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Labiaplasty: motivation, techniques, and ethics

Key Points

  • No criteria exist to provide a definition of labia minora hypertrophy, and the perception of normal labia minora size differs among women, health-care professionals, and cultures

  • Media outlets, such as magazines, show mainly altered images of labia, which affects women's genital self-image

  • Eleven surgical approaches to labiaplasty have been described, meaning no gold-standard technique exists

  • Complication rates are low, and most complications are minor, but severe complications can occur with considerable consequences

  • The limitations of current studies are small sample size, few reporting on satisfaction, complications, and outcomes, and lack of long-term data

  • Patient-reported outcome measures are needed to enable evaluation of patient satisfaction

Abstract

Labiaplasty (also known as labia minora reduction) is attracting increasing attention in the media and in online forums. Controversy exists among health-care professionals on how to manage a request for this surgery. Furthermore, the indications for and outcomes of labiaplasty have not yet been systematically assessed, and long-term outcomes have not yet been reported. Labia minora hypertrophy is defined as enlargement of the labia minora; however, the natural variation of labia minora size has scarcely been studied, with only one study suggesting objective criteria. Perception of the 'normal' appearance of labia minora is influenced by culture, exposure to idealized photographs in media, health-care professionals' opinions, and family, friends, and sexual partners (although this influence has not been substantiated by research). The desire for labiaplasty is predominantly based on dissatisfaction with genital appearance and not on functional complaints. Most health-care professionals believe that women seeking labiaplasty should be referred to a psychiatrist or psychologist for consultation before surgery, although whether counselling and education are effective at alleviating dissatisfaction or a low genital self-esteem is not clear. As the nature of patient motivation for this type of surgery is often psychological, counselling and education could be useful in reducing the demand for labiaplasty. However, current studies on surgical technique and outcomes include few patients, therefore, evidence on the results of different labiaplasty techniques and patient satisfaction is inconclusive. Further research is required to assess the value of this treatment and the appropriate indications for it. Improved understanding as to why women seek this treatment is needed and whether conservative treatments (such as counselling) are effective. Furthermore, systematic assessment of the surgical and patient-reported outcomes of labiaplasty is needed to assess whether it is safe and effective. Moreover, understanding the effect of cultural trends, for example, the way in which many women in Western society see any exception to the ideal body as a problem, will be insightful.

Introduction

Labiaplasty (or labia minora reduction) refers to the surgical reduction of the size of the labia minora as a treatment for labia hypertrophy. Causes of labia hypertrophy are secondary to congenital conditions, such as disorders of sex development, but it can also develop as a result of oestrogen or androgen treatment during childhood1,2, tissue expansion by repetitive pulling, or infection, or it can occur concomitantly with incontinence3,4. However, a clear definition of labia hypertrophy is still lacking, and no consensus exists in the literature with respect to the varying grades and classification of labial hypertrophy5. Only one study has suggested objective criteria for labia minora hypertrophy (width >50 mm) or labia minora asymmetry (difference >30 mm) based on data on natural female genital variation6.

Labiaplasty seems to be a relatively new phenomenon that has emerged in association with the trend for the pursuit of perfection in modern, economically developed societies7; however, François Mauriceau described women requesting treatment for discomfort caused by labia hypertrophy in 16818, and Meissner9 and Treub10 also published such descriptions. Nonetheless, in modern society, this subject is increasingly being addressed among media platforms and medical organizations11. Growing attention for this subject has been reported to be associated with an increasing demand for this procedure12. Articles on labiaplasty invariably introduce the subject by describing an increase in requests for labiaplasty; however, the actual numbers of women requesting labiaplasty, the numbers of women who undergo labiaplasty, and the numbers of medical doctors performing the procedure are unknown. This discrepancy could exist because labiaplasty is offered in a wide range of centres, including hospitals, clinics, and private practices. Furthermore, many women who are recorded as receiving the procedure are lost to follow-up monitoring for several reasons (such as distance, lack of compliance, and lack of scientific interest from the health-care provider), making data collection difficult13. Thus, the need for reliable and representative data on this topic is increasingly pressing. Specialists in sexual health care are divided with regard to their opinions on labiaplasty, with 64% reporting that they would never perform a labiaplasty14. Reasons for this statement differed with some not feeling capable of performing it to because of working in a different field, others not believing that a labiaplasty affects sexual function, and some and being opposed to it. Thus, identifying and understanding the scientific argument for this opinion are important when considering the place of labiaplasty in health care14. The remaining 36% of sexual health-care specialists who would potentially or do already perform the procedure must be equipped with the most recent data concerning patient outcomes and surgical techniques so that they can make informed decisions on the management of their patients.

This Review provides an overview of the current data on labiaplasty and explores current opinions regarding how to define labial hypertrophy and the indications for surgery, including the motivations of patients and surgeons and ethical considerations. Surgical procedures and their outcomes are also discussed. We describe the challenges presented to physicians by patients requesting genital cosmetic surgery and provide information to aid physicians and patients in shared decision making and thereby in making a well-informed decision when deciding on the best treatment options.

Defining 'normal' labia minora

Definition of labia minora hypertrophy. A definition of labia minora hypertrophy is required to select patients for surgery owing to this condition. Currently, no criteria exist to provide a definition of labia minora hypertrophy, and only one published study has suggested an evidence-based cut-off point for the size of labia considered as 'normal', which could be seen as an implicit definition. In this study, 33 women applying for labia minora reduction were screened for labia size at an outpatient clinic. According to the women's own criteria, a labia minora width >50 mm or an asymmetry >30 mm were indications for surgery, as was being >18 years old, based on other research by this same group6. Only three women in this study were offered surgery owing to asymmetry of the labia minora >30 mm; the other 30 women were refused the procedure on the basis of age (<18 years) or size of the labia (width <50 mm or an asymmetry <30 mm). Furthermore, 1 of the 30 women who were refused surgery was referred to psychiatric care owing to a danger of self-mutilation, 12 chose a second opinion, and 11 accepted a referral to a psychologist. No information is available concerning 6 of the 30 women who were refused surgery6. Most women applying for labiaplasty have labia minora that would be considered a natural size by a medical professional, emphasizing the importance of having a validated definition of the natural variation in labia size. Ellsworth and co-workers15 developed an algorithm for selection of surgical technique on the basis of the Franco classification for labia minora size. The Franco classification divides labia minora width into four groups: <2 cm; 2–4 cm; 4–6 cm; and >6 cm16 and the algorithm developed by Ellsworth and colleagues15 assigns a specific type of reduction technique to each group. (Fig. 1). The Gonzalez classification, proposed in 2015, resembles the Franco classification5. These three classifications give an insight in to labia size and shape, but labia minora hypertrophy is not explicitly defined. Thus, a clear definition of labia hypertrophy is still lacking, and no consensus exists in the literature with respect to the varying grades and classification of labial hypertrophy. Justifying the decision of a health-care professional to perform labiaplasty or to refuse to do so is difficult as a strict and evidence-based definition of labia minora hypertrophy has not yet been formed.

Figure 1: The Ellsworth algorithm for selection of technique for labiaplasty11.
figure1

This algorithm is based on the Franco classification of labia minora size9, which divides labia minora width into four groups: <2 cm (type I); 2–4 cm (type II); 4–6 cm (type III); and >6 cm (type IV). The algorithm assigns a specific type of reduction to each group: type I and type II should be treated with de-epithelialization reduction and type III and IV with edge reduction or superior pedicle technique. Reproduced with permission from Ref. 15, Springer.

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Natural biological variation in labia minora width. The extent of natural biological variations in the dimensions of female genitalia has been assessed in two studies.17,18 (Table 1). Lloyd et al.17 performed measurements of female genitals in 50 premenopausal, anaesthetized women before they received routine hysterectomy or diagnostic laparoscopy. No statistically significant association was reported between labia size and age, parity, ethnicity, use of hormones, or history of sexual activity. Labia minora width ranged from 7 mm to 50 mm with a mean width of 21.8 mm17. Basaran et al.18 recruited 50 premenopausal and 50 postmenopausal women and conducted labial width measurements in their outpatient clinic. Mean labia minora width was significantly smaller in postmenopausal women than in the premenopausal group (15.4 ± 4.7 mm versus 17.9 ± 4.1 mm; P = 0.01)18. Why this difference in size exists is unclear and could be an artefact of the small sample size.

Table 1 Reported labia minora width in women

The limited available data suggest that the labia minora width of women who request a labiaplasty generally falls within the range of natural variations6,19 and is not substantially different from that of women who do not desire genital surgery17,18. Thus, labiaplasty is being performed on women who have labia minora that would be considered normal according to current criteria. Interestingly, women in Zambia attempt to elongate their labia minora with the use of weights or pulling. Elongation of the labia is considered an aspect of becoming a proper Zambian woman (one who is ready to get married), creates bonds between girls (by helping each other with pulling their labia), makes a new labia shape (creating a beauty ideal), and enhances sexual well-being because an increased labia length increases sexual pleasure. This behaviour arguably puts the trend towards labia minora reduction in economically developed societies in a different perspective20.

