Idealised images of female external genitalia depicted on pornography and proprietary female genital cosmetic and plastic surgery websites are concerning. These websites drive women to consider elective surgeries to make themselves beautiful—or more beautiful—compared to an idealised composite image of the ‘perfect’ woman. In the case of genital cosmetic and plastic surgery, the ‘ideal’ seems to have been derived from pornography ‘starlets’ in movies and magazines. A historical review of these images reveals a changing view of ‘ideal’. The ‘Barbie doll’ look is now in vogue and eerily true to its plastic namesake—hairless. Even more concerning is the desire for a prepubescent look, where the labia minora are uniformly smaller than the labia majora. These images are a far cry from the normal appearance and variation of external genitalia depicted in Nick Karras’ Petals, Joani Blank's Femalia and Jamie McCartney's Great Wall of Vaginas sculpture.
Women are rarely encouraged by their doctors to examine their own genitals, and the new hype is driven by what they see in the media. It is time to teach women that what is ‘normal’ is usually right between their own legs. First, we need to teach women that it is normal for labia minora to protrude past the labia majora. As women progress from prepuberty into adolescence and full maturity, the labia elongate and darken. Labia minora normally protrude a few millimeters up to several centimeters beyond the labia majora (Lloyd et al. BJOG 2005;112:643–6). Newer classifications of labial anatomy that have appeared in the genital cosmetic surgery literature may mislead women and suggestions for ‘snipping and clipping’ could have potential long-term negative consequences (Chang et al. Aesthetic Plast Surg 2013;37:887–91). In western civilisation, women spend one-third of their lives in menopause. With aging and declining estrogen levels, labia minora and the rest of the external genitalia shrink and become more atrophic. A normal healthy sexual response requires adequate blood flow and intact innervation around the clitoris, vulvar vestibule, labia and vagina to achieve adequate engorgement, arousal and orgasm. No data exist on the potential long-term adverse effects on sexual response related to scarring, tearing and nerve damage that can occur with aesthetic vaginal surgery.
Training is also a significant concern. Pelvic support issues and other pelvic floor disorders affect nearly one in three women and are intimately connected to a woman's quality of life, self-image, self-esteem and sexual function. Plastic surgeons performing labiaplasties or altering the appearance of the mons pubis and other elements as depicted in ‘Mommy Make-overs’, may have training in aesthetics but often lack qualification for adequate repair of pelvic support and treatment of incontinence. Urologists and gynaecologists may not be fully trained in aesthetic techniques, but feel pressured to perform labiaplasty and other female genital cosmetic surgeries related to market demands. It takes more than a surgeon with technical competence in ‘sex surgeries’ to deal adequately and appropriately with a woman's overall pelvic floor and vulvovaginal health issues, sexual dysfunction and psychological needs.
Finally, global women's health education remains at the heart of this issue. How we depict girls and women matters. Labiaplasty is largely an unnecessary procedure, except in cases of extreme asymmetry related to congenital conditions or hyperandrogenism, correction of female genital cutting (ACOG. Obstet Gynecol 2007;110:737–8), urethral meatal obstruction or other functional conditions related to sports and sexual activity (e.g. invagination of labia during intercourse). The social vulnerability and cultural view of women as sex objects needs to end (Cain et al. Int J Gynaecol Obstet 2013;122:169–72). Having honest conversations about the wide variety of normal female genital anatomy would be a great start.