Methods

This was an Internet-based cross-sectional survey study administered through a secure online server at SurveyMonkey (Palo Alto, CA). Institutional Review Board approval was granted by TriHealth, Cincinnati, OH. Funding was obtained through an educational research grant from the E. Kenneth Hatton Medical Education Research Fund, TriHealth, Inc. Males between the ages of 18 and 80 in the United States were eligible and recruited via email addresses obtained through an Internet-based provider, Infogroup Inc (Omaha, NE).

Infogroup is an Internet marketing resource that obtains email addresses from partnered company websites. Individuals providing these email addresses are >18 years old and have agreed to inclusion without compensation. To prevent duplication, a time and date stamp, Internet provider address, and a source Uniform Resource Locator are recorded and stored during data completion. The survey was designed through SurveyMonkey to allow only one response per computer, and participants could only access the survey via the emailed link.

A goal response rate of 600 completed surveys was deemed appropriate for this descriptive study. To account for invalid email addresses and a predicted survey response rate of 1-3%, Infogroup estimated, based on their previous experience, that approximately 150,000 email addresses would be required, with a second email blast 1 week after the initial deployment. All email addresses were kept confidential by Infogroup. The email addresses were selected to obtain a representative age range and geographic sampling of men.

The emails were distributed on Aug. 13, 2014, with a second deployment on Aug. 20, 2014. The email subject was titled, “Survey opportunity,” and the body of the message explained the purpose of the study, contained a link to the survey, and provided a notice that images would be included. The participants were informed that their participation was voluntary and confidential and that consent would be provided by completing the survey. Upon accessing the link, a cover letter explained all the information to the participants again. The survey remained active for 2 months; responses were collected for analysis at that time. Participants could access the questionnaire only once.

The survey, which consisted of 27 questions and included images, was designed by the authors to query men’s familiarity with vulvar anatomy, preferences regarding labial appearance, and awareness of labiaplasty. The survey was pretested with a sample of 30 men, and suggested changes to image labels and language were incorporated into the final version.

Eight demographic questions initiated the survey. The participants were then asked about familiarity with naming the external female genital anatomy and were provided an image to label the anatomy. The image was an artist rendition of the female vulva with arrows pointing towards the following structures: clitoris, urethra, labia minora, labia majora, vagina, and anus. They were provided with a list of anatomic names that included the labeled structures and 2 structures not labeled (the Mons and Skene’s glands) to prevent any guidance in selecting the anatomic labels. The participants were also surveyed regarding their history of sexual activity with female partners, lifetime sexual partners, and the influence of a woman’s genital appearance on their desire for and pleasure with sexual activity.

Six images were reproduced with permission. All images were of unaltered female genitalia. Three images were selected to represent varying labial sizes ( Figure 1 ); 3 others represented varying hair patterns ( Figure 2 ). The men were asked to rate the images as attractive/appealing, neutral, or unattractive/unappealing. The groups of images were followed by 1 question asking about preference of labial size and genital hair patterns. The respondents had the opportunity to select from the following choices for labial size: small, large, no preference, and “I don’t know.” Similarly, they were given the following options for hair pattern: natural, trimmed/partially groomed, partially removed, complete removal, and no preference. Finally, the survey concluded with 4 questions regarding familiarity with FGPS and whether the participant would encourage a female partner to alter her genital appearance or pursue surgery if her appearance was different from his preference.

Labia of varying size

Images of the various labial sizes that were shown to the participants.

Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015 .

Labia of varying hair pattern

Images of the various hair patterns that were shown to the participants.

Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015 .

Statistical analysis was carried out using SPSS software (version 22.0; SPSS Inc, Chicago, IL). Descriptive statistics were calculated for continuous and categoric data. The χ ² test was used to analyze the relationship between demographics and responses (2-tailed, α = .05). Simple logistic regression was used to further analyze significantly associated variables. Multiple logistic regression models were employed to determine which variables had the strongest association with responses.

