Objective To understand women’s reasons for undergoing labial reduction surgery, their expectations and experiences.
Design A retrospective qualitative study.
Setting British National Health Service Hospital.
Sample Six women who had experienced surgery for labial reduction.
Method Qualitative study using semi-structured interviews.
Results Results relating to ‘Normality and defect’, ‘Sex lives’ and ‘The process of accessing surgery’ are presented in this study. The women had seen their presurgery genital appearance as ‘defective’ and sought a ‘normal’ genital appearance. They thought that their presurgery genital appearance impacted on their sex lives, but their expectations of the effects of surgery on their sex lives were not all fulfilled. Information about labial surgery came from both the popular media and the health services. An emphasis on, for example, physical discomfort rather than appearance may have been used to legitimise a request for surgery. The process of accessing surgery had exposed them to potentially conflicting messages about their genital appearance.
Conclusions Women presenting for labial reduction may have unrealistic expectations of surgery, but their perceptions and expectations are long-standing and seem to be based on strong cultural norms. The gynaecologist is also meeting those women who have already negotiated the referral process. As demand for this surgery appears to be increasing, further research is needed. These findings may add to the case for the potential value of specialist staff to provide psychosocial interventions within gynaecology services.
Labial reduction surgery is accomplished through excision of labial tissue, with the aim of reducing the inner labia to a size acceptable to the woman. Media coverage1 has brought this procedure to public attention,2 and the incidence in the British NHS has doubled in the 5-year period from 2004–05.3
While there is exact medical terminology for the anatomy of female genitalia, common language is very inexact,4,5 probably reflecting cultural taboo,4 therefore research into sociocultural representations of the vagina6 may be relevant to consideration of genital appearance. This research suggests that the vagina is represented negatively6 and as ‘a viable site for beautification and normalization’7 (pp. 264).
Variation in genital appearance is to be expected,8 and changes in the labia minora may be associated with normal ageing process.9 Although medical conditions (e.g. incontinence causing diaper dermatitis) may lead to irritation and hypertrophy of the labia minora,10 a distinction should be made between these uncommon cases and women who seek labial reduction when there is no suggestion of disease. It is not that long since writers in respected journals described the patient’s history of sexual experience and masturbation when describing reports of labial reduction surgery, with statements such as ‘Some have attributed the condition (hypertrophy) to masturbation or early sexual activity’11 (pp. 79S), while at the same time stating ‘Little substance has been placed in those causative factors’. In fact, research shows no empirical evidence for an effect of sexual activity on labia length.8
Research into labial reduction surgery has primarily focused on surgical technique.12–16 Some studies referred incidentally to reasons why women requested surgery and presented audit information on patient satisfaction,13–15,17 but the data have been collected by case note audit or short, unvalidated questionnaires. Women seeking such surgery may see medical staff as ‘gatekeepers’ and tailor their reasons for seeking surgery accordingly, and ratings of satisfaction may be biased when this information is collected by the clinical team.
Liao and Creighton’s3 discussion of how healthcare providers should respond to requests for labial reduction includes both a review of relevant professional guidelines and extracts from interviews with women who had undergone such surgery. They suggest that such surgery poses an unresolved dilemma to both the women who seek such surgery and the health professional.
Clearly, very little is known about women’s reasons for undergoing this surgery, their expectations of the procedure or their experience after the operation. The aim of this research was to address this gap. Given the paucity of previous research, a qualitative approach was adopted to allow an exploratory approach.18
This qualitative study took a phenomenological approach, that is one that emphasised the women’s own perspective on their experiences. Semi-structured interviews were undertaken, transcribed and analysed to extract recurring themes in the women’s accounts of their experiences. This allowed a flexible approach, which focused on the experience of the individual women.19 The qualitative research paradigm underpinning this research does not seek a ‘objective’ analysis of these women’s experiences but rather takes a reflexive approach (in which the researchers deliberately consider the interaction between their own feelings and experiences and the material being analysed) to maximise the quality of the interviews and analysis.20,21
Theatre records from a British NHS women’s hospital offering secondary and tertiary care were used to identify women who had undergone surgery to reduce the size of their labia in the previous 2 years. Seventeen women were identified and all of these women were invited to participate in the research.
