Commentary on: The Role of Pornography, Physical Symptoms, and Appearance in Labiaplasty Interest

This well-conceived study confirms the fact that although many women desiring and completing labial reconstruction view pornography, this fact in itself is not the major reason for their desire for and choice of labial reduction surgery.1 Both observers and detractors of women’s rights and reasons for choosing elective revision of their external genitalia have long alleged social influences (eg, pornography and social media) in women’s decisions to effect changes in the appearance and/or function of their external genitalia in order to improve function or aesthetic appearance. Sorice-Virk et al1 confirm this, but remind us that pornography is down on the list, and find other rationales much more significant than pornography.2,3 These include physical discomfort, self-consciousness, appearance and clothing concerns, improvement in self-esteem and sexuality, and a desire for functional improvement provided by diminishment of labial size to avoid chronic chafing, slippage out of underwear and bathing suits, and “bulges” which lead to discomfort secondary to sheer size and aesthetic realities.4,5 Social networking facilitates their search for solutions, and allows for continuity in their decision-making process. To this article’s stated rationales I would emphatically add to the list modern women’s propensity for depilation with the resultant stark visibility and lack of “cushioning,” as well as the ongoing empowerment felt by women and the resultant desire to own their own sexuality. Whether the biggest sexual organ in a person’s body is between their ears or between their legs, female genital plastic/cosmetic surgery (FGCS) is evidence-proven6,7 to adjudicate sexual distress in situations of labial and hood epithelial hypertrophy as well as vaginal floor relaxation. “Sex” and soft-core pornography is used to sell everything. Like it or not, we are surrounded by other-proclaimed “ideals,” and by the certain physiognomy displayed by models selling everything from chevre to Chevrolets. A frequent club wielded by opponents of women’s right to choose both invasive surgical and minimally invasive therapies that may improve comfort and sexual function is that this decision is somewhat or largely influenced by pornography.8-11 Previous studies12 have shown that, although viewed by the patient population, pornography is unlikely to be a primary driver for labiaplasty. Sorice-Virk et al’s study confirms this and should defray the efforts of those who try to deny women the freedom to make their own informed decision about how they choose to treat their genitalia, and to find surgeons appropriately trained to complete their appropriate aesthetic gynecological surgical request. The purpose of Sorice-Virk et al’s study “is to investigate the relative influences of physical symptoms, appearance concerns, and pornography’s influence on patient’s consultation about labiaplasty compared with a control cohort.” This is an excellent and productive project, evaluating a single variable (viewing of online pornographic images), while at the same time collecting valuable ancillary data. The study makes it clear that drivers for labiaplasty include physical and appearance symptoms and that, although many women requesting labiaplasty access pornography, so do members of the general population.13 The media, especially social media, pornography included, influences all that we do; pornography per se is not a driving force towards labiaplasty (“Pornography was not an influential factor to seek labiaplasty in 42% of the labiaplasty cohort and 54% of the control cohort”).1 Put another way, a minority of women in Sorice-Virk et al’s study (11% of the labiaplasty cohort) said that pornography influenced them to seek labiaplasty, but this number is not statistically higher than the 4% in the control population that would be influenced by pornography to seek labiaplasty. Social media, our friends, online influences, etc, influence our actions in many ways. Although most of us (this author included) would wish that images of “ideal” body types, hair styles, piercings, clothes selections, etc, would not have the effect they do on selection of everything from hairstyle to bra selection to toe rings, this is a fact of life. Viewing of pornography occurs. Viewing of fashion magazines and their models occurs. Although both are mediators of fashion and sexual “styles,” Sorice-Virk et al’s study makes clear that this viewing, although it exists and in fact may be a modest influencer in an individual woman’s decision to undergo labiaplasty, is not by a longshot the major influencer. In spite of continued contributions to the respected peer-reviewed literature (ie, Aesthetic Surgery Journal, Plastic and Reconstructive Surgery, Journal of Sexual Medicine, etc), both retrospective and prospective, many case-controlled, over the past 15+ years, for some reason representatives of the American College of Obstetrics and Gynecology (ACOG) apparently feel that journals other than ob-gyn journals (whose editorial policies eschew even considering research and articles evaluating FGCS) do not exist. There are many articles to be found in prominent peer-reviewed evidence-based literature attesting to the high satisfaction and low complication rates of FGCS,8 all of which appear to be ignored by representatives of the ACOG as evidenced by their 2019 reaffirmation of their 2007 Committee Opinion,14 without comment and restating their position that no evidence-based literature on this subject exists. Subsequent to their 2007 Committee Opinion much has appeared in the literature,5,15,-17 apparently not followed by ACOG’s policy advisors as per their reinstatement of the outdated 2007 Committee Opinion “without comment.” The authors’ thoughtful discussion is both instructive and well-referenced and perceptively catalogs ACOG’s taboo regarding a woman’s right to choose to modify her labia should she so choose. ACOG reaffirms a person’s right to the sexual identity of their choice (eg, male-to-female and female-to-male transsexuals), but eschews acknowledging a woman’s right to modify genital appearance and function and appears unsupportive of efforts to educate gynecologic surgeons in the procedure of cosmetic labiaplasty. As the authors say in their Discussion, “the controversy surrounding labiaplasty is unique among cosmetic surgical procedures.” 11,18-20 Opponents of a woman’s right to choose labiaplasty consider this procedure to be offensive because it is “medically unnecessary,” conveniently forgetting that breast augmentation, abdominoplasty, laser skin resurfacing, rhinoplasty, Botox, etc, which they do not rail against, can also be considered “medically unnecessary.” Women requesting labial alteration are often dissuaded from the procedure by healthcare practitioners who know little about the procedure in particular, and often about women’s sexuality in general. As confirmed by Sorice-Virk et al, gynecologists’ and plastic surgeons’ patients often request labiaplasty, and practitioners are frequently ill-prepared to understand and counsel these women. Anything plastic surgery and obstetrics and gynecology organizations can do towards encouraging training programs to teach their residents correct procedure for patient selection, counselling, and technical performance will diminish tragic outcomes and support the health and welfare of women. Dr Goodman is the CEO and Scientific Director of the Labiaplasty and Vaginoplasty Training Institute of America, Inc, a program to train female genital plastic/cosmetic surgeons. The author received no financial support for the research, authorship, and publication of this article.