Ambiguity concerning what constitutes 'acceptable' labia minora width was noted within professional clinical practice, with variation in opinion reported by surgeons. The labia minora width defined in reports as the intended aim of labiaplasty ranges between 1 cm and 4 cm after labiaplasty21,22,23. Only three studies have attempted to define objective criteria for labiaplasty. The algorithm proposed by Ellsworth et al.15 (Fig. 1) is based on the Franco classification16, which divides labial width into four types: type I (<2 cm); type II (2–4 cm); type III (4–6 cm); and type IV (>6 cm). The algorithm advises a de-epithelialization technique for Franco classifications I and II (for labia with a width <4 cm). For labia with a width ≥4 cm, the classification indicates a full-thickness excision. Depending on the desire to remove or to retain the naturally darker edge of the labia, an edge resection technique or a superior pedicle technique is advised. Gonzalez et al.5 modified the Franco classification in 2015 by adding two further dimensions (location of hypertrophy being anterior (A), central (B), or generalized (C) and adding symmetric (S) and asymmetric (AS) classifiers), which give a more complete description than previous classification systems. However, best-fit techniques are not proposed. This classification system can simplify communication among clinicians; for example, '2BS' are labia that are symmetrical and have a central hypertrophy 2–4 cm wide5. All three classifications stipulate type I width as hypertrophy of the labia, which is controversial with regard to Crouch and colleagues' definition of natural labia minora6. The Ellsworth algorithm is especially controversial in this regard, suggesting that type I and type II should be treated with de-epithelialization reduction and type III and IV with edge reduction or the superior pedicle technique15 (Fig. 1). However, Crouch et al.6 suggest that labiaplasty should only be offered to women who have a labia minora width >5 cm or an asymmetry >3 cm on the basis of their research on labia measurements and women's opinions. These investigators concluded that labia minora within this range are normal and that surgery is not required.

Perception of normality. The fluidity of the concept of 'normal labia minora' and the implications for societies are reflected in differing reports on the perception of labia minora within various populations. A study of Zambian women and labia minora elongation showed that, in this population, a labia minora width ranging from 1.5 to 2 inches (3.81 cm to 5.08 cm) was desirable to create a “complete and proper woman”20. At the same time, women in modern economically developed societies want petite and nonprotruding labia minora19.

The results of one study have demonstrated that the perceptions of women in Australia regarding the appearance of vulvas can be influenced by prior exposure to images of natural or surgically modified vulvas24. In this study, women participated in a two-phase study; in phase 1, participants were randomly allocated into one of three groups. One group was shown 35 images of non-modified (natural) vulvas on a computer screen, one group was shown 35 modified vulvas (which had undergone labiaplasty), and the final group viewed a blank screen for 1 minute. In phase 2, all the participants viewed the same 20 randomly ordered photographs of 10 non-modified and 10 modified vulvas and were asked to rate them for normality and the extent to which they represented society's ideal. Women exposed to images of modified vulvas in phase 1 were more likely to rate modified vulvas as more normal than non-modified vulvas than woman who had viewed a blank screen in phase 1; however, the normality ratings given by women who viewed images of non-modified vulvas in phase 1 were not significantly different from those given to either of the other groups. In terms of perception of society's ideal for vulva appearance, all three groups rated modified vulvas as more ideal than non-modified vulvas. Furthermore, women who saw modified vulvas in phase 1 were more likely to rate these vulvas as complying with society's ideal than those who had viewed non-modified vulvas, who in turn were more likely to rate modified vulvas as more ideal than those who had viewed a blank screen. Thus, the concept of what is normal can be influenced by exposure to selected images24. As such, both women seeking labiaplasty and health-care professionals can be biased by altered images, in which modified vulvas become perceived as natural and, therefore, ideal. This observation highlights the importance of showing images of natural vulvas during consultation with women who request a labiaplasty and also discussing normality.

This effect has been shown in another study in which the effect of exposure to pictures of natural vulvas on a woman's genital self-image was analysed using the Female Genital Self-Image Scale (FGSIS)25. Participants in this study were healthy Dutch women who had not requested any genital alterations. Before seeing the pictures, a majority (60.5%) of women scored highly on the FGSIS (selecting agree or strongly agree with each statement, meaning they were generally happy with the appearance of their genitals)26. The women were then split into two groups: one group was shown images of natural vulvas; and the other group was shown images of neutral objects. After viewing the images, the women's views were reassessed using the FGSIS, and then they completed the survey again 2 weeks later. The group of women who viewed the pictures showed a significant increase in positive appraisal of their own genital appearance. (post-test P < 0.001; follow-up point P < 0.005)26. Observing vulvar variation increases women's appreciation of their own genital appearance, which suggests that the concept of what is normal can easily be influenced by exposure to selected images. The investigators concluded that observing vulvar variation positively affects a woman's perception of the appearance of her own genitals26.

In our experience, most women are not aware of what their vulva looks like or are not able to assess their own vulvas in relation to factors such as sexual sensation and function, which was made clear in a study by Schober and colleagues27. Thus, the questions are whether women have the ability to assess whether the appearance of their vulva is different from perceived normal appearance, whether something is wrong with it, and whether there is an anatomical abnormality that needs correcting when they are not familiar with vulvar variation. Thus, counselling, looking at pictures of vulva variation, and educating women are important, as many are reassured and change their mind about labiaplasty. In private practice, the outcome of such interventions might be different, as many women who attend these clinics seem to be determined to have a labiaplasty and are willing to pay for it. Thus, these women can be familiar with vulvar variation but want to change the appearance of their vulva anyway.

Selective exposure. Women in the Western world are increasingly being exposed to images of perceived perfection through all types of media19,28. An analysis of centrefold images in Playboy magazine showed that only 2.7% of images displayed in editions published in 2007 and 2008 depicted the labia minora protruding beyond the labia majora. Moreover, only the labia majora were visible in 82.2% of images of the genitals of centrefold models, whereas 15.1% of pictures displayed the labia minora contained within the labia majora28. This over-representation of idealized images of female genitals generates a substantial risk that the concept of normal labia minora does not match reality. Furthermore, shaving of pubic hair is increasingly prevalent, enabling women to make comparisons between the appearance of their genitals and that of others19,28. In one study, 95% of women were reported to frequently examine their labia minora29, and adolescents presented with concerns about abnormal labial appearance after comparing their genitals with those of other women (for example siblings, Internet images, and anatomical images)19.

Results of one study showed that girls requesting assessment of their genitals or surgery to their labia minora had an asymmetry of their labia minora width ranging from 6 mm to 35 mm or a labia minora width ranging from 22 mm to 55 mm19. These values are not substantially different from the natural range of labia minora width of 7–50 mm suggested by Crouch and colleagues6. Both of these results are from women in England6,19, suggesting that natural biological variation in a population does not necessarily correlate with that population's cultural beliefs.

Together, these studies indicate that women in Western societies are being exposed to a single representation of the appearance of labia minora and are potentially misjudging the reality of vulva appearance, in which vulva size is diverse. Women are apparently negatively influenced by images that they see. However, men are exposed to the same images but do not experience the same effect. For example, a 2007 article in the girls magazine Yes revealed that girls do not give their vulva a name, whereas men often have a name for their penis. Furthermore, men rate the vulva of their girlfriend with an A grade and girls give themselves a C grade30. An experiment was conducted on the social media platform Facebook in which pictures of vulvas were taken and both the woman and her male partner were asked to say what they saw looking at the picture. This reaction was filmed and subsequently shown to the other partner. Women were fairly negative, and men were loving, proud, and moved when looking at the vulva of their partner. The reaction of the men surprised and moved the women31. However, men could be negative about their own genitals, so perhaps all people are critical of themselves.

Counselling. One study has been conducted on effects of counselling on reducing the desire for labiaplasty32. Patients requesting the procedure attended counselling in three separate 1-hour sessions. Initially, a structured interview was conducted, focusing on the reasons for their request and obtaining their medical, psychosocial, and sexual history. Afterwards, patients were informed of the function of the vulva, vagina, and pelvic floor. In parallel, genital normality (supported with images of natural vulvas), surgical techniques, possible results, and the risk of complications were discussed. Psychosexual education was also given in conjunction with an educational physical examination. At the end of the last consultation, patients were asked once more about their considerations and decision whether to undergo a labiaplasty, and 35% of patients chose to refrain from undergoing surgery32. The persistence of the 65% of the women still desiring a labiaplasty could be caused by the fact that they had made up their mind before attending the outpatient clinic. These women are willing to risk possible complications and realize their right of autonomy to change something about their own body. At a plastic surgery meeting of the Nederlandse Vereniging voor Plastische Chirurgie (Dutch Association for Plastic Surgery, NVPC) held in 2009, discussion occurred about whether all plastic surgery patients desiring alterations that were not medically indicated should be referred for counselling or whether people have the right to alter their body by piercing, tattoo, or surgery. A potential reason why labiaplasty is discussed in this context is because of the comparison that is made with female genital mutilation (FGM), which is a sensitive subject.

