“The area’s very uncomfortable”: The trend of teenage labiaplasty

Type ‘labia’ into Google and you will likely find two of the top auto-fill suggestions to be labiaplasty and labia surgery, alongside a range of sponsored posts from private clinics offering the procedures. A growing number of people are feeling insecure about their genitalia, paralleled by a reported surge in Female Genital Cosmetic Surgery (FGCS). FGCS is an umbrella term, commonly marketed as the ‘Designer Vagina’ or ‘Vaginal Rejuvenation’, encompassing procedures such as clitoral hood reduction, vaginoplasty, and hymenoplasty.

The most popular FGCS is labiaplasty, which aims to reshape or reduce the size of the visible labia ‘lips’. In 2016, ISAPS released data from 35,000 plastic surgeons across 105 countries that found labiaplasty to be the fastest-growing cosmetic procedure globally. It appears that the trend is not slowing down either; the number of labiaplasties performed worldwide increased 73% between 2015 and 2019. Still, the procedure remains controversial, as many feel it preys on genital insecurities rather than promoting the realities of body diversity.

A series of reports in 2015–17 suggested that girls under 18 were increasingly requesting and being referred for labiaplasty, both in the UK and in countries such as the USA and Australia. The BBC’s interview with leading gynaecologist Dr. Naomi Crouch revealed that in 2016, the NHS performed 213 labiaplasties on girls aged 18 and under, 152 of which were below the age of 15. Whilst some of these may be for congenital conditions, Dr. Crouch stated she found it “very hard to believe” all of these patients had medical conditions necessitating labia surgery, making it likely the NHS was performing some for cosmetic purposes.

The arguments against performing these surgeries on adolescent girls is not just a moral one. A statement by the British Society for Paediatric and Adolescent Gynaecology asserts that there are often “poor cosmetic outcomes or structural problems that may ensue after a labiaplasty performed before complete pubertal development.” Indeed, given the labia continue to change in shape and structure through puberty, academic research has suggested that aside from moral concerns, girls should be fully developed before considering such procedures. 

One case study cites a 10-year-old girl who was presenting with labial asymmetry, so she had her left labia trimmed. Yet 9 months later, she had to go back in for an operation on her right labia after it grew to match the original left labial size. Had health providers allowed her to develop before intervening, she would have avoided two irreversible surgeries.

Since 2016, the NHS has reformed its guidelines, making the referral process for labiaplasty more stringent. In fact, The Monitor obtained data through a Freedom of Information request which showed that in 2022, there were 119 labiaplasties performed by the NHS on girls under 18, a 54% reduction from 2016. This data may be explained by the NHS reforms, lower referrals during COVID, less commissioner funding available for non-essential procedures or simply due to fewer patients seeking treatment. Still, GP testimony suggests that despite a reduction in actual surgeries being performed, the number of adolescents seeking to obtain labiaplasty remains a serious concern. 

The Monitor spoke with Dr. Crouch, the former chair of the British Society for Paediatric and Adolescent Gynaecology, to discuss her thoughts 6 years on from her BBC report.

“Over the last 15 years, we saw a rise [of underage labiaplasty] on the NHS, and then we’ve seen a fall for a variety of reasons…whilst we don’t see as many referrals, we do still see people who will come along with physical symptoms. But there’s also research suggesting that physical symptoms are over promoted. People will say the area’s very uncomfortable, and can limit their choice of clothing or sporting activity, with no obvious medical condition at all. The majority of teenagers I see, would suggest the only solution to symptoms is an operation.”

Whilst there has been an evident decline in NHS adolescent labiaplasties over the last 6 years, whether this trend extends to private practices remains unclear, as they are not obligated to publish such data. It is therefore possible (although complete conjecture) that the increased stringency of NHS referrals has pushed under 18’s seeking FGCS into the private sector. 

You may be wondering how cosmetic genital surgery on children under 18 is legal, regardless of who is performing the surgery. However, the UK laws around cosmetic surgery and consent for minors remain fairly vague. There is currently no minimum age for cosmetic surgery in the UK; instead, decisions are made on a case-by-case basis. 

Necessary factors for an under-18 year old to be deemed eligible for a cosmetic procedure include: that the surgery would significantly improve mental health problems or bullying; that the child has undergone Body Dysmorphia counselling; and that they have parental consent or are considered ‘Gillick competent’—having the functional ability to consent and advocate for themselves. It is encouraging to see that young people are being taken seriously when presenting mental health problems around their bodies, and being provided a range of options. It is also positive that a range of checks and limits have been imposed. However it seems apparent that these regulations may often leave leeway for people to obtain surgery, perhaps privately, rather than engaging in the root cause of the problem.

