Labiaplasty defended by plastic surgeons

Doctors are fiercely divided on the ethics of surgery to trim the minor labia, with OBGYNs believing physicians have a responsibility to educate patients on what is 'normal' and plastic surgeons believing patients have the right to chose for themselves.

Rise in controversial genital procedure reflects unattainable expectations for physical appearance

Carrie Anne is a triathlete in her 40’s, biking for 8 to 10 hours at a time but limited by the discomfort caused by the length of her labia. (Due to sensitivity issues and to protect her identity Carrie Anne is a fictitious name.)  Thinking it was normal, she lived with it for years until finally getting a labiaplasty, a surgery that ‘trims’ the labia minora or inner labia, the external parts of the female genitalia. 

"I was very uncomfortable," Carrie Anne said. She told CBC's The Current that the surgery is fantastic. "I just feel much more …it sounds maybe weird to say, but attractive."

Many of the images that are portrayed as attractive reflect pre-pubertal development. (Mark Lennihan/Associated Press)

Andre Shakti is a successful sex worker and adult entertainer working in the feminist porn industry, an industry which  aspires to promote positive female body images. Shakti says she was born with larger inner labia that she was "constantly insecure about."

"I’ve been watching pornography since I was nine-10 years old, and I would watch a lot of vulvas that did not look like mine, doing things that I really wanted to do but that I was insecure about doing."

Throughout her teens and early 20's, Andre said she was in a culture that should have made her open to sexuality in all forms. But if given the opportunity, she said she would have chosen to get a labiaplasty.

"This kept me from being as confident as I would have loved to be and stopped me from fully nude stripping and doing any kind of porn or web-camming until about two years ago."

Sex worker and adult entertainer Andre Shakti said she based her idea of what's typical for labia size based on porn. (Courtesy Andre Shakti)

Two women choosing or considering labiaplasty for different reasons — one because of the discomfort that may be caused by longer labia; catching, stretching, and another for appearance.

Labiaplasty, commonly known as the ‘Toronto Trim’, takes about 30 minutes and surgeons say complications like bleeding and infection are minimal, with patients driving themselves home the same day. It costs between $4,000 to $6,000.

While official numbers for the procedure are not available, CBC spoke with 12 Ontario plastic surgeons performing the procedure who collectively said they performed hundreds of labiaplasties in the last year, compared to less than 100 a year a decade ago. 

The surgery is gaining popularity around the world with doctors in the U.S. reporting a 44 per cent increase (5,070 people from 3,521) from 2013 to 2012 according to a report from the American Society for Aesthetic Plastic Surgery released last month. This makes labiaplasty the most increased aesthetic surgery of 2013, tied with buttock implantation.

Celebrities have publicized the procedure. Pornographic actress Houston, reportedly auctioned off her excess labia after the surgery for an estimated $50,000. Sharon Osbourne recently reported that she had the procedure done and said it was the most painful thing she’d ever experienced.

Doctors are fiercely divided on the ethics of the surgery, with obstetrician/ gynecologists believing physicians have a responsibility to educate patients on what is ‘normal’ and plastic surgeons believing patients have the right to chose for themselves.

Labia provide protection and sexual comfort through stretch, explains Dr. Jennifer Blake. (Courtesy Dr. Jennifer Blake)

Most of the surgeons performing the procedure are plastic surgeons, while only a small portion are obstetricians and gynecologists (OBGYNs).

Dr. Jennifer Blake, CEO of the Society of Obstetricians and Gynecologists of Canada (SOGC) said they don’t do the surgery because there is no valid medical reason for it, but there is potential harm.

"Labia provide protection and sexual comfort through stretch," says Blake. "People don’t realize that labia shrink during menopause. Women are having this surgery done when they are young but we have no long term data on it. We have no idea what’s going to happen to these women during menopause."

Two-thirds of women getting this are doing it because they are bothered by how it looks.- Dr. Asif Pirani

The SOGC released a policy statement on female genital cosmetic surgery in December 2013 reviewing the evidence and safety profile of these surgeries, which include vaginoplasty, hymenoplasty and G- spot augmention as well as labiaplasty. The society came out strongly  against these procedures because of a lack of long-term data on consequences and lack of training of physicians doing these procedures.

A 2009 paper in the British Journal of Obstetrics and Gynecology attempted a review of the scientific literature on the surgery, but the authors discovered that most of the papers published on this topic looked at patient satisfaction, which was excellent, but not long-term consequences. 