Experience suggests that a large number of women seeking labiaplasty want to be assured that they are normal; they want to hear that nothing is wrong with their genitals. Counselling and education could make a difference in these circumstances and prevent this group of women from undergoing medically unnecessary surgery. Educating women about the natural biological variations in vulva appearance, providing them with images of natural vulvas, providing correct information about surgery, and suggesting alternative methods of reducing genital discomfort can help women to make well-considered choices regarding genital appearance.

Genital self-image

Understanding the implications of a negative or positive genital self-image on the lives of individual women is important when presented with the difficult question of whether to perform genital cosmetic surgery. Evidence has suggested that as humans, we have an unconscious obsession with sexual organs33. Thus, the implications of having a negative genital self-image might be considerable.

Having a negative genital self-image was shown to have negative effects on sexual self-esteem and an individual's perception of their own attractiveness34. Genital self-image has been shown to correlate with desire for, participation in, and enjoyment of sexual activity35,36. Specifically, increased positive perceptions and reduced negative perceptions were associated with participation in and enjoyment of sexual (especially oral–genital) activity35, and positive genital self-image has been shown to negatively correlate with the incidence of sexual distress and depression36. Conversely, women who are dissatisfied with the appearance of their genitals have increased self-consciousness during physical intimacy, which is associated with reduced levels of sexual self-esteem, sexual satisfaction, and motivation to avoid risky sexual behaviours owing to a lack of sexual confidence37. Risky sexual behaviours could result in an increased incidence of sexually transmitted infections (STIs), which in turn can cause genital discomfort or more shame about their genitals and increase their dissatisfaction with their genitals. Thus, arguably, if genital cosmetic surgery improves genital self-image in these women, such surgery could also improve their sexual health and safety37. However, more conservative methods than surgery are available for, and effective in, improving genital self-image. Data show that if young women with a positive genital self-image are exposed to images of natural vulvas, personal satisfaction with genital appearance improves for up to 2 weeks after image exposure25. Thus, women who have a negative genital self-image could possibly benefit from looking at natural vulvas.

Genital self-image is positively associated with enjoyment of sexual activity but not necessarily with frequency of orgasm25. Data from two studies show that women report the labia minora, the clitoris, and the skin above the clitoris as the most sexually sensitive areas for the achievement of orgasm27,38. This sensual function of the labia minora provides an argument against surgical excision of the labia minora or the clitoral hood. However, the results of one study involving women undergoing labia minora and clitoral hood reduction surgery showed an increase in orgasm frequency in 35.3% of patients (P = 0.013) and an increase in orgasm strength in 35.3% of patients (P = 0.006). Furthermore, 44.1% of women reported an increase in the number of sexual relations experienced at the 6-month follow-up point (P = 0.011). Whether the change in the frequency and strength of orgasm was caused by the clitoral hood reduction, the labia minora reduction, or both is unclear39. No data are currently available on the effects of labiaplasty procedures alone on the sexual sensitivity of the genital area. Having quantitative measures of the sensitivity of the labia minora before and after labiaplasty would be useful to assess the effects of surgery. However, collecting quantitative data on the sensitivity of the labia minora and changes during arousal is difficult.

Current evidence outlines the importance of maintaining a positive genital self-image when optimizing the emotional, sexual, and health-care needs of women. Whether conservative methods or cosmetic genital surgery are effective, and how they compare with regard to boosting genital self-image in women who have a low genital self-esteem, is not yet clear.

Motivation

Reasons for the desire for labiaplasty. Western women have an increasing desire for genitals with an absence of pubic hair and small labia minora, resembling prepubescent female genitals in appearance40,41. This increasing popularity of cosmetic genital surgery can be viewed as another manifestation of the pursuit of the 'perfect body'. However, the perception of 'perfection' depends on culture and exposure. Women are often exposed to unrealistic, idealized images of female genitals and do not have a good idea of the true extent of natural variations in genital appearance. Magazines containing images of genitals rarely show a full genital image or depict genital images without protruding labia minora28. A documentary video called 'The Labiaplasty Fad?' made by an ABC Australia current affairs programme called Hungry Beast, posted on the video streaming website YouTube, and on the Internet page of photographer Nick Karras (www.nickkarras.com)42 provides some insight into the ethical code used by Australian unrestricted soft-pornography magazines regarding labia minora. According to the documentary, the Australian classification guidelines state “Realistic depictions may contain discreet genital detail but there should be no genital emphasis.” This statement seems to have been interpreted as having no protruding labia minora in images of naked women; thus, labia minora are frequently edited out of the images in these magazines42. Exposure to pictures that create a biased reference can lead to an altered genital self-image, especially in younger women, as they could be more susceptible to these images than older women. Current evidence suggests that labiaplasty requests are predominantly based on dissatisfaction with the genital appearance and not on functional complaints. Idealized images presented in the media might provide women with an abnormal perception of normality12; however, whether this skewed perception motivates them to request labia minora modification is not clear. Currently, patient motivation can be divided into two broad categories: physical complaints and social factors.

A number of physical complaints involving the labia minora have been reported, including pain, infection, discomfort during various physical activities (including sexual intercourse), and difficulties with personal hygiene43. However, with the exception of sexual intercourse and satisfaction, physical complaints are not reported to be the leading motivation for women to request labiaplasty44. The leading motivations for seeking surgery are emotional dissatisfaction with genital appearance and dissatisfaction with sexual relationships44,45. Women requesting surgery refer to anxiety about their current sexual partner seeing or touching their genitals or the possible inhibition of future sexual relationships owing to the appearance of their genitals46. Satisfaction with relationships in general was negatively correlated with the consideration for labiaplasty47, and women who reported receiving negative comments about their genitals in previous sexual relationships or who had been subject to sexual abuse as a child had an increased likelihood of requesting surgery48.

Other factors that are positively associated with an increased desire for labia minora cosmetic surgery include reduced overall satisfaction with life and not having a romantic relationship at the time of the treatment request49. Women seeking labiaplasty do not necessarily have a higher incidence of depression or anxiety than those without the desire for surgery, but they do have a generalized negativity towards overall body image, with a considerable proportion meeting the diagnostic criteria for body dysmorphic disorder48,49. Current evidence suggests that motivation for labiaplasty has both psychological and emotional origins rather than being determined by physical difficulties. This theory is reinforced by the finding that 75% of specialists in sexual health choose to refer women who request labiaplasty to psychological services before considering any surgical interventions14.

Thus, the most common argument for performing labiaplasty if no physical abnormality exists is that it improves genital self-image and self-esteem and, thereby, sexual function. A negative genital self-image is a cause of sexual dysfunction50. Thus, alleviation of negative self-image could improve sexual function50. However, the argument could also go the other way; sexual dysfunction could affect the way people feel about their genitals, and a negative self-image could be the consequence50. Both arguments provide support for counselling women who request labiaplasty before performing surgery, as this process could reveal the underlying reason for the request4. Knowing the underlying reason can aid referral. Women who requested a labiaplasty were significantly more likely to have experienced negative remarks about their genitals than those who did not desire the procedure (P < 0.0001)51. Sources of negative comments were mostly previous sexual partners (64.3%), but other sources recorded included peers, mothers, sexually abusive fathers, sons, and health-care professionals32,51. Özer et al.32 reported only negative remarks from the mother.

A combination of the pursuit of the perfect vulva and exposure to idealized images of female genitals might cause feelings of shame and doubt about women's genitals. Physical complaints are mentioned, with the exception of sexual intercourse and satisfaction, but these complaints are not reported to be the leading motivation for women to request labiaplasty. The leading motivations for seeking surgery are emotional dissatisfaction with genital appearance and dissatisfaction with sexual relationships. Negative comments from others have a negative effect on genital self-image and can lead to the wish for a labiaplasty.

The attitude of physicians towards labiaplasty. Lowenstein et al.14 conducted a multinational survey during the 2012 European Society for Sexual Medicine meeting in Amsterdam in which 360 physicians in the field of sexual medicine stated their attitude towards female genital plastic surgery (FGPS). The majority of participants (270, 75%) believed that women seeking FGPS should be referred to a psychiatrist or psychologist for consultation before surgery. Labia minora >5 cm in width was thought by most physicians to be hypertrophic (270, 75%)14. Reistma et al.52 asked plastic surgeons, gynaecologists, and general practitioners to look at four pictures of vulvas with labia minora of different sizes. Plastic surgeons were significantly more likely to think that the largest labia minora looked distasteful and unnatural and consider the size to be an indication for labiaplasty than gynaecologists or general practitioners (P < 0.01). Plastic surgeons were also significantly more open to performing a labiaplasty irrespective of an absence of physical complaints or labia minora size than gynaecologists (P < 0.01). A significant difference between male and female physicians was also reported, with men being more predisposed to performing a labiaplasty (P < 0.01)52. Surgeons performing vulva surgery for aesthetic reasons might also be at risk of unintentionally mistaking pelvic floor disorders for physical complaints caused by hypertrophic labia53. Manifestations that can be mistaken for burden caused by the labia are dyspareunia, small wounds or tears in the vulva area, and a burning sensation in the genital region. Performing surgery will increase pain and pelvic floor overactivity, slow wound healing, and be another negative experience towards the vulva region. Health-care providers attending the 2013 European Society for Sexual Medicine meeting in Amsterdam were at an increased likelihood of referring patients seeking labiaplasty for counselling; however, plastic surgeons were more likely than gynaecologists to have an image of an idealized vulva52. Thus, whether a labiaplasty is performed is influenced by the opinion of vulva appearance held by the consulting doctor. A labiaplasty is surgical reduction of the labia minora, so it is a physical alteration not a treatment for sexual or vulvar complaints such as dyspareunia. In our opinion, a labiaplasty should not be offered as a treatment for genital complaints, as they might not be resolved by the surgery.

