Beyond Motivations: A Qualitative Pilot Exploration of Women's Experiences Prior to Labiaplasty

Abstract

Background

The demand for labiaplasty has increased rapidly over the last 10 to 15 years. Women's reasons for pursuing the procedure have been thoroughly documented in the literature, but other preoperative aspects are less well defined. These include women's expected outcomes, concerns about having the surgery, and the impacts of support from others in their personal lives as well as their treating team.

Objectives

The aim of this study was to explore women's preoperative labiaplasty experiences, particularly expectations, concerns, and interpersonal support.

Methods

Semistructured interviews were completed with 15 adult women in the United States and Australia who had undergone a labia minora reduction. The women were asked about their motivations for having a labiaplasty, expected outcomes, concerns regarding surgery, and support received from family members, friends, and the treating surgeon. The interviews were audio recorded, transcribed verbatim, and analyzed thematically.

Results

Two overarching themes with accompanying subthemes emerged from the analyses: (1) “motivations/influences” which included appearance concerns, physical discomfort, negative impacts on self-confidence, and negative experiences with partners and/or peers; and (2) “perceptions approaching labiaplasty procedure” where women reported concerns about recovery duration and impacts on sexual sensation as well as expectations for their postoperative vulvar appearance to be “neat,” “tidy,” and “natural.” In addition, the women stated that they felt well supported by their surgeons prior to the procedure, but some felt too embarrassed to seek support from family members and friends.

Conclusions

These new insights into women's preoperative experiences may assist clinical teams in enhancing their support and education of women seeking labiaplasty.

Level of Evidence: 4

Labiaplasty is a surgical procedure that aims to reduce the size of the labia minora.¹ The procedures are growing in popularity.² In the United States, for example, 18,813 labiaplasty procedures were reported in 2021, a 36% increase from 2020.³ From a global perspective, according to the International Society of Aesthetic Plastic Surgery, 164,667 labiaplasties were reported in 2020, a 73% increase from 2015.^4,5 There has also been growth in the volume of research conducted in the field of labiaplasty, particularly concerning the motivating and influencing factors for the procedure, as well as its safety and efficacy.⁶

The research focused on motivations to pursue labiaplasty suggests that appearance concerns are the primary motivating factor.^2,7-10 These concerns are in spite of the vast majority of women seeking labiaplasty having labia minora within normal size and appearance ranges, but desiring a “neat” and “tidy” aesthetic.^2,11 There are also physical reasons for pursuing labiaplasty such as discomfort while wearing tight clothing or while engaging in physical activities such as cycling or horseback riding.¹² Additionally, discomfort during sexual intercourse has been reported, with Sorice et al finding that up to 74% of women (N = 50) consulting for labiaplasty experienced tugging of their labia during sexual intercourse.⁹ Negative comments from sexual partners also influence decisions to pursue labiaplasty, as highlighted in a study by Sharp et al, in which 71% of women who had undergone labiaplasty had received a critical comment from a sexual partner.⁷ It is also the case that women may not have received comments directly about their own genitalia, but were exposed to negative commentary about labia minora appearance in general.¹¹ The literature therefore suggests that appearance concerns in combination with physical, sexual, and emotional/interpersonal discomfort can contribute to the decision to undergo labiaplasty.¹⁰

Despite established links with satisfaction with surgical outcomes,^13,14 other aspects of women's preoperative experiences have not received adequate research attention. Specifically, concerns and expectations around postoperative recovery, as well as the impacts of discussions of those involved in the treatment (eg, surgeons) and other important people in the patient's life (eg, family, friends), have yet to be examined in-depth. Understanding how interactions with family and friends as well as the treating surgeon prior to the procedure can affect patient experiences is important service quality information for clinics and can inform the content of initial consultations, as demonstrated for other types of aesthetic surgery.¹⁵

In sum, thorough investigations of women's preoperative concerns and expectations, as well as the impacts of their discussions with their loved ones and treating teams, are yet to be conducted, despite the established links with patient satisfaction.^13,14 In this study, a qualitative approach was adopted involving in-depth interviews with women who had undergone labiaplasty surgery. The study aimed to add to the growing scholarship of motivating and influencing factors of women seeking labiaplasty. Furthermore, this study aimed to investigate preoperative perceptions such as procedure concerns and outcome expectations, as well as support from discussions with family members, peers, and the practicing surgeon. Ultimately, the goal of the study was to better inform genital aesthetic surgeons of the pre-labiaplasty experiences of patients to refine the quality of the patient experience and in turn maximize patient satisfaction.

