Labia reduction

from Wikipedia, the free encyclopedia

Reduction of the labia minora in a young woman: before (left) and after (right) surgery

The reduction of the labia is a form of labioplasty in which the inner labia (labia minora) are reduced in size or even completely removed. Reductions of the outer labia (labia majora) are also performed less frequently . Various surgical techniques can be used here.

In addition to functional impairments, mainly aesthetic motives are cited as the reason for the intervention, the reduction of the labia thus represents a form of cosmetic intimate surgery. Labia reductions are now the most popular form of plastic surgery in some countries . The strong increase in the number of interventions performed is attributed to several social developments. The reduction of the labia for aesthetic reasons is criticized from various sides, in particular the underlying ideal of beauty is critically analyzed.

Indications and motivations

One motive for performing a labia reduction surgery can be the functional impairment when the labia minora or clitoral hood protrudes . The insufficient coverage of the inner by the outer labia leads to the fact that the inner labia are inadequately protected from pressure and stress. Impairments in sports and leisure activities, when wearing tight clothing, during micturition and sexual intercourse are known to be functional reasons for operations .

In the case of sexual dysfunction and the associated orgasm difficulties for the woman, exposing the clitoris by partially or completely removing the foreskin may increase the stimulability and the woman's ability to orgasm. However, there is still insufficient data on the chances of success of such an operation.

In the majority of cases, aesthetic-cosmetic motifs play a role, at least in part, for labia reduction. The German Society for Gynecology and Obstetrics also gives the "size and asymmetry of the labia" and "feelings of shame when showing" as well-known reasons for the operation.

In a US study of 131 women who underwent surgical reduction of the labia minora, 37% did so for purely aesthetic reasons, 32% for complaints and 31% for both reasons. In a further study of 407 women in 2008, 85.5% gave both aesthetic and functional reasons, 13.3% had only aesthetic reasons and only 1.2% had purely functional complaints. A retrospective study published in 2012 that asked 550 women about their motives for labia reduction (not separating aesthetic and functional reasons) found that 97.8% of women were dissatisfied with the protrusion of the inner labia over the outer labia, 96, 9% were dissatisfied with the appearance of the (too dark) labia margins.

If the procedure is purely aesthetic, it is a cosmetic operation . Functional complaints are sometimes put forward to legitimize an operation that is primarily done for aesthetic reasons. However, the subjective perception of aesthetic inadequacy in the vulvovaginal area, as occurs in the context of dysmorphophobia , can be linked to sexual anxiety and lead to sexual dysfunction.

An objective deviation from a normal range is not given in many women who want the operation. The author of a review article on labia reduction concluded:

"It is amazing that all study participants actually had normal-sized inner labia and still wanted an operation."

- Sara Creighton

There is a tendency to carry out a reduction for aesthetic reasons, even in the case of moderate to slightly pronounced inner labia. Like all physical characteristics, the shape and size of the labia are subject to individual variation, which in itself does not represent any disease value.

surgery

Reduction of the inner labia

Various techniques for reducing the labia minora

The reduction of the inner labia is the most common form of plastic surgery in the female genital area, is usually unproblematic and associated with scarcely visible scars.

The procedure is usually carried out on an outpatient basis and under local anesthesia. The tissue that is considered “excess”, which is usually the externally visible part of the inner labia, is removed with a laser or a high-frequency radiosurgery device . The operation takes an average of 45 minutes (Ø 45 ± 15 min). Finally, the wound is sutured with absorbable, self-dissolving sutures. Usually complete healing occurs after about four weeks.

If the operation is carried out properly and without complications, there are no restrictions in function and sensitivity.

Surgical techniques

The incision to remove the tissue and the sewing of the cut surfaces can be done with different methods:

