Designer Genitalia: Fad, Benefit, or Mutilation?

An Expert Interview With Cheryl B. Iglesia, MD

Janet Kim, MPH; Cheryl B. Iglesia, MD


January 28, 2013

In This Article

Editor's Note:
"Vaginal rejuvenation" -- or female genital cosmetic procedures, such as "designer vaginoplasty," "revirgination," and "G-spot amplification" -- are currently experiencing an increase in demand among women seeking to modify genital appearance, reclaim a more youthful vulva, or enhance sexual response. A news article published on Medscape reported that "More than 2,140 U.S. women underwent 'vaginal rejuvenation' last year, according to the American Society for Aesthetic Plastic Surgery. The International Society of Aesthetic Plastic Surgeons put the U.S. total at nearly 5,200 in 2010. Experts note such figures do not include the many procedures done by gynecologists."

However, this growing trend is troubling to some medical organizations and healthcare professionals that are concerned about the safety, effectiveness, and ethics of these procedures.

Medscape explores this issue further with Dr. Cheryl B. Iglesia, a leading expert in urogynecology. Dr. Iglesia is Section Director of Female Pelvic Medicine and Reconstructive Surgery at MedStar Washington Hospital Center and is an Associate Professor of Obstetrics, Gynecology, and Urology at Georgetown University in Washington, DC.

Cheryl B. Iglesia, MD

Medscape: Which cosmetic procedures in particular are more likely to be requested?

Dr. Iglesia: Most likely to be requested are labiaplasties -- lip reductions, more commonly of the labia minora but sometimes also of the labia majora. Some surgeons are performing clitoral hood reductions, supposedly to reduce the frenulum -- the skin or prepuce overlying the clitoris -- so that the clitoris is more exposed. I'm concerned about scarring and denervation injury affecting engorgement and a woman's ability to orgasm.

Vaginal rejuvenation, generally speaking, encompasses traditional reconstructive procedures, such as anterior and posterior repair, where you dissect certain tissue planes, push back the dropped organs, tighten the connective tissue, trim, and then close. Cosmetic surgeons are doing similar tightening using sutures; however, they also tout the use of a laser, which has not been shown to have significant benefits over traditional scalpel or electrosurgery. And they charge high rates that are not covered by insurance.

The bona fide surgical procedures would be covered by insurance if women were evaluated properly and were educated about normal and abnormal vulvar anatomy and pelvic support.

Medscape: What reasons might explain why more women now than in the past are considering or choosing to have these procedures?

Dr. Iglesia: Mostly it involves 2 things: marketing and media. I also feel that the trend toward pubic hair removal gives people a clearer view of the genital area. Many of the images in the media, and certainly on the Internet and in pornography, feature no pubic hair, and the external genitalia appear to be uniform, almost Barbie-like.

We published a study in the November 2012 issue of the American Journal of Obstetrics and Gynecology[1] in which we surveyed approximately 400 women. We divided them into 2 age groups: millennials/Generation X vs baby boomers and older women. Among those who were in their 30s and younger, 84% did some type of waxing, pubic hair grooming, shaving, or laser removal vs only 36% in the older group.

In the first Sex and the City movie, one of the women was wearing her bathing suit and her pubic hair was showing. Another character said that she would never be caught dead or in jail looking like that. So I feel that this is a trend or a fad, and certainly many people are getting their information -- or misinformation -- from the many images available in the media.

By the way, an increasing trend has also been reported from the National Health Service in England. It's hard to believe the numbers, but they went from 500 cosmetic genital procedures in 2001 to over 2000 procedures in 2010.[2]

Medscape: Why is the increasing trend in these procedures a cause for concern, both for healthcare professionals and patients?

Dr. Iglesia: It is a cause for concern if women are having these procedures because of feelings of self-consciousness or that they have to adhere to a certain standard. It is also concerning if women feel bad about normal anatomy because of the opinions of others.

Women are experiencing downsides of having these procedures, and I have seen some of the complications associated with labiaplasty and vaginal rejuvenation surgeries. Complication rates range anywhere from 4% to 18%. People need to understand that these rates are not small. Complications include pain with sex, bleeding, scarring, and improper healing.

The scarring can be substantial. I had a patient who had a vaginal rejuvenation and labia minora plasty procedure for her lover. She thought it would be a great surprise for him to make her vagina tighter and lips smaller. And now every time they have sex, the posterior vagina rips and causes severe dyspareunia. She has a lot of regret. Most women don't realize that this intimate part is highly innervated and vascularized.

In older women, as estrogen levels decline, the labia thin out -- similar to how their lips thin. We don't know the long-term effects for some of these surgeries that are designed to tighten the vagina and can cause scarring. The complications could also be very difficult to repair.

Medscape: The fact that these procedures are being done in prepubescent girls is very concerning.

Dr. Iglesia: These procedures are marketed heavily, and some of the requests for the procedures are being done for prepubescent adolescents. A study by Crouch and colleagues[3] found labiaplasties being requested for girls as young as 11 years of age. I remember being interviewed by a reporter from Cosmopolitan who said she was at a conference where a doctor was saying that a mother brought in her 16- and 11-year-old daughters and wanted them both done. I was appalled.

Yes, this trend is concerning, especially among adolescents. Such children have not even finished puberty. So it's a cause for concern that 11- to 14-year-olds are already so self-conscious about their intimate parts. An image is already being set that something is wrong with them, when it's highly likely that they're completely normal.

The overall expectation for labiaplasty procedures is to improve the appearance of the labia minora (the inner lips), mostly for aesthetic reasons but sometimes for functional reasons -- ie, the labia are getting in the way of exercise and causing chafing, or obstruction or urination is an issue.

The mean labial measurement in one study[4] was 2.6 cm, and the range is anywhere from 7 mm to 5 cm. People don't realize that this wide range is normal. The images in today's media make it look as if the labia minora should be small and not protrude outside of the labia majora, the outer lips. This is just not true. In the majority of women, the labia minora do protrude past the labia majora.

Pediatricians, obstetrician-gynecologists, and other clinicians who see adolescent patients need to get the word out that there is a wide range of normal. These girls have not finished developing completely. Providing images of the variety of vulvas may be useful (a good reference is the book Petals[5]).

On a side note, some providers, particularly in Australia and New Zealand, want these procedures banned because they consider them akin to female genital mutilation, particularly when the surgery includes clitoral hood reduction.