Labiaplasty (labioplasty) is a surgical procedure to reduce the size of the inner lips (labia minora) around the vagina. Women either see gynaecologists or plastic surgeons for this operation.
I have been a doctor for over 30 years and have a busy practice as a consultant gynaecologist.
Five years ago, I would perhaps see one or two teenage girls a year requesting surgery to reduce the size of their labia (mostly on just one side) because they were having discomfort while cycling or inserting tampons. I spent a lot of time talking to these young women to check that they really understood what they were going to put themselves through. I would be able to reassure most girls with simple instructions on how to reduce irritation. Surgery was usually recommended in a tiny proportion of these young women and only after the age of 18, when growth was complete.
We are now seeing an unprecedented surge of referrals, almost exclusively in the private sector. The NHS performed over 2,000 labial reduction operations in 2010 but the NHS has recently stopped offering these, except for a few carefully selected cases, because the request has risen fivefold since then. The concern is that most of these requests are cosmetic in origin.
Often accompanied by their understandably anxious mothers, these young women are typically between the ages of 14 -18 years and tend to be adamant that they want surgery because they are unhappy with the appearance and size of the inner lips. The BritSPAG (British Society for Paediatric and Adolescent Gynaecology) is particularly concerned about labiaplasty being performed on girls under 18 years.
It appears that the US is also seeing a similar increase in requests for surgery with a sharp increase recently as women want to look sleeker in form fitting clothes such as lycra yoga pants. They are worried about throwaway comments from boyfriends about how they look down below or having photos taken with the dreaded 'camel toe' appearance.
What is driving this dramatic increase in requests for surgery? Is the reason for requesting surgery, really a deep-seated insecurity that is encouraging women to ask for a potentially mutilating procedure?
Easy access to pornography and pictures of photo shopped women may be partly responsible, making women worried about how their appearance may affect their sexual relationships. The cosmetic industry may also be fueling these concerns through advertisements and offering deals for combined cosmetic procedures. We need to insist on rigorous standards for such advertising.
One may argue that women increasingly have laser surgery for hair removal, nose jobs, breast augmentations and other surgical procedures but I would argue that labiaplasty is fundamentally different. Some medical professionals have even questioned whether labiaplasty is the same as female genital mutilation (FGM)? There is a difference: labiaplasty is done for cosmetic or medical reasons with full consent, and FGM is done without consent.
As a profession and as a society, we need to explore why so many women are choosing to have surgery. This is a surgical procedure with very real short-term and long-term risks as well as psychological issues that are often not adequately addressed. The labial skin is rich in highly sensitive nerve endings. Amputating or trimming this skin can lead to bleeding, scarring, chronic infection and longstanding pain from nerve damage. Other risks include reduced sexual pleasure and dissatisfaction of the overall appearance resulting in further surgery in some cases. Failure to acknowledge deep-seated issues can result in the young woman setting off on a path of repeated cosmetic surgery on various parts of her body which is not only expensive but also comes with a possibility of surgical complications.
The Royal College of Obstetricians and Gynaecologists (RCOG) has recognised the concerns of gynaecologists in the UK regarding these procedures and has come out with guidance , making several recommendations. The RCOG urges clinicians to provide accurate information and to be aware that in many cases, there is no medical evidence to suggest that treatment will truly benefit the individual.
So what role can responsible professionals play? Educating women early in their high school years about how our anatomy varies is important. Equally necessary is boosting confidence and body image through education and open discussion. Health professionals must not be afraid to recommend psychological assessment and counselling before agreeing to surgery.
Negative attitudes towards natural female genitalia does not just lead to labiaplasty, but also to the popular practice of removing all or most of one's pubic hair. That hair is there for a reason: to protect the external parts of the female genitalia (vulva) and removing it - as well as wearing thongs - can lead to chafing, pulling or trapping of skin. In removing hair, women are also more aware of the appearance of body parts that were previously covered and protected.
We don't all look the same, so why would we expect our labias to look the same? We need to encourage young teenagers to love their body and build their confidence.
Labiaplasty should not be offered to any woman under the age of 18 as her body is still growing. Ideally, we should offer the procedure only when there is a clear medical reason. Physical discomfort can often be managed by simple hygiene measures such as using emollients and chemical free sanitary ware, avoiding harsh perfumed toiletries and wearing appropriate underwear. Young women with emotional distress from the appearance of their labia should have mandatory counselling before surgery is embarked upon.
Currently, there is no consensus in the medical world as to what defines enlarged labia. Of course a woman can do what she wishes to her own body but as doctors who have taken an oath to do no harm, we also have a responsibility to educate and empower these women to accept themselves the way they are. The alternative is to have invasive surgery with the possibility of serious long-term physical and psychological consequences.