  • Excision (contouring): In this method, a curvilinear incision is made along the length of the inner labia. The height of cut determines the amount of tissue removed. Only with this technique is the outer edge of the labia removed, which is often darker pigmented and irregularly shaped, so that the result is that the labia appear lighter and straight. Excision is still the only method that allows complete removal of the labia minora. Compared to the other procedures, it places higher demands on the surgical skills of the doctor performing the procedure and is more time-consuming. The risk of wound healing disorders is lower with the excision than with the other methods. This method can be particularly useful if a lot of tissue is to be removed, i.e. if a large reduction in size is desired.
  • Deepithelial reduction: In this procedure, a piece of tissue is removed from the middle area of ​​the labia, the outer edge remains untouched. Otherwise the method is similar to the W incision.
  • W (edge) incision: Here a triangular or arched piece of tissue ( wedge ) is removed - with the edges sewn up. The method was first described in 1998 and is easier and faster to perform than excision. Various forms of this method are described in the literature, these differ mainly in terms of the shape and position of the removed piece of tissue. There are various sub-forms with special names such as Random Pattern Flap , Inferior Wedge Resection , Lateral Hockey Stick V Excision or the Star Double Wedge - these differ in the type of incision. In contrast to excision, the outer edge of the labia is preserved with this method. This leads to a result that some patients find more natural. The labia are reduced in size, but their basic shape is retained. The risk of wound healing disorders, scars opening, neovascularization , unwanted tissue growth and problems with sexual intercourse is higher with this method.
  • Z-plasty: Similar to the W-incision, a wedge-shaped piece of tissue is removed and the resulting edges sutured. The course of the cut is different, however, resulting in a Z-shaped wound closure. The result is similar to the W incision, but is said to have fewer disadvantages.
  • 3D Reduction Labioplasty: This procedure represents a further development of the known techniques. In contrast to the previous procedures, with the 3D Reduction Labioplasty it is possible to adjust the clitoral hood at the same time as correcting the inner labia. In this context, 3D means that a correction in length (shortening the inner labia), width (correction of the clitoral hood) and height (shifting the clitoral tip) is possible.

Criteria for the choice of procedure

Even if various surgeons present "their" method as superior, there is no consensus on this in the specialist literature. The various methods are discussed in the specialist literature and, according to the authors, should differ in terms of aesthetic results and side effects. The respective advantages and disadvantages are weighted differently in different studies. However, so far there are no independent studies that would give preference to one method over another based on evidence . There is no such thing as “the best method” for all “patients”. The choice of the procedure should be determined by both the initial state and the desired state:

  • Different forms of the labia may suggest different procedures: The excision can be used on almost any patient, regardless of the shape and size of the labia. This only applies to a limited extent to the other procedures.
  • The choice of method also depends on the desired result. The extent and extent of the shortening, i.e. the amount of tissue removed and the appearance achieved, vary as desired and should be discussed in advance between the doctor and the patient. With excision, the outer edge of the labia is removed, with the other methods it is retained. As a result, the labia appear lighter and straighter after the excision, while the other procedures retain their natural contour. The decision as to whether the outer edge of the labia should be retained is ultimately a question of the patient's personal taste. In a survey of 238 patients, 98% wanted the inner labia to be at the same level as the outer labia or shorter, just as many wanted the result to have lighter edges (72% found the edges of the inner labia too darkly pigmented).

Regardless of the method used, it is crucial that the doctor has experience with this method.

Proportion of different procedures for reducing the labia minora

Excision is the most common and widely used method. A survey of 750 doctors carried out in 2009, all of whom performed labia reductions, showed the prevalence of the various procedures. The doctors surveyed indicated which procedures they used: 52.7% excision, 36.1% V-wedge incision, 13.9% Z-plasty and 1.2% de-epithelial reduction, 18.3% other procedures (it could several procedures can be specified).

Reduction of the outer labia

Labia reduction on the outer labia is rarely performed compared to the labia reduction procedure on the inner labia. Accordingly, there are few reports in the specialist literature. Strong outer labia can be congenital and represent a natural range of variation around a normal distribution . The motive for a reduction is usually the patient's dissatisfaction with the appearance. A disease value can only be objectified in the rarest of cases.

In the case of a reduction or tightening, an elliptical cut is made along the entire base of the envelope to the inner labia and fatty tissue is removed (liposuction). The reduction in size of the inner and outer labia can be carried out simultaneously in one operation.

Possible complications and complication rates

Complications that can occur are postoperative bleeding , hematoma , wound healing disorders, altered sensations and scarring . The most common complication reported is dehiscence , i.e. the surgical wound opening up as a result of poor wound healing. This occurs especially with a simple form of the wedge incision (inferior V-shaped resection) .

The existing medical studies report consistently low complication rates and good clinical-anatomical results as well as high patient satisfaction. This applies at least to reductions in the inner labia; the data on interventions on the outer labia do not permit any conclusions. However, numerous published publications have the character of case studies , from which possible complications and complication rates cannot be reliably estimated. Meaningful independent studies on the psychological, aesthetic and functional benefits of labia reduction are rare.

