Abstract
Labiaplasty has become an increasingly popular procedure. However, the psychological outcomes of this procedure, such as the effects on women’s sex lives and psychological well-being, have received little attention from researchers to date. In addition, the investigation of factors which predict satisfaction with surgical outcomes is also lacking.
To examine the effect of labiaplasty on women’s sexual satisfaction and psychological well-being. To also identify patient characteristics which predict surgical satisfaction.
This retrospective study involved 48 adult women who had undergone a labiaplasty procedure between 3 and 204 months prior. These women completed an online questionnaire which contained measures of satisfaction with labiaplasty, genital appearance satisfaction, sexual satisfaction, and psychological well-being.
Most women were very satisfied with their labial appearance and function after surgery. The women also reported statistically significant increases in their genital appearance satisfaction (P < .001), sexual satisfaction (P = .009), and psychological well-being (P < .001) at the time of completing the questionnaire compared to their recalled levels prior to surgery. Undergoing labiaplasty to address physical/functional concerns (P = .025) as well as sexual concerns (P = .037) was associated with greater satisfaction with surgical outcomes. In contrast, experiencing post-surgery complications (P = .015) was related to lower satisfaction.
Women appear to be very satisfied with the results of their labiaplasty and they also seem to experience improvements in their sexual satisfaction and psychological well-being. Physical/functional motivations for undergoing labiaplasty are associated with greater satisfaction with outcomes.
The demand for labiaplasty has risen considerably over the last 10 to 15 years. In the last year alone in the United States, there was a 16% increase in the number of labiaplasty procedures performed (ie, 7535 to 8745),1 and similar increases have been noted in other countries like the UK2 and Australia.3 From the retrospective reports of women who have undergone labiaplasty, satisfaction rates for this procedure appear to be high. For example, 97% of 177 women in the US who underwent a labiaplasty and/or reduction of the clitoral hood reported that they were satisfied with the result.4 Similarly, in France, Rouzier et al5 reported that 87% of 98 labiaplasty patients were satisfied with the aesthetic outcome, 93% with the functional outcome, and 96% with the overall outcome. In addition to high levels of satisfaction with surgical outcomes, a few studies have also investigated the broader effects of labiaplasty on women’s lives including their sexual satisfaction and psychological well-being. In a US study, 93% of the 166 women involved reported that their self-esteem had improved at least “somewhat” after labiaplasty and 71% reported their sex lives had improved.6 In addition, a German study found that 90% of 812 patients reported a reduction in their psychological distress after surgery.7 These studies and others8-10 suggest that women are generally very satisfied with their labiaplasty outcomes and this appears to extend to improvements in sexual and psychological functioning for some women. Nevertheless, despite the increasing demand for labiaplasty in Australia,3 there have been no retrospective investigations of surgical and psychological outcomes in these women. Thus, the current study aimed to address this gap.
Another important issue which has received very little attention in labiaplasty research to date, and also aesthetic surgery research more generally,11,12 is the examination of predictors of satisfaction with surgical outcomes. As discussed above, although the majority of women report high levels of satisfaction after labiaplasty, a small percentage of women are not satisfied and some of these women may attribute blame to and consider suing their treating physician.13 Clearly, the identification of factors associated with poorer outcomes will assist medical professionals in deciding who is or is not a suitable candidate for labiaplasty and potentially avoid such legal issues. In Honigman et al’s14 review of 14 studies investigating predictors of poor psychosocial outcomes for cosmetic surgery (not including labiaplasty), demographic characteristics, psychological functioning, and previous cosmetic surgery experiences were predictive of psychosocial outcomes. However, according to Honigman et al,14 none of the 14 studies involved a rigorous statistical evaluation of predictors and so the results should be interpreted with some caution. In the current study, we aimed to systematically examine whether demographic characteristics, psychological well-being, experience with cosmetic surgery, and the nature of women’s motivations for labiaplasty (eg, aesthetic, functional) predict satisfaction with labiaplasty outcomes (after labiaplasty).
METHODS
Participants and Procedure
Ethics approval for the study was obtained from the Flinders University Social and Behavioral Research Ethics Committee (Adelaide, Australia) prior to study initiation. From July 2014 to February 2016, 48 adult Australian women who had undergone a labiaplasty procedure during the period of February 1999 to October 2015 were involved in the study. The participants were between 3 and 204 months postoperative (mean, 44.4 months; median, 24.0 months; and standard deviation [SD], 52.4 months) when they completed the questionnaire. The study was advertised as an online questionnaire entitled “Labiaplasty Experiences and Outcomes” on a range of websites including cosmetic surgery discussion forums (eg, “Plastic Surgery Forum Australia” and “Plastic Surgery Hub”) and social media news stories, as well as via email to former labiaplasty patients via four private cosmetic surgery clinics throughout Australia. Any adult woman aged 18 or over living in Australia who had undergone a labiaplasty procedure (ie, reduction of the labia minora) three or more months prior was eligible to participate in the online questionnaire study. Participants were presented with online versions of the study information before commencing the questionnaire. Completion of the online questionnaire was considered to be informed consent, according to the Australian National Statement on Ethical Conduct in Human Research.15 Participants were given the option to enter a draw to receive a 50 Australian dollar store voucher at the end of questionnaire. Table 1 shows participant demographic information.
