According to the 2016 report of the American Society of Plastic Surgeons , the number of people seeking cosmetic surgery continues to rise, with an increase of 3% from the previous year. The majority (92%) of the consumers were women. This amounted to a total of 17.1 million cosmetic surgeries performed in the United States. Breast augmentation remains the most popular and common cosmetic procedure, with more than 290,000 American women receiving breast enhancement in 2016, up 4% from 2015 and up 37% since the year 2000.
Empirical research on psychological factors in the uptake of breast augmentation is sparse. Some research has studied background psychological and personality characteristics. A review of 65 studies found that in general, women who sought cosmetic surgery were more likely to have a narcissistic personality (25% of those seeking surgery vs. 1% of the general population) defined by an unexplained grandiosity and need for admiration . The review also found those seeking cosmetic procedures are more likely (10% of the patients vs. 1.8% of the general population) to have a histrionic personality, defined in terms of attention-seeking behaviour and extreme emotionality.
Women seeking breast augmentation are more likely to be Caucasian, in the age range of 20s to mid-40s, thin and tall, well educated, and have a higher likelihood of a history of depression and anxiety . They are also more likely to be a smoker, to regularly consume alcohol, and to have had a psychiatric hospital admission in the past . A study by Moser and Aiken  applied the Theory of Planned Behaviour to explore intentions for seeking breast augmentation, from both positive and negative cognitive and emotional perspectives. Through a combination of 11 focus groups and subsequent questionnaires administered to 400 women who were considering breast augmentation, they found that women’s intentions were significantly predicted by anticipated regret (i.e., women expecting to regret the surgery were less likely to seek surgery), and subjective norms and attitudes (i.e., women attuned to the approval from others were more likely to seek surgery). Women’s indirect attitudes, such as expectations for better self-image, enhanced sex appeal, and better perceived appearance were associated with lower levels of anticipated regret over having the breast augmentation. The findings from this study suggest that psychosocial factors can predict cosmetic surgery uptake and outcome. Psychosocial research could therefore usefully inform psychological assessment and interventions.
Although female genital cosmetic surgery (FGCS) was not among the top five most popular cosmetic surgeries in the 2016 report of the American Society of Plastic Surgeons , it was notable that FGCS was up 39% in 2016 from 2015, an increase that was greater than in every other type of cosmetic surgery. Though systematic reviews have yet to be conducted on the characteristics of women seeking FGCS, insights into personality types and motives for surgery may be drawn from the literature examining other individuals who seek cosmetic procedures. Some argue that women seeking breast augmentation share similar traits to women seeking FGCS given that both entail alteration to parts of the body associated with female sexuality, although the surgical procedures are clearly different, with different possible complications. Indeed, among women seeking FGCS, previous breast augmentation was the most common prior cosmetic procedure obtained by this group .
Among the different types of FGCS, labiaplasty, or surgical alteration to the labia majora and minora, has become the most popular surgery, founded on widespread denigration of female genitalia. Often described as a passive receptacle for the penis, female genitals have been depicted as disgusting, sexually inadequate, vulnerable/abused and even dangerous . The problem-saturated views of female genitalia have undoubtedly impacted on how women view female genitals including their own . A study with young adult women showed a clear relationship between women’s perceptions of female genitalia and their own genital self-perceptions .
Anxiety associated with perceived vulvar anomalies has undoubtedly increased over recent decades. Hairless, undefined vulvas that have no protruding labia minora have been increasingly emphasised in Western culture and media [8–10]. Women have become more self-conscious of their genitals as a result of these depictions [3,11,12]. Pubic hair removal has thus become popular if not normative and further draws attention to vulvar appearance details , in private and public spaces (e.g., communal showers). Women’s preference and perception of ‘normal’ is now the ‘Barbie doll ideal’ . For example, women will rate vulvar images as more ‘normal’ and ‘representative of society’s ideal’ with digital and surgical modifications .