In a larger study in 2000, 163 women were examined postoperatively over a period of nine years. In all of them, the inner labia were reduced, mostly for aesthetic reasons. No significant complications were found, 89% of the patients were satisfied with the aesthetic results and 91% with the functional results. However, 17% were not completely satisfied with the result and 4% would not repeat the operation. Many women reported having had pain for a few weeks after the operation; in many cases, the doctor did not fully explain the procedure and results to them. A 2010 multicenter study on the results of plastic genital surgery with 258 patients (187 with labia reduction, alone or in combination with clitoral hood shortening or vaginoplasty ) over a follow-up period of 6 to 42 months showed that 91.6% of women were satisfied with the results of the operation . There were no significant complications.

Aesthetically motivated labia reduction as a fashion trend

Growing demand

Aesthetically justified labia reductions were first described and discussed in 1984.

The demand for this form of plastic surgery has increased significantly in recent years. In the United States, procedures are growing by 30%. In a poll conducted by an American women's magazine, around a third of all women surveyed said they might be considering labia reduction (although many of the women were not excessively enlarged). In Great Britain , the procedure is the fastest growing area within plastic surgery, the demand for a labia reduction increased by 300% in 2008 compared to the previous year, and by as much as 700% since 2005. The majority of labia reductions are done in the privately funded sector, but even the National Health Service has doubled operations over a four-year period (2008). In Austria the number of labia reductions performed increased fivefold between 2001 and 2011.

In Germany , too , the reduction of the labia is "a strongly booming segment". While an extrapolation for 2005 still suggested around 1000 operations, the extrapolation for 2011 already resulted in 5400 "labia corrections".

The trend towards operative changes to the labia also exists within the body modification scene.

Reasons for the increase in aesthetically motivated interventions

Aesthetically motivated labia reduction is culturally understood as part of a broader body cult among women. Several related factors are assumed as specific reasons for the increase in demand, which Michael Krause, the doctor and board member for quality management at the Nuremberg Clinic , summarizes:

“The cause is the increasing media marketing of photos, videos or films with or by naked women. The fad of a shaved or partially shaved female genitals has become generally accepted among women under 30 years of age. Their visual representation in the various media draws public attention more than ever to this intimate area. This creates an ideal that many young women try to achieve. It is all too easy to forget that pictures in glossy magazines and trend magazines are often reworked, 'flawed' areas are retouched, technically corrected and thus idealized. "

- Michael Krause

Popularity of the intimate shave

Pubic hair removal has become more popular in both sexes, but especially women and in younger age groups . The full intimate shave became fashionable in the late 1990s. In 2009, in a representative survey of young adults between 18 and 25 years of age, half of all women committed to intimate shaving ; a previously conducted survey among female students of medicine and psychology even showed a share of 88% for this population group. Pubic hair removal can make manifestations of the labia more visible, which can subjectively be viewed as unaesthetic. The increasing popularity coincides with the increasing demand for female genital surgeries.

Development of a genital ideal of beauty

According to the medical psychologist and sociologist Elmar Brähler , the "new visibility" of the external female genitals is developing an ideal of beauty and design imperative for this body region as well:

“The increasingly scarce swimwear and the strong presence of nudity in the media are contributing to the development of aesthetic norms for these areas. Especially in the area of ​​intimate shaving for women, it can be said that it is the 'new' visibility of the external female genitalia that leads to the development of beauty norms here as well: For the first time, a generally applicable intimate aesthetic that is binding for large sections of the population is developing . A region of the body that up until now was primarily a private sphere - the pubic region - is now subject to a design imperative. "

- Elmar Brähler

Stefan Gress, specialist in plastic and aesthetic surgery, describes the genital ideal of beauty as follows:

"The aesthetic ideal is the shape of the vulva of a young woman, in which taut, full outer labia completely cover the inner labia, similar to the silhouette of a mussel."

- Stefan Gress

In a study carried out in the Netherlands in 2010 , 90% of all doctors (including general practitioners, gynecologists and surgeons) stated that “a vulva with very small inner labia most closely corresponds to the social ideal of beauty”.

Media influence

In many erotic, lifestyle and soft porn magazines, such as Playboy and comparable media, “today, in addition to a full shave, invisible inner labia are standard”. The inner labia are removed by means of graphic processing , made unrecognizable with a soft focus or the women are photographed so that they are not visible. As a result, the female genital area appears reduced to a narrow, smooth gap. On the one hand, it is intended to meet the (supposed) aesthetic needs of readers and consumers. On the other hand, there are legal barriers: Under the youth protection regulations of some countries, visible inner labia can be understood as a detailed representation of the genitals and prevent the free sale of the magazine. The statistical comparison of vulvar depictions in various media, carried out in a scientific study in 2010, confirmed this development. Compared to medical literature and feminist publications, the inner labia were significantly smaller in pornographic images and showed less variance.

