Female Genital Cosmetic Surgery in Saudi Arabia: A Systematic Review of Awareness, Attitudes, Satisfaction, and Clinical Outcomes

Abstract

Female genital cosmetic surgery (FGCS) has gained international attention because of changing beauty standards, social media influence, and greater access to surgical services. Although global evidence highlights rising awareness and uptake, data from Saudi Arabia remain scarce. This review followed PRISMA 2020 guidelines. A systematic search of PubMed, Google Scholar, the Saudi Medical Journal archive, and Index Medicus for the Eastern Mediterranean Region was conducted up to August 25, 2025. Eligible peer-reviewed English-language studies were those conducted in Saudi Arabia that examined awareness, attitudes, satisfaction, complications, or ethical perspectives. Methodological quality was appraised using Joanna Briggs Institute checklists. Of 1421 records identified, 5 studies met the inclusion criteria: 4 cross-sectional surveys and 1 case series. Awareness among Saudi women was moderate (∼50%), with 19% considering FGCS, whereas uptake remained low (7%-8%). Satisfaction among women who underwent surgery exceeded 85%. Physicians and medical students expressed cautious, ethically concerned attitudes, particularly toward hymenoplasty and vaginal rejuvenation. Reported complications were infrequent (<10%) and minor, although 1 case series described clitoral hood hair-thread tourniquet syndrome in pediatric patients. FGCS in Saudi Arabia is an emerging field. The findings highlight persistent ethical debates among physicians and underscore the urgent need for larger prospective studies and culturally sensitive national guidelines to regulate practice and align patient autonomy with societal values. This review aimed to systematically gather and summarize existing studies on FGCS in Saudi Arabia, with attention to awareness, attitudes, satisfaction, complications, and ethical concerns.

Level of Evidence: 4 (Risk)

Over the past 2 decades, the popularity of female genital cosmetic surgery (FGCS) increased worldwide, driven by factors like social media influence, greater access to surgical services, and the evolution of beauty standards.^1,2 This growing demand is also accompanied by increased knowledge and awareness of the different types of FGCS procedures, such as labiaplasty, clitoral hood reduction, and vaginoplasty. The purpose of which is to enhance the appearance and/or function of the female genitals.³ Research on FGCS has also drawn attention to procedures shaped by cultural traditions as much as by aesthetics. Clitoral reconstructive surgery, performed for women who have undergone female genital mutilation/cutting, reflects the medical and surgical diversity included within this field.⁴ In Morocco, hymen restoration is another example, where cultural expectations around virginity play a critical role in how the procedure is understood and requested.⁵ These cases show that FGCS is not only linked to beauty ideals but is also deeply influenced by social and cultural contexts.

According to the 2024 Global Survey by the International Society of Aesthetic Plastic Surgery, labiaplasty represented ∼1.2% of all surgical cosmetic procedures worldwide in 2023, and the overall volume of aesthetic procedures has risen by >40% since 2020, highlighting labiaplasty as one of the fastest-growing categories.⁶ On the other hand, surveys in Saudi Arabia have shown that ∼7% to 9% of Saudi women have had FGCS, with another 19% considering it. This shows an increased popularity of these procedures despite cultural and religious barriers.⁷

Research in Saudi Arabia started exploring this topic from multiple aspects, such as women's knowledge, attitudes, and practices; awareness among medical students and health professionals; patient satisfaction; physician attitudes; and rare clinical complications such as clitoral hood hair-thread tourniquet syndrome.^7-11 Although these studies provided a useful starting base for providing a glimpse of FGCS in Saudi Arabia, they still did not explore all aspects of this subject. Accordingly, this review is intended to provide a descriptive overview of the existing literature on FGCS in Saudi Arabia, rather than to evaluate clinical effectiveness of outcomes. Therefore, the aim of this review is to systematically identify the available studies on FGCS in Saudi Arabia. By bringing together findings from women, physicians, and health professionals and comparing them with international studies, this review gives an overview of FGCS research in Saudi Arabia.

