From Reassurance of Diversity to the Patient’s Perspective

The first published article on labiaplasty appeared in 1971, and between 1971 and 2008, 20 reports on labiaplasty appeared in medical journals [8]. Beginning with the first article discussing labiaplasty, clinicians noted female patients came to them out of concern about the size of their labia. In his 1971 article, American gynecologist Capraro wrote about occasions when practitioners would see girls “with marked hypertrophy of the labia minora” and the girl – or her mother – would be worried about it as an “abnormality” [10]. French gynecologist Rouzier and colleagues in 2000 similarly noted “large labia projecting beyond the labia majora are occasionally a concern among adolescent and adult women” [11].

However, some clinicians noted that when presented with a patient concerned about the size or shape of her labia, they found reassuring the patient about the diversity of female genitalia usually sufficed. Capraro said patients usually only needed “reassurance that this is simply a variant of normal, such as big ears or big feet” [10]. In 1988, American gynecologists Gowen and Martin wrote “often all that is needed” was to reassure the woman variation was normal [12]. In 1989, American physicians Chavis, LaFerla, and Niccolini wrote “in many cases concern about vulvar appearance can be resolved by reassurance alone” [13]. Similarly, in 1997, Australian physician Fliegner noted women concerned with “labia minora projecting beyond the labia majora” often “require reassurance only” [14]. In a 1999 article, Netherland physicians Maas and Hage agreed, writing “concerns about the appearance of labia minora extending beyond the labia majora can often be alleviated by explaining variation in size is normal” [15]. In 2004, Japanese gynecologists wrote that most patients who “subjectively reported hypertrophic labia minora require reassurance” of the diversity of female genitalia [16]. In 2008, New Zealand practitioners Lynch and colleagues wrote “females need to be reassured that hypertrophy of the labia minora is simply a variant of the normal” [17].

By around the time of publication of Lynch’s article, however, clinicians writing about labiaplasty seemed to stop noting often all that was needed was reassuring the patient of genital diversity. Though some physicians continued to note that “normal female genitalia vary widely,” they did not state whether this was something they told their patients [18]. Instead, some practitioners suggested enlarged labia were not part of the diversity of female vulvas. For example, in 2010, American gynecologists Reddy and Laufer wrote that once enlarged labia “was considered a variant of normal anatomy,” suggesting this was no longer so [19]. Echoing this sentiment, Chinese physicians in 2012 wrote “[p]reviously, it was believed that hypertrophy of the labia minora is a variant of normal anatomy” [20]. Though Canadian physicians Lista and colleagues wrote in 2015 “it was important for plastic surgeons to stress that a patient demonstrate a variance of normal when this is the case,” since the “essence of aesthetic surgery is that plastic surgeons operate on patients who have a normal appearance with the goal being to improve their appearance,” noting to a patient genital diversity did not seem relevant to cosmetic surgery [21].

Diversity in genital appearance, then, changed from being clinically normal to normality at the discretion of the woman. This was because, as Colombian physicians wrote in 2012, women “can now compare themselves, see how others look, and decide if their genital appearance is acceptable or not” [18]. Clinicians supported the assertion that women could decide if their genitals needed surgery by stating there was “little consensus on the definition of labia minora hypertrophy” [22]. Possibly some of this shift – from reassurance about genital diversity to differing to the woman’s view of genital (ab)normality – can be tied to changes in the doctor–patient relationship, with physicians being less patriarchal and more respectful of the autonomous decision-making of their patients, a change that began in the 1970s in the United States [23]. But this change also occurred during a time of additional changes in American medicine, something I address shortly.

From Uncommon Exceptions to an Increasingly Common Offering

Though physicians writing about labiaplasty from 1971 until around 2008 often noted they reassured their patients about genital diversity, starting with the 1971 article, clinicians also noted there were exceptions to reassurance. Capraro wrote if the condition was “embarrassing to the patient, or is a source of irritation, excision, and plastic repair, may be done” [10]. In 1976, American gynecologist Radman suggested that if “abnormalities” resulted in symptoms “that are incompatible with comfort and personal hygiene” then “corrective operative procedures” should be done [24]. Similarly, in 1978, two Canadian physicians discussed surgically reducing the size of the labia of two patients who presented with “floppy” labia resulting in chafing and discomfort [25]. And in 1984, Americans Hodgkinson and Hait wrote, “reduction of the labia minora may improve the physical comfort and sexuality of some women” [7].

