26 December 2016

Labiaplasty – Why the controversy?

Several reports have shown that there has been a significant increase in the number of women seeking labiaplasty procedures both in the NHS and in the private sector. In the United States, there was a 49% increase in demand for the procedure from 2013 to 2014 and similar trends have been documented in other Western countries, including the UK and Australia.

Labiaplasty most commonly involves reducing the size of the labia minora, with the goal of achieving minimal or no protrusion of the labia minora beyond the labia majora. It may also be performed to correct asymmetry.

The procedure remains controversial for some and this article is designed to discuss some of the main issues surrounding labiaplasty.

Why do women have labiaplasty?

Research suggests that cosmetic concerns are the primary motivation for women seeking to undergo labiaplasty, followed by physical or functional concerns of both a sexual and non-sexual nature. For example a study of 163 labiaplasty patients in 2000 showed that cosmetic dissatisfaction with labia (87%), discomfort when wearing clothing (64%), discomfort when taking part in sports (26%), and painful sexual intercourse (43%) were the main reasons for having surgery. A more recent study of 35 women showed that 71% had concerns with appearance, 69% with physical (non sexual symptoms), 60% with sexual function and 45% with psychological symptoms such as self esteem.

Designer vaginas or Designer vulvas?

Labiaplasty is grouped amongst other procedures such as vaginal tightening under the banner of designer vagina surgery. The labia form part of the external genitalia and anatomically speaking the labia minora are part of the vulva and not the vagina. Therefore the term designer vagina should not really be used to encompass labiaplasty.

Female Genital Mutilation (FGM)

labiaplasty FGM

FGM is defined by the World Health Organisation (WHO) as procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons. Some commentators have used this to describe labiaplasty in consenting adults as a form of FGM.

This completely fails to take on board the fact that the procedures listed by the WHO refer to ones which include partial or total removal of the clitoris or deliberate narrowing of the vaginal opening designed to prevent sexual intercourse. The vast majority of such procedures are carried out on unconsenting children against their will. Labiaplasty clearly does not fall into this category.

A fourth category cited by the WHO includes: all other harmful procedures to the female genitalia for non-medical purposes. The important term here is “harmful”. Labiplasty has consistently been cited as having one of the highest satisfaction rates amongst all cosmetic surgery procedures. The risks of the procedure are well known and any reputable surgeon will ensure that prospective patients are well informed of the risks. All cosmetic surgery procedures by definition carry a risk of adverse outcomes. To argue that labiaplasty falls under this fourth category by the WHO is akin to argueing that all cosmetic procedures are harmful.

Pornography and media exposure

pornography designer vagina surgery

There have been many ill informed opinions on the reasons for the increased demand in labiaplasty. For example an article published in the Observer Newspaper in 2011 blamed the increase in labiaplasty surgery on pornography. Many other commentators have expressed similar concerns. Whist the increased availability of pornography and its idealised portrayal of women’s external genitalia may have affected women’s perceptions of their labia it is important to look at the available evidence.

A recent study published in the Aesthetic Surgery Journal in 2006 by Sharp and coworkers looked at factors that Influence the decision to undergo labiaplasty.  They compared a group of 35 women seeking to undergo labiaplasty to a control group of 30 women who were not. The two groups did not differ on their exposure to female genitals on television and in their exposure to pornography. The authors did however demonstrate a greater exposure to media images of female genitals in the labiaplasty group, specifically via the Internet and genital cosmetic surgery advertising. The authors conclude that – the issue with mainstream media being women’s primary source of information regarding female genital appearance is that the mainstream only displays a very narrow range of labial appearances. For women who are already concerned about their genital appearance, seeing images of female genitals on the Internet (some of which have been air-brushed) may confirm to them that they are “abnormal” and require surgery to become “normal”.

There is no doubt that increased awareness of cosmetic surgery and reality TV shows such as Embarrassing Bodies have contributed to an increased acceptance of cosmetic surgery procedures. Whilst increased availability of pornography may have an influence the evidence is lacking and it certainly does not explain the whole picture.

Labial Pride Movement

The labial pride movement is a feminist movement to raise awareness of the normal appearance of the vulva and to defy the trend towards cosmetic surgery on the female genitals.

labia pride movement

The London-based feminist group UK Feminista organized “the muff march” through Harley Street, an area synonymous with its private medical providers, in December 2011. More than 320 women paraded the street, with slogans like: “Keep your mits off our bits!”, “There’s nothing finer than my vagina!”, and “Harley Street puts my chuff in a huff”.

Other groups have encouraged women to release images of their vulvas by posting photo submissions of anonymous vulvas on their websites. For an example visit the labia library. The aim being to establish a sphere for women to get realistic impressions of normal vulvas. Such campaigns have been criticised by others for giving the false impression that protruding labia are the anatomical norm and small inner labia are the adaptation to beauty standards.