The research team consisted of a trainee clinical psychologist (C.M.) who conducted the interviews and analysis. An experienced chartered health psychologist specialising in women’s reproductive health (R.B.) supervised the research and was actively involved in all stages of the analysis (see below). Another perspective was provided by the second supervisor, an experienced gynaecologist (A.S.G.), who initiated the project, had conducted some of the operations, facilitated access and contact with women and provided a very different experience on which to draw in the analysis. In line with usual practice in qualitative research, all three members of the team reflected on their different approach to the data and this was actively used to encourage a reflexive approach in the analysis.21
Permission for this research was granted by the Local Research Ethics Committee. Potential participants were sent an information sheet outlining the study with a consent form to return should they decide to take part, alongside a form that gave participants the choice of how and when they would like to be contacted. Once signed consent forms were received, the researcher (C.M.) contacted the women in the manner they requested. Participants were given a choice of being interviewed at home or at the hospital—all chose to be interviewed at home.
At interview, time was taken to review the participants’ understanding of the research and answer any queries or questions. All participants were informed that the interview could be terminated at any time, for any reason, and that participants were not obliged to answer any questions if they did not wish to. The interviews were recorded on audiotape and then transcribed.
A semi-structured interview schedule was developed, which retained flexibility for participants to shape the interview.22 In order that the interview would reflect the women’s own perspective on their experiences rather than assumptions by the research team, participants were asked about events in a chronological order, from the origins and experience of her dissatisfaction with her genitalia, through the process of accessing surgery and her view on her genitalia since surgery. The schedule was there to guide the interviewer (C.M.) to explore these key areas with the participant, and the same framework was used in all interviews. However, when the participant raised issues in a different sequence, or of a different nature, she was encouraged to continue in the manner she had chosen.
The interview transcripts formed the data analysed by C.M. A thematic analysis was undertaken as follows. The transcripts were carefully read many times to allow C.M. to be immersed in the data and become very familiar with the women’s accounts. Multiple readings of the transcripts enabled extraction of relevant chunks of text. This enabled the researchers to identify broader categories. As these categories emerged, the formation of large, overarching themes was clear. These emergent themes form the results, which are described below. Within this process, things said in the interviews, which did not relate to the categories or add to the research question were dropped from the analysis. R.B. acted as supervisor in this process, reading all transcripts and discussing the analysis in detail at all stages. Also, as a check on the analysis, the data was scrutinised for disconfirming evidence, that is communications, which were inconsistent with the emerging themes. Emergent themes, their interpretation and implications for practice were discussed with A.S.G., who provided an alternative perspective.
Six women, aged 16 to 45 years, agreed and all were interviewed. The 16-year-old chose to be interviewed in the presence of her mother, who had been present for many of her medical consultations and who contributed some of her views and experiences to the interview. All had undergone surgery to reduce the size of one or both labia. In two cases, the women were dissatisfied with the result and a second operation was performed.
Eighteen categories organised into five overarching themes emerged from the analysis. Themes related to descriptions of appearance and physical discomfort before and after surgery as well as the women’s response to these, finding out about surgery, perceptions and attitudes towards and demand for surgery, were more descriptive. As it is not possible to do justice to all the emergent themes in this paper, the following account focuses on themes selected because they have not figured in previous literature and are of strong clinical relevance. Therefore, this paper focuses on results relating to ‘Normality and defect’, ‘Sex lives’ and ‘The process of accessing surgery’.
Normality and defect
A theme that was present for all the women was that of ‘normality’, which was returned to throughout the conversations, with the women feeling as if their genital appearance prior to surgery was ‘odd’, ‘weird’ or made them ‘freaks’. References to their ‘abnormal’ appearance often implied that there was a ‘normal’ genital appearance.