Surgical techniques

Different views on the optimal surgical technique for labiaplasty, in order to obtain an aesthetically and functionally satisfactory result, have been presented. Overall, 11 different techniques have been reported, which can be categorized into three groups: edge resection; wedge resection; and central resection (Fig. 2).

Figure 2: Surgical technique for labiaplasty.
figure2

A | Edge resection is a technique in which excess labial tissue is removed by resecting the most protruding part of the labia minora. Aa | The straight excision, which follows the curve of the labia in which the labia minora was reshaped with subcuticular polyglycolic acid sutures, can be completed using a scalpel, diathermia, or a combination of both. Some surgeons use a clamp to first crush the site of incision and also to reduce blood loss. Ab | An S-shaped resection is used to reduce the effects of scar contraction, to interrupt the straight line, and to increase the length of the scar. Ac | A double-W-shaped incision technique starts alternately on the inner and outer side of the labia minora so that the tissue can be folded into place easily. The Z-plasty, which is a widely used technique within plastic surgery, is used to reduce the extent of scar contraction. B | Wedge resections are the most popular labiaplasty techniques. These techniques also include various modifications that improve aesthetic results (such as preserving the shape and colour of the labium) or prevent loss of function or sensation. The wedge is marked first on the smallest labium if a difference in size is present, and this marking is then transferred onto the other labium. The reduction is achieved by resecting the wedge that was marked, which is accomplished by incising the skin with a scalpel and the labia tissue with diathermia. The location of the wedge can be adjusted to the most protuberant part of the labia minora. Ba | The central wedge resection can be performed with or without first identifying and preserving the main labial artery55,56. Bb | A predesigned template can be used to perform a 90° Z-plasty in order to prevent scar contraction. When reduction of the clitoral hood is also desired, a central wedge can be combined with a “lateral anterior curved excision of redundant lateral labium and excess lateral clitoral hood”56. Bc | The wedge can also be placed more posteriorly, which can be termed a posterior wedge resection23,57 or inferior wedge resection and superior pedicle flap reconstruction58. C | Central resection is used to maintain the original texture, contour, and pigmentation of the labial edge and includes de-epithelialization21 and fenestration59. Ca | A triangle-shaped marking centred in the labia minora allows for the de-epithelialization of the area. The rough edges are sutured together with catgut. Cb | Ostrzenski et al.59 marked the amount of tissue to be removed centrally in the labia minora in a 'bicycle helmet' shape. Excision is performed, and the inner and outer surface of the labia minora are sutured separately, without suturing the erectile tissue between them.

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Edge resection. In an edge resection, excess labial tissue is removed by resecting the most protruding part of the labia minora. This removal can be performed either in a straight line that follows the curve of the labia1, in a lazy S-shaped resection54, or in a W-shaped resection22. A curved resection is chosen to forestall contraction of the scar (Fig. 2A). The straight excision can be completed using a scalpel, diathermia, or a combination of both; some surgeons use a clamp to first crush the site of incision and then to minimize blood loss1 (Fig. 2Aa). Chavis et al.1 do not mention whether a scalpel or diathermia was used, but the labia minora was reshaped using subcuticular polyglycolic acid sutures. Felicio et al.54 introduced an S-shaped resection in order to reduce the effects of scar contraction, to interrupt the straight line, and to increase the length of the scar (Fig. 2Ab). Maas et al.22 further developed this idea by using a double-W-shaped incision, which starts alternately on the inner and outer side of the labia minora so that the tissue can be folded into place easily. The Z-plasty, a widely used technique within plastic surgery, is used to reduce the extent of scar contraction (Fig. 2Ac).

Wedge resection. Wedge resection techniques are the most popular labiaplasty techniques. These techniques include various modifications that have been made to improve aesthetic results (such as preserving the shape and colour of the labium) or to prevent loss of function or sensation. The wedge is marked first on the smallest labium if a difference in size is present, and this marking is then transferred over to the other labium. Infiltration of local anaesthesia is performed using xylocaine and adrenaline. The reduction is achieved by resecting the wedge that was marked and incising the skin with a scalpel and the labia tissue with diathermia. The labia are approximated in layers using vicryl 4.0, and the skin is closed using vicryl 4.0 or 5.0 or monocryl 5.0; internal dogears can be corrected easily. The location of the wedge can be adjusted to the most protuberant part of the labia minora. The central wedge resection can be performed with or without first identifying and preserving the main labial artery55,56 (Fig. 2Ba). Giraldo et al.3 even use a predesigned template to perform a 90° Z-plasty in order to prevent scar contraction (Fig. 2Bb). When reduction of the clitoral hood is also desired, a central wedge can be combined with a “lateral anterior curved excision of redundant lateral labium and excess lateral clitoral hood”56. The wedge can also be placed posteriorly, which is a posterior wedge resection23,57, or inferior wedge resection and superior pedicle flap reconstruction can be performed58 (Fig. 2Bc). The greatest advantage of the wedge reduction technique is the fact that the labia cannot be reduced too much; with edge resection, care must be taken to leave enough labia minora length that the patient does not experience inconvenience when wearing underwear, dryness, infections, vaginal discharge, or stretching of the vaginal introitus during intercourse. Thus, the wedge reduction is relatively safe, as the labia cannot be over-reduced. Most surgeons experience central or edge dehiscence during wedge resection, but this occurrence is not reported as a complication in the literature.

Central resection. Other techniques proposed in order to preserve the original texture, contour, and pigmentation of the labial edge include de-epithelialization21 and fenestration59. Choi et al.21 described a de-epithelialization technique using a triangle-shaped marking centred in the labia minora. After injecting lidocaine and adrenaline, the central marked part of the labia minora is de-epithelialized (Fig. 2Ca). The rough edges are sutured together with catgut21. Ostrzenski et al.59 first applied lidocaine–prilocaine cream (in a 2.5% to 2.5% ratio) and an ice pack 30 minutes before surgery and determined and marked the amount of tissue to be removed centrally in the labia minora in a 'bicycle helmet' shape (Fig. 2Cb). Lidocaine and adrenaline were injected into the labia minora and also at the superficial part of the deep branch of the perineal nerve and the posterior labial nerve. Excision is performed with a scalpel15, and the inner and outer surface of the labia minora are sutured separately without suturing the erectile tissue between them59.

Ellsworth and colleagues15 developed an algorithm for selection of the type of reduction that should be used for specific widths of labia minora hypertrophy by comparing the positive and negative aspects of each technique on the basis of their own experience of 12 procedures performed on patients. The surgeon chose one of three reduction techniques (edge excision, inferior wedge resection, or de-epithelialization) on the basis of the degree of hypertrophy and the patient's requirements regarding labial edge colour and contour15. Gonzalez et al.5 modified the Franco classification in 2015 by adding two further dimensions (location of hypertrophy being anterior (A), central (B), or generalized (C) and adding symmetric (S) and asymmetric (AS) classifiers), which give a more complete description. However, best-fit techniques were not proposed5. We believe that the best technique to use is the technique that the surgeon is most confident performing given their own previous experience.

Outcomes of labiaplasty

Few studies report on the surgical outcomes of labiaplasty (Table 2). Those that do report outcomes have a mean cohort size of 65 patients, a variable follow-up period, and mostly poorly defined outcomes. The level of evidence of all studies was 4, a low level of evidence based on the Centre for Evidence-Based Medicine levels, which range from 1 to 560. Outcomes evidence for labiaplasty is currently insufficient, but some studies have provided an evaluation of patient satisfaction with the wedge resection method in enough patients to enable analysis of patient reported outcomes (between 113 and 407 patients)13,23,61. In one study including 163 patients, 93% were satisfied with the anatomical results of surgery 1 month after surgery. Of the 98 women who completed satisfaction questionnaires, 81 (83%) patients were satisfied with the results, 87 (89%) were satisfied with the aesthetic results, and 91 (93%) were happy with the functional outcomes. Only four women in this cohort would not undergo the same procedure again23. In another study, 166 out 407 patients returned their postoperative satisfaction questionnaires. Most of these women were pleased with the results of surgery, with the average score being 9.2 out of 10 and 10 being most pleased. Overall, 93% of women experienced an improvement in self-esteem, 71% had an improved sex life, and 95% had reduced levels of discomfort. The complication rate was low (4% of patients)13. In a study involving 113 women, 15 reported experiencing transient symptoms, including swelling, bruising, and pain, one patient had bleeding, and four needed revision surgery; however, no major complications were reported61. The results of these three studies suggest that labiaplasty does not cause too much discomfort and improves satisfaction and self-esteem. Unfortunately, the conclusions of these studies are not comparable with the outcomes of other surgical techniques reported. Patients requesting labiaplasty should be provided with all the information required in order to make an informed decision on their treatment. Sometimes this procedure causes discomfort, pain, and swelling for a few weeks, but the proportion of women experiencing these issues is very small. Furthermore, if women expect to be free of sexual problems, talking to them about the fact that labiaplasty is a reduction of labial tissue not a cure for sexual problems and insecurity is very important. Levels of genital anatomy awareness need to be increased in the general population, expectations of women requesting labiaplasty should be explored and adjusted if necessary, and patients should be informed of the risks and potential vulva results, all without compromising the autonomy of the patient62.

