1. The idea of individual choice underpins the ethical acceptability of all cosmetic surgery. Women who feel embarrassed about the size and shape of their genitals have a right to be able to change them if they so desire, but what happens if individual choice is being shaped by outside influences? A 2009 study by Koning, Zeijlmans, Bouman and van der Lei found that 14% of a sample of 482 women had received negative comments about their labia from a partner; 7% had received comments from other women.
2. Women who have labia that droop down substantially are diagnosed as having a condition called hypertrophy of the labia minora. Defining hypertrophy is difficult because the size and shape of female labia vary so dramatically. Some researchers claim that labia minora measuring 5 cm or more from the base to the tip merit the label. Others claim that 3-4cm is hypertrophic. In a 2006 paper published in the International Journal of gynecology and Obstetrics, Pardo et al. defined labia minora of less than 2 cm as ''normal size'', which implies that anything larger is abnormal.
3. In the last fifteen years the number of women consulting cosmetic surgeons because they are concerned about their genital appearance has increased dramatically. The number of labiaplasty operations performed on the National Health Service in the U.K. has almost trebled across a decade: from under 400 in 1998-1999 to nearly 1200 in 2007-2008. U.S. data from the American Society of Plastic Surgeons (ASPS) indicated a 30% increase in ''vaginal rejuvenation'' between 2005 and 2006 (from 793 to 1030).
4. Blame the internet. The first clinical reports of cosmetic labiaplasty procedures appeared in 1984, but by the late 1990s the "designer vagina'' had entered public discourse, largely as a result of media coverage in glossy women's magazines. These articles were fuelled by the internet, which had only recently enabled high-profile surgeons to publicise their services on their own websites.
5. The wider medical community has continually expressed concern about the lack of medical regulation applied to cosmetic surgery in general, and genital cosmetic surgery in particular. Cosmetic surgeons are naturally defensive about this criticism. In a 2005 letter published in the journal 'Plastic and Reconstructive Surgery' cosmetic surgeons V.R. Girling, M. Salisbury, and R.A. Ersek claimed, "every one of our patients has been delighted with the results. Among them was a bathing suit model who came to us very embarrassed about this problem. She had never had a serious relationship before the procedure. Shortly thereafter, she sent us the announcement of her wedding to a professional golfer." Justification indeed.
6. There is also increasing anxiety about the content of online advertisements for female genital cosmetic surgery. A study by Lih-Mei Liao, Neda Taghinejadi and Sarah M Creighton from the UCL Institute of Women's Health which was published in the British Medical Journal in 2012, described the level of clinical information provided by firms advertising female genital cosmetic surgery as 'poor' and 'erroneous'. The terminology used to describe the three main procedures; labiaplasty, hymenoplasty and vaginoplasty, was also found to be confusing; 72 different terms were used to to label a small number of procedures, for example labiaplasty was called "vulval reshaping", "vulva and vaginal rejuvenation" while hymenoplasty was referred to as "revirgination" and vaginoplasty was a "Mommy Makeover".
7. All of the websites in the study claimed that surgery would improve vulval appearance. In several sites, labial surgery was recommended to promote a 'youthful' vulval appearance. One site suggested that 'a woman might have a face lift and look really young until she goes to bed and a partner can see the evidence of ageing there'. Hymenoplasty was recommended to 'improve the woman's hidden aesthetics' and to ensure that 'you should bleed on your wedding night and keep your head high'.
8. Unsubstantiated claims of physical, psychological and sexual benefits were present on every website but there is no clinical evidence to support these claims. In fact vaginal anatomy and sexual function are not necessarily associated at all.
9. Although women who have had cosmetic surgery to their genitals generally seem to feel that it was worth the expense and the pain, aesthethic improvement has a negative effect on sexual function. Cutting through the complex web of nerve endings and blood vessels in the labia and vagina compromises sensitivity and interferes with the process of engorgement during sexual arousal and intercourse.
10. One can't help wondering if the partners of women who undergo genital surgery are as concerned about their diminished sexual pleasure as they were about their genital aesthetics.