In an effort to make “real women” feel better about themselves, some labia proud ladies are taking shots at girls whose labia actually look like the imaginary “Barbie” ideal. Turns out, some girls are actually born like that. Labia, like boobs or entire bodies, come in all shapes, sizes, colors and textures. Shaming one to make another type feel better is bad news. Think of it in terms of thin women who are often shamed or shunned in support of body image advocacy for larger girls. Jessica Sager 2013

What is normal?

We inform all of our prospective patients that there is no definition of what is normal when it comes to labia minoras. Labia come in all shapes, sizes and colours.

The artist Jamie McCartney has focused on female genital anxiety through his work ‘The Great Wall of Vagina‘. The Great Wall of Vagina comprises 400 plaster casts of women’s genitals arranged in ten panels. It is a highly provocative response to the exponential rise in cosmetic labial surgery. By confronting the viewer and revealing the diversity of female genital appearance, McCartney opposes any notion of a singularly “perfect” aesthetic, thereby forcing society to rethink its relationship with the vulva.

labiaplasty Edinburgh

For any woman considering labial surgery it is well worth reflecting on this quote,

Vulvas and labia are as different as faces and many people, particularly women, don’t seem to know that. McCartney hopes this sculpture will help to combat the exponential rise, seen in recent years, of cosmetic labial surgeries. This new fashion for creating ‘perfect’ vaginas sets a worrying trend for future generations of women.

Cosmetic surgery can be defined as “the intentional alteration of physical features to enhance the appearance“. With some procedures there are also functional benefits such as relief of physical symptoms which many labiaplasty patients display. The argument that labiaplasty involves the removal or destruction of normal tissue is not valid in this context. Other common plastic surgery procedures such as breast surgery and facial rejuvenation essentially involve the alteration/ removal of “normal” tissue yet there is not the same controversy involved with these procedures.

“Barbie” Labiaplasty

The “Barbie” labiaplasty was developed by Dr. Alinsod, a gynaecologist from California. He describes the the procedure as a more aggressive reduction of the labia minora to the point of complete excision. According to his website this is the most requested technique of labial surgery Dr. Alinsod performs and the most popular appearance wanted on the West Coast.

This procedure is essentially a complete amputation of the labia minora and is achieved using the “trim” method of labiaplasty. Whilst there is no definition of what is normal for labia minora size, what is not in doubt is that it is normal to have some labia minora!

In our practice we would never perform a complete amputation of the labia minora and the technique we use (“wedge” method) makes it impossible to remove too much tissue as it would not be possible to close the wounds edges together.

Trends in shaving/ tighter clothing

Recent trends in shaving the pubic area have also been postulated to have made women more aware of labia minora which may be protruding. Likewise the trend in tighter clothing such as skinny jeans may also be implicated in increasing possible discomfort.

Evidence on labiaplasty outcomes

As mentioned previously, several studies have reported very high satisfaction rates amongst women who have had labiaplasty. These studies have been published not just by plastic surgeons but by gynaecologists and psychologists.

A recent study by Goodman and colleagues published in 2016 supported earlier findings that body, genital, and sexual dissatisfaction shown by labiaplasty patients improved with time following surgery. Over time, rates of genital, body, and sexual satisfaction among study participants became equal to or better than rates for the control group in their study.

A large multi center study looking at 258 women who had female genital cosmetic surgery found that 91.6% of patients were satisfied with the results of their surgery after a 6-42 month follow-up. Significant subjective enhancement in sexual functioning was noted and complications were acceptable and not of major consequence.

 

Disclaimer: Article written by a plastic surgeon who performs labiaplasty

 

References:

A large multicenter outcome study of female genital plastic surgery.
Goodman MP, Placik OJ, Benson RH 3rd, Miklos JR, Moore RD, Jason RA, Matlock DL, Simopoulos AF, Stern BH, Stanton RA, Kolb SE, Gonzalez F.
J Sex Med. 2010 Apr;7(4 Pt 1):1565-77

Evaluation of Body Image and Sexual Satisfaction in Women Undergoing Female Genital Plastic/Cosmetic Surgery.
Goodman MP, Placik OJ, Matlock DL, Simopoulos AF, Dalton TA, Veale D, Hardwick-Smith S.
Aesthet Surg J. 2016 Oct;36(9):1048-57

Factors That Influence the Decision to Undergo Labiaplasty: Media, Relationships, and Psychological Well-Being.
Sharp G, Tiggemann M, Mattiske J.
Aesthet Surg J. 2016 Apr;36(4):469-78.