Below is a very well written article on Female Genital Cosmetic Surgery. Women are not rushing to have these procedures as some media sources may be implying and as with any surgical procedure there are risks such as infection and complications that could have a negative impact on a woman's sexual function. In the January 2009 issue of Obstetrics and Gynecology there was a commentary on Female Genital Cosmetic Surgery by a surgeon who performs such procedures.
TWSHF position has always been to understand the risks and benefits of any procedure and for women to do their research. The below article and more on the topic can be found at http://www.womhealth.org.au/healthjourney/genital_cosmetic_surgery.htm
Genital Cosmetic Surgery
In recent years numerous women’s magazines have featured articles on genital cosmetic surgery. In 2006, the UK and US editions of Cosmopolitan included sealed sections on “designer vaginas”. It is thought that the trend towards Brazilian waxing has led to more attention being placed on the appearance of women’s genitals. In the United States there has been a rise in the marketing of various genital cosmetic surgery procedures, many claiming they will enhance women’s sex lives. While the procedures have not yet received the same attention in Australia, women’s awareness of genital cosmetic surgery appears to be growing thanks to the internet. So what is genital cosmetic surgery and who is really having it?
There are a number of procedures that fall under the general group of genital cosmetic surgery including labiaplasty, labia majora augmentation, mons pubis reduction and vaginoplasty.
Labiaplasty - This involves reducing the size of the labia minora (inner lips) or, less commonly, the labia majora (outer lips). Labiaplasty of the labia minora is the most commonly performed genital cosmetic surgery procedure. The main reason it is carried out is to reduce the size of the inner lips so that they do not protrude below the outer lips. Correcting asymmetry of the labia minora (where one lip is significantly different in size to the other) is also performed. Women seek labiaplasty of the labia minora because they are unhappy or embarrassed with the appearance of their genitals. They feel their genitals look unfeminine or are noticeable under tighter clothing. In addition, some women may find that their labia minora cause pain and discomfort during physical activity (eg., cycling, walking), sex or when wearing certain clothes.
Labia majora augmentation - When women reach menopause, the connective tissue and fat deposits under the skin are reduced, resulting in a thinning of the labia majora (outer lips). Labia majora augmentation seeks to plump up the outer lips by injecting them with fatty tissue taken from another part of the woman’s body.
Mons pubis reduction - The mons pubis is the pad of fatty tissue covered by the pubic hair. Some women feel that their mons pubis is too prominent and wish to have it reduced. Liposuction is used to remove fat deposits from the area. This procedure is also referred to as vulval lipoplasty.
Vaginoplasty - This involves tightening the vagina muscles and removing excess vaginal lining. As a result, the vagina will have a decreased diameter. It is often promoted as the solution to women who have experienced a loss of vaginal tone due to childbirth. Vaginoplasty is also often referred to as ‘vaginal rejuvenation’ and is one of the more controversial genital cosmetic surgery procedures.
Others - Re-virgination and G-spot amplification are other procedures being promoted in the United States. Re-virgination is the surgical reconstruction of the hymen and is predominantly carried out for cultural reasons. G-spot amplification involves injecting a substance such as collagen into the G-spot in order to enhance its size (which in theory should enhance a woman’s sexual pleasure).
Who is having the procedures?
It has been reported in the media that genital cosmetic surgery has grown by 30% in recent years (1). The inference is that many women are undergoing such procedures and they are becoming almost commonplace. An internet search on genital cosmetic surgery would also have people believing this is the case. When researchers Liao and Creighton conducted a Google search using the term 'labia reduction', they found around 490 000 results. Forty seven of the first 50 of these results consisted of advertisements from clinical providers of the surgery (2). One might assume that with the sheer amount of information available on genital cosmetic surgery, that these procedures are popular with many women. This is, however, not necessarily true. While there has been an increase in procedures being performed, this increase is from a very small number to begin with. In 2006, for example, only 1 030 vaginal rejuvenation procedures were performed in the United States (3). When one considers there are 100.4 million women aged between 15 and 64 living in the United States, it becomes obvious that the percentage of women having this surgery is extremely small (4).
Despite the relatively few number of women actually having genital cosmetic surgery it continues to receive attention in the mass media. This is most likely due to it being new and also because it includes a certain amount of shock value. People are now familiar with more common forms of cosmetic surgery like breast augmentation so women’s magazines and other media need to include something different.