Dr. Sean Rice, a plastic surgeon in Toronto, said that complications like bleeding and infection are extremely rare, patient satisfaction is close to 100 per cent, and most patients do come in for medical reasons — physical discomfort — and are referred by their family doctors.

"I’m not a judge, I’m a surgeon. If there’s something glaringly wrong with the patient that puts their motivation in question, that’s one thing. But the majority of these people are adults."

Toronto plastic surgeon Dr. Sean Rice says most patients seeking labiaplasty do so for medical reasons. (Courtesy Dr. Sean Rice)

But Dr. Asif Pirani, another plastic surgeon in Toronto, said the reason is usually cosmetic. "Two-thirds of women getting this are doing it because they are bothered by how it looks."

A 2011 study in the British Journal of Obstetrics and Gynecology looked at the motivation and clinical characteristics of 33 women in the UK considering labiaplasty and found twenty of the women were concerned about appearance and six about discomfort. All of the women in the study had labia within the normal range, up to 50mm (this definition can vary in the literature). 

Stephanie Guthrie, a Toronto-based feminist writer and activist, and recent speaker at the TEDx Toronto on body image, says the answer lies not with the doctors, but in how society defines what is ‘normal’ and ‘not normal.’

"The rise in labiaplasty procedures is a reflection of unattainable expectations for physical appearance we put on people, especially women," says Guthrie. "The problem is that women don’t know what normal genitalia looks like. There is no normal."

Andre Shakti agrees. "I was basing the idea of typical on what I’d seen in porn because I didn’t know differently. When I found out about the surgery at 19, it was always there at the back of my mind, ‘when I can afford it, I’ll do it.’"

"Many of the images that are portrayed as ‘attractive’ are actually pre-pubertal development," says Blake. "Women are being persuaded that a normal look is that of a 12-14 year old. And when impressionable young women see these images, whether consciously or subconsciously, it affects them."

In the 2011 study, of the 33 women considering the surgery, 8 women were younger than 16 and 20 of them reported starting to feel dissatisfaction before the age of 20.

"In some cultures, women stretch their labia to make themselves more attractive," Blake says. "What we’re talking about is a fad. The problem with a fad of the body is that you can’t regrow it once the fad is over."

Rice says that the mandate of plastic surgeons is to help people who feel insecure.

"We do surgeries that impact quality of life. These issues affect confidence and can cause significant anxiety. This is no different from a rhinoplasty [nose job] or a breast augmentation," says Rice.

But Blake disagrees, saying that unlike a rhinoplasty, labiaplasty has the potential to affect function.

Both Blake and Rice agree, however, that increasing training may be necessary, as these procedures are not taught in a formal training program. Rice said he does 40 to 50 of these procedures and has been doing them for over 10 years, but learned how to do them outside of formal training, from conferences.

Male and female views differ

An informal survey presented at the American Society of Aesthetic Surgeons meeting in Vancouver in 2012 showed that male and female expectations of 'attractiveness' in genitalia were quite different, with women preferring a more groomed look and shorter labia and men preferring slightly longer labia and being less particular.

"We have to educate women about what’s normal," says Blake. "It’s much easier to go along with someone’s insecurity and say, ‘Sure, let’s get rid of it.’ But it takes time to explain to someone what’s normal and reassure them. It’s our job as physicians to help people accept themselves."

She concedes there may be the rare, medical reason for labiaplasty, but that these patients should be carefully screened.

"Anyone that presents with this request should get a full sexual history and counselling."

Blake suggests that to ensure no conflict of interest exists, the surgeon doing the counselling should not be the one doing the surgery.

Shakti said that, in hindsight she’s glad she didn’t get it done and is happy the procedure is expensive — if it was more affordable, more people would have the surgery without thinking it through carefully.

"I’m not saying that no one should ever get a cosmetic procedure done, but people should make sure that the decision is coming from a healthy, knowledgeable place."

She said that if someone had showed her variations of normal when she was younger, it would have saved her a lot of anxiety.

But experts say that changing the definition of beauty and the idea of normal takes time, effort and conviction. And while multiple OBGYN groups have issued cautionary statements, the number of procedures performed continues to increase.

Women and men have different perspectives, according to a survey presented to the American Society for Aesthetic Plastic Surgery. (Courtesy Dr. Christine Hamori)


Dr. Meera Dalal is an Internal Medicine resident at the University of British Columbia and a journalism fellow at the Munk School of Global Affairs at the University of Toronto.