Significant labia minora hypertrophy has been described in cases of chronic lymphedema [13] and chronic irritation due to rubbing in, for instance, chronic diaper dermatitis in incontinent women [14]. Marked asymmetry between the labia minora incidentally occurs, comparable to asymmetry in breast development or due to lymphedema in one labium, which may be disappreciated by the woman. In some women, labia minora may be very small [5].

In the Western world, during the last two decades, female genitals have become more apparent in the public domain than ever before. In magazines, Internet sites, and television programs, female genitals are more explicitly shown than before, and size and function are openly discussed. In addition, the visibility of female genitals has been enhanced in general due to the trend of shaving pubic hair. But here, perhaps, also a side effect of modern medicine may become visible. The more we technically can achieve, the less tolerant we become toward imperfection. In evolution, however, variability within the species prevails above individual standardization so there will always be “anomalies,” even without clear functional status. In a world dominated by and obsessed with “youthful appearance,” all aspects of the female body, except for the breasts, should be “small.”

In daily language, vulvas are usually called “vaginas,” which might suggest that female genitalia consist mainly of the “inner genitalia” (vagina, uterus, ovaries, etc.), while women, just like men, clearly have visible external genitalia (labia majora, labia minora, clitoral hood, and clitoral tissue).

In erotic and soft-porn magazines and Internet sites, it is common to digitally remove protruding labia minora. Although there is a wide variety of vulvar appearances, numerous aesthetic clinics market labiaplasty procedures by falsely suggesting that “normal” labia minora should be smaller than and lying beneath the level of the labia majora. While protruding labia minora are very common, these suggestions and advertisements give it a negative meaning, possibly influencing women negatively with regard to their genital body image [2]. Women considering labia reduction surgery are mostly influenced by television programs and secondly by magazines [8]. Furthermore, personal predisposition of the physician and gender may influence the way women seeking labiaplasty are counseled. A Dutch study revealed that plastic surgeons are more inclined to perform a labia reduction procedure as compared to gynecologists. And male physicians are more open to this procedure than female physicians [15]. Because surgical intervention is invasive and irreversible and health-care resources are scarce, the request for labia surgery addresses more than just “a matter of taste” or cultural norms. It forces us to make a deliberate choice in which different types of reasoning may be followed.

In comparison to controls, women seeking labiaplasty do not seem to be more anxious or depressed, neither did they experience more adverse childhood events. However, the latter express reduced sexual satisfaction and less satisfaction with genital appearance and more distress about their genital appearance than control women [10]. In a study comparing women seeking labiaplasty with healthy controls, the former more frequently reported that they received negative comments concerning the appearance of their labia minora, resulting in less satisfaction with the appearance of their own genitalia [16]. The size of the labia does not seem to be associated with satisfaction with the genital appearance. In some publications, it is reported that women mainly choose labiaplasty for their own personal reasons rather than for reasons determined by others [10, 16]. This is an interesting observation that reflects the Western vision on personal (here female) autonomy. This is in contrast to more family-oriented cultures or to the evolutionary psychological perspective, in which man is an ultra-social species, for whom social reputation means everything [17]. Therefore, probably more interesting is the finding that in most women seeking labiaplasty, the size of the labia minora is within normal limits [6].

Each domain will be briefly discussed here, i.e., autonomy, non-maleficence, beneficence, and justice:

In women with vulvar complaints and/or request for labia reduction surgery, a thorough history should be taken [18]. It is important to examine which possible factors might be the reasons behind the request. A biopsychosocial approach should be used to examine the full scope of the underlying complaint. In addition to history taking, the physician can make use of validated questionnaires (Genital Appearance Scale (GAS) and Cosmetic Procedure Screening-Labia (COPS-L)) to obtain better insight into genital satisfaction and to screen for body dysmorphic disorder [10]. It is essential to have an open attitude in order to invite the patient to express herself about the complaint and its consequences for her. Ask the patient what she expects that the operation will bring her. Be aware of previous traumatic experience, such as childhood abuse and adverse sexual experiences that might affect satisfaction with the genital appearance and/or the decision-making process. If thinking about the current appearance of or about vulvas at all is unbearable for the patient, if things cannot be put into words, how do you come to a well-balanced decision?