Clinical characteristics of well women seeking labial reduction surgery: a prospective study

Authors


SM Creighton, UCL Elizabeth Garrett Anderson Institute of Women’s Health, 250 Euston Road, London NW1 2PG, UK. Email sarah.creighton@uclh.nhs.uk

Abstract

Please cite this paper as: Crouch N, Deans R, Michala L-M, Liao L, Creighton S. Clinical characteristics of well women seeking labial reduction surgery: a prospective study. BJOG 2011;118:1507–1510.

Objective  To assess clinical characteristics and expectations in well women requesting elective labial reduction surgery.

Design  Prospective study of women attending an outpatient gynaecology clinic.

Setting  General gynaecology clinic at a Central London teaching hospital.

Sample  Women requesting labial reduction surgery and referred by their general practitioner.

Methods  The labia minora width and length were measured for all participants for comparison with published normal values. The presenting complaint was recorded, along with demographic details, expectations of surgery and sources of information regarding appearance of the labia.

Main outcome measures  Labial measurements, reported symptoms and expectations of surgery.

Results  The labia of all participants were within normal published limits, with a mean (SD) of 26.9 (12.8) mm (right labia), and 24.8 (13.1) mm (left labia). The majority of complaints were regarding appearance or discomfort. Expectations were to alter the appearance with surgery.

Conclusions  All women seeking surgery had normal-sized labia minora. Clear guidance is needed for clinicians on how best to care for the worried well woman seeking surgery.

Introduction

The demand for cosmetic surgery has been growing year on year.1 Women account for over 90% of procedures. Female genital cosmetic surgery (FGCS) is becoming increasingly popular.2 Although the majority of requests are met by the private sector, the consumer demand is likely to rebound on the public sector. This appears to be true of the UK, and the number of labial reduction procedures in the National Health Service has increased five-fold in the past 10 years (Figure 1).3

Figure 1.

 Labial reduction surgery in the NHS 2001–2010.3

The most popular first-line request for FGCS is reduction of the labia minora. Complaints that lead to a woman seeking help can be seen as falling into two broad categories—physical and psychological. Physical complaints include discomfort and chafing, either while wearing tight clothing or during activities such as cycling. Psychological complaints include embarrassment about the genital appearance leading to anxiety about certain sexual activities. There is no known increase in labial pathology in recent years. There is also no available evidence on the safety or efficacy of labial reduction surgery.4 Women’s complaints may reflect social expectations about the female genitalia and medical consumerism.

The main aim of this study was to examine the labial dimensions of women presenting to gynaecology clinics for labial reduction surgery.

Methods

This was a prospective study of all women seen in a general gynaecology clinic requesting labial reduction between 2007 and 2010. The project had ethical approval from the joint university and hospital ethics committee (project 03/0173). The presenting complaint was noted as well as reasons for current dissatisfaction, expectations of genital surgery and previous exposure to genital images. Demographic details were noted, including education level and relationship status.

Current practice in this service is to examine all referred women and offer labial reduction surgery to those aged 18 years or above with either or both of the following presentations:

  • • measurement for labial width is >50 mm, which is the largest width reported by this group in a study on normal genitalia.5
  • • marked labial asymmetry with >30 mm difference in width between the labia.

All women were examined by a gynaecologist (NSC, LM, RD or SMC) and the length and width of the labia minora were measured using methodology previously reported by this group.5 All women for whom surgery is refused are reassured that their labia are within normal limits and are offered education and counselling with a clinical psychologist (LML).

Results

All 33 women presenting for labial reduction were included in the study. The mean age was 23 years (range 11–45 years). Twenty-eight women (84%) self-identified as white, two as black (6%), one as Asian (3%), one as southeast Asian (3%) and one as mixed race (3%). In terms of occupational status, ten (30%) women were in paid employment, 22 (66%) self-identified as students and one (3%) gave no information. Eight participants (24%) were aged 16 or under (all of whom were in full-time education). Of the 25 women who were aged 17 or above, two (8%) had no qualifications, ten (40%) had GCSEs, and 13 (52%) had (or were pursuing) tertiary education. Twenty-two (66%) of the participants were single, ten (30%) were in a relationship and one (3%) did not give information. Five (15%) of the participants had children.