Table 2 Studies reporting outcomes of labia minora reduction procedures

Complications. Overall, low complication rates have been reported, most of which are minor complications (Table 2). Out of sixteen studies, four had no data on complications1,39,55,63, four reported uneventful recovery21,56,59,64, and four detailed minor complications, such as bleeding, pain, haematoma, swelling, and minor wound dehiscence3,22,57,61. Four studies reported more considerable complications that sometimes needed a second procedure or revision.13,23,58,65. Three of these studies also mentioned sexual problems after labiaplasty. Alter et al.13 reported that nine women experienced a negative change in sexual sensation. Moreover, five women had orgasm difficulties, four women reported decreased labial sensation, and one had increased pain during intercourse13. Rouzier et al.23 indicated that 64% of women had postoperative pain, 45% experienced postoperative discomfort, and 23% had entry dyspareunia for between 3 and 90 days23. In another study, one woman complained of a slight aching introitus, two experienced reduced sexual arousal, one had discomfort wearing tight clothes, and one woman regretted the labiaplasty65. However, reoperations (mostly performed for aesthetic reasons) were reported in up to 7.9% of patients. Unfortunately, long-term data are limited, and variable durations of follow-up monitoring have been reported.

In a study by Veale et al.65 including 23 women, 26% of women reported one or more minor adverse effects at a 3-month follow-up point. However, 17 women (74%) reported having no adverse effects, 96% of women had clinically significant improvements in Genital Appearance Satisfaction (GAS) scale results at 3 months after surgery (P < 0.0005), and 91% still had significant improvements at the long-term follow-up point (P < 0.0005). Furthermore, Cosmetic Procedures Scale-Labia scores at the 3-month follow-up point showed significant improvement (P < 0.0005), which also remained significant at long-term follow-up assessment (P < 0.0005). The results of both of these questionnaires suggest that women had improved levels of satisfaction and reduced levels of concern regarding the appearance of their genitals. Adverse effects occurred in 26% of women and included difficulty with urination, pain at the vaginal opening, reduced levels of sexual arousal, noticeable scarring of the labia minora producing a jagged appearance, slight aching on one side of the vaginal entrance, and discomfort wearing tight clothes. One patient expressed regret about having the surgery65. Alter and colleagues13 concluded that complication rates could be higher than was reported in their study, as only 123 patients of a total of 407 included in the study (30%) were examined at 2 weeks postoperatively, and only 166 patients (41%) responded to the questionnaire. This loss of patients to follow-up monitoring outlines a problem with studies that are mostly conducted in private clinics13.

Complication rates are low, most complications are minor, and complications tend to resolve by themselves, but the more severe complications have considerable consequences, including revision surgery and sexual problems. In our opinion, the largest issue is the labiaplasties that end up too short, as women feel amputated or experience sexual problems and pain. Sometimes reconstruction in these instances is not possible, and these women have more physical problems after surgery than before. However, labia being too short has not been reported as a complication. If increased attention was paid to potential complications during counselling of women requesting labiaplasty, women might not be so dissatisfied when complications do occur.

Satisfaction. High percentages of favourable patient satisfaction are observed within follow-up monitoring periods in 11 of 16 studies1,13,21,22,23,56,58,59,61,64,65 (Table 2). However, satisfaction was usually not measured independently using standardized measures. In one study in which postoperative sensitivity after a labia minora and a clitoral hood reduction procedure was measured, a sexual function questionnaire was also administered39. The questionnaire was given at baseline, 2 weeks, 3 months, 6 months, and 12 months postoperatively to the 37 women involved in the study. The results showed improvements in the extent of labial sensitivity and sexual function, including significant increases in sensitivity at the left and right labial locations (P = 0.046 and 0.027, respectively) and significant increases in orgasm frequency (P = 0.013) and of orgasm strength (P = 0.006) at 6 months postoperatively. Whether these increases are the result of labia minora excision or the clitoral hood reduction is not known. A significant 44.1% increase in the number of sexual relations (P = 0.011) was reported and occurred because of decreased embarrassment and increased confidence in genital appearance, suggesting that the procedure has positive psychological effects. In addition to these outcomes, 90% resolution of body dysmorphic disorder was observed in a group of nine patients at 3 months after the procedure. This result means that their labia had less or no effect on their functioning, sexual or otherwise39.

In a prospective, case-controlled cohort study, 120 women who underwent genital plastic surgery were compared with those of a demographically matched group of women who had not requested a labiaplasty63. At 6 months, 12 months, and 24 months after surgery, the study population resembled the control group with regard to Index of Sexual Satisfaction results. Furthermore, women who underwent surgery reported slightly better scores on both the Index of Sexual Satisfaction and the Body Esteem Scale than women who did not have surgery. However, body dysmorphic disorder and FGSIS scores did not differ between groups63.

Results from studies show improved levels of sensitivity and sexual function after surgery. However, generally, women who have not had surgery and who have relatively large self-assessed labia minora size, and, therefore, increased surface area, had more satisfying sex, more frequent sex, and more intense orgasms than women with relatively small labial surface area38. During counselling, the positive effect of having large labia should be addressed.

The limitations of all these studies are small sample size and few studies reporting on satisfaction, complications, and outcomes. These limitations combined with a lack of long-term data means that making reliable conclusions regarding postoperative outcomes for patients is currently not possible. In general, the data on outcomes seem positive, with few long-term problems. Good patient-reported outcome measures (PROMs) need to be developed, as does a reliable method of gathering quantitative measures on sensation before and after labiaplasty. In PROMs, such as the FACE-Q developed by Klassen and colleagues66, patients themselves indicate the issues that matter to them. Klassen et al.66 created the questions within the FACE-Q together with patients and using words familiar to the patients, which makes the questionnaire very reliable and also recognizable to the people who answer it. A desire for a Genital-Q exists, as it could be useful for aesthetic surgery, reconstructive surgery, patients with disorders of sex development, and maybe even after giving birth.

Ethical aspects

Social pressure and autonomy. Vulvar cosmetic surgery is largely seen as a medically unnecessary procedure by organizations involved in feminist or sexology issues, with justification for the procedure based on the belief that it improves the psychological well-being of the patients13. The psychological effects of discontent with genital appearance can potentially be considerable, causing feelings of shame and low self-esteem, but these effects can be largely attributed to societal pressures. A conflict between autonomy in wanting to change your genital appearance and altering your body to meet an opposed idealized genital image can, therefore, exist. These psychosocial aspects of genital appearance are intertwined with ethical viewpoints, and arguments both for and against the procedure are well developed on both sides.

A comparison between labiaplasty and the practice of FGM has been made. FGM is perceived as an unacceptable practice that results from inappropriate and harmful societal pressures owing to cultural rituals, and genital pricking has been banned by the WHO67. This argument has been extended to the practice of vulvar cosmetic surgery in economically developed countries, in which extensive genital modifications, including labiaplasty and reduction of clitoral tissue, are considered acceptable and are legal in many European countries. Johnsdotter and Essén argue that a consistent and coherent international position, focused on key social values including protection of children, bodily integrity, bodily autonomy, and equality before the law, is required, and nondiscriminatory policies need to be formed to remove the discrepancy in societal perceptions of genital cutting67.

Regardless of this argument, vulvar cosmetic surgery is currently available in many Western health-care institutions. The argument in support of this availability does not discredit the value of social intervention and prevention mechanisms in reducing the need or desire for surgery but rather states that the unfortunate perception of normality, combined with the strength of marketing and media in many countries, means that the procedure should be available to those who could benefit from it68. To support this argument, Borkenhagen and Kentenich68 state that, in order for the procedure to take place, it must be strictly regulated by a set of guidelines, enabling optimum patient autonomy and nonmaleficence. The guidelines presented require that the patient's motivations for undergoing surgery are explored thoroughly, that a medical indication for surgery is present, that the patient is aware that no scientific evidence exists that psychological or physical complaints will diminish, and that risks, including infections, change in sensibility, dyspareunia, adhesions, and scars, are discussed. These factors need to be fully addressed during patient–surgeon consultations before each procedure68.

Physician viewpoint. Physicians have expressed different viewpoints on the justifications for performing labiaplasty. Arguments in favour of labiaplasty, according to some physicians, include a patient's right to autonomy, the fact that the majority of patients undergo labiaplasty for functional reasons and not for aesthetic reasons, and the fact that vulvar surgery is more comparable to cosmetic breast surgery than FGM69,70,71. This argument is based on autonomy in altering your own body, whereas cultural genital cutting can be caused by societal pressure rather than an autonomous desire.