Results

After 2 email deployments, a total of 2403 participants responded to the survey. The first deployment delivered 144,501 email messages, with an estimated open rate of 13.7%. The second deployment delivered 190,620 email messages, with an estimated open rate of 12.6%. The larger second deployment included the original email messages and additional email messages to account for invalid email addresses in the first deployment. Due to the confidential nature of responses, we were unable to adequately estimate the proportion of email messages that were delivered or viewed and therefore could not ascertain a true response rate. Of the 2403 participants, 556 had to be excluded because the reported age was outside the eligibility range or because the survey was not completed in its entirety; therefore, 1847 survey responses were analyzed.

The median age of respondents was 55 years (interquartile range, 16). Over half of respondents (57%) were 45-64 years old; 2% were 18-24 years old; 18% were 25-44 years old, and the remaining 23% were >65 years old. The majority was white (87%), not Hispanic (93%), completed high school or beyond (97%), married (68%), employed (69%), and had a household income of >$65,000 (55%). The respondents were distributed almost evenly with regard to region of habitation; the largest proportion lived in the southern United States (33%). Approximately one-third (32%) reported living in urban areas with populations >500,000 ( Table 1 ).

A significant majority (95%) reported currently being or having ever been sexually active with women; the largest proportion of respondents (39%) reported >10 lifetime partners. Eighty-six percent felt “very” or “somewhat” familiar with naming the female anatomy. When asked to label the anatomic diagram, the majority correctly labeled the female genital anatomy, with the clitoris and anus being correctly labeled most often (92% and 93%, respectively; Table 2 ).

The participants were asked to rate their opinion of the images of various sized labia. Regarding the images most viewed as attractive, 43% of the respondents rated small labia as attractive/appealing; 43% rated middle-sized labia as attractive/appealing, and 24% rated large labia as attractive/appealing.With respect to finding the images unattractive or unappealing, men most often reported viewing the large labia this way (46%), followed by the middle-sized labia (20%), and finally the small labia (16%) ( Figure 3 ). However, over one-third of the respondents (36%) were neutral towards the appearance of all 3 images. Additionally, when specifically queried whether they had a preference of labial size, over half reported no preference (54%; Table 2 ).

Male preferences of labial size and hair pattern

Responses of the participants to the attractiveness of ( top ) various labial sizes and ( bottom ) hair patterns.

Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015 .

Men also rated their preferences for hair pattern of the female genitalia. They most often reported the partially groomed image as appealing/attractive (67%) compared with the images of complete hair removal (47%) and natural hair pattern (37%; Figure 3 ). When specifically asked regarding any preference for hair pattern, 16% responded that they would prefer a natural hair pattern; 39% preferred partial removal of hair; 24% preferred complete hair removal, and 19% reported no preference ( Table 2 ).

Fifty-one percent of men reported that the appearance of a woman’s genitalia would influence his desire to engage in sexual activity with that woman. Notwithstanding, 60% responded that the appearance would not impact their pleasure with sexual activity ( Table 2 ).

Regarding FGPS, only 42% of respondents were familiar with these procedures. When they reported familiarity, they most often learned about it via a nonsocial networking Internet site, followed by information from a female friend (data not shown). Overall, 75% of respondents would not encourage a female partner to alter the appearance of her genitalia, even if the appearance was not his preference, and only 10% stated they would encourage a female partner to pursue surgical alteration ( Table 2 ).

Using χ ² tests of association and simple logistic regression, the relationship between demographic variables and responses were tested. Responses that were analyzed were (1) the perception that small labia or complete hair removal is attractive, (2) the perception that large labia or natural hair pattern is unattractive, (3) a response of “yes” to encouraging changing vulvar appearance or pursuing surgical alteration, and (4) reporting familiarity with FGPS. After this initial analysis, variables significantly associated were entered into multiple logistic regression models.

Both age and the number of lifetime sexual partners remained significantly associated with reporting the image of small labia as attractive. When compared to respondents ≥65 years older, younger respondents 18-24 years old were approximately 3 times more likely to find the small labia attractive ( Table 3 ). Additionally, respondents with >10 lifetime sexual partners were most likely to find small labia attractive compared to respondents with zero sexual partners ( Table 3 ).

