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“I hate mine, hate, hate HATE it! It's like a tongue sticking out for heavens sake!” “What if they told everyone in school ‘yeah, she's pretty but there's something wrong down there.’ ” “I'd like to cut them off.”1
This article is about women's motivations for considering a surgical reduction of their labia, or labiaplasty (labioplasty). The focus will be on a reduction of the labia minora through surgical procedures rather than on other forms of female genital cosmetic surgery, such as surgery of the labia majora or clitoral hood.2 There is broad consensus that female genital surgery for a reduction in the size of the labia minora has risen sharply in recent years [1, 2], and sociocultural explanations and implications are broadly discussed [3-8]. Our study aim was to provide further empirical evidence on the question about what motivates individual women to consider this very intimate form of surgery. The study is based on two original data sources. The first is a quantitative content analysis of motivations for considering labial reduction surgery as shared by 78 American, British, and Dutch members of women's online communities in recent years. The motivations for considering labial reduction surgery that the women gave in this anonymous, nonclinical context were systematically coded and analyzed to identify recurrent patterns. The second data source is a content analysis of motivations for considering labial reduction surgery given on 40 surgery providers' websites, allowing comparisons between women's online communities and surgery providers' websites.
The extant knowledge of individual women's motivations for considering labial reduction surgery is based almost exclusively on reviews of the medical records or surveys of surgery providers' patients (for reviews: [9-11]). A critically confounding factor of the findings obtained in this clinical context however is that women may not reveal all of their motivations in this context [9, 12]. There are at least two reasons for this. First, because surgery providers function as gatekeepers in women's admission to labial reduction surgery, and a woman may not be accepted for the surgery if the doctor believes she is psychologically unstable or under third-party influence . In addition, women in most Western countries are denied insurance coverage unless the doctor can confirm that the procedure is for purely functional reasons . In fact, every community we analyzed for the present research included women seeking advice from other women about the right prompters to say to the doctor to warrant surgery and coverage. Second, issues related to the genitals are an extremely sensitive topic that the majority of women would find awkward talking about, including during the medical encounter [15-17]. Indeed, many members of the women's online communities expressed intense fears of having to talk about and undergo a medical examination of their labia with a doctor. Both these factors may seriously complicate the interpretation of motivations for labial surgery as recounted in patient–provider communication.
One study that reported interviews with women about their motivations for considering labial reduction surgery that were conducted outside a direct clinical context  identified feelings of “imperfection” and issues in sexual relationships as the primary motivations. With six interviewees, however, the study was exploratory in nature.
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This study was based on the posts of 78 members of online communities about labial reduction surgery and on 40 websites of providers of such surgery. Both the online communities and the websites were sampled via a Google search using the search terms “labia reduction,” “labia correction,” “labiaplasty,” and their literal Dutch translations. Four online communities that contained recent threads about labia reduction surgery (one from the Netherlands, two from the United States, and one from the United Kingdom)3 were selected. Details about these online communities are presented in Table 1. Only female community members who referred to a reduction of the labia minora (as opposed to other genital surgeries) and shared their personal motivations (as opposed to members giving a moral opinion or only asking other women questions) were sampled. The final sample consisted of 78 women: 28 from the Dutch, 25 from the American, and 25 from the British online communities. Not all women mentioned their age, but of those who did, the youngest member indicated that her age was 12 years and the oldest was 61 years; the mean was 21.5 years (standard deviation [SD] = 9.6).4
Table 1. Details of online communities in the sample
|Forum name||Thread topic name||Nationality||Oldest/latest post||n sample|
|Medisch Foruma||“Schaamlip correctie”||Dutch||May 2007–March 2013||28|
|Cosmopolitanb||“Labia reduction?”||British||May 2008–Feb. 2013||25|
|The Fabulous Vaginac||“Labia reduction surgery experience”||American||July 2005–Feb. 2012||10|
|Experience Projectd||“I had labiaplasty”||American||Feb. 2009–March 2013||15|
The sample of surgery providers' websites consisted of 40 English or Dutch language websites from Australia, Canada, Ireland, the Netherlands, New Zealand, South Africa, the United Kingdom, and the United States. Only providers offering clients an actual surgical reduction of the labia minora were sampled (as opposed to online platforms, sites that provided only information, or sites for health care professionals). Nearly all providers also offered a range of other cosmetic surgeries, such as mammoplasty (breast augmentation) or blepharoplasty (eyelid surgery), and sometimes also other forms of cosmetic genital surgery, such as vaginoplasty (vagina tightening) or clitoral hood reduction. Eleven websites (28%) also showed “before and after” labiaplasty pictures. Twenty-three websites (57.5%) gave price indications for labial reduction surgery, varying from €795 (£703/ US$825) to €3,500 (£2,983/US$4,579), with an average of €1,581 (£1,348/US$2,068).
