Labiaplasty: The Stigma Persists

Abstract

Background

Heightening interest in labiaplasty has driven potential patients to online fora, permitting the dissemination of material by potentially unqualified or inexperienced individuals. The discourse surrounding this procedure has been injected with strong opinions that are not entirely consistent with medical best-practice or evidence-based knowledge.

Objectives

The aim of this study was to explore the rationale for ongoing public opposition to labiaplasty and to investigate if awareness of the similarities between labiaplasty and breast reduction can alter an individual’s perception.

Methods

Four hundred and forty-eight adult women were surveyed concerning their opinion of a surgical procedure to reduce the size of an unspecified organ related to a woman’s sexuality, breast reduction, and labia reduction.

Results

Reduction of an unspecified organ and breasts was met with significantly greater acceptance than labia reduction (P < 0.0001). Presenting responders with an educational tool comparing each procedure’s indications, risks, and potential benefits did not alter respondent opinions, indicating notions about sexual surgery are relatively fixed. The most common reason respondents persisted in their relative opposition to labia reduction was a perceived deficiency in social acceptance (27.1%), followed by a perceived similarity to female genital mutilation (14.8%).

Conclusions

Attitudes towards labiaplasty seem firmly based on emotion or correlation to other unacceptable practices. Informational resources do not sway these biases; thus, there is a limited role for surgeon-led education in the normalization of labiaplasty because it requires a societal shift in acceptance. Labiaplasty is a procedure whose time for popular acceptance has not yet come.

See the Commentary on this article here.

See the Commentary on this article here.

As a result of patients’ increasing willingness to publicly discuss aesthetic surgery, labiaplasty, a previously obscure procedure, has entered the public consciousness. This heightening interest has driven potential patients online, where plastic surgeons have followed to promote their services and educate potential patients. Unlike the privacy of an examination room, online fora permit the dissemination of material by potentially unqualified or inexperienced individuals. The margin for error and misinformation is large, and the reliability of the general public to adequately assess the procedure is questionable.^1,2 As a result, much of the discourse surrounding this procedure has been injected with strong opinions that are not entirely consistent with medical best-practice or evidence-based knowledge.

Adding further controversy, recommendations issued by the American College of Obstetricians and Gynecologists suggest that labiaplasty and other vulvovaginal surgery for appearance and sexual function reasons are medically unnecessary.³ This statement ignores patient satisfaction as a measure of success and opposes long-established principles of cosmetic surgery.⁴ Critics often characterize patients as being exceptionally vulnerable to societal influence, despite studies that prove otherwise.⁵ Comparable cosmetic procedures have not been subjected to similar scrutiny, and plastic surgeons have been compelled to defensively justify this procedure on behalf of their patients.⁶ Scrutiny surrounding a patient’s motivation for seeking labiaplasty has driven many to overemphasize physical complaints to legitimize their request for surgery, presumably for self-justification.^7-9

The underlying motivation to conduct this study is to understand why labiaplasty, which is tantamount in risks and benefits to breast reduction, is less acceptable to the public.^10-14 Our objectives were to explore the rationale for heightened public opposition to labiaplasty and assess if raising awareness of the similarity between labiaplasty and breast reduction can alter an individual’s perception. This study, which was based on a crowdfunding model, reflects the need to justify autonomous individuals’ desire to live their authentic selves as manifested in their physical appearance.

METHODS

This study utilized previous research in its design, which demonstrated that educational exposure is an effective intervention when directly diminishing an individual’s stigma towards an entity.¹⁵

Adult women were queried about their opinions of various surgical procedures to reduce the size of a bodily organ. Respondents were English-speaking females 18 years of age or older from all educational backgrounds who could complete a visually based CAPTCHA challenge.¹⁶ Males and transgender females were excluded because questions to survey sexuality and sexual perception properly in this population were not included. Responses were deidentified automatically to maintain maximum respondent confidentiality.

Study Design and Distribution

Using a 5-point Likert scale, respondents were first asked to express their degree of (1) personal interest, and (2) support for a third party, in the surgical reduction of an unspecified organ related to a woman’s sexuality (Appendix A, available online at www.aestheticsurgeryjournal.com). Next, 2 questions with synonymous wording were posed in which respondents were asked for their opinion specific to breast reduction and labia reduction. An informational table comparing the 2 procedures was then displayed, during which respondents were unable to progress through the survey for 1 minute to ensure adequate time for review (Table 1). Lastly, follow-up questions identical to those initially asked were posed to determine the effects of this information on respondent sentiment. All questions and information pertaining to labia and breasts were presented in a randomized order to eliminate leading question bias and limit the impression of normality of one procedure over the other.

The survey was crowdsourced online via Amazon Mechanical Turk (Seattle, WA) for 1 week in February 2021. Respondents were compensated $1US for their completion of this survey. In addition, those respondents deemed more critical of labia reduction than breast reduction were later asked to answer additional questions to explain and classify the cause of this inequality (Appendix B, available online at www.aestheticsurgeryjournal.com).

Statistical Analysis

Paired t tests were utilized to compare responses between the sexual organ of interest, the effects of an informational table, and the differences in opinion when the surgical subject is the self vs a third party. Significance was set at P < 0.05. Statistical analyses were performed with GraphPad Prism version 9.1.0 (GraphPad, San Diego, CA).

RESULTS

Four hundred and forty-eight adult women completed the survey sufficiently for analysis (Table 2). Respondents were between the ages of 18 and 61, with a median age of 32. Personal interest in surgery was rated at 2.61 for an unspecified sexual organ, 2.71 for breasts, and 2.20 for labia (higher is greater interest). Support for a third party receiving surgery was rated at 3.08 for an unspecified sexual organ, 3.18 for breasts, and 2.80 for labia.