Nevertheless, the women revealed uncertainty about what a woman’s genitalia could and should look like. Sometimes this confusion and the source of information on what was or wasn’t normal was directly stated
I told my mum and she said it wasn’t normal, so…because I didn’t know if it was normal of not. (Participant 1)
Despite the common feeling of not having ‘normal’ genitalia, several of the women interviewed implied that they were aware that there was a natural variation in how women’s genitalia appeared. Participant 3 expanded on this theme, saying
I sort of began to realise later, as I grew up that, you know, that wasn’t unusual really—for the labia to be sort of irregular shapes and uneven sizes in some people. I suppose that became more evident when I trained as a midwife…
However, such recognition did not protect these women from disliking their genitalia, as clearly evidenced when participant 3 concluded her statement with the words
…but it still bothered me.
Notions of normality may also have been linked to ideas of normal male and female genital appearance. Participants 5 and 6 reported an experience where a child relative had, on seeing them naked, commented that they had
…got a willy
(colloquialism for a penis), an experience the women found distressing, although hard to express.
The theme of ‘normality’ also related to women’s interactions with healthcare professionals in the process of accessing surgery (see below).
There was a sense of women attempting to achieve ‘normal’ genital appearance through resolution of a perceived specific defect, such as asymmetry or labia that were ‘too large’.
I just didn’t want that skin there. No, I just wanted it gone basically. (Participant 4).
Women’s comments on their post-surgery appearance also gave insight into their desire for symmetry and invisibility. Some were very satisfied with their new appearance,
It’s all on the inside now. Not pulling tongues anymore. Nice. (Participant 2).
Others participants were perhaps less openly enthusiastic about their new appearance,
It’s still not quite right there, there’s still some excess tissue that side that doesn’t look quite right…there’s still no perfect symmetry. (Participant 3).
This theme includes the women’s expectations of surgery and their experience of the impact it actually had on their sex lives and relationships.
An experience common to the sexually active women was the impact their dislike of their genitalia had on their sex lives prior to surgery. The women referred to anxiety about their partner seeing or touching their genitals, inhibition in sexual relationships or anxieties about starting a new relationship.
… sort of trying to keep that area hidden, you know, not on view at all. Nobody can look there! (Participant 3)
Participant 1 was still a virgin, but reported similar presurgery concerns about becoming sexually active.
Those women who were sexually active had undergone the surgery expecting that this would improve their sex lives. In some cases, there was also a hope that this would improve or save a relationship.
Maybe like a last-ditched attempt really—if I was a bit more feminine, or if I was a bit more, I don’t know, a bit more attractive then maybe he would change. (Participant 4).
When considering the actual effect of the surgery, the women’s experience was more mixed. Expectations of an improved sex life were not met for all participants.
But I guess it’s not that much different really. I don’t feel very much different about it. I think I still feel conscious of that area as you know, quite an ugly area that’s kept as private as possible. (Participant 3).
Participants who had hoped that a relationship might be changed did not find this happened.
… my husband was still not interested, and that’s all over now. (Participant 4).
However, surgery did have the effect of making the women less self-conscious.
… it has made a difference even being sexual with him from before the surgery because it’s just, you know, I’m not thinking about that it’s just not an issue in my head, so when he’s touching me I’m not worried… (Participant 6).
In cases where the women had moved on to new relationships, they reported feeling more confident and at ease in the new sexual relationship, although it was difficult to disentangle the impact of their changed genital appearance and of the new relationship.
One respondent described physical discomfort during and after intercourse prior to surgery,
Well you know it was long and it used to swell up terrible you know like a big golf ball, it used to be terrible you know when I had sex and that (Participant 6).
She reported that surgery had changed this,
Participant 6: But even having sex now, it’s better than ever
Interviewer: What do you put that down to?