Cosmetic surgery providers have also been quick to report a climb in the numbers of women requesting the surgery. Like the media, cosmetic surgery providers typically portray the women having the surgery as just everyday people. This in turn works to further normalise the procedures. One Australian provider, for example, comments that whereas his labiaplasty patients used to be strippers and pole dancers, now days the typical patient is “a successful, unmarried young women in her 20s or early 30s who simply didn’t like what she had” (5). All of these portrayals have the same effect, they can potentially create a demand for a product/service where there was not one previously. Liao and Creighton warn that “[t]he provision of genitoplasty could narrow acceptable ranges further and increase the demand for surgery even more” (6).
What health professionals say
There are divided opinions on the issue of genital cosmetic surgery in the medical community. Recently, the topic generated a heated discussion on the list-serve of the International Society for the Study of Women’s Sexual Medicine. Following the list-serve discussions six people were asked to submit evidence-based opinions, for publication in the Journal of Sexual Medicine (7). The article provides some interesting viewpoints on the topic. While some practitioners feel that it is a woman’s right to have such procedures (in the same way as having liposuction, nose reshaping and breast augmentation) they believe women need to know the real risks and benefits in order to make an informed choice. Gloria Bachmann explains that in the case of labiaplasty women should be clearly told that prominent labia minora “are variations of normal genital anatomy” and language that implies the surgery ‘restores’ the genitals should, therefore, be avoided (8). Goldstein and Goldstein apply four medical ethical principles, autonomy (rights of individuals to decide what medical procedures they receive), nonmaleficence (first do no harm), beneficence (to do good) and justice ( being fair or just to the wider community ) to the procedure of labiaplasty. They conclud that “this procedure is not always ethical, nor is it always unethical” (9).
The growing publicity around genital cosmetic surgery has prompted the American College of Obstetricians and Gynecologists (ACOG) to release an official opinion on the topic. In September, ACOG advised women that so-called vaginal rejuvenation, designer vaginoplasty, revirgination and G-spot amplification were not medically indicated, nor was there documentation of their safety and effectiveness (10). They added that it was “deceptive” to give women the impression that such procedures were “accepted and routine surgical practices” (11). ACOG warns that “patients who are anxious or insecure about their genital appearance or sexual function may be further traumatized by undergoing an unproven surgical procedure with obvious risks” (12). A member of ACOG’s Committee on Gynecologic Practice, Abbey Berenson suggests that it is “imperative that studies on these procedures be conducted in peer-reviewed publications so that the evidence and clinical outcomes can be reviewed” (13).
ACOG does however believe that some procedures are medically indicated, including labiaplasty for the treatment of labial hypertrophy (increased labia size/bulk) or asymmetrical labial growth (14).
The role of health professionals
A greater awareness of the variations of what constitutes normal genitals can certainly assist women to feel more comfortable about their bodies. Often all that is needed is for women to learn that there is nothing ‘wrong’ with their genitals. Health professionals who work in the area of gynaecological health can play an important role here as they see a wide variation of genitals in their practices. They can allay any concerns a woman might have about the appearance of her genitals by explaining the commonness of different variations and how the genitals change throughout life.
Some health professionals, however, may lack the confidence and communicative skills to discuss normal genital variations with their female patients. Liao and Creighton examined women’s referral letters from general practitioners and found they “might have been unsure how to respond to their patients’ intimate concerns without trivialising them” (15). They felt that some referrals may have been made in the hope that the specialist would advise the woman of her normality. However, the very referral may be misinterpreted by the woman as evidence they have a legitimate problem that requires medical attention.
Health professionals can also play an important role in providing accurate information on the benefits and risks of cosmetic genital surgery. Much of the information available on the topic comes from cosmetic surgery providers. The advantages of surgery are sometimes exaggerated and the risks and side effects played down. For example, a possible side effect of labiaplasty is reduced sexual sensation. This is because the labia minora play a role in sexual arousal, filling with blood and swelling with sexual stimulation (16). The CosmeticSurgeryAustralia.com.au website however, makes no mention of this risk, only discussing the possible benefits: “Sexual feeling after Labiaplasty depends on the degree of labia abnormality to begin with. If excess labia tissue interferes with sexual activity prior to Labiaplasty, then you and your partner may notice improvement after surgery” (17). Health professionals can ensure that women receive adequate information on risks so that they can make informed decisions about genital cosmetic surgery.
