Over recent years there has been justifiable concern about the increasing demand for labiaplasty, in both state-funded and private healthcare sectors. In particular the wide adoption of vulval procedures by cosmetic plastic surgeons (Mirzabeigi et al. Ann Plast Surg 2012;68:125–34), sometimes accompanied by aggressive marketing, has led to the conclusion that doctors are complicit in medicalising normal anatomical variation for commercial gain. In this context, labiaplasty for cosmetic indications can be seen as an extension of patriarchal control over women's’ bodies and women's’ sexuality, an impression reinforced by the finding that male surgeons may be more likely to undertake these procedures (Reitsma et al. J Sex Med 2011;8:2377–85).
In our efforts to limit the promotion of labiaplasty, and limit the promotion of minimal labia minora as an adult ideal, we should however be cautious not to restrict access to care for women requesting surgery for functional reasons. The current literature suggests that only a minority of women present with purely cosmetic concerns (Goodman et al. J Sex Med 2010;7:1565–77; Veale et al. Psychol Med 2013;10:1–12). More typically, women are distressed because their labia are pushed into the vagina when they have penetrative sexual intercourse, or insert a tampon; or that the labia rub when they undertake physical activity such as cycling (Veale et al. Psychol Med 2013;10:1–12).
A desire for symmetry, lack of functional restriction, and normal sexual function seem to be entirely reasonable concerns, not qualitatively different from many other elective aesthetic or urogynaecological procedures. Some opponents of vulval surgery have compared cosmetic genital surgery to female genital mutilation. However, it seems to us most closely aligned with breast reduction, a procedure widely performed for a mixture of functional and aesthetic indications, without the same media concern as surrounds labiaplasty.
It is right that we should evaluate the safety and efficacy outcomes of labiaplasty, as we would for other urogynaecological procedures, and try to define appropriate criteria for intervention. Clinicians should be aware that a minority of women presenting for care meet the criteria for Body Dysmorphic Disorder (Veale et al. Psychol Med 2013;10:1–12). The validated Genital Appearance Satisfaction scale, and the Cosmetic Procedures Screening questionnaire (Veale et al. J Psychosom Obstet Gynaecol 2013;34:46–52), may be useful tools to screen women requesting cosmetic labial surgery.
While evidence of safety and efficacy has lagged behind the popularity of this procedure, the available case series report good overall satisfaction rates (Goodman et al. J Sex Med 2010;7:1565–77). The risks of the procedure may relate largely to the technique employed, and comparative studies of different techniques are not yet available. As for any other intervention with uncertainties relating to harm, it should be the responsibility of the practicing surgeons to routinely follow-up patients, and rigorously audit individual outcomes. However, provided women have realistic expectations about outcomes, we believe they should still be free to opt for cosmetic genital surgery.