by Dr Raj Persand and Professor Kathleen Martin Ginis

Female Genital Cosmetic Surgery is becoming increasingly popular, but as most of these medical procedures are done privately in the UK, precise figures are difficult to obtain.

Lindy McDougall, an anthroplogist from Macquarie University, Sydney, in a recent study where she interviewed 20 cosmetic and plastic surgeons willing to perform Female Genital Cosmetic Surgery, quotes figures for the UK; that in thepast 10 years there has been a five-fold increase in the number of labiaplasties performed on the British National Health Service.

Raj Persaud
Source: Raj Persaud

Female Genital Cosmetic Surgery includes labiaplasty, liposuction of the mons pubis, vaginal tightening, clitoral hood reduction, clitoral repositioning, G-spot amplification and hymen reconstruction.

Lindy McDougall found labiaplasty of the labia minora is usually the most frequently performed procedure, and is primarily done for aesthetic reasons. It prevents folds of skin, referred to as the labia minora, protruding below the labia majora, or corrects asymmetry. Beyond cosmetic reasons, some women complain that they experience discomfort during physical activities such as cycling, walking or sexual intercourse - surgery performed for these reasons would not be regarded as cosmetic.

In her study entitled, 'Towards a clean slit: how medicine and notions of normality are shaping female genital aesthetics', examining reasons for the recent dramatic growth in this area of cosmetic procedures, Lindy McDougall reports a surgeon explaining that women want their genitals to have 'nothing hanging down', or protruding below the labia majora. Some want their mons pubis reduced - which is achieved through liposuction.

One of the surgeons she interviewed for her research, published in the journal, 'Culture, Health & Sexuality', described protruding labia as a 'disability', and looking like a penis. Another said it looks as if 'they have got testicles,' implying that protruding labia look inappropriate for a feminine woman.

Lindy McDougall argues there has been a recent rise of a 'clean slit' aesthetic - which emphasises smoothness, and no external structures visible. This is the look that surgeons explain patients most request. One account for this is that current fashions have become progressively skimpier and tighter, particularly lingerie, jeans, leggings and swimwear.

The surgeons also reported that women often seek labiaplasty in order to appear attractive to (hetero)sexual partners. They're seeing a lot more young girls who are concerned that their sexual partners may be put off by the appearance of their vulvas.

Therefore, larger or asymmetrical labia are operated on, not because they are physically abnormal, but because they are deemed aesthetically displeasing. Surgeons also explained that the increasingly hairless look means, as you often get to see more of that area, women were increasingly concerned about how the rest of their genitals looked after hair removal.

Raj Persaud
Source: Raj Persaud

Some surgeons describe themselves as responding to female desire for surgery almost reluctantly, as if they were victims of more assertive, demanding women today. This means the surgery is performed primarily to please the patient, and almost sometimes against the surgeon's better judgement. But Lindy McDougall points out surgeons also promote these procedures on their websites and in advertisements, so some sections of the medical profession, she contends, are complicit in creating the "clean slit' ideal by promoting surgery as a rational and empowering choice for women.

For example, one patient described as very beautiful by her surgeon requested labiaplasty, yet after it was performed, she  returned for further surgery in that area, despite the fact the surgeon didn't feel any further work was  necessary. This overly fastidious woman convinced her reluctant surgeon to re-operate, to improve  the symmetry of her labia.

But in stressing the demanding nature of some of their patients, Lindy McDougall argues in her study surgeons are justifying their own actions and trying to distance themselves from their patient's decisions. Increased access to information regarding cosmetic surgery has resulted in women presenting to surgeons with their own definite requests. Now the clinicians complain everyone is an expert on cosmetic surgery because of access to reality television programs, the Internet and press articles.

Women who choose to have surgery don't appear as hapless victims of consumer culture, to the surgeons, but as thoughtful, assertive, autonomous women making positive choices to improve their lives. However, Lindy McDougall concludes that offering procedures alleged to improve self-esteem can prey on the insecurities of vulnerable women who suffer genital anxiety as a result of comparing themselves with images found in the media.

Lindy McDougall's study quotes Armstrong, who wondered in 'Sirens', an online women's magazine, why even enviably beautiful women now appear 'totally freaked out' by their vaginas. In contrast while men have grappled with genital insecurity for a lot longer, Armstrong points out there was a yardstick, literally, by which they could measure up against a preferred ideal. Bigger might be better for men, but for women, what is the ideal and where does it come from?

Another theory could be that the "clean slit" ideal is pre-pubescent plus Barbie doll-like. Just as the female body image ideal has become more slender, maybe this trend is a natural progression of that ideal to female genitalia?

Lindy McDougall also interviewed 10 'beauticians' who offer Brazilian waxing. Although less invasive than genital surgery, its growing popularity indicates a general change in 'genital aesthetics'.

The beauticians she interviewed emphasised the importance of cleanliness and neatness as a major advantage of Brazilian waxing. Preferring 'it without hair' was more a 'hygiene thing'. Lindy McDougall argues neatness is linked to cleanliness and control over one's body.

Raj Persaud
Source: Raj Persaud

Others blame the 'mainstreaming' of pornography through wider availability on the internet. Soft-core pornography might be instrumental in spreading the clean slit ideal.

Yet, Lindy McDougall suggests it may also be that women prefer to see idealised body types in soft-core pornography, as opposed to male consumers who may prefer to view a more realistic variety of genital forms. Paradoxically the full range of normal genitalia, is rarely seen in soft core pornography, but is in hard-core pornography, an industry that many would argue demeans women. Yet it's the neat and tidy genitals found in soft-core pornography which have become the ideal.

'Soft core' pornography tend to show women's genitals with no, or very little, hair, neat, symmetrical and frequently digitally altered. As one soft-core pornography magazine editor is quoted in Lindy McDougall's research said; 'It's not because they've chosen to only photograph women with "innies". Many of the models actually have "outies" in real life, which have been "healed to a single crease" with the aid of image editing software.

Think of it as "digital labiaplasty"'.

Kathleen Martin Ginis is a Professor in the Department of Kinesiology at McMaster University in Ontario, Canada.

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Raj Persaud and Peter Bruggen are joint podcast editors for the Royal College of Psychiatrists and also now have a free app on iTunes and Google Play store entitled ‘Raj Persaud in conversation’, which includes a lot of free information on the latest research findings in mental health, psychology, psychiatry and neuroscience, plus interviews with top experts from around the world.

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