Participant 6: I don’t know if it’s that, I don’t know, it feels different and everything. It might be that, I don’t know
The process of accessing surgery
Women had heard about surgery to reduce the labia in different ways, the majority finding out through contact with the NHS. Indeed, a two-way communication of information between NHS personnel and clients showed itself,
So I just mentioned it to the nurse on one of my visits to the Colposcopy clinic and I said “is it normal? Can anything be done about it?” And she said “oh yeah you can get if snipped off” and made it sound like a really simple…and “oh I’ll tell you what I’ll give you a referral.” (Participant 4)
… a patient I was seeing in the course of my work when I was taking a medical history and talking about any surgical history and she said “Oh, I’ve just had this surgery at X hospital to reduce my labia” and I said “Oh, that’s interesting”. (Participant 3).
Women’s glossy magazine articles were also cited as having provided information about the existence of this procedure or giving further information once the operation was already known about.
I read something in a magazine, and I thought, “Oooh I didn’t know it was possible”. (Participant 2).
Participant 3 described a process of anticipating difficulty in gaining access to labial reduction surgery, at least within the NHS, as she felt that this would not be provided on the basis of her dissatisfaction with her genital appearance alone. This led to a conscious decision to try to facilitate access by emphasising the physical difficulty she sometimes experienced.
I thought they’re not going to be happy with this as a cosmetic issue, and I was having a slight problem in that the side that was bigger was protruding and from time to time it would rub on my clothing and become very uncomfortable and quite sore and I used to have to push it up, you know as it was sort of getting rubbed, and I thought well “this is a quite good reason actually”. So I mentioned that to the GP and she had a look, and said oh I see what you mean, and she said I’ll refer you to (surgeon at Hospital X).
For other participants, there was no explicit mention of a decision to emphasise the physical aspect of their difficulty. However, their accounts of contact with referral agents show that the physical element was presented in a way that potentially added legitimacy to their request for intervention. Participant 2’s account suggests that her framing of her difficulties was influential in securing a referral.
I went to the doctor and just told her it was uncomfortable and stuff…she was saying, “oh, it’s fine” but she referred me anyway because I was uncomfortable.
As already described, in all accounts of their experiences, the women seemed to have at some stage grappled with the concept of the normality of their genital appearance. The theme of normality was again found to be present in women’s accounts of their experiences with healthcare professionals during gaining access to a referral to gynaecology or the surgical procedure itself. As described previously, Participant 2’s GP told her appearance was ‘fine’, but issued a referral because of the participant’s discomfort. On accessing secondary services, she recalled finding out she could access surgery and being told
“Oh, it’s fine, there’s nothing wrong with it, it’s normal”, but she understood that I was uncomfortable with it.
It could be suggested that communications of this nature could cause confusion as women hear reassurance of their normality, but alongside a communication that further investigation or surgical intervention is still warranted. Participant 4 recalled a similar conversation with a referral agent,
“Is it normal?” and she said, “yeah it’s normal, it’s just a bit bigger than most people”
which it could be argued served to communicate reassurance about normality, alongside a communication about the participant also being outside of the sphere of normal genital appearance. Participant 5 describes how she had originally been reassured that
When I went for smears and everything like that the doct.. (sic) nurses haven’t mentioned nothing when they done the smears…. I know I never mentioned nothing, but thinking I must be normal or they’d have said something
but had moved from this passive acceptance of reassurance to mentioning her concerns to a nurse at the genito-urinary medicine clinic. In her recall of events, health professionals then confirmed her view that her labia were not ‘normal’,
the nurse said it wasn’t normal
and, during her the consultation with the consultant
she said, oh yeah it’s a bit long.
This analysis suggests that important themes in these women’s desire for labial reduction surgery were their perceptions of an abnormal or defective appearance and the impact of their labial appearance on their sex lives.
While there is little research to draw on, an analysis of women’s magazines showed they present a social norm that women’s genitalia should be invisible and that there should be a smooth curve between the thighs with no protruding labia.23 This is consistent with the premise that women’s genitalia are an ‘absence’ contrasted with the ‘presence’ of the male phallus.7 It seemed this simplistic typing of male and female genitalia from a young age had led to an actual experience by two respondents of a child relative mistaking their labia for a penis. It may also be important that the labia minora typically do not protrude in children. It has frequently been asserted that the Western feminine ideal is a child-like body.24 There is also a practical point that women may have more opportunities to observe young children naked than adults.