Most of the women (29; 87%) were referred by their general practitioner, two (6%) were referred by obstetric and gynaecology registrars, and two (6%) by a consultant paediatric endocrinologist. The primary presenting complaints are listed in Table 1.

Table 1.   Presenting complaints of women seeking cosmetic alteration of the labia
Presenting complaints from the 33 womenn (%)
  1. *More than one symptom may co-exist.

Physical complaints*
Pain or discomfort19 (57)
Difficulties with intercourse7 (21)
Difficulties with cycling or sports5 (15)
Problems with underwear or clothing5 (15)
Psychological complaints*
Appearance26 (78)
Anxiety, embarrassment or distress3 (9)
Relationship difficulties3 (9)

None of the participants had undergone previous labial surgery but one woman had undergone two cosmetic rhinoplasties and breast augmentation surgery. In terms of previous mental health history, four (12%) reported having been psychological services users in the past, and one (3%) had received psychiatric treatment.

Eleven (33%) of the participants reported having seen advertisements for FGCS, five (15%) reported having looked up medical illustrations and four (12%) reported having viewed pornography. When asked what they would like to achieve with surgery, 20 (60%) women stated a wish to make the labia smaller to ‘improve’ appearance, six (18%) to reduce discomfort, three (9%) to improve confidence, two (6%) to improve experience of coitus, one (3%) to ‘make clean’, and one (3%) said she was seeking advice about the need for surgery (see Figure 2). Nineteen of 31 women (61%) who answered the question reported having never been sexually active with a partner.

Figure 2.

 Expectations of women seeking surgery.

Twenty-seven women (81%) were able to identify the age at which they had first become dissatisfied with the labia minora. Of these, five (15%) reported this to be under the age of 10, ten (30%) between the ages of 11 and 15, five (15%) between 16 and 20, four (12%) in their twenties, and three (9%) in their thirties. Eleven women offered explanations for their dissatisfaction: six (54%) of them reported having become increasingly self-aware of the genital area without any further elaboration, two (18%) reported having become aware of the physical discomfort, two (18%) reported having received comments from a partner and one (9%) from friends, and one (9%) woman reported having seen a television programme on cosmetic genital surgery.

On vaginal examination, 22 (66%) of the women were noted to have shaved pubic hair, seven (21%) to be wearing a thong, and none had genital piercings. All study participants had labial measurements within published normal limits (see Table 2 and Figure 3). In terms of referral outcomes, three (9%) women were offered unilateral labial reduction to address a significant asymmetry. No other procedure was performed. Of the 30 women who were refused surgery, 11 (36%) accepted a referral for psychology, 12 (40%) said that they would opt for a second opinion or for surgery either in the NHS or in the private sector, and one (3%) was referred urgently to mental health services for a risk assessment for potential self-harm.

Table 2.   Dimensions of labia minora
 Right sideLeft side
Width of labia (mm) (medial to lateral)26.9;0–50 (12.8)24.8;5–50 (13.1)
Mean; range (SD)  
Length of labia (mm) (anterior to posterior)38.2;10–80 (17.4)37.5;10–80 (15.8)
Mean; range (SD)  
Figure 3.

 Dimensions of labia minora compared with upper limit (50 mm) of published normative values. The open circles represent those with asymmetry of >30 mm.

Discussion

This is the first report on the labial dimensions of women seeking cosmetic labial reduction surgery. In three women there was significant labial asymmetry and surgery was offered. In all other women, all labial dimensions were within the normal range. It is therefore surprising that all of the study participants and their referring doctors should have felt that surgery was an appropriate treatment. Despite reassurances that their labia were normal, 40% of the participants remained keen to pursue surgery by any other available route. Some primary-care trusts are declining to fund labial surgery on the NHS unless strict criteria are met, such as marked asymmetry. All women in our study were offered the option of sessions with a clinical psychologist to explore issues leading to their request for surgery in addition to being given the reassurance of having normal anatomy.