METHODS

Participants

Participants were 15 cisgender females living in Australia (n = 9) or the United States (n = 6). Any adult female who had undergone a labia minora labiaplasty, was aged at least 18 years, and was proficient in English was eligible to participate in this research. Participants had undergone labiaplasty between January 2014 and February 2019 at the private plastic surgery clinic owned by author J.O. in Australia or the clinic owned by author C.H. in the United States, and were between 1 and 72 months postoperative (mean [standard deviation, SD], 28.2 [24.3] months). The surgical technique used by J.O. was a free edge trim technique with multiple layers of internal running dissolving sutures, and the technique used by C.H. was the extended wedge. None of C.H.'s patients reported undergoing clitoral hood reduction, while 2 of J.O.'s patients (22.2%) reported also having clitoral hood reduction, which was conducted by vertical skin ellipse excisions in the lateral groove of the prepuce. Note that the participants were post-labiaplasty despite the focus on pre-labiaplasty experiences in this study due to this study being part of a larger research project. The 15 interviews were conducted during the period January 2019 to April 2019, with 15 participants considered to be a moderate to large-sized study in qualitative research.¹⁶ Participant demographic characteristics are outlined in the Table 1.

Table 1.

Participant Demographic Information (N = 15)

Characteristic	n (%)
Age (years), mean [SD]	36.7 [12.7]
Range	18-52
Ethnicity
White	13 (86.7)
Hispanic	1 (6.7)
Mixed	1 (6.7)
Sexual orientation
Heterosexual	15 (100.0)
Current romantic relationship
Yes	8 (53.3)
No	7 (46.7)
Children
Yes	8 (53.3)
No	7 (46.7)
Highest education achieved
High school	2 (13.3)
Trade/certificate diploma	4 (26.7)
Undergraduate degree	8 (53.3)
Postgraduate degree	1 (6.7)

SD, standard deviation.

Procedure

Reception staff at the 2 private plastic surgery clinics involved in the study contacted patients who had previously undergone labiaplasty in the last 7 years via email, mail, or telephone call to provide information about the interview study. The treating surgeons (J.O. and C.H.) were not involved in contacting potential participants. Interested participants were directed to contact the first author, G.S., to organize a suitable time to conduct a telephone interview with a member of the research team. Participant consent was provided in writing and again verbally at the start of the interview. The interviews lasted between 20 and 55 minutes (mean, 28.3 SD [8.5] minutes). Ethics approval for the study was obtained from Monash University Human Research Ethics Committee.

Interviews

Interviews were semistructured and were all conducted by author G.S. The specific interview questions are provided as a file in the Appendix. All telephone interviews were audio recorded and transcribed verbatim by a professional confidential transcription service. The transcriptions were read and analyzed according to the method outlined by Braun and Clarke.¹⁷ The transcriptions were first read and familiarized with by author A.N.F. The data were then coded, and codes were grouped into themes and subthemes of interest that were relevant to the preoperative perceptions and experiences explored in this study. Codes and themes were generated by author A.N.F. and were discussed and confirmed with author G.S.

RESULTS

Data from 15 female participants aged 18 to 52 years (mean, 36.7, SD [12.7] years) presented various themes that described influences around the decision to pursue labiaplasty as well as perceptions and feelings approaching the surgery. The main influences or motivations for pursuing labiaplasty were “concerns about appearance,” “physical discomfort,” “impact on self-confidence,” and “negative experiences with partners/peers.” Pre-surgery perceptions varied and specifically explored “concerns” and “expectations” prior to the procedure, “support from family members/friends,” and “discussions with health professionals.” The themes and subthemes are discussed below.

Motivations/Influences

Concerns About Appearance

There were a variety of reasons participants reported for pursuing labiaplasty, with the main reason being concerns with labia minora appearance (n = 13, 86.7%). Some participants reported appearances not aligning with what they considered “normal”:

“It was like ‘yuck’ like that's not normal!’… I was uncomfortable … it's embarrassing.” (Participant 7, aged 23 years, 60 months postoperative, Australia)

Physical Discomfort

Some participants expressed discomfort when wearing tight-fitting clothing (n = 8, 53.3%) as a motivating factor to pursue labiaplasty:

“I always had to wear a panty liner [shield] in my underwear because I used to sweat so much and I used to have rubbing.” (Participant 12, aged 52 years, 42 months postoperative, Australia)