There was no significant difference in personal interest/support for a third party regarding surgery on an unspecified sexual organ vs breasts (P = 0.1918, t = 1.310/P = 0.0769, t = 1.778). However, a significant difference was found in personal interest/support for a third party regarding surgery on an unspecified sexual organ vs labia (P < 0.0001, t = 5.122/P < 0.0001, t = 4.316). Additionally, there was a significant difference in personal interest/support for a third party regarding surgery on breasts vs labia (P < 0.0001, t = 6.263/P < 0.0001, t = 6.065). Respondents consistently rated their support for a third party regarding surgery on an unspecified sexual organ/breasts/labia higher than personal interest (P < 0.0001, t = 6.617/P < 0.0001, t = 6.332/P < 0.0001, t = 7.955).

Effects of Informational Table

Although personal interest/support for a third party regarding surgery after reviewing the informational table increased to 2.86/3.30 and 2.56/3.15 for breasts and labia, respectively, the changes were not found to be statistically significant (P ≥ 0.2319 for all analyses).

Supplementary Survey

Of the 148 respondents deemed persistently relatively critical of labiaplasty, 101 (68%) were available for a follow-up survey (Table 3). The most commonly cited reason for opposition to the procedure relative to breast reduction was social acceptability (27.1%), followed by a perceived lack of benefit (14.8%) and perceived similarity to female genital mutilation (FGM) (14.8%).

DISCUSSION

Reduction of a body part is common and relatively well tolerated by society when performed by plastic surgeons (ie, breasts, excess upper/lower eyelid skin, pendulous earlobes, neck redundancy, mammary hypertrophy, skin excess following massive weight loss, lax or prominent abdominal pannus).^17-21 Despite lay beliefs that plastic surgeons may be primarily financially motivated, patients are satisfied and derive numerous benefits from undergoing these procedures; thus, it is natural for us to be their advocates.^22-25 Plastic surgeons commonly consider a labiaplasty to be medically and ethically consistent with these interventions, with comparable complication rates, patient satisfaction, and recommendation rates.^26-38 However, labiaplasty is met with considerably greater public opposition relative to these other procedures.^{39, 40}

The results of our study show that reduction of an unspecified sexual organ and breasts are met with equal public acceptance, but when the specifics of reducing vaginal labia are presented, there is significant opposition. Presenting responders with an educational tool comparing the indications, risks, and potential benefits did not alter their opinion towards the procedures individually or relative to each other, indicating notions about sexual surgery are fixed and immutable. This has significant implications because patients presenting for surgical labiaplasty consultation likely equate the risks with other commonly performed interventions and have few prejudices which need to be overcome, whereas those inherently uninterested are resistant to educational persuasion.

After reviewing the informational table, the most common reason respondents persisted in their relative opposition to labia reduction was a perceived lack of social acceptance (27.1%). Only 10.32% of respondents opposed the procedure due to perceived increased risks, and 2.58% because it is a relatively more intimate area than the breasts. These results indicate that respondents’ bias against labia surgery is primarily due to societal standards of acceptance vs an informed decision, further explaining the ineffectiveness of education in altering their opinion towards the procedure. This deficit in societal acceptance can most logically be attributed to heightened sensitivity of the vulva, physically and emotionally, relative to other erogenous zones. Western culture’s historical emphasis on female virginity, and subsequent expectations that women project themselves as expressly nonsexual beings in public, have contemporary effects and remain the primary obstacle to open discussion regarding female sexuality and acceptance of potential medical needs.^41-49

Although the data reveal relative support for autonomous decision-making by a third party, respondents paradoxically indicated a preference not to recommend labiaplasty for others, suggesting a paternalistic approach unique to labia surgery. Furthermore, a significant source of opposition to labiaplasty in public discourse is its conflation with FGM.⁵⁰ Despite repeated efforts to clarify the distinction by plastic surgeons, anthropologists, and journalists, our study confirms the existence of this misunderstanding.^51-53 Given that patients are overwhelmingly pleased with the results of surgery, we believe it is a responsibility for the benefit of our patients to persist in these educational attempts.^{35, 37, 54-56} FGM is often performed on young girls between infancy and 15 years of age without their consent to delay or prevent sexual activity.^{57, 58} Conversely, female genital plastic surgery (ie, labiaplasty) is carried out with autonomous decision-making by consenting adult patients to improve self-confidence through enhanced sexual self-image, satisfaction, and function.^59-62

Limitations of this study include self-selection bias; all the respondents chose to participate in this survey. Non-English-language speakers were excluded but are needed to further generalize our results and avoid sampling bias. Although there is concern that an anonymous crowdsourcing model can introduce insincerity in patient response, these surveys have historically produced better-quality data than population-based models.^{63, 64} Lastly, males and transgender females were excluded from this analysis because the complexity of gender and sexual function was outside the scope of this study.

Future studies could benefit from visual schematics, such as before-and-after photographs, patient testimonials, and education specific to FGM to allow for greater informed decision-making by respondents. The geographic specificity of respondents and the inclusion of languages other than English may provide more precise information regarding the opposition to this procedure and its conflation with FGM, which can vary according to local practices.

CONCLUSIONS

The lines remain sharply divided in attitudes uniquely towards labiaplasty in marked contradistinction to other societally accepted plastic surgery interventions. These impressions seem firmly based on emotion or correlation to other unacceptable practices or beliefs. Simple informational resources do not appear to sway these biases, and thus, there is a limited role for surgeon-led education in the normalization of labiaplasty, as it requires a societal shift in acceptance. Labiaplasty is a procedure whose time for popular acceptance has not yet come.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes