Modification of the external genitalia has become one of the top-20 most frequently performed cosmetic surgeries. Increased demand for labiaplasty has been attributed to increased visibility of the vulva with shaving or waxing, access to pornographic images of the external genitalia, and advertising in the media. Of 482 women surveyed in a gynecologic practice, 78% found out about labial reduction through the media, and 14% believed that their vulva was abnormal in appearance. Increasingly, women are examining their external genitalia, with over half of women examining their vulva at least monthly. Thankfully, most women think that their vulva is normal and are satisfied with its appearance. Nonetheless, approximately 10% of women in one survey considered undergoing vulvar cosmetic surgery.

The increased demand for vulvar surgery is spurred by the belief that the vulva is abnormal in appearance. What is normal in terms of labial anatomy? We know from limited studies as well as clinical experience that there are wide variations in labial size, symmetry, and coloration. Proponents of labiaplasty aim to create labia that are symmetrical, small, and hidden by the labia majora; characteristics that are shared with prepubescent girls. In fact, in adult women, complete labial symmetry is not common, and the labia minora commonly protrude outside the labia majora. Proponents of labiaplasty state that the procedure improves sexual function and body image, however, limited published data do not confirm improved sexual function in either the patient or her partner. A review of labiaplasty Internet marketing found unsubstantiated claims for physical, psychological, and sexual benefits on most sites. In reality, prospective comparative data using validated outcome measures are lacking regarding the safety and efficacy of labiaplasty.

The World Health Organization defines female genital mutilation surgery as procedures that involve the partial or total removal of external female genitalia for nonmedical reasons. Of course, female genital mutilation surgery is largely performed on nonconsenting children, and female cosmetic surgery is performed on consenting adults. Nonetheless, labiaplasty does fit the definition of nonmedically indicated removal of part of the external female genitalia. One wonders if the marketing of “ideal” labial appearance purporting to improve the lives of women is just another form of furthering exploiting the social vulnerability of women.

Proponents of labiaplasty most often quote the ethical principle of autonomy, stating that a woman has the right to choose or refuse treatment, including labiaplasty. Autonomy must be weighed against other important ethical principles including beneficence, nonmaleficence, and justice. “Beneficence” is defined as acting in the best interests of the patient; “nonmaleficence,” that the physician should “first, do not harm”; and “justice,” that we pay attention to the distribution of scarce resources. Our patients’ trust is based on the principle of beneficence; patients are confident that there is no incentive, financial or otherwise, for their physician to perform a particular procedure. The fathers of medical ethics, John Gregory (1724 through 1773) and Thomas Percival (1740 through 1804) wrote “…surgeons should protect and promote the patient’s health-related interests as their primary concern and keep their economic and other forms of self-interest systematically secondary.” In addition, they wrote “…surgeons should not [act] as a merchant guild that exists to protect the economic, political and social interests of its privileged members.” Often accompanied by concurrent cosmetic surgeries such as labia major augmentation, G spot amplification, vaginal rejuvenation, hymenoplasty, or clitoral hood reductions, labiaplasty is nearly always performed on a fee-for-service basis that is costly for the patient and lucrative for those who offer these services. In 2007, Dr Pauls wrote “What is unique to this area is the patented and secretive nature of some of the most marketed technologies and the large financial gain driving this industry.” Unfortunately, the widespread marketing of labiaplasty and other vulvar cosmetic surgeries undermines the principle of beneficence and calls into question the motivation underlying these practices.

The principle of nonmaleficence has not been met with the performance of labiaplasty. While a relatively minor procedure, the majority of publications regarding labiaplasty are either case series or expert opinion written by proponents of the procedure. While the physical risks of labiaplasty are thought to be minor, until prospective comparative data with validated outcome measures are available, the safety and efficacy of labiaplasty will remain unknown. Finally, the principle of justice has not been met. In an environment of increasing health care costs and scarcity, diversion of resources to nonmedically indicated procedures with little to no safety or efficacy data is unjust.

As gynecologists, we are often the primary provider of health services; women look to us to provide guidance and counsel on their health and well-being. I agree with Dr Pauls’ statement in 2007: “Our offices should be a safe haven for women to feel beautiful and accepted because we see them at their most vulnerable. Succumbing to a ‘boutique’ mentality of practicing medicine does not become us.” Exploitation of the social vulnerability of women as sex objects needs to end.