Arguments against labiaplasty include the issues that literature on the complications of surgery is currently lacking and that women seeking labiaplasty need educating about the realities of genital anatomy and diversity72. Furthermore, physicians could be tempted to undertake medically unnecessary procedures when presented with patients who pay them for the service73.

Various health-care professionals' opinions and individual justifications for performing the procedure are also presented in survey results. These results showed that female gynaecologists were more likely to consider labial hypertrophy a “condition driven by societal influence” and offer only reassurance to their patients than male practitioners, who were more likely to perform the procedure on the grounds that labial hypertrophy is a “bothersome quality of life condition”74. Other data suggest that plastic surgeons are more likely to describe images of a large labia minora as distasteful and unnatural than gynaecologists and general practitioners52. Health-care professionals need to be aware of their personal predisposition in regard to labia minora appearance when making clinical decisions regarding their patients. The physician's preference should not be used to guide or influence the decision of women in regard to genital alteration — it should not convince or discourage them from their personal ideas.

Age. Data presented in several publications indicate that women <18 years of age might also request or even undergo labiaplasty6,13,19,21,23,46,64, with the youngest patient being only 11 years old6. In the Netherlands, the minimum age for genital surgery or cosmetic surgery is 18 years old because of the physical and psychological effects this kind of surgery can have75. The performance of this surgery on children makes the need for ethical discussions on this topic much more urgent. Whether genital cutting before the age of 18 years old is ethical and whether we should alter the genital appearance of children so that they will meet an idealized image are major ethical questions. Counselling at a young age should be aimed at making the period until the age of 18 years old bearable. Those who are against performing labiaplasty outline the parallels between labia minora surgery and FGM, which also often occurs in childhood and reduces or removes labia minora67.

Guidelines have been developed by the NVPC, the Dutch Association of Esthetic Plastic Surgery (NVEPC) and the Dutch Society for Obstetrics and Gynecology (NVOG)75, the Royal College of Obstetricians and Gynaecologists (RCOG) and the British Society for Paediatric and Adolescent Gynaecology (BritSPAG)76, the American College of Obstetricians and Gynecologists (ACOG)4, and the Society of Obstetricians and Gynaecologists of Canada (SOGC)77 to aid health professionals dealing with the growing number of adolescents seeking genital cosmetic procedures4,75,76,77. These guidelines state that the obstetrician–gynaecologist providing care for adolescents who present with an interest in genital modification should have good working knowledge of the nonsurgical alternatives for improving comfort and appearance, indications, and timing of surgical intervention and referral. When surgery is indicated, education and reassurance is often the first step, but assessment of the maturity and emotional readiness of the patient and screening for body dysmorphic disorder should also be undertaken. These guidelines also state that labiaplasty in girls <18 years of age should be considered only in those with considerable levels of congenital malformation, those with persistent symptoms believed to be a direct result of labial anatomy, or those with both. Furthermore, these guidelines assert that surgical alteration of the labia that is unnecessary for the health of an adolescent <18 years of age is a violation of federal criminal law4,75,76,77.

The ethical discussion is often a debate between the right to choose (autonomy) and being a victim of external pressures. In our opinion, a line should be drawn at the treatment of underage women (girls <18 years old) when no medical indication exists. The performing of labiaplasty on children makes the ethical discussion on the topic important. During adolescence, young women develop sexual awareness and sexual self-image. Girls and adolescents requesting labiaplasty are unlikely to have a fully developed concept of genital normality. Surgical genital modification in this young population is, therefore, a controversial practice. In our view, building a realistic concept of genital normality in these women through education is much more relevant to their presenting complaint than offering surgery.

Improving education

Evidence on the outcomes of labiaplasty is still lacking; however, whether counselling and education are effective in alleviating dissatisfaction or a low genital self-esteem is not clear. Education in schools could be a way of increasing knowledge of vulvar anatomy, genital appearance, and the variations in genital anatomy present in both women and men. This education might strengthen genital self-esteem and appreciation, leading to an improved body image and increased overall self-esteem and quality of life. A major hope is that education will result in reduced levels of insecurity during sexual development and sexual activity and increased enjoyment of sexuality. Education on normal genital appearance could improve sexual function and also reduce the desire for genital surgery3,22,39,51,63.

One study reported the effects of counselling on the desire for hymen reconstructive surgery78. The investigators conducted a series of interviews consisting of education, discussion of alternatives, and instructions for self-examination during a first visit, a second visit that involved an educational examination, a third visit in which a decision on operation or an alternative therapy was made, and a fourth follow-up visit. Women were informed about the hymen and blood loss myth and empowered to talk to their future husband. Of the women who received surgery (n = 19), 17 did not experience blood loss during first marital intercourse. Participants frequently choose conservative methods, such as pelvic floor exercises, and only 29% decided to receive surgery78. These results suggest that counselling and education can inform a woman's decision as to whether to undergo surgery.

Many medical schools and schools in general throughout the world already have programmes to educate high school students on issues regarding sex and sexual development. For example, in the Netherlands, a sex education programme is run by the International Federation of Medical Students Association Standing Committee on Reproduction and AIDS. This organization trains medical students to educate high school students on the subjects of reproduction, STI and HIV, and enjoying sexual encounters. Many teenagers are more open about subjects such as sex or the pleasure associated with having sex and not only the dangers associated with sex (these aspects being highly important but also very delicate subjects) when talking with peers than with adults, who could be in a position of authority. This education programme provides a good opportunity to discuss genital anatomy, natural variations in appearance, and function. Most importantly, education could normalize the variations in the way that students perceive the human body and maybe reduce the effect of social or conventional media.

Currently, much information is accessed through the Internet and social media and reliable information is hard to find, mostly owing to modified images of genitalia. Furthermore, parents might attempt to limit or control information gained by their children via the Internet concerning sex; however, many young people gain access despite being restricted in this manner. These factors might enhance the prevalence of misinformation and, therefore, affect genital self-image negatively. Creating a web-based learning environment where people can chat with experts, ask questions, play games, and find information could be a solution to providing reliable, easy to find information. In an era of eHealth, this web-based learning environment could be the best way to reach young people. Ideally, this platform would be developed by young people for young people using their vocabulary and meeting their expectations. Such an environment would enable children to educate themselves in a fun, anonymous, and safe way in the privacy of their own room. Subjects that could be covered include genital anatomy variation, body image, self-esteem, relationships, sexuality, and pleasurable consensual sex alongside conventional topics, such as STIs and HIV. Delivery of education must be in the vocabulary of the target group, be appealing, and be honest.

Future research should evaluate the effects of counselling and education on genital self-image and desire for surgery. Observed effects could form the basis for establishing recommendations for treatment and improve the care of women requesting labiaplasty. Combining the effects of counselling with the effects of treatment, whether surgical or not, could improve our understanding of patients' desires and whether their expectations have been reached. This information could contribute to improved treatment of patients who request surgery that is not medically indicated, as a part of a well-informed, shared-decision-making process.

Conclusions

Dissatisfaction with genital appearance is the primary motivation of women who request labiaplasty, but physical complaints associated with the labia minora, such as pain, infection, discomfort during various physical activities including sexual intercourse, and difficulties with personal hygiene, are also reported. The clinician must evaluate the patient fully when presented with a desire for aesthetic surgery (including psychological testing and educational physical examination) in order to preoperatively identify mental health issues or pelvic floor disorders and distinguish those issues from patients who have true labial hypertrophy. For those women who have true hypertrophy without a pelvic floor element and whose motivation is of a psychological nature, several options for counselling and education about genital anatomy, variation, and function might be useful in reducing the desire for cosmetic surgery. Unfortunately for those women who maintain a wish for labiaplasty, only inconclusive evidence is available for each of the different surgical techniques, which illustrates the urgent need for PROMs, preferably a Genital-Q. A balance must be reached in which women are protected from undergoing unnecessary surgery but their autonomy is respected.

Publisher's note

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Review criteria

Relevant papers were sourced from the Medline, EMBASE, and PsycINFO electronic databases between June and October 2016. The keywords and index terms, including applicable MeSH and Emtree terms, were applied to each database. Search terms were generated under three broad headings referring to subject matter: labia; surgery; and self-contempt. The following corresponding MeSH terms were applied to Medline searches: “labia and vulva”; “surgery and operative”; and “self-contempt”. Reference lists were checked for relevant articles. Experts in the field were contacted for relevant articles. No restrictions were placed on date of publication. The search was limited to publications in the Dutch, English, or German language. Information from commentaries, conferences, and published abstracts was excluded.

References

  1. 1

    Chavis, W. M., LaFerla, J. J. & Niccolini, R. Plastic repair of elongated, hypertrophic labia minora. A case report. J. Reprod.Med. 34, 373–375 (1989).

    CAS  PubMed  Google Scholar 

  2. 2

    Hagisawa, S. & Arisaka, O. Effect of excess estrogen on breast and external genitalia development in growth hormone deficiency. J. Pediatr. Adolesc. Gynecol. 25, 61–63 (2012).

