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 labiaplasty 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.

Research shows that cosmetic concerns are the primary motivation for women seeking to undergo labiaplasty, followed by physical issues 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%) or 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), 60% with sexual function and 45% with psychological symptoms such as self-esteem.

Labiaplasty is referred to by some as 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 be used to encompass labiaplasty.

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 definition fails to take on board the fact that the procedures listed by the WHO refers 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 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 critical term here is “harmful”. Labiaplasty has one of the highest satisfaction rates amongst all cosmetic surgery procedures. The risks of the surgery are well known, and a reputable surgeon will inform prospective patients of these risks. All cosmetic surgery procedures by definition carry a risk of adverse outcomes. To say that labiaplasty falls under this fourth category by the WHO is akin to arguing that all cosmetic procedures are harmful.

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. While 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 essential 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 more significant 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. While the increased availability of pornography may have an influence, the evidence is lacking, and it certainly does not explain the whole picture.

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

The London-based feminist group UK Feminista organised “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 mitts 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 example, visit the labia library — the aim being to establish a sphere for women to get realistic impressions of normal vulvas. Others have criticised such campaigns 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 look like the imaginary “Barbie” ideal. It turns out, some girls are actually born like that. Labia, like boobs or entire bodies, come in all shapes, sizes, colours 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 

Dr Alinsod, a gynaecologist from California, developed the “Barbie” labiaplasty. He describes 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 popular technique of labial surgery Dr Alinsod performs, and the appearance most 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. While 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 edges of the wounds together.

As mentioned elsewhere, 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 sizeable multicenter study looking at 258 women who had female genital cosmetic surgery found that 91.6% of patients were satisfied with the results of their operation after a 6-42 month follow-up. Significant subjective enhancement in sexual functioning was noted, and complications were acceptable and not of significant consequence.

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.