Psychologist Lih Mei Liao and gynecologist Sarah M. Creighton, authors of a BMJ article from 2007, report that their patients consistently wanted a flat vulva, similar to the “prepubescent aesthetics from advertising”. The women often bring pornographic photos with them to “illustrate” the desired look. The illustrations usually came from advertising or pornography and would always be selective and possibly digitally altered. It is assumed that today's norms of girls and women are shaped by manipulated representations and representations of operationally reduced labia. In a psychological study, test subjects were confronted with either photos of the labia before or after a labia reduction, as well as photos from Playboy . The women should now estimate the length of their own labia. Those women who saw the Playboy photos or the photos of operated labia assessed their own labia to be significantly longer than women who had previously seen photos of the labia before the operation. The pictures served them directly as a benchmark.

A representative survey in the Netherlands among women of different age groups in 2007 and 2008 showed that 95% of the participants regularly examine their labia minora. 43% found the appearance of the labia minora to be important. 95% of respondents had learned about the possibility of surgical labia reduction in the past two years, with 78% acquiring this knowledge through the media (mainly television and newspapers). The study's authors suspect that the results reflect the influence of increased media coverage on the topic.

Controversy and criticism

The increasing spread of labia reduction and the associated “ideal of genital beauty” has been criticized from various sides. Both the intervention as such and the social developments that motivate women to undertake the intervention are called into question. The specialist organization Medical Women's International Association issued a statement in 2012 that was critical of “intimate surgery for purely aesthetic-cosmetic reasons”. According to Vice President Waltraud Diekhaus “women would be persuaded that all labia should look the same and as youthful as possible.” Deviations are presented as an indication for surgery. That is not acceptable.

Wrong conceptions of norms and a lack of education

The qualified psychoanalyst Ada Borkenhagen , who specializes in body optimization, cosmetic surgery and identity and personality disorders, recognizes ambivalences in the trend towards the “designer vagina”: On the one hand, genital surgery in women in the West is “almost always” justified with the argument “more ability to orgasm”; this would presuppose or promote a liberated female sexuality. On the other hand, the idea that only a perfectly youthful-looking genital can have good sex is also associated with a significant new cultural restriction on female sexuality. The health risks of cosmetic genital surgery are usually played down by providers and the media. The reduction of the labia in particular is often presented as a “minor intervention”. However, here too, complications could result in severe functional and sensory impairments. In addition, there is no scientific evidence that these interventions cause lasting psychological or functional improvements. According to Borkenhagen, the desire for genital surgery often conceals depression , narcissistic disorders , sexual disorders or maturation conflicts. The dissatisfaction of women and girls with their genitals, fueled by the media, should be countered through information and awareness-raising.

Psychologist Lih Mei Liao and gynecologist Sarah M. Creighton suggest that women's decisions about surgical changes to the genitals may be based on misguided assumptions about normal dimensions. A British study from 2005, in which 50 women participated, found a large variance in the measurement of the external genitalia. The authors claim that women considering genital surgery should be educated about this finding. Even within the medical profession, the term “hypertrophy”, or abnormal enlargement, is applied to labia that are within the statistical normal range. A non-existent defect is suggested to the women concerned.

Marchitelli et al. found in a retrospective case study in 2010 that most of the women interested in plastic surgery in the vulvovaginal area in their clinic did not need any surgery and only received information on female anatomy and sexuality. According to the experience of the authors, there are exaggerated expectations on the part of those interested in the possibilities of aesthetic-surgical interventions in the vulvovaginal area. In fact, the surgical procedures would be expected to treat sexual disorders that have no anatomical background. Marchitelli et al. a. therefore demand that when working out indications for plastic surgery in the vulvovaginal area, those cases are also taken into account in which patients could be helped without surgery. In addition, there are reports that gynecologists brought the suggestion to reduce the size of the labia to the patient without the patient being previously dissatisfied or reporting any problems.

Criticism of the ideal of beauty

The ideal of beauty conveyed through the media and pornography is criticized. This previously private body region is now, following the rest of the body, subjected to a social, aesthetic norm. Tightness and smoothness are considered desirable: "Shame becomes the woman's second face" . In particular, the vulva should have a youthful appearance: "Age-related slack labia" are returned to a juvenile state, the "ideal is the youthful labia".