Discomfort during sexual activity (n = 6, 40.0%) was also an influencing factor to pursue labiaplasty:

“… sex was not painful but it was uncomfortable.” (Participant 12, aged 52 years, 42 months postoperative, Australia)

Additionally, discomfort during exercise was reported by some participants (n = 4, 26.7%):

“I started getting into cycling and it was … just … discomfort from that.” (Participant 9, aged 38 years, 6 months postoperative, Australia)

Impact on Self-confidence

Concerns towards appearance were reported to have an impact on participants’ self-confidence in relationships, with some participants (n = 5, 33.3%) avoiding participating in sexual activities or relationships entirely:

“I think I held myself back from dating or like becoming intimate with men just because I knew at some point we would end up having sex and I would be self-conscious of it [labia minora appearance] and I just didn’t even want to get there with anyone.” (Participant 3, aged 26 years, 48 months postoperative, United States)

Overall confidence was also impacted by participants (n = 4, 26.7%) and labiaplasty was being pursued to improve this confidence:

“I used to feel like I wasn’t a woman … and I couldn’t do what other women could and I felt less.” (Participant 6, aged 28 years, 11 months postoperative, United States)

Negative Experiences With Partners/Peers

A smaller sample of participants (n = 4, 26.7%) reported developing concerns towards labia minora appearance as a result of comments made by partners/peers:

“He [partner] said it [labia minora] reminded him of a piece of roast beef … it was just so traumatizing to me when my partner said that to me.” (Participant 14, aged 52 years, 48 months postoperative, United States)

Perceptions Approaching Labiaplasty Procedure

Concerns About Labiaplasty Procedure

Participants reported a variety of concerns about undergoing labiaplasty. A predominant concern was the “course of recovery,” with participants (n = 6, 40.0%) concerned about pain and discomfort levels as well as how soon they could resume normal activities:

“The only concern I had was the recovery afterwards … how long it would take for everything to wear off and how much time I would have to have off work and when I can go back to general activities.” (Participant 5, aged 23 years, 72 months postoperative, Australia)

Another prevalent concern in this sample was the risk of losing sensitivity in the labia minora (n = 6, 40.0%), which participants reported learning either from discussions with their surgeon or through their own research on the internet:

“… the only fears I had about the actual procedure itself was that I read that people can sometimes lose feeling, like lose sensitivity.” (Participant 3, aged 26 years, 48 months postoperative, United States)

Some participants (n = 4, 26.7%) reported having no concerns either due to feeling well informed about the procedure and confident with their surgeon or feeling that labiaplasty could only improve their condition:

“… not really. I thought my sexual life was so bad by this point that I thought it couldn’t get worse. … I was so tired of having this problem.” (Participant 6, aged 28 years, 11 months postoperative, United States).

Expectations From Labiaplasty Procedure

Most participants (n = 8, 53.3%) expected less protrusion of the labia minora allowing for a “smooth,” “symmetrical,” and “tidy” genital appearance:

“Just nice and clean … I just wanted those little things [protruding labia minora] chopped off.” (Participant 7, aged 23 years, 60 months postoperative, Australia)

Some participants reported expecting a “natural” look, hoping their genital appearance would not appear surgically altered:

“… just for it to be normal I suppose and for the discomfort to go away. … I just wanted something natural.” (Participant 5, aged 23 years, 72 months postoperative, Australia)

One participant reported not having any specific related expectations and only desired the removal of excess labia minora tissue:

“I didn’t really care like really what it looked like. It was just getting rid of all that excess skin that was there.” (Participant 9, aged 38 years, 6 months postoperative, Australia)

Support From Family Members/Friends

There was great variability in participants speaking to those around them prior to their procedure. Some participants (n = 4, 26.7%) had informed family members or friends prior to the procedure for either practical assistance on the day of surgery or for moral support:

“It was my best friend since … I was five years old. She thought that it [labiaplasty] was unnecessary to do but she was on board to drive me [to the clinic] and help me out with whatever I needed.” (Participant 3, aged 26 years, 48 months postoperative, United States)

Some participants (n = 4, 26.7%) decided not to discuss or draw support from individuals in their personal lives prior to the procedure, most either feeling embarrassed about discussing the topic or feeling that this decision should only consider their own feelings:

“I was a bit embarrassed and didn’t want it out there for everyone as well. Like if I got something done, I didn’t really want the whole world knowing. I just wanted it for myself and only for me to know.” (Participant 5, aged 23 years, 72 months postoperative, Australia)

Discussions With Health Professionals

All women reported feeling well informed prior to consenting for the procedure and felt safe and confident in their surgeon's abilities to perform the procedure to a high standard:

“They mailed me a stack of information. … So I really knew what I was expecting.” (Participant 6, aged 28 years, 11 months postoperative, United States)

This contrasted with a conversation 1 participant had with her general practitioner (which was required to obtain a referral for labiaplasty for this patient) who expressed confusion and uncertainty towards the details of the labiaplasty procedure. This elicited a great deal of embarrassment in the participant:

“I was so nervous. She didn’t know what like it was … she had to Google ladies who have to do it. … I just remember leaving in tears. … I was so embarrassed.” (Participant 7, aged 23 years, 60 months postoperative, Australia)

All participants expressed a great deal of satisfaction with the way in which they were able to discuss the procedure with their surgeon:

“[The doctor] didn’t rush anything and spoke to me quite extensively. [The doctor] would speak to me again if I needed to and all this sort of thing so … in the end I was like, ‘yes, I’m doing this.’” (Participant 12, aged 52 years, 42 months postoperative, Australia)

Additionally, participants (n = 6, 40.0%) also reported having discussions with their surgeon regarding the normal variation in labia minora appearance. For some, this assured participants that their own appearance was indeed within the normal range; however, despite this, these participants still decided to pursue the procedure:

“So like everything was normal but I knew that I didn’t like it.” (Participant 8, aged 20 years, 4 months postoperative, Australia)

DISCUSSION

As one of only a very limited number of qualitative studies to date in the field of women's experiences of seeking labiaplasty, this study suggests several novel findings. In addition to confirming themes around women's motivations, this study potentially outlines new insights addressing preoperative experiences, such as concerns and expectations around recovery and outcomes, as well as the role of discussions with surgeons and family members or friends prior to the procedure.

The findings regarding motivations and influences of women seeking labiaplasty were supported by previous studies.^2,7-10 Appearance-related concerns were the most common motivating factor followed by physical discomfort reasons, negative impacts on self-confidence, and critical comments from sexual partners and peers. The consistency in these findings across studies, countries, and clinical settings^7,18 suggests that these should be standard areas of enquiry for surgeons in initial consultations with patients seeking labiaplasty.

The women in the study expressed only a limited range of concerns about the outcomes of their labiaplasty procedure. The main concerns focused on duration of recovery and potential negative impacts on sexual experiences, for example, changes in sexual sensation. Decreases in sensitivity during sexual encounters have previously been reported as a “rare” complication of labiaplasty¹⁸ and so women may potentially be overestimating this risk. However, this may be the result of women reporting low levels of sexual satisfaction and confidence prior to their surgeries.¹⁹ Thus, an outcome of even lower satisfaction after surgery would be highly distressing. It is important that women are aware of the potential for a decrease in labia minora sensation (albeit a very low risk) as well as additional possible outcomes such as scarring so they are able to consider such factors against perceived benefits before undergoing the procedure.

The study also provided some insights into the specific expectations held by women seeking labiaplasty. A desired feature concordant with previous research was the removal of labia minora tissue such that the vulva looked “neat” and “tidy.”^7,13 The other notable expectation reported by women in the study was a “natural” postoperative vulvar appearance. This desire for a “natural” look could reflect the more recently trending concept of “natural beauty” promoted by current beauty campaigns.²⁰ It potentially suggests that having a cosmetically altered look is less desirable and stigmatizing.²⁰ The expectation of a “natural look” which is also “neat” and “tidy” possibly indicates the importance of surgeons having explicit discussions about what patients might expect their vulvar appearance to be after surgery. It is also a chance for surgeons to discuss the potential influence of media sources on women's postoperative expectations, particularly patients comparing themselves to female pornography actors,^11,21 for whom more aggressive labiaplasties are seemingly the norm.²² Recent advancements in technology, namely augmented reality (eg, computer-generated images) and virtual reality, can help to facilitate these discussions by providing an opportunity for more personalized preoperative planning of surgeries and to predict outcomes of aesthetic procedures.²³

The study also showed that, when approaching the labiaplasty procedure, some women sought support from family members or peers for emotional reasons or purely for practical reasons on the day of the surgery (eg, driving them to and from the clinic). There was potentially a tendency for women, particularly in younger age groups, not to notify people in their lives (family and friends) about undergoing the procedure due to embarrassment. In addition, hesitancy to discuss decisions to undergo labiaplasty with family members or friends appeared to be related to feeling as though such figures in their lives would not be able to empathize and understand their decision to undergo the surgery. Therefore, these women could have possibly felt unsupported and alone in a time where both emotional and physical support is expected to be beneficial.