Speaking to a Portsmouth-based therapist who asked to remain anonymous, The Monitor heard that “many, many young girls will go through Body Dysmorphia counselling, with no interest in engaging in the therapy. They do their 8 weeks and go back to their GP saying it didn’t work, so they can go on to get a cosmetic procedure”.

Comparisons are often drawn between underage FGCS and Female Genital Mutilation (FGM). Countries such as the UK, USA, and Australia have been some of the staunchest opponents of religious and cultural genital cutting practices and have specific provisions outlawing FGM. Consequently, some academics have pointed out the certain irony of genital cutting rapidly rising across the Global North whilst support and practice are consistently falling in places that historically practiced FGM, such as Sub-Saharan Africa and parts of Asia. 

Dr Crouch has spoken up on the “uncomfortable comparisons” between Western cultural standards of small, tucked in vulva lips, and FGM.

“To me, if you read the absolute letter of the law, it says you can’t alter the labia for cultural reasons. Well, we do have a culture in Western society, culture isn’t something that happens to other people, the law should apply to all and be colour blind.” She goes on to say, “I’ve heard doctors say in this debate that the difference [between FGM and FGCS] is around consent. But it isn’t actually, in the UK law it says it’s illegal even if it’s performed by a medical practitioner and consent is given.”

Whether labiaplasty is medically necessary for women of any age remains contentious. Many private providers and plastic surgeons advertise labiaplasty as an appropriate treatment for ‘labia hypertrophy’, which presents symptoms such as pain and itching from rubbing and twisting of the labia. Recent research suggested such symptoms were the primary motivators for women seeking the surgery and that these symptoms can be alleviated by the procedure. However, many argue that there is a complete lack of diagnostic criteria or defined boundaries for labia hypertrophy, making it unobjective and unable to fulfil biomedical standards. To this end, creating a pseudo-medical condition is at best jargon and at worst, a way to instil fear over completely normal body parts. 

Rather than operating, many practitioners would prefer to treat the perceptions, attitudes and mental health problems young people have about their bodies. 

Speaking with the Monitor, Hampshire-based GP Dr. Colinette Margerison said, “a lot of the work that’s not done is around the psychology of what’s happening rather than the physical. Sometimes, particularly for teenagers, they walk into this kind of surgery, have something done, and it doesn’t actually fix the problem. Because the problem is more psychological, even after surgery, they will still persist in believing there’s a problem, or the problem will shift to a different part of their body.”

The usual culprits have been cited as the primary reasons for genital anxiety and the subsequent rise in labiaplasty requests. The increasing use of social media and pornography from a younger age are believed to have led many children to have a skewed understanding of what a normal body should look like. 

Dr Crouch notes how search engine algorithms promote labiaplasty,

“If you look up labia on google, it comes up with labiaplasty before and after photos. And if you look at those before photos and you think, I look a bit like that, what are you going to conclude? That there is a problem, and a solution, which is surgery.”

One more specific issue is that the widespread increase in shaving and waxing pubic hair, both in the media and in public practice, has led to greater visibility of an area that was once covered. This has caused women in general to be more aware of how their own and others' genitalia look. Whilst not inherently bad, this has arguably created a new arena of insecurities.

When asked what she believed were the primary drivers of genital anxiety and insecurity, Dr. Margerison said, “Secrecy and the lack of communication about the anatomical parts of our bodies is a big problem. All of that contributes to the difficulties of young girls knowing what’s normal about their bodies and young boys knowing what’s normal about girls bodies”.

She advocates for more open discussions about the range of normal to help women understand and feel comfortable, not just with their vulvas, but with their bodies in general.

There are activists and artists working hard to achieve this, opening up the conversation to end the stigma around labial diversity. The Great Wall of Vulva, formerly misnomered the Great Wall of Vagina, is a project by British Artist Jamie McCartney, exhibiting 400 vulval casts to help educate people on the range of genital differences. The comments and reviews left on the site make for an emotional read.

One 16 year old says, “Growing up with ideology of how a vagina should look from pornography, I always found mine to be unattractive and I had hated it…I wasn’t happy with how it looked.”

Another commenter writes, “I was going to have labia surgery, convinced my labia were too long, had boyfriends comment that they were uneven... Even with all the risks, I was still going to do it, thought my pussy was supposed to look neat and tidy... I cried when I saw your artwork for the first time in Brighton, then and there, my insecurities were blown apart.” You can ‘virtually visit’ the exhibit here.

Other creators, such as @the.vulva.gallery and @jessica_ann_pin, use their platforms to educate and campaign for better vulval understanding and to celebrate diverse bodies.

If you have felt insecure about your labia or are interested in finding out more about labia diversity, a helpful resource is linked here.

*note that trans and intersex genital diversity will be discussed in part two of this article series, as it was felt that the topic was too broad to be included in just one article.