The complete removal of the labia minora is sometimes advertised as a youth look or a Barbie look . The idealized vulva is hairless and has no protruding skin areas, but visibly hanging labia are associated with age and slackness.

From a feminist point of view, the focus on this ideal of beauty represents a form of male dominance over the female body: at the expense of anatomical diversity, the reduction of the labia leads to a “uniform volva” oriented towards male-visual wishes. Christa Stolle , managing director of the women's rights organization Terre des Femmes , sees male preferences as the cause of the demand for labia reductions and as an expression of violence against women:

“The defining power of the male gaze is a form of structural violence that bows down and for which more and more girls and women are ready to bleed. It is sad that mostly young girls decide that they are not pretty enough 'down there' and save up to 4,000 euros for getting a tight-lipped, hairless, color-less conspicuous, closed and therefore childlike designer beast as carved by Mattel. "

- Christa Stolle

Unclear demarcation from genital mutilation

The reduction of the labia is differentiated from the circumcision of female genitals , as it is practiced in some African countries. Female circumcision, in contrast to the reduction of the labia, usually restricts the woman's ability to lust. While the former often results in the amputation of the clitoris or parts of it or the vagina is closed, the clitoris and vagina are usually not included in the operations carried out in Western countries. The inclusion of the clitoris is emphasized by Edvin Turkof from the Medical University of Vienna as a decisive difference:

“One thing is the labia, which can be corrected if they are annoyingly enlarged. The other is the clitoris - and that is the limit. You can't touch them. "

The main criterion for differentiation is more likely to be seen in the fact that the intervention in Africa is usually carried out on children without their consent. In the western world it is an operation that an adult woman can be informed about and voluntarily decides about. But even this criterion does not apply unreservedly, since circumcision is carried out in adulthood, at least for some ethnic groups. However, it is often assumed that even adult African women have a lower capacity to give consent. To what extent the two practices (in adults) can be distinguished from one another with regard to “voluntariness” and “consent” is, however, controversial.

The women's rights organization Equality Now is concerned that political initiatives against female circumcision in Africa , also known as “female genital mutilation”, will lose credibility due to the increasing voluntary “genital change” in the West.

Almut Dorn, a psychologist in the field of gynecological psychosomatics , commented:

"Especially in view of the Western European efforts to act against initial circumcision of girls, it seems surprising that European girls voluntarily allow themselves to be 'circumcised'."

- Almut Dorn

The Irish Associate Professor of Biostatistics , Ronán M. Conroy, regards the aesthetically motivated labia reduction, inspired by comparison with pornographic photos, as a form of so-called female genital mutilation established in modern western societies:

"In other words, women are constantly being mutilated to fit in with male masturbation fantasies."

- Ronán M. Conroy

Conroy points out that the WHO definition of “female genital mutilation” covers all procedures in which female genital organs are partially or completely removed or damaged for non-therapeutic reasons. The practice of female genital mutilation is nowhere in the world growing - "except in our so-called developed societies". According to Conroy, it is western medicine that is promoting the spread of female genital mutilation by fueling women's fear of having a problem "that requires the knife."

Marge Berer, editor of the journal Reproductive Health Matters , also rates labia reduction as a mutilation of female genitals and criticizes the unequal legal treatment of cosmetic genital surgery and traditional circumcisions. She considers the labia reduction to be a criminal offense under British FGM law and calls for appropriate prosecution .

Although a comparison of the performing cosmetic surgeons is rejected, the boundaries between the procedures are less clearly defined on closer inspection. Not all forms of circumcision practiced in Africa include the clitoris. Closing the vagina, known as infibulation , is the exception rather than the rule in Africa and is regionally limited. With regard to the anatomical changes, many forms of circumcision of female genitals are comparable to the reduction of the labia. An operation that is limited to the labia and without medical necessity actually falls under the WHO definition of "female genital mutilation", which the organization itself recognizes and raises as a problem:

"Some practices, such as genital cosmetic surgery [...], which are legally accepted in many countries and not generally considered to constitute female genital mutilation, actually fall under the definition [of FGM] used here."

"Some practices, such as cosmetic genital surgery [...] that are legal in many countries and are not generally considered female genital mutilation, actually fall under the definition [of FGM] used here."