In reality, the notion of ‘normal’ is a fallacy given that, like snowflakes, no two vulvas look the same. Their size, shape, texture and colour vary enormously; these variations are not reliably predicted by differences in ethnicity, hormone use, sexual history and other personal and demographic dimensions . Sexualising media have helped to construct a ‘designer vulva’ that minimises naturally occurring normal variations .
Given the subjectivity in the perception of what is ‘normal’ when it comes to vulvar appearance, there is a critical need to consider the key role for psychological factors in women’s genital self-perceptions, dissatisfaction and the desire for cosmetic alteration. However, the literature on psychological predictors of FGCS is not only sparse, but biased, owing to the expectancy of patients and the surgeon carrying out costly assessments. For example, women may downplay any negative or judgemental attitudes that could be perceived as contributing to their requests. Among the existing studies that have examined psychological characteristics of women seeking FGCS, there is evidence for the influence of personal negative judgements and evaluations, perceived partner-related dissatisfaction and perceived negative evaluations by others. In order to adequately consider each of these domains in the context of a psychosocial assessment of women seeking FGCS, it is important to explore each of these in turn.
A Google search of ‘labiaplasty’ in 2018 produced 1.32 million hits. Google analytics keep track of such searches generated by high-risk women, and increase direct-to-consumer marketed advertisements that offer low-cost procedures, feeding the consumer market that thrives off self-conscious women [17–20]. In a general sample of women, self-esteem is significantly and negatively associated with satisfaction with genital appearance, suggesting that women with low self-esteem may be particularly vulnerable to appearance schemas (defined as cognitive structures that organise one’s experience and actions related to their appearance) , though in another study there were no significant differences in self-esteem between women who were and those who were not seeking FGCS . There is significant pressure on women to meet impossible and unrealistic beauty standards. These findings suggest that women with low self-esteem are especially at risk, leading to a vicious cycle such that women’s insecurities about their body lead to more exposure to, and vulnerability of, FGCS practices that promise to quell anxieties and raise satisfaction. Indeed, aesthetic dissatisfaction is the leading reason for seeking FGCS and supersedes functional reasons such as vulvar discomfort or pain .
In the only controlled study of women seeking FGCS (n = 55) versus those who were not (n = 70), the surgery seekers had a lower overall quality of life and body image, although they were no more likely to experience anxiety and depression than the control group .
Some women may seek FGCS as a means of improving sexual function. Sexual difficulties affect up to a third of women across ages , and psychological factors, such as depression, anxiety and body image, are strong predictors of women’s sexual response and satisfaction . Some advertisements for FGCS promise to improve sexual function, and according to a short-term retrospective study conducted by the surgical providers, 92% of their patients and their partners reported satisfaction and improved sexual responses with vaginal tightening and labiaplasty . In the only prospective study to evaluate the effects of FGCS on sexual response, only 18 of the original 33 women evaluated at pre-surgery completed post-surgery measures of sexual function, and even fewer completed the follow-up 6–9 months later . Most measures of sexual response did not significantly change post-FGCS. Thus, whereas sexual satisfaction improved at immediate post-surgery, rates fell back to baseline levels when women were assessed at follow-up.
The lack of a control group and the bias inherent in having the treatment team conducting the assessments means that the reliability of these findings is questionable (see Chapter 6, this volume). Given how common relationship and sexual difficulties and dissatisfaction are for women, including younger women [24,28], the promise of positive sexual outcomes would be a compelling motivation to seek cosmetic genital procedures. However, women are not likely informed that the impact of these surgical procedures on the underlying vascular and neural pathways that contribute to sexual response and pleasure is totally unknown (Chapters 2 and 9, this volume).
In summary, although women may seek FGCS to increase sexual desire and/or improve sexual response, at present there is no evidence to suggest that these expectations are met, especially over the long term. The implications for counselling women seeking FGCS are considered in a later section.
As a group, women seeking cosmetic labiaplasty are more self-conscious, believe that they are less attractive to their partner, and tend to be less satisfied with their lives overall [3,29]. Being in a relationship seems to buffer somewhat against these negative psychological attributions . Although women seeking labiaplasty are concerned that partners do not find them attractive , there is evidence that partners themselves have more favourable views than the women might expect . Given women’s distorted views about their partner’s perception of their genitals, it can be useful for women who are in relationships to be accompanied by their sexual partner at the pre-surgery assessment. This has the advantage of allowing a clinician to identify partner-related perspectives and to gauge whether outcome expectancy is realistic. In a controlled comparison of one group of women seeking and another not seeking FGCS, there were no group differences in the women’s reported relationship satisfaction . The authors concluded that women are not likely to be seeking FGCS as a means of improving relationship satisfaction. Nonetheless, women may still be having specific worries about a partner’s view of her genitals, even if the overall relationship was unproblematic.
In one of the few studies comparing women seeking FGCS to a control group , the influence of media ideals and women’s internalisation of those ideals differed quite significantly between groups. Those seeking FGCS were more likely to have seen more media images and expressed a stronger desire to resemble those images. In particular, internet images and exposure to advertisements for FGCS were identified as predictors of wish for FGCS . This replicated findings in other studies [11,30].
Negative evaluation by others or negative comments about female genitals made by others can also impact on female genital self-image. In one study, a third of the women who sought FGCS had experienced negative comments by partners, family members or friends . Bullying behaviour is known to contribute to self-consciousness, poor psychological functioning and increased desire for cosmetic procedures in teenagers . It is therefore especially important that during the consultation, the clinician assesses whether there have been harmful comments by others, and whether these comments were actual, perceived or anticipated.
Body dysmorphic disorder (BDD) is a diagnosis in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders  and characterised by one or more perceived defects of flaws in physical appearance. The perceived flaw may be not observed or observed only minimally by others. Nevertheless, to the person affected, it evokes clinically significant distress or impairment which is associated with compensatory behaviours such as mirror checking, reassurance seeking and/or comparing her appearance to that of others. BDD typically begins in adolescence and can have a chronic course punctuated by remissions and relapses . People with BDD make maladaptive interpretations of their appearance, leading to increased anxiety, depression and unhelpful behaviours .
BDD is more prevalent among cosmetic surgery users. Only 2% of the general population meet formal criteria for BDD  compared to 18–20% of women requesting labiaplasty, according to some studies [20,23]. This is in line with the 14–24.5% prevalence in people pursuing aesthetic surgery . Although there could be short-term improvement in BDD symptoms, cosmetic surgery does not lead to long-term improvement of BDD symptoms [34,35]. While only a proportion of women seeking FGCS would meet formal diagnostic criteria for BDD, we strongly recommend that BDD is part of a comprehensive psychological assessment before surgery. Guidelines for the psychological assessment of BDD among women seeking FGCS are outlined in a subsequent section.
The literature is scant when it comes to evaluating the psychological characteristics of women seeking FGCS. Even less is known about the psychological, relational and sexual outcomes of FGCS. More importantly, among the existing studies, this literature suffers from significant methodological limitations. These are outlined in Table 13.1, in which strategies for future research are also suggested.
|Existing limitation||Proposed alternative for future research|
|Sample sizes tend to be very small.||Studies need to be powered to detect significant differences. Effect sizes, response rates and attrition rates at follow-ups should be reported in all studies.|
|Studies do not include a comparison group of women with similar demographic profiles.||Demographically matched groups of women not seeking FGCS need to be included.|
|Retrospective design||Outcomes should be measured before and after surgery and at a future follow-up time point.|
|Participants are recruited from specialty and/or private clinics that offer FGCS, which may bias outcomes given that women have typically paid expenses out-of-pocket for such procedures, and cognitive dissonance theory, which posits that people seek to have harmony between behaviour (spending money on cosmetic procedures) and beliefs (seeking FGCS is a good thing), is at play.||Recruitment should be broader, from public hospitals and health centres. There is a critical need for future research to take account of cognitive dissonance factors in women’s self-reported FGCS outcomes.|
|Lack of long-term follow-up of women who have received FGCS – there is preliminary evidence that even when there are self-reported improvements after surgery (at least in the domain of sexual satisfaction), these tend to disappear by 9-month follow-up .||Women should be assessed in the long-term follow-up.|
|Regret long after the surgery is not typically measured, yet may impact outcomes.||Together with measuring cognitive dissonance , efforts should be made to measure regret.|
This topic is addressed in detail in Chapter 12 (this volume). Suffice to say that physicians at the point of entry into the medical system play a crucial role in beginning the process of critical psychoeducation for women seeking FGCS  influenced by factors such as appearance concerns, physical discomfort, media influence, genital shame and perceived partner expectation . Most women requesting labiaplasty have normative labial dimensions . Visible labia minora are as common as recessed labia minora . The viewing of manipulated vulval images can negatively influence a woman’s perception of what she considers normal and desirable [14,41], while viewing of images of natural vulvas can improve genital self-image  We strongly recommend that health care providers keep a variety of educational resources in their office setting including, for example, picture books like Petals , educational websites like the Labia Library  and Great Wall of Vagina  and videos such as Labiaplasty  (see also Resources in the appendix). Surgery should never be offered on the initial consultation and never to teenage girls whose genital development is as yet incomplete [37,39]. Adolescents should be supported in their exploration of identity and self-concept rather than being operated on .
The probing for pre-existing psychological factors such as poor self-esteem, eating problems and tendencies to anxiety require the skills of a psychological clinician. In our experience, this kind of integrated care is far from typical in the cosmetic surgery industry. Nevertheless, we strongly recommend that every woman seeking FGCS undergoes a comprehensive psychosocial and psychosexual assessment by a qualified mental health expert. The components of this assessment, as outlined in Table 13.2, should include (1) motivations for FGCS; (2) assessment of psychiatric symptoms and diagnoses, including BDD; (3) assessment of body image, self-esteem and genital self-image; (4) sexual and relationship factors, including current sexual response and expectations of change with surgery; and (5) exposure to and influence of media ideals, and associated perceptions of others’ evaluations.
|Motivation for FGCS||Assess for motivations related to perceived physical flaw in genital appearance, concerns about appearing abnormal, physical discomfort and pain. Given that women may be highly motivated to receive FGCS and aware of barriers or difficulties toward that end, women may minimise psychological motivations and emphasise functional ones.|
|Assessment of psychiatric symptoms and diagnoses, including BDD||A history of anxiety and depression are significant risk factors for poor psychosocial outcomes after cosmetic surgery and must be assessed. This includes history as well as current symptoms of an anxiety disorder and major depressive disorder, as well as subthreshold clinical syndromes. Given that women with BDD are more likely to seek cosmetic surgeries of all types, it is important that the clinician assess for the symptoms of BDD and determine the extent to which perceived distortions of the genitals are contributing to the desire for FGCS.|
|Assessment of body image, self-esteem, and genital self-image||Assess general attitudes to female genitalia and the individual’s perceptions of her own genitals. Ask about her perception of normal and consider showing photos of a range of vulvas during this assessment to gauge reactions on the perception of what is normal. Assess self-esteem by asking questions about the woman’s life more generally and her feelings about key aspects of her life.|
|Sexual and relationship factors, including current sexual response and expectations of change with surgery||Ask about all domains of sexual function: desire, arousal, lubrication, orgasm, sexual satisfaction and sexual pain. Validated measures can also be used. Inquire about the woman’s expectations about the impact of FGCS on sexual functioning. If in a relationship, ask about partner’s own sexual function, and her perceptions of the partner’s view of her sexual functioning. Ask about pressure placed on her by a partner to seek FGCS, and whether this pressure is actual or perceived. If possible, try to assess the partner separately to inquire about the woman’s reasons for FGCS. This might also include asking about partner’s perceptions of the look of the woman’s genitals and what has been expressed.|
|Exposure to and influence of media ideals, and associated perceptions of others’ evaluations||Inquire about exposure to pornography and the woman’s attitudes, beliefs and emotions when viewing such images, and how those images might have influenced her wish for FGCS. Assess for negative evaluation by others or negative comments about female genitals made by others. Bullying behaviour is known to contribute to self-consciousness and poor psychological functioning, so that a desire for cosmetic procedures in teenagers should be assessed.|
We recommend that the provider carry out a thorough assessment of BDD using the criteria laid out by the DSM-5 . A diagnosis of BDD is a predictor of poorer psychosocial outcomes after cosmetic surgery , and effort should therefore be made to screen for BDD in advance. This entails a careful, respectful and Socratic-style questioning of preoccupations with the appearance of the genitals. In some cases, we would recommend the use of a validated assessment of BDD, such as the Body Dysmorphic Disorder Questionnaire  which can be used as a screening tool, or the Body Dysmorphic Disorder modification of the Yale–Brown Obsessive–Compulsive Scale  as a much more detailed assessment of BDD.