METHODS

Search Strategy

This review follows PRISMA 2020 guidelines.¹² A systematic search was conducted in PubMed, Google Scholar, the Saudi Medical Journal online archive, and the Index Medicus for the Eastern Mediterranean Region up to August 25, 2025. The PubMed strategy combined Medical Subject Headings (MeSH) and free-text terms as follows:

(“Cosmetic Techniques”[Mesh] OR “Surgical Procedures, Operative”[Mesh] OR “Esthetics”[Mesh] OR labiaplasty OR labioplasty OR vaginoplasty OR “vaginal rejuvenation” OR hymenoplasty OR clitoroplasty OR “female genital cosmetic surgery” OR FGCS OR “aesthetic gynecology” OR “cosmetic gynecology”) AND (“Female Genitalia”[Mesh] OR vulva OR vulvovaginal OR vagina OR clitoral OR hymen) AND (“Saudi Arabia”[Mesh] OR “Saudi Arabia” OR “Kingdom of Saudi Arabia” OR KSA).

Analogous keywords were applied in Google Scholar, Saudi Medical Journal, and Index Medicus for the Eastern Mediterranean Region. The Index Medicus for the Eastern Mediterranean Region search initially retrieved 64 regional records; however, none were specific to Saudi Arabia, so they were excluded before screening (reflected as n = 0 in the PRISMA flow diagram). Attempts were also made to search the Saudi Digital Library, but institutional login restrictions prevented full access. Search results were extracted from PubMed in a (.nbib) format and Google Scholar in a (.ris) format, then merged in Excel together with the results exported from the Saudi Medical Journal. Duplicates were identified based on title, author names, year of publication, and DOI (when available) using Excel's filter functions and then manually verified by the authors.

Search Limitations

Authors acknowledge 2 main limitations of the search strategy. First, access to the Saudi Digital Library was unsuccessful because of login restrictions. Second, the focus on English-language publications may lead to a language bias. But the search of Index Medicus for the Eastern Mediterranean Region gave no Saudi-specific results, which suggests that the literature on this topic in Arabic may currently be limited. Nevertheless, the inability to comprehensively search Arabic sources remains a potential constraint on the review's comprehensiveness.

Inclusion Criteria

Studies were included if they met the following criteria:

1. Conducted in Saudi Arabia

2. Populations of women, physicians, or medical students

3. Focus on FGCS or vulvovaginal aesthetic procedures

4. Observational designs (cross-sectional surveys, case series, or prevalence studies)

5. Reported outcomes related to awareness, attitudes, uptake, satisfaction, complications, or ethical perspectives

Exclusion Criteria

Studies were excluded if they met the following criteria:

1. Outside Saudi Arabia

2. Non-FGCS interventions

3. Reviews, editorials, letters, conference abstracts, and theses/dissertations

4. Arabic-only publications

5. Studies involving male-only populations

Screening and Study Selection

The authors independently screened all titles and abstracts in duplicate. Decisions at each stage were recorded in a master spreadsheet that serves as an audit trail of inclusion/exclusion. Disagreements were resolved by discussion until consensus was reached. All 5 full-text articles retrieved met eligibility criteria; no full-text reports were excluded.

A total of 1421 records were identified (PubMed n = 59, Google Scholar n = 78, Saudi Medical Journal n = 1284, Index Medicus for the Eastern Mediterranean Region n = 0 since none were Saudi specific). After the removal of 4 duplicates, 1267 titles and abstracts were screened by the authors. Of these, 1262 were excluded as irrelevant. Five full-text articles were retrieved and included in the review. Reasons for exclusion at each stage as well as the study selection process are summarized in the PRISMA 2020 flow diagram (Figure 1). Given the limited number of available studies and their observational design, this review was conducted as a descriptive synthesis rather than an evaluation of clinical outcomes.

Figure 1.

PRISMA 2020 flow diagram of study selection. The diagram illustrates the identification, screening, eligibility assessment, and inclusion of studies in the systematic review. It details the number of records identified through database searching, the removal of duplicates, records screened, full-text articles assessed for eligibility, and the final number of studies included, along with reasons for exclusion at each stage. IMEMR: Index Medicus for the Eastern Mediterranean Region.