The unit of analysis for the online communities was the individual member, and for surgery providers, it was the web page(s) on labial reduction surgery.5 Each motivation for considering labial reduction surgery mentioned in the member's posts or on the provider's website was coded as belonging to categories of emotional vs. functional discomfort and discomfort vs. enhancement-related motivations. Functional (or “medical”) vs. emotional (sometimes also “aesthetic” or “psychological”) motivations are commonly used denominators in categorizing motivations for female genital surgery and for cosmetic surgery in general [9-11]. The discomfort vs. enhancement (or “treatment/enhancement”) distinction refers to motivations grounded in the cure of a perceived disease or disability vs. those that are grounded in the improvement of a regular condition . An overview of the categories, including examples, is presented in Tables 2 and 3.
Table 2. Incidence and prominence of motivations for labial reduction surgery on online communities*
|% [CI]||M (SD)|
|Emotional discomfort||71.0 [61.0–81.0]||52.0 (40.5)|
|Self (feeling “freakish,” self-loathing)||48.8 [37.6–59.9]a||18.3 (25.8)a|
|Social (shame, fear of ridicule)||38.8 [27.8–49.7]ab||15.0 (23.8)ab|
|Sexual relations (fear negative partner reaction)||37.5 [26.7–48.3]ab||15.8 (26.4)ab|
|Emotional enhancement||32.5 [22.0–43.0]||14.4 (25.2)|
|Private area (normal, likable appearance)||28.8 [18.6–38.9]b||11.6 (23.3)abc|
|Sexual relations (more enjoyment)||11.3 [4.2–18.3]cd||2.8 (9.7)d|
|Functional discomfort||52.5 [41.3–63.7]||31.1 (36.8)|
|Private area (tight clothing, hygiene)||27.5 [17.5–37.5]b||10.7 (21.0)abc|
|Sexual relations (pain during intercourse)||21.3 [12.1–30.4]bc||8.1 (20.0)bc|
|Exercise (soreness when cycling, dancing)||21.3 [12.1–30.4]bc||7.2 (17.0)c|
|Functional enhancement (no rubbing, better hygiene)||7.5 [1.6–13.4]d||2.5 (12.3)d|
Table 3. Incidence and prominence of motivations for labial reduction surgery on online communities vs. surgeons' websites†
|Online communities||Surgeons' websites||Online communities||Surgeons' websites|
|% [CI]||% [CI]||M (SD)||M (SD)|
|Emotional discomfort||71.0 [61.0–81.0]||98.0 [92.0–100]***||52.0 (40.5)||38.6 (23.8)*|
|Self||48.8 [37.6–59.9]||65.0 [49.6–80.5]||18.3 (25.8)||12.8 (16.9)|
|Social||38.8 [27.8–49.7]||72.5 [58.0–87.0]***||15.0 (23.8)||21.5 (22.5)|
|Sexual relations||37.5 [26.7–48.3]||15.0 [3.4–26.6]*||15.8 (26.4)||2.0 (5.1)***|
|Emotional enhancement||32.5 [22.0–43.0]||37.5 [21.8–53.2]||14.4 (25.2)||11.0 (17.4)|
|Private area||28.8 [18.6–38.9]||35.0 [19.6–50.5]||11.6 (23.3)||8.3 (13.6)|
|Sexual relations||11.3 [4.2–18.3]||17.5 [5.2–29.8]||2.8 (9.7)||2.7 (6.5)|
|Functional discomfort||52.5 [41.3–63.7]||90.0 [80.3–99.7]***||31.1 (36.8)||47.1 (24.8)*|
|Private area||27.5 [17.5–37.5]||82.5 [70.2–94.8]***||10.7 (21.0)||20.5 (13.1)**|
|Sexual relations||21.3 [12.1–30.4]||15.0 [3.4–26.6]||8.1 (20.0)||2.1 (5.4)|
|Exercise||21.3 [12.1–30.4]||65.0 [49.6–80.5]***||7.2 (17.0)||13.4 (11.4)*|
|Functional enhancement||7.5 [1.6–13.4]||20.0 [7.0–33.0]*||2.5 (12.3)||3.3 (7.1)|
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The present research findings shed new light on why women consider undergoing labia reduction surgery. Extant research so far was almost exclusively conducted in a clinical context, where women aim to be accepted for the surgery and may feel awkward talking about sensitive emotional issues. Motivations recounted in the anonymous, unsolicited context of online communities are less confined by these restrictions. This is not to suggest, however, that motivations recounted on online communities are necessarily more “real.” First, this is because we cannot automatically assume that the accounts of women who participate in online communities about labial reduction surgery are representative of all women considering labial reduction surgery. Second, just as the clinical context shapes the accounts given by women, online accounts can also be assumed to be shaped by the opportunities and constraints provided by the immediate online context [19, 20]. Within these constraints, our findings lead to a number of conclusions that will be addressed below.