Definitions of ‘normal’ are problematic. However, clinicians require criteria for deciding whether to treat or not to treat. The literature contains few reported studies on labial dimensions of well women. In view of this, this group has set their own upper limit of labial width as that found in their own small study of 50 asymptomatic women.5 There is an urgent need for data based on a large adult general population sample stratified according to age, ethnicity and parity.

Reasons for the participants’ distress are likely to be complex, and the qualitative data begin to assess this. Physical symptoms may be exaggerated by current grooming trends especially pubic hair removal (66% in this study) that renders the labia more exposed and may irritate sensitive skin. However, although 19 of the 33 participants (57%) complained of physical discomfort, only six (18%) said that they believed surgery would ameliorate the discomfort. Despite this they sought surgery.

The finding that the labial appearance was of overriding concern was unsurprising. A third of our sample of help seekers had consulted advertisements for FGCS. Given the reason for these sites is to generate demand for FGCS, it is unlikely that women and girls would be exposed to illustrations that celebrate diversity. Rather, the image of a smooth exterior with the labia minora tucked inside the labia majora is idealised and negative comparisons are encouraged.2–6

These findings inevitably highlight clinicians’ ethical dilemma.7 Legislation in the UK prohibits incision, excision and infibulation of the labia majora, labia minora or clitoris for cultural or non-therapeutic reasons, even if an adult woman were to give consent and even if it were carried out by medical practitioners. The legitimacy of all forms of FGCS in westernised nations involves valorising FGCS as ‘therapeutic’ and but positioning by othering the genital cutting in non-westernised nations as ‘cultural’.7 This is slippery ground indeed. It is difficult to see how operations on normal sex organs in the absence of quality data could be therapeutic. It is equally difficult to see how FGCS could be anything other than cultural.

A particular concern in this study is the age of some of the referred women—as young as 11 years. The age of presentation has been a concern for adolescent gynaecologists for some time.8 Development of the external genitalia continues throughout adolescence and in particular the labia minora may develop asymmetrically initially and become more symmetrical in time. Younger girls may not be able to understand the potential long-term risks of surgery on sensation or be able to appropriately weigh up the risks and benefits of such an unstudied procedure.

The prohibition of surgery on normal children should not require debate. But, even in the case of adult women, informed consent requires the individual to understand the full implications of treatment. This information is simply unavailable. If anything, scientific studies suggest that genital surgery is associated with reduced sensitivity, which could affect sexual function.9 Recently, oestrogen receptors have been demonstrated at the free edge of the labia minora, which would be disrupted during surgery.10

Clinicians are in urgent need of clear guidance. In 2009 the Royal College of Obstetricians and Gynaecologists issued a statement advocating that any decision for surgery be based only on clinical grounds. However, the statement leaves it to individual practitioners to define these grounds for themselves.11 The British Association of Aesthetic Plastic Surgeons12 advises the need to determine whether a problem exists or whether an alternative solution may be preferable, but offers no advice on how to judge a problem. Interestingly, the private provider BUPA has a procedure code for labial reduction and categorises it as a cosmetic operation, for which cover is not provided. Hence a private medical insurance company appears to be able to come to a conclusion when professional bodies are reluctant to act. This raises the uncomfortable and as yet unvoiced issue of partisan interest.

Conclusions

Many women seeking labial reduction surgery have normal genitalia that are not different from those of women not seeking surgery. This suggests that the growth of FGCS is potentially infinite. The onus of decision-making regarding labial reduction surgery lies not only with informed clinicians. National care standards are urgently needed. This responsibility falls on the professional bodies and specialist societies.

Disclosure of interests

Nothing to declare.

Contribution to authorship

NSC wrote the paper, collected data and contributed to the discussion. RD and LM collected data and contributed to the discussion. LML wrote the paper and contributed to the discussion. SMC designed the study, collected data, wrote the paper and contributed to the discussion.

Details of ethics approval

The project was approved by the joint hospital and university ethics committee (project: 03/0173).

Funding

Nothing to declare.

Ancillary