Data Extraction

The authors then extracted data from the included studies into an Excel sheet which included the first author, year of publication, study design, setting, sample size, population, and primary outcomes. Then, they recorded secondary outcomes such as complications, ethical concerns, and practice patterns in the main extraction sheet. The main characteristics of the included studies are summarized in Table 1.

Table 1.

Characteristics of Included Studies on Female Genital Cosmetic Surgery (FGCS) in Saudi Arabia

Author (year)	Setting (Saudi Arabia)	Study design	Population	Sample size	Primary focus/outcomes
Alrashed et al (2023)7	Multiple regions	Cross-sectional survey	Women	594	Awareness, attitudes, consideration, uptake (∼7%-8%)
Iqbal et al (2021)8	Medical universities	Cross-sectional survey	Medical students and health professionals	165	Awareness, ethical perceptions of FGCS
Al-Jumah et al (2021)9	Riyadh	Cross-sectional survey	Women	100	Satisfaction after FGCS (>85%), complications (<10%)
Sawan et al (2022)10	Jeddah	Cross-sectional survey	Physicians	165	Physicians’ attitudes, ethical concerns
AlJahdali (2022)11	Pediatric hospitals	Case series	Female pediatric patients	6	Clitoral hood hair-thread tourniquet syndrome (clinical complication)

Risk of Bias Assessment

The methodological quality of included studies was appraised using the Joanna Briggs Institute Critical Appraisal Checklists, applying the cross-sectional survey tool to 4 studies and the case series tool to 1 study.^1-5 These tools were chosen because they are specifically designed for observational study designs, which matched the methodologies of all included studies. Each checklist domain was reviewed, and when items were unclear, the full text was revisited until consensus was reached. For example, in Al-Jumah et al, limitations in the sampling strategy led to a classification of “some concerns” and an overall moderate risk of bias rating.⁹ The overall assessments are summarized in Table 2.

Table 2.

Risk of Bias Assessment of Included Studies Using Joanna Briggs Institute (JBI) Appraisal Tools

Author (year)	Study design	JBI tool used	Overall risk of bias	Key notes
Alrashed et al (2023)7	Cross-sectional survey	JBI cross-sectional	Low	Large sample size, clear reporting, representative
Iqbal et al (2021)8	Cross-sectional survey	JBI cross-sectional	Low	Appropriate sampling, ethical concerns noted
Al-Jumah et al (2021)9	Cross-sectional survey	JBI cross-sectional	Moderate	Smaller sample size, possible selection bias
Sawan et al (2022)10	Cross-sectional survey	JBI cross-sectional	Low	Well-structured survey, ethical considerations addressed
AlJahdali (2022)11	Case series	JBI case series	Moderate	Very small sample (n = 6), limited generalizability

Synthesis Approach

Given the heterogeneity in study designs, populations, and reported outcomes, a meta-analysis was not appropriate. Instead, a narrative synthesis was performed, with descriptive statistics (eg, awareness percentages and satisfaction rates) reported where available.

Data Transparency

All raw search exports (Pubmed.nbib, GoogleScholar.ris, SaudiMedicaljournal.xlsx) and the consolidated screening sheet are provided as supplementary files, alongside the PRISMA 2020 flow diagram, to ensure transparency and reproducibility.

PROSPERO Statement

This review was not registered in PROSPERO. Although registration can enhance transparency, all methods were defined in advance and are fully documented in the manuscript and supplementary materials.

Ethics

This systematic review used only published studies and did not involve human participants; therefore, ethics approval was not required.

RESULTS

Study Selection

A total of 1421 records were identified (PubMed n = 59, Google Scholar n = 78, Saudi Medical Journal n = 1284, and Index Medicus for the Eastern Mediterranean Region n = 0). After removing 154 duplicates, 1267 records remained for title and abstract screening. Of these, 1262 were excluded for not meeting eligibility criteria (eg, wrong topic, non-Saudi setting, non-FGCS intervention, or unsuitable publication type). Five articles met inclusion criteria and were included in the review.^7-11 No full-text articles were excluded. Attempts to search the Saudi Digital Library were unsuccessful because of login restrictions, and therefore this source could not be incorporated.