Similarly, Chavis and colleagues argued that, in a case such as the one they reported – when the woman “experiences mechanical difficulties, such as dyspareunia, pressure under tight clothing and difficulty cleansing after elimination because of aberrant labia,” – then “elongated labia may be amenable to effective and safe surgical treatment” [13]. Likewise, in 1995, American gynecologists Laufer and Galvin wrote that while “hypertrophy of the labia minora” was a variant of “normal anatomy,” “occasionally a patient will complain of severe symptoms that require intervention.” The most common, they believed, were “poor hygiene and problems with sexual relations” as well as a “poor sense of self-esteem” [26]. Gowen and Martin wrote there were “women with legitimate complaints” making “surgical reduction acceptable and necessary.” Such complaints included “pinching or chaffing when walking or sitting,” hygiene issues related to menstruation or bowel movements, or “interference with vaginal penetration during intercourse,” and for these patients “surgical reduction of the labia minora” is “not unreasonable” [12].

Fliegner agreed, writing that though he felt labiaplasty was “rarely required,” if the labia were enlarged to a “gross degree,” it warranted surgical reduction for “functional, aesthetic, or social reasons” [14]. Similarly, Maas and Hage noted enlarged labia minora “can be functionally or psychosocially bothersome,” including problems with irritation, “personal hygiene during menses or after bowel movements, interference with sexual intercourse, and discomfort during cycling, walking, or sitting are generally accepted as indications for surgical reduction.” Additionally, “aesthetic concerns influence the psychological and social well-being of the patient” and were further reasons for surgery [15]. Rouzier and colleagues noted while “hypertrophy of the labia minora is not a pathologic condition,” when the “patient has aesthetic or functional concerns, labia minora reduction should be proposed” [11].

Note clinicians here were suggesting that in some cases labiaplasty was indicated, but for particular, uncommon indications. The few articles published from the 1970s through the 1990s and the small number of patients in the articles – until a 1999 article reported on 13 cases, no one reported on more than three cases – signifies concern for enlarged labia to the extent surgery was proposed was unusual. Some of the clinicians writing during this time explicitly noted the infrequency of the procedure. To illustrate, Chavis and colleagues noted women’s external genitalia “represent an area on which plastic surgery is performed infrequently” [13]. In a particularly interesting, and unusual, instance, an editorial comment before Fliegner’s article stated the journal “accepted this paper for publication since we agree with the author that it is rare for patients to request surgery for enlargement of the labia minora” [14]. Similarly, Rouzier and colleagues noted they wished to “stress” that labiaplasty constituted a “very minor part of our practice” [11]. Sakamoto and colleagues wrote “medical intervention is usually unnecessary,” while in 2005, Brazilian cosmetic surgeon Munhoz and colleagues wrote, “aesthetic surgery of the female genitalia is an uncommon procedure” [16, 27]. In 1998, Alter wrote, “aesthetic surgery of the female genitalia has not been of significant interest among physicians” [28].

However, in articles published in 1989 and 1995, the authors speculated on whether physicians should perhaps offer labiaplasty because conceivably more women and adolescent girls were concerned about the size of their labias. In 1995, Laufer and Galvin stated that with the “increasing emphasis in society on physical appearance, women are more concerned about their bodies and any perceived imperfections,” a “trend” that could result in gynecologists seeing “more patients seeking treatment of asymptomatic labial enlargement” [26]. Similarly, in 1989, Chavis and colleagues wrote that as women were “socialized to consider their genitalia as ‘off limits’ for discussion,” some women were perhaps reluctant to discuss concerns with their doctors about the appearance of their labia. These women “may be silently troubled,” and the authors wondered if there could be “a considerable number of women” who were “not being helped as much as they could be because they are too uncomfortable to voice their concerns or because their physicians are reluctant to view the problem as one worthy of surgical treatment” [13]. Perhaps there was, these comments suggested, an unmet interest in labiaplasty; perhaps more women were concerned about the aesthetics of their labia or had issues concerning chaffing.

These speculations came to fruition a decade later, as physicians started noting a growing interest in the surgery. For example, Alter in 2008 wrote, “demand for labia minora reduction has increased” [29]. Additionally, in the cosmetic surgery newsletter article “The Shape of Things to Come,” the author suggested labiaplasty be added to the “popular list” of surgeries, as it was “experiencing a growth spurt” [30]. Others noted the growth of labiaplasty was a result of the increased interest in the “aesthetics of female genitalia” as “an area of concern among women over the past 10 years” [31]. This increased interest, physicians asserted, rose from popular media images of female genitals.