    Article  Google Scholar 

  3. 3

    Giraldo, F., Gonzalez, C. & de Haro, F. Central wedge nymphectomy with a 90-degree Z-plasty for aesthetic reduction of the labia minora. Plast. Reconstr Surg. 113, 1820–1825 (2004).

    Article  Google Scholar 

  4. 4

    Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 378: vaginal “rejuvenation” and cosmetic procedures. 110, 737–738 (2007).

  5. 5

    Gonzalez, P. I. Classification of hypertrophy of labia minora: consideration of a multiple component approach. Surg. Technol. Int. 27, 191–194 (2015).

    PubMed  Google Scholar 

  6. 6

    Crouch, N. S., Deans, R., Michala, L., Liao, L. M. & Creighton, S. M. Clinical characteristics of well women seeking labial reduction surgery: a prospective study. BJOG 118, 1507–1510 (2011).

    CAS  Article  Google Scholar 

  7. 7

    Burger, M. P. M. Het neotene genitaal [DUTCH]. Nederlands Tijdschrift Voor Obstetrie & Gynaecologie 121, 220–223 (2015).

    Google Scholar 

  8. 8

    Mauriceau, F. Traité des Maladies des Femmes Grosses et de Celles qui sont Accouchées [FRENCH] 3rd edn (Par la Compagnie des libraires, Paris, 1681).

    Google Scholar 

  9. 9

    Meissner, F. L. Die Frauenzimmerkrankheiten nach den neuesten Ansichten und Erfahrungen, ersten Bandes erste Abtheilung [GERMAN] (Otto Wigand, Leipzig, 1842).

    Google Scholar 

  10. 10

    Treub, H. Leerboek der Gynaecologie (van Doesburgh, Leiden,1892).

    Google Scholar 

  11. 11

    Goodman, M. P. Female cosmetic genital surgery. Obstetr. Gynecol. 113, 154–159 (2009).

    Article  Google Scholar 

  12. 12

    Placik, O. J. & Arkins, J. P. Plastic surgery trends parallel Playboy magazine: the pudenda preoccupation. Aesthet. Surg. J. 34, 1083–1090 (2014).

    Article  Google Scholar 

  13. 13

    Alter, G. J. Aesthetic labia minora and clitoral hood reduction using extended central wedge resection. Plast. Reconstr. Surg. 122, 1780–1789 (2008).

    CAS  Article  Google Scholar 

  14. 14

    Lowenstein, L. et al. Physicians' attitude toward female genital plastic surgery: a multinational survey. J. Sex. Med. 11, 33–39 (2014).

    Article  Google Scholar 

  15. 15

    Ellsworth, W. A. et al. Techniques for labia minora reduction: an algorithmic approach. Aesthet. Plast. Surg. 34, 105–110 (2010).

    Article  Google Scholar 

  16. 16

    Franco, T. & Diogo, F. Nympha hypertrophy. J. Bras. Ginecol. 103, 163–168 (1993).

    Google Scholar 

  17. 17

    Lloyd, J. N. S. C., Minto, C. l., Liao, L. M. & Creighton, S. M. Female genital appearance: 'normality' unfolds*. BJOG 112, 643–646 (2005).

    Article  Google Scholar 

  18. 18

    Basaran, M., Bayar, U. & Civelek, B. Characteristics of external genitalia in pre- and postmenopausal women. Climacteric 11, 416–421 (2008).

  19. 19

    Michala, L., Koliantzaki, S. & Antsaklis, A. Protruding labia minora: abnormal or just uncool? J. Psychosom. Obstet. Gynaecol. 32, 154–156 (2011).

    Article  Google Scholar 

  20. 20

    Pérez, G. M., Mubanga, M., Aznar, C. T. & Bagnol, B. Zambian women in South Africa: Insights into health experiences of labia elongation. J. Sex. Res. 52, 857–867 (2015).

    Article  Google Scholar 

  21. 21

    Choi, H. Y. & Kim, K. T. A new method for aesthetic reduction to the labia minora (the deepithelialized reduction labioplasty). Plast. Reconstr. Surg. 105, 423–424 (2000).

    Article  Google Scholar 

  22. 22

    Maas, S. M. & Hage, J. J. Functional and aesthetic labia minora reduction. Plast. Reconstr Surg. 105, 1453–1456 (2000).

    CAS  PubMed  Google Scholar 

  23. 23

    Rouzier, R. M., Louis-Sylvestre, C., Paniel, B. J. & Haddad, B. Hypertrophy of labia minora: experience with 163 reductions. Am. J. Obstet. Gynecol. 182, 35–40 (2000).

    CAS  Article  Google Scholar 

  24. 24

    Moran, C. & Lee, C. What's normal? Influencing women's perceptions of normal genitalia: an experiment involving exposure to modified and nonmodified images. BJOG 121, 761–766 (2014).

    CAS  Article  Google Scholar 

  25. 25

    Laan, E., Hesselink, S., Snijders, N. & van Lunsen, R. H. W. Young women's genital self-image and effects of exposure to pictures of natural vulva. J. Psychosom. Obstet. Gynaecol. 38, 249–255 (2017).

    Article  Google Scholar 

  26. 26

    Brauer, M. et al. Motives for vulvar surgery of women with lichen sclerosus. J. Sex. Med. 12, 2462–2473 (2015).

    Article  Google Scholar 

  27. 27

    Schober, J., Chan, J., Mayoglou, L. & Meyer-Bahlburg, H. Self-assessment of genital anatomy, sexual sensitivity and function in women focusing on the labia for surgical implications. J. Sex. Med. 7, 456 (2010).

    Google Scholar 

  28. 28

    Schick, V. R., Rima, B. N. & Calabrese, S. K. Evulvalution: the portrayal of women's external genitalia and physique across time and the current Barbie Doll ideals. J. Sex. Res. 48, 74–81 (2011).

    Article  Google Scholar 

  29. 29

    Koning, M. Female attitudes regarding labia minora appearance and reduction with consideration of media influence. Aesthet. Surg. J. 29, 65–71 (2009).

    Article  Google Scholar 

  30. 30

    Meer, P. V. D. Wij noemen haar het liefst gewoon niet en geven haar een magere 7. Híj geeft onze vagina een dikke 8. Yes, Sanoma (2007).

    Google Scholar 

  31. 31

    Martens, L. Your vagina is more beautiful than you think. YouTube https://www.youtube.com/watch?v=Dp8-dYvEfuk (2017).

    Google Scholar 

  32. 32

    Ozer, M., Laan, E. T. M. & van Lunsen, R. H. W. Read my lips: het effect van counseling van vrouwen met een verzoek tot labiareductie [DUTCH]. Reproductieve geneeskunde, gynaecologie en obstetrie 646–650 (2009).

  33. 33

    Cassell, W. A. Body awareness and somatic delusions involving sexual organs. Am. J. Psychoanal. 40, 125–135 (1980).

    CAS  Article  Google Scholar 

  34. 34

    Amos, N. & McCabe, M. Positive perceptions of genital appearance and feeling sexually attractive: is it a matter of sexual esteem? Arch. Sex. Behav. 45, 1249–1258 (2016).

    Article  Google Scholar 

  35. 35

    Reinholtz, R. K. & Muehlenhard, C. L. Genital perceptions and sexual activity in a college population. J. Sex. Res. 32, 155–165 (1995).

    Article  Google Scholar 

  36. 36

    Berman, L., Berman, J., Miles, M., Pollets, D. & Powell, J. A. Genital self-image as a component of sexual health: relationship between genital self-image, female sexual function, and quality of life measures. J. Sex. Marital Ther. 29 (Suppl. 1), 11–21 (2003).

    Article  Google Scholar 

  37. 37

    Schick, V. R., Calabrese, S. K., Rima, B. N. & Zucker, A. N. Genital appearance dissatisfaction: Implications for women's genital image self-consciousness, sexual esteem, sexual satisfaction, and sexual risk. Psychol. Women Q. 34, 394–404 (2010).

    Article  Google Scholar 

  38. 38

    Schober, J. M., Alguacil, N. M., Cooper, R. S., Pfaff, D. W. & Meyer-Bahlburg, H. F. Self-assessment of anatomy, sexual sensitivity, and function of the labia and vagina. Clin. Anat. 28, 355–362 (2015).

    Article  Google Scholar 

  39. 39

    Placik, O. J. & Arkins, J. P. A prospective evaluation of female external genitalia sensitivity to pressure following labia minora reduction and clitoral hood reduction. Plast. Reconstr. Surg. 136, 442–452 (2015).

    Article  Google Scholar 

  40. 40

    McDougall, L. J. Towards a clean slit: how medicine and notions of normality are shaping female genital aesthetics. Cult. Health Sex. 15, 774–787 (2013).

    Article  Google Scholar 

  41. 41

    Veale, D. et al. Validation of genital appearance satisfaction scale and the cosmetic procedure screening scale for women seeking labiaplasty. J. Psychosomat. Obstetr. Gynecol. 34, 46–52 (2013).