Table 3

Results of multiple logistic regression models

Category	n (%)	Odds ratio (95% confidence interval)	P value c
Responses of “attractive/appealing” to picture of small labia a,b
Age category, y
65-80	130 (31)	1 [Reference]
45-64	476 (45)	1.63 (1.24–2.14)	< .001 c
25-44	173 (52)	2.26 (1.61–3.16)	< .001 c
18-24	19 (53)	3.15 (1.52–6.54)	.002 c
No. of sexual partners
0	5 (14)	1 [Reference]
1-2	113 (36)	4.15 (1.54–11.14)	.005 c
3-5	120 (41)	5.17 (1.92–13.91)	.001 c
6-10	144 (44)	5.70 (2.12–15.27)	.001 c
>10	367 (51)	7.62 (2.88–20.17)	< .001 c
Prefer not to answer	49 (32)	3.55 (1.28–9.85)	.02 c
Responses of “attractive/appealing” to picture with hair completely removed a,b
Age category
65-80	130 (31)	1 [Reference]
45-64	476 (45)	1.90 (1.45–2.49)	< .001 c
25-44	173 (52)	2.55 (1.82–3.58)	< .001 c
18-24	19 (53)	4.25 (2.01–9.01)	< .001 c
Income category
<$10,000	6 (23)	1 [Reference]
$10,000-25,000	23 (30)	1.40 (0.48–4.11)	.54
$25,001-45,000	92 (50)	3.15 (1.16–8.59)	.02 c
$45,001-65,000	120 (52)	3.50 (1.29–9.48)	.01 c
$65,001-85,000	126 (49)	2.92 (1.08–7.90)	.04 c
>$85,000	363 (48)	2.70 (1.02–7.20)	.046 c
Prefer not to answer	144 (44)	2.66 (0.99–7.17)	.05 c
No. of sexual partners
0	5 (14)	1 [Reference]
1-2	113 (36)	3.19 (1.36–7.47)	.01 c
3-5	120 (41)	2.76 (1.18–6.46)	.02 c
6-10	144 (44)	3.76 (1.61–8.79)	.002 c
>10	367 (51)	4.32 (1.87–9.96)	.001 c
Prefer not to answer	49 (32)	2.28 (0.94–5.55)	.07 c
Response of “yes” regarding familiarity with labiaplasty d,e
Level of education
Graduate school	243 (49)	1 [Reference]
Some graduate school	62 (50)	0.96 (0.64–1.45)	.86
College graduate	221 (43)	0.73 (0.56–0.95)	.02 c
Some college	169 (37)	0.56 (0.42–0.74)	< .001 c
High school graduate	60 (29)	0.43 (0.30–0.63)	< .001 c
Less than high school	5 (31)	0.58 (0.18–1.88)	.37
Prefer not to answer	17 (40)	0.58 (0.28–1.21)	.15
Age category, y
65-80	143 (34)	1 [Reference]
45-64	462 (44)	1.55 (1.21–1.99)	.001 c
25-44	155 (46)	1.89 (1.38–2.59)	< .001 c
18-24	17 (47)	2.62 (1.26–5.43)	.01 c
Hispanic
No	707 (41)	1 [Reference]
Yes	44 (57)	1.79 (1.10–2.91)	.02 c
Prefer not to answer	26 (46)	1.29 (0.71–2.35)	.40
US region
Midwest	114 (34)	1 [Reference]
Northeast	222 (42)	1.35 (1.01–1.82)	.04 c
South	270 (44)	1.41 (1.05–1.88)	.02 c
West	171 (46)	1.47 (1.06–2.02)	.02 c
No. of sexual partners
0	11 (31)	1 [Reference]
1-2	103 (33)	0.97 (0.44–2.13)	.95
3-5	118 (40)	1.39 (0.64–3.05)	.41
6-10	143 (44)	1.59 (0.73–3.46)	.24
>10	351 (49)	1.93 (0.90–4.15)	.09
Prefer not to answer	51 (34)	1.09 (0.48–2.50)	.83

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