Clinicians noted starting in the 1980s the role the media played in women’s perceptions of their genitals. In 1984, Hodgkinson and Hait wrote the “exposure of female genitals in popular magazines allows more critical appraisal of female genital aesthetics by both men and women” [7]. But in photographs of women appearing in either tight clothing or naked in women’s magazines, a study in 2002 found the vulva area was typically obscured or depicted as smoothly curving between the woman’s thighs [32]. These images, then, failed to show the diversity of the genitalia and instead showed genitalia as uniformly flat and smooth.

In addition, however, to women’s magazines as a reference for labia depictions, clinicians also referenced sexually explicit media as influencing ideas. Alter in 1998 wrote “women have become more aware of differences in genital appearance owing to publication of nude pictures in magazines and nude presentation in movies” [28]. Labiaplasty practitioners when interviewed in the popular media often mentioned the influence of pornography as a driver of the surgery. For example, in a 2004 article, physician Matlock said, “I can’t tell you how many pages and pages of pornographic material women have brought into me saying ‘I want to look like this’” [33]. Young, the chair of the ASPS’s emerging trends task force, said in 2005 he thought the rise of labiaplasty was a result of the “mainstreaming of pornography.” Male partners “see images on the Internet or in movies and comment” to their female partners, resulting in the woman thinking “‘I didn’t know I was ‘abnormal.’ Or she doesn’t think she’s as cute,” Young said [34]. Other clinicians also pointed to explicit media motivating women to seek labiaplasty to be more in line with models in Playboy [35].

An analysis of Playboy centerfolds from 2007 to 2008, however, found the exposed labia resembled that of a prepubescent female, giving a narrow view of female genitalia [36]. Regardless, then, of why physicians stopped noting they reassured women of normality and started instead implying normality was at the discretion of the woman, this change occurred in parallel to when clinicians also began noting women approached them with images of the labia that failed to show the diversity of the labia – indeed that portrayed a very narrow view. And it also occurred alongside an increase in the popular media covering labiaplasty.

Beginning in the mid to late 2000s, clinicians noted the media as driving an increased interest from women in labiaplasty. Alter, for example, in 2008 noted that the increase in demand for labiaplasty was because of “recent media coverage of this operation” [29]. Many FGCS practitioners over the next decade similarly credited the rise in patients’ demand for labiaplasty to the increase in lay press coverage [37]. Indeed, a report in Ob. Gyn. News in 2010 noted while there had only been “a handful of papers in scientific journals” regarding labiaplasty, this number was “dwarfed by coverage of the procedure in women’s magazines and the lay press” [9].

Popular Media and the Increase of Labiaplasty

The first popular article regarding labiaplasty appeared in 1994. In the For Women First article “Intimate Surgery,” reporter Meyer interviewed “Dawn,” a 27-year-old woman embarrassed by what she considered her enlarged labia. Dawn felt “like a freak” and told Meyer she could not “wear certain outfits – nothing clingy or sexy.” Dawn was considering labiaplasty, described as a “simple outpatient operation” whereby a surgeon “snips off the excess labia tissue with a small pair of surgical scissors,” despite the out-of-pocket costs of between $1,500 and $3,000. Meyer also interviewed Antell, a New York cosmetic surgeon, who said “many women with oversize labia, like Dawn,” complain their labia can be seen through pants or chafe when they walk. These complaints, however, were not the reason Dawn was considering the surgery, nor were they apparently the only reasons for which Antell performed the surgery: as Antell said, by “having her labia trimmed” it gave “a woman greater freedom and helps her feel better about her body and about herself in general” [38].

Meyer’s article provided no evaluation of the procedure; indeed, in her critique of the article that appeared in Ms., Rogan called Meyer’s article a “free ad” for Antell, albeit one Rogan said misinformed its readers regarding typical labia and uncritically portrayed labiaplasty as a solution [39]. Some of the articles in the popular media were little short of announcements for the procedure and the clinicians – but they also indicate an uptake of labiaplasty by clinicians as an elective offering. The Toronto Sun in February 1999 told readers they no longer had to “fly to L.A. or New York to get the hottest trend in the world of cosmetic surgery – labiaplasty” as it was being offered “right here in T.O.” The article provided information about the cost and length of labiaplasty [40]. Similarly, a 2011 article in Jet described the spa of a physician in Beverly Hills that included labiaplasty, described as a procedure that “trims the labia.” And though noting cost could be high and recovery took six weeks, “for the many women who have issues with the appearance of their vagina,” labiaplasty was “worth it to be comfortable in their skin” [41].

