A growing number of Australian women are going to their doctors with concerns that their protruding labia minora are abnormal or their labia majora are too large, and sheepishly asking questions about genital cosmetic surgery. The trend has led the Royal Australian College of General Practitioners (RACGP) to develop world-first guidelines to help doctors better understand women's motivations for seeking surgery and counsel them through concerns about their appearance.
Guidelines author Dr. Magdalena Simonis said some women sought genital cosmetic surgery because they had a "lack of knowledge" of their own genital anatomy and mistakenly believed they were "abnormal" when in fact they were medically average.
She warned that labiaplasty—a surgical procedure for altering the inner labia—was a serious and potentially risky operation and many women were unaware of its ramifications.
"Genital cosmetic surgery is not the same as having your nose modified or a breast augmentation," Dr. Simonis told VICE. "If you are going to embark on some modification procedure which involves removing and cutting away highly sensitive genital tissue that plays a part in the whole erotic experience, then you're really making a decision that could cause irreversible harm."
I actually think that we need to stop talking about 'normal.'
Given that "normal" occupies a broader definition than what many apparently believe, the idea that women are having serious, expensive surgery (operations can cost between $3,000 and $9,000) because of misplaced anxiety is at best cause for alarm.
"I actually think that we need to stop talking about 'normal,'" said Dr. Simonis. "It's like saying, 'What is a normal nose?' ['Normal'] is a range, a spectrum. Even if a woman has very long, very large labia minora, if she is comfortable with that, then that is normal."
Experts have attributed women's dissatisfaction with their appearance to the proliferation of online pornography and the popularity among young women of Brazilian waxing. With the curtains pulled back, many are shocked—and in some cases, unhappy—with what lies beneath.
"The cloak of pubic hair has been removed… Removing pubic hair is now pretty much the norm for this generation," said Dr. Simonis. "Twenty-five years ago when I started a general practice everybody had pubic hair and nobody apologized for it. Whereas now I find a lot of young women apologize for having pubic hair or for not having removed it prior to a consultation."
Medicare data reveal the number of claims for genital cosmetic surgery doubled in the decade between 2003 and 2013. Although Medicare does not provide rebates for non-therapeutic cosmetic surgery, a 2014 health department review found there was no standard procedure for determining why women had labiaplasty, raising concerns that many were claiming for cosmetic and not medical reasons.
Dr. Hugh Bartholomeusz, president of the Australian Society of Plastic Surgeons, said Medicare had since tightened its requirements for patients seeking labiaplasty and vulvoplasty and now only covers congenital abnormalities and functional issues.
"Medicare basically have said 'We are not prepared to pay for this procedure on the public purse if there isn't a reason for the procedure being performed other than purely cosmetic reasons,'" Dr. Bartholomeusz told the ABC.
"The doctors concerned need to send photographs to Medicare, they have a panel that review these photographs and then make a decision as to whether they will allow the item number to be used," he said.
Of course, this will not prevent women from seeking surgery via the private system, which is not required to publish data on patients and procedures.
"Medicare has only really measured the tip of the iceberg," said Dr. Simonis. "The plastic and cosmetic surgeons…who are advertising these procedures openly admit that this is a very new, booming, lucrative industry for them."
In addition to the influence of Internet pornography, Maggie Kirkman, a Senior Research Fellow at The Jean Hailes Research Unit at Monash University, believes we should also be exploring the impacts of Australia's censorship laws on women's—and men's—attitudes toward their genitals.
In partnership with a long list of women's health organizations, Dr. Kirkman is currently undertaking research in order to understand what drives women to seek labiaplasty, partly via an anonymous survey open to the general public.
"Most people probably aren't aware that in M-rated magazines you're not allowed to show women's genitals," Dr. Kirkman told VICE. "They have to be hidden or airbrushed out… with no requirement that the image is identified as having been digitally altered."
Indeed, the Australian Classification Board mandates that images of vulvae "must be healed to a single crease"—this, despite the fact that many women's inner labia do not neatly tuck into their vulva.
"Clearly whoever set up those rules didn't want women's genitals to be visible," Dr. Kirkman added. "Men are allowed to have penises and balls, women are just meant to have a kind of 'Barbie' finish, or a pre-pubertal, childish look."
Both Dr. Kirkman and Dr. Simonis pointed to Women's Health Victoria's The Labia Library as an important resource for educating people about the female anatomy. Launched in 2013 in response to the increase in women seeking genital cosmetic surgery, the website aims to portray the diversity of women's genitals by featuring real, unaltered photographs of different vulvas.
"We're all different downstairs and healthy vulvas come in lots of different shapes and sizes. Labia size, symmetry, and color vary a lot between women," the website reads. "Even if you can't see what your vulva looks like in these images, chances are it's perfectly normal and healthy."
Related: Ladies and Gentlemen, the Vulva
Still, some women say the appearance of their vulva negatively affects their self-confidence and intimate relationships. Until she had labiaplasty in 2013, Louise, a 19-year-old Sydney woman, told ABC TV she'd hated how she looked since she was 14. She felt her labia were abnormal, and saved up for "quite a while" to have the expensive surgery.
Post operation, Louise admitted that while the result wasn't perfect, it was a significant improvement. "It's not exactly how I wanted it, but it's a lot better than it was," she said. "[Labiaplasty] definitely gave me a lot more confidence in myself."
Laura, a 23-year-old writer and performer from Melbourne, said she was frustrated that many women felt self-conscious about their vulvas, but was not surprised given our cultural reluctance to discuss women's bodily functions and sexual health.
"If young people only ever see and hear about vulvas that have no protrusions or 'ugly' bits, then of course they will worry that theirs is abnormal, and of course they will want to take steps to fix it," she told VICE.
"Although I do not judge those who choose to have genital cosmetic surgery, it saddens me that this is even a thing," Laura added. "The decision to undergo this type of elective surgery is not something that has happened in a vacuum—it is the result of years and years of negative messaging surrounding women's bodies and women's sexualities."
According to Dr. Kirkman, dismantling the stigma that surrounds women's sexuality would help reduce the shame many feel about their genitals.
"There does seem to be something in the idea that women's sexuality and bodies are somehow frightening," Dr. Kirkman said. "For whatever reason there is a large portion of society who fear women being in control, not just of their own bodies but of other things as well.
"And so we just have to resist this sense that there is only one way of being a woman, one kind of woman's body."
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