Factors influencing increased demand for FGCS

The sociocultural norms that are believed to influence women’s perceptions of ‘normal’ are considered to be significant in driving the climb in this group of procedures.^1,25–27

Not only does modern culture classify the minimalist vulva, where the labia minora do not extend beyond the margin of the labia majora, as ‘good’, but also the protruding labia as ‘bad’.^{27, 28–31}

Currently available research indicates that perceptions of ‘normal’ versus ‘desirable’ may be skewed and disparate, resulting in a narrow definition of normal.^29–31 Labiaplasty has also been intensively marketed as an unproblematic lifestyle choice for women.^{1,14,18,20,27,32}

There is little doubt that today’s digital age is changing the way we acquire information and communicate. As a result, people are influenced by information and digitally-modified images found on the internet. Despite access to these images and the plethora of internet-based pornography, there is little firm knowledge regarding female genital structure, function and vocabulary within the community.33 Pornography mostly depicts digitally-modified images that portray women’s genitals with no labia minora protrusion, thus potentially skewing young women’s (and men’s) perceptions of what is considered normal.^32,34,35,36

A recent study from South Australia’s Flinders University revealed that women who had greater exposure to images of female genitals were more likely to consider labiaplasty. Of the 351 women aged 18–69 who were surveyed as part of the study, 17% were interested in having labiaplasty.²⁷

Most women who are contemplating any form of FGCS are likely to seek information from provider websites. These sites often describe aesthetically pleasing or desirable genitalia as the neat single slit. The quality and quantity of clinical information in FGCS provider sites is poor, providing erroneous information in some instances.^14,28,29,34

Health professionals are influenced by similar sociocultural forces that skew preferences for desirable versus normal.^10,37,38 It is important to be mindful of this when addressing women who present requesting FGCS or have concerns regarding their own appearance (also refer to Appendix 1 for information on the Australian media code of conduct on body image).

People have limited formal education in the areas of female genital anatomy and its variations^10,33 and, to date, there is no evidence-based research that outlines what its normal spectrum is considered to be.

The most common complaint is protrusion of the labia minora beyond the labia majora.^10,11,37 Given the paucity of textbook images that provide measurements and ranges of anatomical diversity, GPs who do not perform regular gynaecological examinations as a part of their routine practice may not feel comfortable stating that something is considered normal.

General practice and other medical training curricula do not currently include education in the area of genital anatomy and its diversity. With the absence of formal training, it is not surprising that GPs, surgeons and other health professionals are influenced by the same kind of sociocultural forces that skew preferences for normal versus desirable.^10,34

Women have few opportunities to see other women’s genitals throughout their life due to the fact the region is concealed, for the most part, behind pubic hair and there is little opportunity along the educational lifespan of women (and men) to become better informed. The inherent lack of understanding of the diverse normal platform that exists in the community is, therefore, quite understandable.

Recent studies have shown that women have limited knowledge regarding the names and function of genital parts and the diversity of appearance.^11,23,24,31

Grooming and fashion trends are believed to influence women’s attitudes to their genital region. Practices such as ‘Brazilian’ waxing involve removal of most or all pubic hair, exposing sensitive genital tissue and areas that could not be seen prior to hair removal.^11,24 This practice is now extending to permanent hair removal via laser treatments.

Tight-fitting clothing and sportswear tend to give definition to the genital area, and poorly-fitting undergarments, such as G-strings, cover a minimal portion of the mons pubis. These factors can create the feeling that women’s genital size should be small and discrete.

Fashion that depicts genital contour has resulted in the evolution of new terms like ‘camel toe’ and ‘outie’, which appear in popular media. While women often comment that wearing these items can feel uncomfortable, they remain popular fashion items.

Few will dispute that the request for Brazilian waxing and genital hair removal has gradually become commonplace over the past 20 years. The results from a phone review of the course work undertaken by Australian beauty therapists during their training indicate they receive little formal training regarding all aspects of genital anatomy.³⁹ Given women are more likely to visit their beauty therapists than their GP, supporting this frontline group through the provision of information regarding genital anatomy and teaching them how to talk with women who might express concern at their appearance could also be a useful way of addressing women’s lack of knowledge and provide reassurance.