Popular print media covering labiaplasty were not always as glowing. A 1998 Cosmopolitan article, for example, discussed a woman who decided to “hop-on the latest, most controversial Hollywood plastic-surgery bandwagon” and have her labia surgically reduced. Though Cosmopolitan said labiaplasty “could actually work wonders,” under a “Reality Check” subheading, it cautioned labiaplasty could remove skin, resulting in a “lessening of sensation.” Cosmopolitan also noted because labiaplasty “is considered purely cosmetic” insurance would not cover the upwards of $3,000 cost, and the long recovery from swollen labia [42]. Indeed, Cosmopolitan – despite being focused on (hetero)sexual performance – in 2010 published an even more critical account of labiaplasty under the definitely not glowing title: “Vaginas Under Attack: Don’t Let Greedy Gyno Talk You Into This Horrible Mistake” [43].

Though some labiaplasty practitioners complained that the media “in their quest for sensationalism frequently portrays labiaplasty as unnecessary and potentially dangerous” – as Hamori wrote regarding the 2010 Cosmopolitan article – these stories were sometimes driven by public relations agents for labiaplasty practitioners [31, 44]. But just because the story originated from a press release did not mean the resulting article was favorable. As an illustration, in 1998, reporter Kamps described her decision to follow up on what she described as a “curious press release” from Alter that encouraged women to “get out their hand mirrors” and examine their labia. Kamps considered this a joke – were “women really worrying about the size and shape of their labia” she wondered – so she interviewed Alter. Alter showed her before-and-after labiaplasty photographs. Kamps noted that though Alter “seems convinced there’s something freakish about the [pre-surgery] women,” she thought they looked normal. Indeed, she found the postoperative photographs to be “eerie” and “carbon copies of each other.” After interviewing another surgeon who said the consequences of labiaplasty could be severe, Kamps concluded by noting Alter failed to see how he was one of the people throwing out the so-called problem of what he deemed “labia envy” and that women “shouldn’t catch the pitch” [45].

Regardless of the perspective on labiaplasty in the popular media, the articles educated readers about “labia envy” and provided the names of practitioners who offered labiaplasty. In that way, even the articles critical of labiaplasty were essentially free advertising for the surgery and its practitioners. As one industry newsletter noted: “the press has jumped on the bandwagon for labiaplasty, creating curiosity among women” [46]. This curiosity could arise even from articles not on the bandwagon.

But in addition to print media as effectively (if perhaps unintentionally) marketing labiaplasty, practitioners also said reality television shows focusing on cosmetic surgery increased awareness. These shows included the 2002 Extreme Makeover, and in 2004 The Swan and Dr. 90201 [47]. In particular, practitioners pointed to Matlock’s appearance on Dr. 90210 and subsequent shows featuring labiaplasties [48]. Alter, who also appeared on Dr. 90210, said in 2007 that “[d]oing these procedures on a television show … makes people aware that they are available to them” and made labiaplasty “more acceptable” [49].

These shows could endlessly repeat and be shared on the internet, access to which began, by the late 1980s, to increase [50]. The advent and growth of the internet paralleled – and enabled – the growth of labiaplasty by allowing women, as a cosmetic surgery magazine noted in 2006, “to learn more in the privacy of their homes” [46]. Though in 2006 practitioners reported it was still more likely for patients to find them through word of mouth, it had become “more popular” for women to find out about them from the internet [46]. Women interviewed in 2006 indicated they initially found out about labiaplasty by doing searches for information on the internet, where they often found practitioners’ websites [51, 52]. This trend of using the internet as a first means of gathering medical information only increased [53]. Searches were also done for cosmetic surgery: in one study, 95% of those surveyed said they used the internet to collect information about cosmetic surgery before seeing a clinician. This same study, however, found a “high percentage of poor quality internet sites,” resulting in people coming away with “unrealistic expectations” created by the information they found on the internet [54].

Doing internet searches regarding labiaplasty easily led those seeking information to practitioner websites. A 2009 survey of ASPS members found that of the 750 (19.7% of members) who participated, a little more than half indicated they performed labiaplasty, and 18.9% advertised this surgery, with the internet being the most common method [55]. A 2012 study, however, found labiaplasty practitioners’ websites provided no information about the diversity of female genitalia or regarding risks of labiaplasty [52].