The women in this study expressed an ambiguity as to what constituted ‘normal’ labia, which resonates with the expressions of uncertainty reported by Liao and Creighton.3 There was an apparent contradiction between the acknowledgements (by at least some interviewees) of the normal variation in labia shape, while at the same time they expressed the view that their labia was ‘abnormal’. This may be understood by reference to the work of Gilman on the use of aesthetic surgery to ‘pass’ as a member of a desired social group.25,26 In Gilman’s terms, these women were expressing the view that their genital appearance, while shared with many other women, had stigmatised them as a member of an ‘out’ group rather than someone who showed the ‘normal’ appearance of the favoured or dominant group in society. It is not clear exactly how long labia are stigmatised in our society, but Gilman’s historical analysis suggests that this may involve racial stereotyping or the belief that long labia indicate sexual promiscuity.27
The health professional should be aware, however, that women requesting labial reduction describe their genitalia as ‘abnormal’ may not mean that it falls outside the normal range, but rather that it is in some sense stigmatising. Showing pictures which demonstrate natural variation in appearance may therefore not address their concerns.
The women were of different ages and had different relationship histories, but the perceived impact of genital appearance on their sexual lives and satisfaction was an important theme, consistent with the way in which this surgery is described in the media.2 Most of the women talked about a lack of confidence and a desire to conceal. Their expectation was largely that increased confidence would help them to enjoy more fulfilling sex lives. Participant 4 had had an expectation of a change not just in her own feelings but also in her husband’s behaviour. She felt that he wasn’t interested in sex and that a more attractive and feminine genital appearance for her would change this.
It is not in the nature of a retrospective qualitative study of this kind to establish causal links and there were, of course, other changes in the women’s emotional life over the time since the operation. Some of the women themselves expressed some uncertainties about the causes for any change in their experiences of sex. The women did describe improvements in confidence, which in turn impacted positively on their experience of sex. This is consistent with existing research, which shows that genital self-perception and self-image relates to desire, sexual participation and sexual distress,28,29 although not with other aspects of sexual function.29 Overall body image has also been associated with frequency of sexual activity and comfort with most sexual practices, but overall satisfaction with the self was a better predictor.30 A rare prospective study has also shown that a physical change (weight loss), which resulted in improved body image increased sexual activity,31 but it is difficult to be sure whether changed body self-image was the key factor or the self-confidence associated with meeting weight loss goals or indeed the improvement in general health.
It seems likely that an effect on these women’s sex lives was due to their improved self-image rather than a change in their attractiveness as perceived by their partner, and it is notable that participant 4 did not find a change in her husband’s sexual behaviour.
Participant 5 placed strong emphasis on physical discomfort during and after intercourse prior to the surgery. The experiences that she ascribes to the size of her labia may be consistent with, for instance, problems of sexual arousal and orgasm, which may in turn be influenced by lack of sexual confidence or sexual technique. However, it was not the purpose of these interviews to probe sexual problems, and so it is impossible to draw firm conclusions. The data does suggest, however, that future research in this area may need to address sexual behaviour and pleasure directly.
This was a relatively small study of women from one hospital. It was retrospective and necessarily relied on participant recall, which may have been filtered by subsequent experiences. The interview was semi-structured and was responsive and reflective rather than to a standardised format. This included conducting one interview with the (16-year-old) respondent’s mother present, at the respondent’s request, considered both ethically appropriate but also true to clinical reality, as her mother had been present throughout her interactions with health professionals. The interviewer’s impression was that this respondent talked freely about, for instance, her (future) sex life and seemed to be quite open.
