Cosmetic genital surgery may be fuelling women's insecurity about their body and their body parts, argue two senior doctors in this week's BMJ.
They believe that women should be warned about the risks of cosmetic genital surgery, and that alternative solutions to concerns about the appearance of their genitals should be developed.
More and more women are said to be troubled by the shape, size, or proportions of their vulvas, write Lih Mei Liao and Sarah Creighton from the UCL Elizabeth Garrett Anderson Institute for Women's Health. Demand for cosmetic genital surgery (genitoplasty) is increasing and the number of labial reductions in the NHS has doubled in the past five years.
But decisions about surgically altering the genitalia may be based on misguided assumptions about normal dimensions, they warn.
Surgery carries risk, such as loss of sensitivity and the long term benefits are unclear, they say. Some doctors even align the practice with "female genital mutilation." So what makes women take such risks when their genital characteristics fall within typical ranges?
They interviewed healthy adults who had undergone surgical reduction of normal labia.
Some patients cited restrictions on lifestyle as reasons for their decision, including inability to wear tight clothing, ride a bicycle comfortably, or avoidance of some sexual practices. The authors noted that men with similar problems seek alternative solutions.
Patients consistently wanted their vulvas to be flat with no protrusion beyond the labia majora, even though there is nothing unusual about protrusion of the labia minora or clitoris beyond the labia majora, say the authors. Some women brought along images to illustrate the desired appearance, usually from advertisements or pornography that may have been digitally altered.
The increased demand for cosmetic genitoplasty may reflect a narrowing social definition of normal, or a confusion of what is normal and what is idealized, they write. And the provision of genitoplasty could narrow acceptable ranges further and increase the demand for surgery even more.
Surgery is an extreme and unproved intervention in this instance, and it should be thought of as the last resort, not the first port of call, they argue.
"Initiatives involving health agencies, educational bodies, the voluntary sector and the media are needed to help women and girls deal with feelings of insecurity about their genitals and about their bodies in general, they say. "We also need more commitment and investment in research as well as innovative interventions in the community to help women and girls to approach concerns about their appearance skilfully and imaginatively."