Advertising and economic context

Most of the operations are carried out by private plastic surgeons who charge an average of around 800 euros for the operation, but often well over 1,000 euros. Far less is charged for it in public clinics. Compared to other gynecological-surgical interventions, the relatively simple and quick-to-perform labia reduction made large profit margins possible. As a result, the procedure is increasingly offered by private doctors and clinics and advertised accordingly. The American author and essayist Marie Myung-Ok Lee discussed the economic context in which the intervention usually takes place in an article for The Atlantic magazine under the heading “Perverse Incentives” . Stefan Gress, who as a specialist in plastic and aesthetic surgery himself offers labia reductions, claims in an article for the Medführer Internet portal that “a large number of women” “suffer” from “unsightly variations” in the external genital area. The advertising monitors of the Hamburg subway were used to draw attention to the addresses of providers of labia reductions. It is criticized that the advertising:

"[...] suggests that there is actually a connection between inadequate genital aesthetics and self-confidence, and that this can be treated surgically."

- Carolin Nestle-Krämling

In addition, a secondary market is being created for further training courses and seminars where doctors can learn the techniques (and how to market them) necessary to perform the operation. These are advertised at specialist conventions and can cost up to $ 75,000.

Social reactions

Feminist protest

Courageous Cunts - Protest flyer against labia reductions, 2012

The New York- based, feminist New View Campaign is directed against the “ medicalization of sex” and, in this context, also against cosmetically motivated labia reduction. In addition to information events and publications, the association organized a public protest in front of the Manhattan Center for Vaginal Surgery in 2008 . The initiator is the psychologist and sex therapist Leonore Tiefer. She calls for an advertising ban for cosmetic intimate surgery as long as there is no scientific evidence that women benefit from these interventions and are not harmed by it. In 2011, an initiative called VULVANOMICS: 2011 was started that consisted of collections of signatures, protest videos and demonstrations in front of beauty clinics that offer the operation.

In December 2011, the Muff March (English muff : colloquially the vulva) was held in London's Harley Street as a protest against cosmetic surgery in the female genital area. The event was organized by the British feminists association UK-Feminista .

The Centrefold Project , supported by the British Wellcome Trust , is dedicated to providing critical information. The discourse on the subject of labia reduction should be stimulated through interviews with scientists and animated films. The feminist and psychoanalyst Susie Orbach and Jamie McCartney, whose plaster cast- based sculptures The great Wall of Vagina became famous, are among others involved in the project .

The cyber activism group Courageous Cunts, which sees itself as feminist , has been protesting on the Internet since 2012 against what it sees as an “alliance between pornography and the medical industry” and its “campaign to give us the perfect labia to sell".

Development of ethical standards

The increasing demand for aesthetically motivated labia reductions has led medical professionals and medical ethicists to demand that ethical standards be established with regard to patient treatment. In addition to the results of the operation, these can be used as a yardstick to assess the quality of a doctor or a clinic. The following principles should be assumed for this:

  • Right of self-determination : The free and informed decision is the basis for performing the operation. The doctor must ensure this in advance and investigate doubts about it. Mental disorders, especially depression and body dysmorphic disorders , should serve as exclusion criteria. It should be clarified in the conversation whether the patient requires the operation due to external constraints, for example at the request of a friend or husband. Last but not least, the doctor himself should refrain from advertising his offer through misleading statements.
  • Primum non nocere : As the highest principle, damage should be avoided. In this context, damage can be understood as an undesirable consequence for the patient. The patient must be informed about the possibility of these complications. This principle also includes refusing the operation if there are any doubts about its feasibility.
  • Care : The operation should improve the patient's condition. In the case of an aesthetically motivated labia reduction, this means that the patient is more satisfied with the appearance of her labia than before. Specifically, this can mean that the doctor has a wide range of skills and techniques and can apply them in a manner appropriate to the situation and the patient. There are various surgical procedures for reducing the size of the labia , although many doctors only master or use one procedure. However, different requirements in the anatomy or the desired result (whether an adjustment of the symmetry, a reduction in size or complete removal of the inner labia is desired) may suggest different techniques. Doctors should strive to acquire different techniques. To this end, professional societies and associations should increasingly offer opportunities for training and courses, since the techniques of labia reduction have so far not been taught or only little taught in training.
  • Fairness : In the case of a voluntary and non- indicated operation, this demand can only relate to a fair business relationship. This includes an appropriate pricing that is appropriate to the - comparatively low - effort of the intervention. A doctor should also refrain from billing medically unnecessary interventions through health insurance.

In Germany (by the German Society for Gynecology and Obstetrics and the German Society for Intimate Surgery and Genital Aesthetics ) as well as in Austria (by the Vienna Program for Women's Health ) guidelines have been drawn up for performing labia reduction.

