By Emma Barnard and Professor Sonia Grover

“There is a lot of stigma around vaginas and genitalia and it’s very ‘hush hush’. You don’t really talk about it much I think because when you are in your teens that’s kind of the time where you are thinking about your body more – things are changing, there’s hair and stuff like that – so it was good to have that experience (of seeing a doctor) and to know there was nothing wrong with (my labia)” – Kathy*

Kathy was just 13 when she started thinking her vagina didn’t look right.

Her worries began in PE class at school when she saw textbook drawings that she felt didn’t look like her vulva at all. She was so worried she made her Mum take her to a doctor to explore the option of surgery.

She was referred to the Royal Children’s Hospital in Melbourne where a specialist adolescent gynaecologist was finally able to reassure her that she was perfectly normal.

Kathy, now 18, is part of a new pilot study aimed at understanding why a growing number of Australian girls, as young as 11, are seeking cosmetic surgery on their otherwise normal genitals.

Among grown women, research suggests that their view of what is normal and sexually desirable is being skewed by a modern culture that promotes an unrealistic “minimalist” vulva as the ideal. Typically, these are images in which the inner folds of skin surrounding the vagina, the labia minora, aren’t visible, when in real life, in half of women they are.

But what’s additionally concerning is that these unrealistic views of what is normal also appears to be making even young girls anxious about how they look.

“What I’m finding is that you don’t have to be an adult to have these concerns,” says University of Melbourne health researcher Emma Barnard who is interviewing young women who had sought genital cosmetic surgery as girls. “It is happening much earlier than I anticipated.”

YOUNG AND ANXIOUS

While the research study is still in its early stages, with eleven interviews so far, Ms Barnard says those she has spoken to had little sense at the time of what a normal vulva looked like. And that uncertainty can sometimes begin with their mothers.

Among the 41 girls and young women referred to the Royal Children’s Hospital in Melbourne between 2000 and 2012 because of concerns over how their labia looked, the median age was just 14.5, and in nearly a quarter of cases it was the mother who was concerned. None of them was abnormal.

“For nearly all the women I spoke to, this experience of having concerns is happening from around 13 to 16. It is a very specific and fraught time when they are trying to figure out who they are and how their bodies work,” says Ms Barnard, from the School of Population and Global Health.

It was this spike in referrals to the Royal Children’s that first alerted hospital adolescent gynaecologist Professor Sonia Grover that there was a problem.

“It was very troubling. We were concerned that we were suddenly getting so many referrals and we wanted to know why girls were becoming anxious at such a young about what their vulvas looked like,” says Professor Grover. In the ten years before 2000 says she would have only seen two or three girls worried about the look of their genitals.

The Royal Children’s doesn’t carry out cosmetic surgery, but will on very rare occasions do surgery in cases where the patient is in physical discomfort when all other factors have all been considered.

“There can be cases where the patient is in discomfort and surgery can be justified, but generally we discourage it because in the vast majority of cases the patient is completely normal,” Professor Grover says.

Professor Grover says that in the majority of cases, any concerns girls may have about their labial appearance can be effectively managed through education and counselling.

While clinicians like Professor Grover have a clinical consultation with girls who are referred to them, she says there isn’t usually the scope to find out in depth about what is motivating their concerns. But there’s also the added problem that teenage girls are often reluctant to talk openly about their genitals.

And this is where Ms Barnard’s study comes in – she is talking with these girls later in life when they are young adult women, in a free-flowing interview that lasts 60-90 minutes.

COSMETIC CONCERNS

Gynaecologists and obstetricians don’t endorse female genital cosmetic surgery, arguing there is no evidence to justify it. There are also risks. According to the Royal Australian College of General Practitioners, these include infection, wound rupturing, pain during intercourse and reduced lubrication. Yet demand for the procedure is going up and it is being widely marketed by commercial cosmetic clinics.

In Australia, Medicare claims for labiaplasty and vulvoplasty, that both involve cutting back the folds of skin around the vulva, more than doubled from 707 in 2002-03 to 1,584 in 2013-14. And the number of claims among 15 to 24-year-olds was similar to that among both 25 to 34-year-olds and 35 to 44-year-olds.

More recent data is unavailable because Medicare restricted claims for the procedure in 2014, which means that that demand is being driven wholly into the private sector.

And this isn’t just a trend in Australia – countries around the world are seeing the same spike. In the US the number of labiaplasty procedures tripled between 2011 and 2014, while in the UK the number increased from less than 500 in 2001 to over 2,000 in 2011.

So what exactly are the patients asking for? What is female genital cosmetic surgery?

Most commonly, female genital cosmetic surgery involves a “labiaplasty” to cut the edges of the labia minora so that it doesn’t extend beyond the outer skin folds, the labia majora. It can also extend to procedures like vaginoplasty to tighten the vagina, or vulval lipoplasty to remove fat around the vulva.

THE WIDE RANGE OF NORMAL

Ms Barnard says much of the anxiety her interviewees felt about their genital appearance stemmed from them having little idea at the time of what the wide range of normal is. Their insecurity was further stoked by the onset of puberty and the prospect of intimate relations with someone actually seeing their genitals.

“Some told me they had never really seen what anyone else really looked like and they were unlikely to have seen realistic images,” says Ms Barnard. “Pictures in textbooks and magazines are stylised or airbrushed, and there is a real lack of understanding about the real range of genital diversity.”

This in part reflects Australian media censorship laws dictating that “realistic depictions (of nudity) may contain discreet genital detail but there should be no genital emphasis.”

Instead of realistic images, Ms Barnard says interviewees remembered relying on stylised images in textbooks, or internet searches that often took them to advertisements promoting the benefits of cosmetic surgery.

Despite widespread concerns that easy access to stylised pornography was skewing peoples view of what female genitals really look like, Ms Barnard says interviewees haven’t so far highlighted it as much as she would have expected.

“They told me the sources are generally a bit more banal than pornography.”

The problem of knowing what normal looks like is exacerbated by many general practitioners themselves being unsure how to judge whether a woman’s genitals look normal. A 2016 Australian survey study of over 400 doctors found that about 25 per cent weren’t confident in their ability to judge normality.

Interviewees also remember being influenced by what seemed to them a sudden cultural shift in which women’s genitals were suddenly a focus of fashion, from Brazilian waxing to tight fitting clothing and G-strings.

“I think it is fair to say that something has changed in the culture in the last 10-15 years to make women and girls more aware of the appearance of their genital anatomy,” says Ms Barnard.

“Going back to my own adolescence this issue is one that never occurred to me. But there are clearly significant numbers of young people who are having this experience and whose voices are just not in any of literature, possibly because it is a really difficult thing to talk about.

“But if we can have a better idea of how troubling this is for young people then that could potentially improve clinical practice.”

* Not her real name

For Information on the natural diversity of women’s genitals see Women’s Health Victoria’s The Labia Library.

This article originally appeared on University of Melbourne's Pursuit website and has been republished here in accordance with Creative Commons.