This has potential wider implications on patient care and patient safety, particularly after surgery, as some of these women reported taking sole responsibility of postoperative care when surgeons had required postoperative care to involve external assistance (family member or friend). Surgeons should be particularly aware of this issue with younger patients. To minimize the occurrence of such situations, surgeons could potentially provide information developed specifically for family members or friends who would be supporting the patient through the pre- and postoperative period. This information could serve to help family members/friends understand why a loved one is choosing to undergo labiaplasty and how surgical outcomes have previously benefited patients (eg, improvements in psychological wellbeing and sexual satisfaction).^14,19,24,25 The findings therefore potentially indicate that surgeons consider the risks of patients not informing someone for support and implement strategies to prevent this from occurring, as well as following up to ensure patient safety and appropriate aftercare more broadly.

In contrast to mixed experiences with family and friends, all women reported having positive experiences with the 2 surgeons in Australia and the United States respectively and their clinical staff in their consultations leading up to the procedure. This was in opposition to some other medical professionals, such as general practitioners, who were less familiar with the procedure and thus entered into discussions that were uncomfortable for the patient.²⁶ For surgeons, women reported being pleased with the extensive information provided and felt confident in their surgeon's ability to perform the procedure safely and to a high standard. Additionally, the women recalled discussions with their surgeon on the wide range of “normal” genital appearance and viewing images of other vulvas. Despite seeing these images and coming to the realization that their own appearance fell within the “normal” range, these women followed through with their decision to have a labiaplasty. However, previous research conducted in the Netherlands demonstrated that such education can dissuade some women from having surgery.²⁷ The current study results, however, potentially suggest that once dissatisfaction towards genital appearance has developed, discussions about normal variation and photographic depictions may reassure women that their appearance falls within normal ranges, but not alleviate dissatisfaction. This too has been suggested by Bramwell et al, who found that despite knowing what constituted “normal” genital appearance, dissatisfaction remained.²⁸ Counselling prospective labiaplasty patients on the natural diversity of female genital appearance is still important, as this concept is not well known to many women, and allows them to make the most informed decision about surgery.¹⁸

As with all studies, there are some limitations to acknowledge. First, this study was retrospective and therefore required participants to recall perceptions and experiences before undergoing labiaplasty. In this sample, some participants would have had to recall experiences from up to 6 years prior to the study interview. Additionally, there was potential bias in the patients who chose to participate in the study. It was likely that the findings were skewed towards patients with more positive preoperative experiences. It is also possible that the participants involved were the most satisfied with their surgical outcomes. Although the study was able to identify specific expectations held by patients before the labiaplasty procedure, whether these expectations were met after labiaplasty was not specifically analyzed as this is the subject of other research. Finally, patients from 2 clinics (1 in Australia and 1 in the United States) were included in the study and experienced different labiaplasty techniques. It did not appear that there were any major differences in their experiences, but it was not possible to determine this explicitly due to the smaller-scale qualitative rather than larger-scale quantitative study design. Furthermore, examining differences based on, for example, country and surgical technique was not the focus of this study, but could be usefully examined in future research.

CONCLUSIONS

This qualitative study was ultimately able to provide further insights into the motivating factors and influences of women seeking labiaplasty—the dominant factor being appearance-related concerns. Notably, this study was able to potentially provide some new insights into the feelings of concern about recovery time and surgical complications approaching the procedure as well as expectations from the procedure mostly describing a “neater,” “natural” genital appearance. Moreover, the study revealed that some women remained private about their decision to undergo labiaplasty. These findings can help surgeons refine their approach when consulting women interested in labiaplasty and can help clinicians more broadly in using evidence-based knowledge to empower patients concerned about their genital appearance. Patients seemed greatly satisfied with the level and quality of information and service provided by their surgeons, and these findings can hopefully serve to better manage expectations, outline risks, and maximize patient care and safety to ultimately increase patient satisfaction.

Supplemental Material

This article contains supplemental material located online at www.aestheticsurgeryjournal.com.