Educating young people

Age of first dissatisfaction with the inner labia: result of a survey of labia reduction patients

The majority of the requested operations are not caused by physical problems, but by a self-perceived dissatisfaction with the appearance of the vulva. This is especially true for younger women and girls, whereby it can be assumed that the norm image of an “ideal vulva” is most widely established, especially in this generation. Protruding inner labia are considered "uncool". According to a survey of young people, of all body regions, the genital area would be most likely to be considered for cosmetic surgery. The psychologist Erich Kasten from the Institute for Medical Psychology in Magdeburg describes the uncertainty of a young woman as follows:

“Somehow I felt even more naked when I was naked. When my best friend was at school, there was always only a delicate slit to be seen, while my labia were always pushed apart by my bulging labia and I had the feeling that everyone was staring at me in the sauna, in the shower, while doing sports, etc. . "

The reasons for this are likely to be found in the high exposure to pornography on the Internet and its role in the socialization of young people compared to previous generations . Young people of both sexes often get an idea of ​​what the ideal of a female genital should look like from images in the media, with the labia being digitally processed for the reasons mentioned above. This gives an idea of ​​what is socially acceptable and desired by potential male sexual partners, but not what is biologically and anatomically normal.

"Love your Labia! (Love your labia!) "- Poster on the London Muff March (2011)

According to Bettina Weidinger, sex consultant at the Institute for Sex Education of the Austrian Society for Sex Research , the aim should be to give young girls an acceptance of their own physical condition:

"My labia may look different from those of the others, but they are mine, they belong to me, are part of my individuality and therefore have a special value."

- Bettina Weidinger

Dissatisfaction with one's own labia is often independent of supposed objective hypertrophy. Most of the girls and women who want a labia reduction perceive their genitals as "abnormal", although they are within the physiological-anatomical fluctuation range or in the normal range. Anatomical normality and social norm are not clearly separated. Especially among girls at the beginning of puberty, deviations from these norm expectations can lead to insecurities and self-doubt. One possible prevention is the early transfer of knowledge about the condition of the genitals within the framework of sex education . The professor for health sciences at the University of Hamburg , Ingrid Mühlhauser, said:

"There must be a much stronger public awareness that there is a spectrum of normality and diversity of the human body that should not correspond to a certain norm."

- Ingrid Mühlhauser

This includes, in particular, the presentation of images of non-operated genitals in order to convey a differentiated picture of the natural variance of the labia. For example, the youth magazine Bravo endeavors to convey a realistic body image by depicting unretouched genitals in their natural diversity on photographic images.

Legal situation

Performed in adults

As with other aesthetically motivated interventions, even non- indicated operations on the external genital organs make very high demands on the preoperative information in terms of detail and ruthlessness. Since gynecological cosmetic surgery deals with areas of the body that are particularly important psychosexually, it is also necessary to be particularly sensitive to the patient's motivation, goals and information. Doctors should therefore inform their patients about the normality of their development and appearance before the operation. A detailed medical consultation should be carried out before the procedure, in the case of indications of psychological problems, with the assistance of a psychologist or psychiatrist .

The Higher Regional Court of Dusseldorf in 1984 spoke of a woman who had shortened a surgeon at his own request, the labia, for pain and suffering to. As a justification, the court stated that there was no medical indication for the operation . Before the intervention, the doctor should have consulted a psychologist or psychiatrist in order to "determine the cause and extent of the psychological or sexual maladjustment". There was bodily harm without effective consent .

Outside of a clear legal basis, the labia reduction takes place in the body modification community. The procedure is carried out unofficially by professional piercers. While there are no judgments on this in Germany so far, this has led to arrests in both the USA and Canada . The behavior of the judiciary was criticized within the scene as incapacitating. In all cases, adult women opted for this with consent.

Implementation for minors

The patient's ability to consent must be ensured in all cases prior to the operation. The majority of requests for labia reduction come from young adult women and older teenagers , but also from younger, sometimes under 14-year-old girls. The reduction of the labia is legally problematic, especially in young, underage girls. There is a strong increase in demand for the operation from these. However, the ability to give consent is particularly questionable in those cases. As with all interventions that are not medically necessary, but purely aesthetic or sexual reasons, the consent of the legal guardian should therefore be available for children under 16 years of age.