Exclusion Reasons

Of the 1262 records excluded at the title/abstract stage, the vast majority were unrelated to FGCS (n = 1227), whereas 35 were excluded for being conducted outside the Saudi context. No full-text articles were excluded after retrieval.

Characteristics of Included Studies

Five studies published between 2020 and 2023 were included, all conducted in Saudi Arabia. Four were cross-sectional surveys, and 1 was a case series.^7-11 Populations included Saudi women (n = 594 and n = 100), physicians (n = 165), medical students and health professionals (n = 165), and pediatric patients with clitoral hood hair-thread tourniquet syndrome (n = 6). Sample sizes ranged from 6 to 594. Key study characteristics are summarized in Table 1.

Risk of Bias

Methodological quality was appraised using Joanna Briggs Institute (JBI) checklists. Three surveys were rated low risk of bias, one was rated moderate because of potential selection bias from single-site sampling, and the case series was rated moderate given its very small sample size.^7-11

Narrative Synthesis

Awareness of FGCS was moderate among women but higher among health professionals, although attitudes were mixed. Uptake was low (∼7%-8%), yet satisfaction among those treated was high (>85%). Physicians were cautious, particularly about hymenoplasty, and complications were a rare and usually minor; 1 small case series reported clitoral hood hair-thread tourniquet syndrome.

Uptake and Satisfaction

Uptake among women was ∼7% to 8%, whereas satisfaction was high (>85%) among women who had undergone procedures, although this was reported in a single-center study.^7,9

Satisfaction and complication rates should be interpreted with caution, because these findings were largely based on self-reported data from cross-sectional surveys. Participants’ responses may have been influenced by recall, personal expectations, or willingness to disclose sensitive information, and the absence of follow-up limits assessment of longer-term outcomes.

Physician Attitudes

Physicians expressed cautious and sometimes critical views, particularly toward hymenoplasty and vaginal rejuvenation.^8,10

Complications

Reported complication rates were low (<10%), limited to minor pain, infection, or delayed healing.⁹ A pediatric case series highlighted clitoral hood hair-thread tourniquet syndrome, underscoring rare but clinically relevant complications.¹¹

DISCUSSION

This review synthesizes the limited but growing topic of FGCS in Saudi Arabia; it depends on 5 studies that were published between 2020 and 2023.^7-11 The fact that all included studies were published in this period indicates the novelty of FGCS research in Saudi Arabia, not a restriction of the search strategy. Yet, they still provided insights into awareness, attitudes, satisfaction, complications, and ethical debates in Saudi Arabia. Although evidence from the wider region may offer a useful comparison, this review focused on Saudi Arabia to reflect the country's specific cultural and ethical context.

The level of awareness among Saudi women was moderate, with almost half of the participants being familiar with FGCS and 1 in 5 possibly considering it.⁷ When these numbers are compared with international reports, they show that cosmetic genital procedures are being recognized more in Saudi Arabia, but we still cannot disregard that decisions are more strongly influenced by cultural and religious considerations in Saudi Arabia.¹³ On the other hand, awareness between medical students and health professionals was higher, and also their attitudes remained mixed, which shows a level of professional hesitation and ethical concerns.⁸ This suggests that although FGCS is recognized within the medical field, it is not yet fully accepted as a normalized practice.

Despite that moderate awareness, the uptake of FGCS among Saudi women still remains low, with only 7% to 8% reporting that they had undergone some of these procedures.⁷ And when asking those who underwent the surgery, they showed high levels of satisfaction, exceeding 85%.⁹ Compared with international reports, the satisfaction rates match, above 90%.¹⁴ This contrast between low uptake and high satisfaction rates may represent the influence of social stigma, family expectations, and religious standards that may discourage them from undergoing these types of surgeries, although the satisfaction rates were high.