Furthermore, as symptoms of BDD may overlap with symptoms of a social anxiety disorder , the latter should also be part of the assessment. Essentially, it is important to decipher whether the woman’s fear of being negatively evaluated by a partner or by others is due to her appearance or to a more general fear of being embarrassed.
Depending on the range and severity of distorted body-related thoughts experienced by the woman seeking FGCS, and by the range and intensity of the associated emotions, an individualised psychological treatment plan may be required. Ideally, this would be offered as an alternative to FGCS. There is, however, as yet no evidence that psychological interventions can reduce the prevalence of FGCS. In our own experience working within a multidisciplinary team in a large metropolitan centre, however, targeted psychological therapy can prevent or delay surgery in the majority of cases. Even if the woman has already decided on surgery, should there be clear indications for psychological interventions, they could take place post-surgery at some point.
Based on the generic empirical literature for body image concerns and distortions, we recommend individually tailored applications of psycho-therapeutic techniques drawn on: (1) behaviour therapy, (2) cognitive behavioural therapy, (3) mindfulness-based therapy and (4) sex therapy.
Behaviour therapy focuses on identifying problematic behaviours including avoidance. This type of work focuses on helping people to take a step at a time to distract from, delay, or inhibit performing unhelpful behaviours and on taking up more adaptive new behaviours. A component of behaviour therapy is exposure. This involves the progressive and systematic exposure to what is feared or avoided, in this case an area of the body, that elicits anxiety and shame. By building exposure to the feared object or situation, anxiety will progressively decrease. This is often part of a program known as systematic desensitisation . For example, in the case of a woman with genital image concerns, she may be guided to first construct a hierarchy of fear or aversion. The hierarchy may include items such as looking at an image of a vulva in a book using, e.g., available resources [43–46], looking at a vulva in a video online, looking at her own vulva, inspecting her labia more closely with a hand-held mirror, asking a partner to look closely at her vulva and so on. These items are rank ordered on the hierarchy and the woman is exposed to the easiest item and progresses to the more challenging ones. After several weeks of consistent practice, she may be able to progress to the most distressing item (e.g., asking a partner to look closely at her vulva) with significantly less, or hopefully minimal, distress.
Another configuration of mirror exposure technique may involve the woman fixing her gaze on her reflection in the mirror, and describing her body from head to toe, and then from toe to head, using neutral descriptive language and avoiding judgement or value-laden words as if ‘describing it to a blind person’ . Three sessions administered to women with significant body-related concerns were sufficient to significantly reduce body checking, body image avoidance, body dissatisfaction, depression and low self-esteem. Since this intervention combined exposure therapy (sustained looking at the feared object) together with mindful describing without judgement, the authors were not able to decipher which aspect of the treatment contributed to the positive outcomes. It seems that either modality, or their combination, would be suitable for women with concerns about vulvar image. More information about mindfulness-based approaches appears in the text that follows.