What women need to know
Women should be reassured that genitals, like other parts of women’s bodies, come in all different shapes and sizes. It is often difficult, however, for women to gain a sense of what’s normal as they do not generally see other women’s genitals to be able to compare (in the same way that men do). Other visual representations of women’s genitals, such as that which appear in adult magazines are not realistic. For an adult magazine to be classified as ‘unrestricted’ by the Office of Film and Literature Classification (meaning it can be publicly displayed in a newsagent ect) the genitals must be “discreet” and there can be no “genital emphasis” (18). In order to obtain an unrestricted classification, adult magazines typically airbrush female genitals so that they are less prominent, even resembling the genitals of a pre-pubescent girl.
Women should consider that, as with any cosmetic surgery procedure, genital cosmetic surgery may not necessarily provide the whole solution. In the case of vaginal rejuvenation which promises greater sexual pleasure, it is important that women recognise that physical changes are only one aspect. Women’s sexual satisfaction is often closely tied to how they are feeling emotionally. Having a tighter vagina, therefore, will not guarantee a good sex life.
If a woman experiences any complication or side effects from the surgery it could even have a negative effect. If a person’s body image and self-esteem are very low, it is unlikely that surgery will be able to fully address these underlying issues. Liao and Creighton comment that “health agencies, educational bodies, the voluntary sector, and the media are needed to help girls and women deal with feelings of insecurity about their genitals and about their bodies in general. We also need more commitment and investment in research as well as innovative interventions in the community to help women and girls to approach concerns about their appearance skillfully and imaginatively” (19).
A study which measured the genitals of 50 pre-menopausal women between 18 and 50, found that the labia minora ranged from 20-100mm longways and from 7-50mm in width (20). This variation occurred amongst only 50 women and is, therefore, no doubt even wider across the general female population. In addition, the colour of the labia minora can be anywhere from deep pink, brownish pink to reddish pink and asymmetry is not uncommon.
1 McLean T. Young women ‘seeking vagina surgery’ AAP Bulletin Wire Sydney: Apr 14, 2007; 1
2 Liao LM & Creighton SM. Requests for cosmetic genitoplasty: how should healthcare providers respond? BMJ 2007; 334:7603:1090-1092
3 American Society of Plastic Surgeons 2000/2005/2006 National Plastic Surgery Statistics: Cosmetic and Reconstructive Procedure Trendshttp://www.plasticsurgery.org/media/statistics/loader.cfm?url=/
commonspot/security/getfile.cfm&PageID=23628 [website] date accessed: 21 September 2007
4 Griffin M. Surgeons nipping and tucking at a hidden frontier The Age April 8 2007
5 McLean T. Ibid
6 Liao LM & Creighton SM. Ibid; 1091
7 Goodman MP et al. Is elective vulvar plastic surgery ever warranted, and what screening should be conducted preoperatively? J Sex Med 2007; 4:2:269-76
8 Goodman et al. Ibid
9 Goodman et al. Ibid
10 Committee on Gynecologic Practice. Vaginal “Rejuvenation” and cosmetic vaginal procedures Obstet Gynecol 2007; 110:3: 737-738
11 Committee on Gynecologic Practice. Ibid
12 Committee on Gynecologic Practice. Ibid
13 American College of Obstetricians and Gynecologists. ACOG advises against cosmetic vaginal procedures due to lack of safety and efficacy data ACOG news release September 1 2007.
14 Committee on Gynecologic Practice. Ibid
15 Liao LM & Creighton SM. Ibid; 1091
16 Stewart E & Spencer P. The V Book: Vital Facts About the Vulva, Vestibule, Vagina and More London Piatkus 2002; 26-27
17 CosmeticSurgeryAustralia. Frequently Asked Questions About Labiaplastyhttp://www.cosmeticsurgeryaustralia.com.au/labiaplasty_faq.htm [website] date accessed 19 September 2007
18 The Guidelines for the Classification of Publications 2005. Commonwealth of Australia Lawhttp://www.comlaw.gov.au/ComLaw/Legislation/
OpenDocument [website] date accessed: 19 September 2007
19 Liao LM & Creighton SM. Ibid; 1092
20 Lloyd J et al. Female genital appearance: ‘normality’ unfolds BJOG 2005; 112:5:643-646
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This article was written by Kirsten Braun and reviewed by the Editorial Committee for Health Journey, Vol 4 2007.
University of Sydney researcher seeks participants for study on the Effects of Genital Image and Body Image on Sexual Functioning in Women
The study invites women aged 18 years and above to complete an on-line questionnaire (will take approximately 20-30 minutes). The study has been approved by the University of Sydney, Human Research Ethics Committee.
Click here for more information about the study.