Physician attitudes also had their complexities, where results from the conducted surveys showed that they are more culturally sensitive when discussing FGCS, especially with procedures like hymenoplasty and vaginal rejuvenation.^8,10 These concerns match the opinions of international organizations such as the American College of Obstetricians and Gynecologists, which cautions against elective FGCS because of limited evidence and ethical concerns, and the International Federation of Gynecology and Obstetrics, which also highlights the ethical challenges associated with such procedures.^15,16 Similar cultural influences are evident in other regions. In Morocco, hymen restoration was reported as a procedure strongly shaped by societal and familial expectations, whereas clitoral reconstructive surgery has been performed as part of care for female genital mutilation/cutting survivors in North Africa and Europe.^4,5 These examples parallel the Saudi experience, where moral and religious frameworks influence both patients’ choices and physicians’ practices. In Saudi Arabia, cultural and religious standards play an important role in shaping what is considered medically necessary and morally acceptable. The tension between patient autonomy and physician responsibility confirms the urgent need for culturally sensitive ethical and professional guidelines. The boundaries between cosmetic, reconstructive, and therapeutic indications are not always distinct. For example, carbon dioxide laser therapy has been used for vulvovaginal atrophy in cancer survivors as a functional intervention.¹⁷ Although outside the elective cosmetic domain, such therapies demonstrate the clinical overlap with FGCS and emphasize the need for context-sensitive guidelines that acknowledge both aesthetic and functional motivations.

Studies suggested that FGCS is to some extent safe when performed by qualified surgeons.¹⁴ Reported complaints were rated below 10% and were mainly limited to minor complaints, such as transient pain, infection, or delayed healing; this matches international findings.^9,14 At the same time, the pediatric case series of clitoral hood hair-thread tourniquet syndrome highlights that clinical practice in this area extends beyond elective cosmetic procedures, stressing the need to clearly distinguish between reconstructive or urgent interventions and aesthetic surgery.¹¹

This review has several strengths, including adherence to PRISMA 2020 standards, where a systematic search across multiple databases was conducted, and proper quality appraisal using JBI tools was done. It provides structured synthesis of FGCS research in Saudi Arabia. The main limitation that the authors acknowledge is that despite the large number of studies that were collected, only 5 studies were eligible to be included in this study, and most of them depended on cross-sectional surveys that asked participants to report their own experiences and opinions. The restriction to English-language publications may represent bias, but when searched for Arabic-written papers (Index Medicus for the Eastern Mediterranean Region, Saudi Digital Library) it showed no results. Finally, because of the small number and variety of available studies, it was difficult to combine their results into one overall estimate.

Because of limitations in the literature, this review revealed major gaps in FGCS in Saudi Arabia, including the small number of available studies, reliance on surveys, lack of long-term outcome assessment, limited exploration of cultural and ethical influences, and the absence of national guidelines to inform practice for clinicians. Such a sensitive topic should be approached with careful, culturally sensitive counseling that acknowledges both the potential benefits and the ethical concerns, especially for Saudi women. Also, developing national guidelines could provide a shared framework for practice, helping to balance patient autonomy with cultural values and align Saudi experience with international recommendations.

Research on FGCS in Saudi Arabia remains limited, where most studies are survey-based. As a result, they reflect participants’ views or experiences at one moment rather than changes over time. As a result, the findings describe reported perceptions and outcomes, not how attitudes or results may evolve.

Many results, including awareness, satisfaction, and complications, were based on self-report. Given the sensitive nature of FGCS, some participants may have underreported or overreported their experiences. In addition, several studies were conducted in specific clinics or institutions, which may not fully reflect the wider Saudi population.

There was also no consistent way of measuring outcomes across studies, and none followed patients for extended periods. In addition, none of the included studies used prospective designs, standardized outcome measures, or objective clinical endpoints, further limiting the strength of the evidence. As a result, conclusions about long-term outcomes and safety are limited. In short, the literature is mainly descriptive, and firm conclusions cannot yet be made.

CONCLUSIONS

The existing literature indicates that FGCS in Saudi Arabia remains a relatively underexplored area. Awareness among women appears moderate, uptake is low, and women who reported undergoing procedures generally described high satisfaction. Ethical concerns remain prominent among physicians, and although reported complications are uncommon, isolated clinical cases point to the need for caution. Taken together, the available evidence is limited and largely descriptive, underscoring the need for further research to better understand practice patterns and to inform culturally appropriate guidance.

Supplemental Material

This article contains supplemental material located online at https://doi.org/10.1093/asjof/ojag089.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.