The German Medical Association and the professional association of paediatricians generally advocate an explicit ban on purely aesthetically motivated interventions on minors. Furthermore, in the case of a medically unnecessary reduction of the labia in minors, it is difficult to define a demarcation from the circumcision of female genitals. Regardless of this, the procedure for minors, also for cosmetic reasons, is legal in Germany. In Austria , unlike in Germany, since 2013 aesthetic-surgical interventions in under 18-year-olds have been linked to psychological advice and a medical indication.

Regardless of the legal situation, it is recommended to wait until adulthood to reduce the size of the labia, since the labia undergo major changes in their severity during puberty .

Section 226a of the Criminal Code

The anti-circumcision laws of some European countries, such as § 226a StGB introduced in Germany in 2013 or also in Great Britain or Sweden, contain an absolute prohibition on the circumcision of female genitals - regardless of age and consent - while cosmetically motivated labia reduction is legal is. This can lead to the paradoxical situation that the same procedure - performed by the same doctor under the same conditions - is legal for a European woman, but is a criminal offense for a woman of African origin . In both cases, the intervention would not be medically necessary, but justified by cultural ideals, but the African woman is denied the possibility of an autonomous decision. This problem also exists in Germany because - according to the German Medical Association - “female circumcision is punishable even if the operation is carried out at the request of the patient” and points out that “according to the general obligation clause of the professional code for German doctors, such practices are to be punished under professional law. "

The legal situation is unclear, especially in the case of adolescent girls who want a labia reduction. In Switzerland , this problem was addressed by the National Council in a parliamentary initiative in 2009 :

“If this principle were consistently implemented, common practices such as tattoos, piercings or cosmetic surgery in the genital area would also be punished in this country, which are usually not for medical, but for aesthetic or other reasons. For this reason, Article 122a (2) E of the Criminal Code expressly anchors the possibility of the injured person's justification for such interventions. […] The Commission is of the opinion that, on this point, migrants who undergo traditional genital mutilation in order to increase their chances of getting married should not be treated any differently than Swiss women who have their labia smaller or the vagina narrowed for aesthetic reasons leaves."

- Swiss National Council : Report of the Commission for Legal Affairs of February 12, 2009

The discourse on this topic is strongly valued and is often conducted very emotionally, with prejudices and stereotypes against the supposedly “primitive” culture playing a role. In an interdisciplinary research project of the Austrian Academy of Sciences , the difference between the two interventions is to be elaborated and "criticism of a hegemonic discourse is to be exercised, which represents Western body practices as unproblematic - because voluntary - and non-Western body practices as an expression of patriarchal oppression." ( Sara Paloni ) The doctor and bioethicist Barbara Meier sees, with all the differences between the interventions, decisive similarities in the basic motives: socially shaped ideals of beauty for the female genital area lead to the necessity of an operative change of the genitals in order to correspond to the norm and to establish social acceptance.

In the European medical literature of the 19th century, attempts were made to explain genital circumcision in Africa with the same “indications” as the reduction in size of the external genitalia practiced in Europe at that time. The enlargement of the labia was mistakenly seen as a result of excessive sex drive and masturbation.

See also

literature

  • Brigitta Balogh: Plastic Surgery: Mamma, Trunk, Genitals . Springer, Berlin 2006, ISBN 3-540-00143-3 (especially pp. 359–379, online in the Google book search).
  • L. Benadiba: Labiaplasty: Plastic or cosmetic surgery? Indications, techniques, results and complications. In: Annales de chirurgie plastique et esthétique. 2009, PMID 19223103
  • Julia Ganterer: Intimate Aesthetics in Cis Women: Beauty Norms and Body Industries since the "Sexual Revolution". Hochschulverlag Merseburg, Merseburg 2019, ISBN 978-3-948058-14-2 .
  • Hohl, Scheidel, Schüssler: Designer Vagina . In: Frauenheilkunde aktuell. 01/2008, pp. 4-13 (PDF; 263 kB).
  • Anna-Katharina Messmer: Excess tissue: intimate surgery between aestheticization and medicalization. Springer, Berlin 2017, ISBN 3-658-17053-0 .
  • Diethelm Wallwiener , Walter Jonat , Rolf Kreienberg , Klaus Friese , Klaus Diedrich, Matthias W. Beckmann (eds.): Atlas of gynecological operations. Chapter VI Vulva and Vagina , 6.3 Surgical Techniques . 7th edition. Thieme, Stuttgart 2009, ISBN 978-3-13-357007-7 , pp. 439-440.

Web links

Commons : Labia Reduction  - Collection of pictures, videos and audio files

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