The response rate to requests for participation (35%) was relatively high. Those who agree to interviews in sexuality research have been shown to be more willing to disclose sexual information,32 and these interviewees seemed to be quite open about their sexual experiences before and after surgery. It is possible that the sample was biased towards those with the most positive or negative experiences of surgery. Previous research suggests that research respondents are more likely to be interested in the topic of research33 but less likely to have had an ‘extreme’ experience,34 so these women’s openness to discussing their experiences in a research study may relate to broader personality characteristics.35
However, a qualitative study is not intended to present a ‘representative’ sample according to the criteria applied to quantitative research. Smith36 argues that a more appropriate test is whether there is an internal coherence in the results. The key themes presented here were consistently addressed by all the women in this study and produced an analysis, which is supported by existing relevant theory. Therefore, judged on this criterion the study shows good internal coherence and this is a more appropriate test than whether it is sufficiently large or unbiased according to the tests that would apply to quantitative research.
It is also important to emphasise that this study was undertaken as an exploration of women’s experience rather than as an ‘evaluation’ of labial surgery. Arguably, any evaluation of the psychological benefits of labial reduction would have to build on research such as this study, which defined the important outcomes for women.37
Implications for practice
Requests for labial reduction surgery may be an increasingly common experience for gynaecologists. An important finding of this research was that health professionals may have unwittingly reinforced the women’s perception that their labia were ‘abnormal’. In addition, the gynaecologist may be facing a woman experiencing relationship difficulties who has unrealistic expectations about the impact that surgery may have on her sexual confidence or her partner’s behaviour. These aspects of the women’s expectations may not be immediately evident, as it is clear that at least some of the women interviewed had focused on issues such as physical irritation as more acceptable reasons for seeking surgery. In the current UK context, it is likely that the only option available to the gynaecologist other than a simple refusal to operate is to refer to a psychosexual counsellor. However, such services are currently rare and typically have long waiting lists. Furthermore, women who see the problem as physical may resist referral to psychosexual or other psychological services.
Being faced with patients whose symptoms may be social or emotional rather than physical in origin is not a unique experience for gynaecologists, who routinely see patients with, for example, pelvic pain without organic cause. Previous research on unexplained menstrual symptoms has suggested that women’s expectations that the gynaecologist could improve psychological wellbeing were significantly related to the use of communication strategies, which in turn increased the likelihood of surgical intervention, including a direct request for surgery.38 This may parallel the woman who has strong expectations that labial reduction may improve their sexual and personal confidence and who makes a direct request for surgery. In the absence of viable alternative treatments, health professionals may by nature and training is understandably unwilling to offer no treatment in the face of a direct request, continuing the pattern of the ‘mixed message’ of offering reassurance about the ‘normality’ of genital appearance but also referral or treatment.
It is important not to underestimate what is involved in changing the perceptions and expectations of adult patients with entrenched attitudes and feelings who have already negotiated a referral process. In the absence of any specific research in this area, it is impossible to state conclusively what model of psychosocial intervention might beneficial to women requesting labial reduction. An appropriate intervention for future trial would be an individual or group psychoeducational programme. Such programmes have been shown to be clinically useful in, for instance, dealing with premenstrual distress.39 This would probably involve 6–8 weekly sessions of approximately 1 hour, plus ‘homework’ tasks, although there is precedence for the effective delivery of such an intervention in the form of a self-help pack.39 Quite apart from the therapeutic skills and preparation required, this is clearly a very different order of magnitude compared with the typical gynaecology consultation. Changing women’s perception of their need for surgery to reduce their labia minora is therefore probably not an intervention, which could be undertaken within the usual gynaecological consultation appointment. There is also likely to be considerable resistance to engaging in any psychoeducational intervention, which may make any such intervention ineffective. Clearly, further research would be needed to evaluate the clinical effectiveness of any such approach.
Gynaecologists and other health professionals may, however, find that good information and communication around ‘normal’ genital appearance at an earlier stage may be much more effective. This might begin with sex education and include addressing concerns expressed by women, especially younger women, accessing gynaecology or obstetric care for other reasons. It may also extend to providing expert input to the media, where opportunities present.