial circumcision."[40] Labiaplasty opponents argue that both labiaplasty and female genital mutilation are unethical, medically unnecessary procedures that exploit female patients who are insecure about their bodies and fall victim to a culture that portrays women as sex objects.[1–3,10,12–14,39,40] The solution they offer is patient education about the diversity of female genital appearance to correct the media-derived perception that the adolescent-like vulva is normal.[16]

Even among those who accept labiaplasty as a beneficial procedure, there is disagreement about the indications. Although a patient's complaints may be accepted by some physicians as legitimate justification for the procedure,[9] others adhere strictly to labia measurements to determine surgical candidacy, regardless of symptomatology.[14,41] Qualifying lengths vary by the classification used. Felicio defined different degrees of labia hypertrophy, from type I (<2 cm) to type IV (>6 cm),[42] whereas others have defined hypertrophy as a length greater than 4 cm[1] or 5 cm.[43] Women seeking labiaplasty often have labia lengths that fall within "the normal range," and on that basis surgery is denied.[14,41]

Fueling the labiaplasty debate, particularly where the procedure is covered by national health services, is the perception that the fee-for-service payment system under which labiaplasty is often performed tempts surgeons into convincing women to have an unnecessary procedure.[16] Despite the maelstrom, between 2011 and 2015, the number of labiaplasties performed in the United States by surgeons across different specialties has jumped over 400 percent, from 2141 to 8745[44] (Fig. 1). Although previous studies have investigated women's motivations for seeking labiaplasty, their numbers are few and their results varied. Sharp et al. and Sarwer found patient concerns to be primarily functional,[29,30] whereas others have found them to be primarily aesthetic.[13,14,18,25,28,34,36,45] Still others have found that most patients have both functional and aesthetic complaints.[1,4,6,23,26,35,46,47] The purpose of this study was to better understand the motivation behind why women seek labiaplasty.

Figure 1.

This 39-year-old woman demonstrates a typical appearance of the labia minora protruding below the labia majora, before labiaplasty (above) and 8 months after labiaplasty (below). The patient gave written consent for the publication of her photographs.

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