First, emotional discomfort with the appearance of the labia, such as feeling “freakish” and ashamed, was highly prevalent on the online communities, with 42.5% of members mentioning only this motivation for considering labia reduction surgery. The intensity of the emotion was also often very high, as illustrated by the quotes from the online communities given earlier. We know of two clinical studies that have also divided patients into those who indicated emotional/aesthetic concerns alone, those who indicated functional concerns alone, and those who indicated both. The first of these, Alter , reports that 13.3 of patients indicated aesthetic concerns alone, while Miklos and Moore  report 37%. This suggests that mentioning emotional reasons as the single motivation is more prevalent on online communities than in clinical encounters. Further, emotional discomfort was mentioned as one of the motivations by 70% of community members, regardless of age and nationality. Some clinical studies, such as Goodman et al. , have reported lower percentages of around 55% of women indicating emotional/aesthetic concerns as at least one of their motivations. Other clinical studies, however, have reported higher percentages of up to 100% [24-26]. This would suggest that when women can indicate additional reasons in the clinical encounter, emotional reasons are actually mentioned at least as often as on online communities.
Some functional complaints were mentioned by more than half of the members of the online communities. Interestingly, however, these were mentioned by 75–100% of clients in clinical contexts [21-26]. Particularly, functional interference with exercise, sexual intercourse, and tight-fitting clothes was reported by more than half of the women in a series of clinical studies [21-26], while each of these issues was mentioned by less than 30% of the members of the women's online communities.
A second way in which our findings shed new light on the research to date concerns the role of age and nationality. Functional discomfort in sexual relationships was a more prevalent motivation among the older age group, which can probably be explained by age- and parity-related changes in female physiology of the genitals . Apart from that, motivations for considering labial reduction surgery were remarkably similar across nationalities and age. We thereby hasten to emphasize that the women in our sample came from Western countries, as female genital surgery can obviously have a very different meaning across cultural and religious contexts [28, 29].
The media in general, and surgery providers' websites in particular, have been fiercely criticized for inciting negative associations with larger labia and encouraging women to seek labia reduction surgery [3, 7, 30, 31]. The third way in which our findings shed new light on the extant knowledge is that provider's websites recounted an on average equal share of emotional and functional motivations. Furthermore, the less controversial motivation of functional discomfort was mentioned on providers' websites more regularly and more prominently than by the members of the online communities. Providers' websites also seemed on average to be more reserved in emphasizing emotional issues and particularly sexual relationships as motivations for considering labial reduction surgery than the members of the women's online communities. It should be emphasized that our study obviously cannot disprove or confirm claims that surgeons' websites can impact upon the perceptions and actions of women with larger labia, and to our knowledge, such effect studies do not exist in this area. Extant media effects research, however, rarely supports direct, one-to-one relationships between media content exposure and audience reactions [32, 33]. All in all, our findings suggest that the content of surgery providers' websites likely cannot fully explain the high prevalence of emotional discomfort among women considering labial reduction surgery.
Critical scholars on female genital cosmetic surgery have coined the term “pudendal disgust” to label strong negative associations with the female genitals [2, 7, 28, 29]. Reluctance to talk about this sensitive emotional issue, as well as fear to not be accepted for the surgery and the desire to obtain health insurance coverage, may drive women to emphasize the functional aspects in the clinical encounter more. Our research, however, has provided new, quantitative evidence across nationalities and age groups that such feelings of “pudendal self-loathing” are a highly prevalent force among women considering labial reduction surgery.
The Internet without a doubt is a very important, if not the most important, site where the lay public finds and exchanges information about cosmetic surgery [34, 35]. The present study has analyzed the online contents available to women seeking labial reduction. Awareness of significant patterns in these materials, scrutinized by so many clients before ever setting foot into a practitioner's office, could potentially assist surgery providers in client communication.