    Article  Google Scholar 

  42. 42

    Hungry Beast The labiaplasty FAD? YouTube https://www.youtube.com/watch?v=pK9GtT-khb0&oref=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DpK9GtT-khb0&has_verified=1 (2011).

  43. 43

    Reddy, J. & Laufer, M. R. Hypertrophic labia minora. J. Pediatr. Adolesc. Gynecol. 23, 3–6 (2010).

    Article  Google Scholar 

  44. 44

    Zwier, S. “What motivates her”: motivations for considering labial reduction surgery as recounted on women's online communities and surgeons' websites. Sex. Med. 2, 16–23 (2014).

    Article  Google Scholar 

  45. 45

    Crouch, N. S. & Creighton, S. M. Long-term functional outcomes of female genital reconstruction in childhood. BJU Int. 100, 403–407 (2007).

    Article  Google Scholar 

  46. 46

    Bramwell, R., Morland, C. & Garden, A. S. Expectations and experience of labial reduction: a qualitative study. BJOG 114, 1493–1499 (2007).

    CAS  Article  Google Scholar 

  47. 47

    Sharp, G., Tiggemann, M. & Mattiske, J. Predictors of consideration of labiaplasty: an extension of the tripartite influence model of beauty ideals. Psychol. Women Q. 39, 182–193 (2015).

    Article  Google Scholar 

  48. 48

    Veale, D. et al. A comparison of risk factors for women seeking labiaplasty compared to those not seeking labiaplasty. Body Image. 11, 57–62 (2014).

    Article  Google Scholar 

  49. 49

    Sharp, G., Tiggemann, M. & Mattiske, J. Factors that influence the decision to undergo labiaplasty: media, relationships, and psychological well-being. Aesthet. Surg. J. 36, 469–478 (2016).

    Article  Google Scholar 

  50. 50

    Laumann, E. O. & Rosen, R. C. Sexual dysfunction United States. Prevalence predictors. JAMA. 281, 537–544 (1999).

    CAS  Article  Google Scholar 

  51. 51

    Veale, D. et al. Psychological characteristics and motivation of women seeking labiaplasty. Psychol. Med. 44, 555–566 (2014).

    CAS  Article  Google Scholar 

  52. 52

    Reitsma, W., Mourits, M. J. E., Koning, M., Pascal, A. & van der Lei, B. No (wo)man is an island—the influence of physicians' personal predisposition to labia minora appearance on their clinical decision making: a cross-sectional survey. J. Sex. Med. 8, 2377–2385 (2011).

    Article  Google Scholar 

  53. 53

    Iglesia, C. B., Yurteri-Kaplan, L. & Alinsod, R. Female genital cosmetic surgery: a review of techniques and outcomes. Int. Urogynecol. J. 24, 1997–2009 (2013).

    Article  Google Scholar 

  54. 54

    Felicio Y. Labial surgery. Aesthet. Surg. J. 27, 223–228 (2007).

    Google Scholar 

  55. 55

    Laufer, M. R. G. & Galvin, W. J. Labia hypertrophy: a new surgical approach. Adolesc. Pediatr. Gynecol. 8, 39–41 (1995).

    Article  Google Scholar 

  56. 56

    Alter, G. A new technique for aesthetic labia minora reduction. Ann. Plast. Surg. 40, 287–290 (1998).

    CAS  Article  Google Scholar 

  57. 57

    Kelishadi, S. S., Elston, J. B., Rao, A. J., Tutela, J. P. & Mizuguchi, N. N. Posterior wedge resection: a more aesthetic labiaplasty. Aesthet. Surg. J. 33, 847–853 (2013).

    Article  Google Scholar 

  58. 58

    Munhoz, A. M. et al. Aesthetic labia minora reduction with inferior wedge resection and superior pedicle flap reconstruction. Plast. Reconstruct. Surg. 118, 1237–1247 (2006).

    CAS  Article  Google Scholar 

  59. 59

    Ostrzenski, A. Fenestration labioreduction of the labium minus: a new surgical intervention concept. ISRN Obstet. Gynecol. 2014, 1–7 (2014).

    Article  Google Scholar 

  60. 60

    OCEBM Levels of Evidence Working Group. The Oxford levels of evidence 2. CEBM http://www.cebm.net/wp-content/uploads/2014/06/CEBM-Levels-of-Evidence-2.1.pdf (2011).

  61. 61

    Lista, F., Mistry, B. D., Singh, Y. & Ahmad, J. The safety of aesthetic labiaplasty: a plastic surgery experience. Aesthet. Surg. J. 35, 689–695 (2015).

    Article  Google Scholar 

  62. 62

    Goodman, M. P. Female genital cosmetic and plastic surgery: a review. J. Sex. Med. 8, 1813–1825 (2011).

    Article  Google Scholar 

  63. 63

    Goodman, M. P. et al. Evaluation of body image and sexual satisfaction in women undergoing female genital plastic/cosmetic surgery. Aesthet. Surg. J. 36, 1048–1057 (2016).

    Article  Google Scholar 

  64. 64

    Jothilakshmi, P. K., Salvi, N. R., Hayden, B. E. & Bose-Haider, B. Labial reduction in adolescent population—a case series study. J. Pediatr. Adolesc. Gynecol. 22, 53–55 (2009).

    CAS  Article  Google Scholar 

  65. 65

    Veale, D. et al. Psychosexual outcome after labiaplasty: a prospective case-comparison study. Int. Urogynecol. J. 25, 831–839 (2014).

    Article  Google Scholar 

  66. 66

    Klassen, A. F. et al. Development and psychometric validation of the FACE-Q Skin, Lips, and Facial Rhytids Appearance Scales and Adverse Effects Checklists for Cosmetic Procedures. JAMA Dermatol. 152, 443–451 (2016).

    Article  Google Scholar 

  67. 67

    J. Johnsdotter, S. & Essén, B. Genitals and ethnicity: The politics of genital modifications. Reprod. Health Matters. 18, 29–37 (2010).

    Article  Google Scholar 

  68. 68

    Borkenhagen, A. & Kentenich, H. Cosmetic genital surgery as “normalizing practice”. Sexuologie 16, 37–42 (2009).

    Google Scholar 

  69. 69

    Bewley, S. Should a psychiatrist give legal advice on cosmetic genital surgery? Arch. Sex. Behav. 42, 323 (2013).

    Article  Google Scholar 

  70. 70

    Cartwright, R. & Cardozo, L. FOR: women should be free to opt for cosmetic genital surgery. BJOG 121, 767 (2014).

    Article  Google Scholar 

  71. 71

    Matlock, D. L. & Simopoulos, A. FOR: cosmetic vulvar surgery is a safe and effective option for our patients. BJOG 121, 767 (2014).

    Article  Google Scholar 

  72. 72

    Creighton, S. AGAINST: labiaplasty is an unnecessary cosmetic procedure. BJOG 121, 768 (2014).

    Article  Google Scholar 

  73. 73

    Tracy, E. E. Elective vulvoplasty: a bandage that might hurt. Obstet. Gynecol. 109, 1179–1180 (2007).

    Article  Google Scholar 

  74. 74

    Westermann, L. B. et al. Attitudes Regarding Labial Hypertrophy and Labiaplasty: A survey of members of the Society of Gynecologic Surgeons and the North American Society for Pediatric and Adolescent Gynecology. Female Pelvic Med. Reconstr. Surg. 22, 175–179 (2016).

    Article  Google Scholar 

  75. 75

    Nederlandse Vereniging voor Plastische Chirurgie & Nederlandse Vereniging voor Obstetrie en Gynaecologie. Counseling en behandeling van vrouwen met een verzoek om reductie van de labia minora. NVPC https://www.nvpc.nl/uploads/stand/22labiumreductie_rl.pdf (2008).

  76. 76

    Royal College of Obstetricians and Gynaecologists. Joint RCOG/BritSPAG release: issues surrounding women and girls undergoing female genital cosmetic surgery explored. RCOG https://www.rcog.org.uk/globalassets/documents/guidelines/ethics-issues-and-resources/rcog-fgcs-ethical-opinion-paper.pdf (2013).

  77. 77

    Society of Obstetricians and Gynaecologsts of Canada. Female genital cosmetic surgery. SOGC https://sogc.org/wp-content/uploads/2013/09/December2013-CPG300-ENG-Online_final.pdf (2013).

  78. 78

    van Moorst, B. R., van Lunssen, R. H., van Dijken, D. K. & Salvatore, C. M. Backgrounds of women applying for hymen reconstruction, the effects of counselling on myths and misunderstandings about virginity, and the results of hymen reconstruction. Eur. J. Contracept. Reprod. Health Care. 17, 93–105 (2012).

    Article  Google Scholar 

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M.Ö., I.M., and E.P.J. researched data for the article. M.Ö. decided the content. M.Ö. and I.M. wrote the manuscript, and M.Ö. and M.G.M. reviewed and edited the article before submission.

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Correspondence to Müjde Özer.

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Özer, M., Mortimore, I., Jansma, E. et al. Labiaplasty: motivation, techniques, and ethics. Nat Rev Urol 15, 175–189 (2018). https://doi.org/10.1038/nrurol.2018.1

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