Participant Demographic Information (n = 48)
| Demographic variable | n (%) |
|---|---|
| Age in years, mean (SD) | 39.4 (11.6) |
| Range | 19-60 |
| BMI, mean (SD) | 23.7 (4.5) |
| Range | 16.3-34.3 |
| Ethnicity | |
| White/Caucasian | 44 (91.7) |
| Asian | 1 (2.1) |
| No response | 3 (6.3) |
| Sexual orientation | |
| Exclusively heterosexual | 34 (70.8) |
| Predominantly heterosexual | 4 (8.3) |
| Predominantly heterosexual but more than incidentally homosexual | 4 (8.3) |
| Equally heterosexual and homosexual | 2 (4.2) |
| Predominantly homosexual but more than incidentally heterosexual | 0 (0.0) |
| Predominantly homosexual | 0 (0.0) |
| Exclusively homosexual | 1 (2.1) |
| No response | 3 (6.3) |
| Current sexual partner status | |
| Yes | 40 (83.3) |
| No | 7 (14.6) |
| No response | 1 (2.1) |
| Children | |
| Yes | 25 (52.1) |
| No | 20 (41.7) |
| No response | 3 (6.3) |
| Education | |
| Secondary school | 4 (8.3) |
| Trade/certificate/diploma | 20 (41.7) |
| Undergraduate degree | 8 (16.7) |
| Postgraduate degree | 14 (29.2) |
| No response | 2 (4.2) |
| Demographic variable | n (%) |
|---|---|
| Age in years, mean (SD) | 39.4 (11.6) |
| Range | 19-60 |
| BMI, mean (SD) | 23.7 (4.5) |
| Range | 16.3-34.3 |
| Ethnicity | |
| White/Caucasian | 44 (91.7) |
| Asian | 1 (2.1) |
| No response | 3 (6.3) |
| Sexual orientation | |
| Exclusively heterosexual | 34 (70.8) |
| Predominantly heterosexual | 4 (8.3) |
| Predominantly heterosexual but more than incidentally homosexual | 4 (8.3) |
| Equally heterosexual and homosexual | 2 (4.2) |
| Predominantly homosexual but more than incidentally heterosexual | 0 (0.0) |
| Predominantly homosexual | 0 (0.0) |
| Exclusively homosexual | 1 (2.1) |
| No response | 3 (6.3) |
| Current sexual partner status | |
| Yes | 40 (83.3) |
| No | 7 (14.6) |
| No response | 1 (2.1) |
| Children | |
| Yes | 25 (52.1) |
| No | 20 (41.7) |
| No response | 3 (6.3) |
| Education | |
| Secondary school | 4 (8.3) |
| Trade/certificate/diploma | 20 (41.7) |
| Undergraduate degree | 8 (16.7) |
| Postgraduate degree | 14 (29.2) |
| No response | 2 (4.2) |
SD, standard deviation; BMI, body mass index (weight kg/height m2).
Participant Demographic Information (n = 48)
| Demographic variable | n (%) |
|---|---|
| Age in years, mean (SD) | 39.4 (11.6) |
| Range | 19-60 |
| BMI, mean (SD) | 23.7 (4.5) |
| Range | 16.3-34.3 |
| Ethnicity | |
| White/Caucasian | 44 (91.7) |
| Asian | 1 (2.1) |
| No response | 3 (6.3) |
| Sexual orientation | |
| Exclusively heterosexual | 34 (70.8) |
| Predominantly heterosexual | 4 (8.3) |
| Predominantly heterosexual but more than incidentally homosexual | 4 (8.3) |
| Equally heterosexual and homosexual | 2 (4.2) |
| Predominantly homosexual but more than incidentally heterosexual | 0 (0.0) |
| Predominantly homosexual | 0 (0.0) |
| Exclusively homosexual | 1 (2.1) |
| No response | 3 (6.3) |
| Current sexual partner status | |
| Yes | 40 (83.3) |
| No | 7 (14.6) |
| No response | 1 (2.1) |
| Children | |
| Yes | 25 (52.1) |
| No | 20 (41.7) |
| No response | 3 (6.3) |
| Education | |
| Secondary school | 4 (8.3) |
| Trade/certificate/diploma | 20 (41.7) |
| Undergraduate degree | 8 (16.7) |
| Postgraduate degree | 14 (29.2) |
| No response | 2 (4.2) |
| Demographic variable | n (%) |
|---|---|
| Age in years, mean (SD) | 39.4 (11.6) |
| Range | 19-60 |
| BMI, mean (SD) | 23.7 (4.5) |
| Range | 16.3-34.3 |
| Ethnicity | |
| White/Caucasian | 44 (91.7) |
| Asian | 1 (2.1) |
| No response | 3 (6.3) |
| Sexual orientation | |
| Exclusively heterosexual | 34 (70.8) |
| Predominantly heterosexual | 4 (8.3) |
| Predominantly heterosexual but more than incidentally homosexual | 4 (8.3) |
| Equally heterosexual and homosexual | 2 (4.2) |
| Predominantly homosexual but more than incidentally heterosexual | 0 (0.0) |
| Predominantly homosexual | 0 (0.0) |
| Exclusively homosexual | 1 (2.1) |
| No response | 3 (6.3) |
| Current sexual partner status | |
| Yes | 40 (83.3) |
| No | 7 (14.6) |
| No response | 1 (2.1) |
| Children | |
| Yes | 25 (52.1) |
| No | 20 (41.7) |
| No response | 3 (6.3) |
| Education | |
| Secondary school | 4 (8.3) |
| Trade/certificate/diploma | 20 (41.7) |
| Undergraduate degree | 8 (16.7) |
| Postgraduate degree | 14 (29.2) |
| No response | 2 (4.2) |
SD, standard deviation; BMI, body mass index (weight kg/height m2).
Questionnaire
A brief questionnaire was devised by the researchers (containing newly developed measures for satisfaction with labiaplasty, sexual satisfaction, and psychological well-being) to ensure the length of the questionnaire was not prohibitive for participants to complete in an online format. Participants were firstly asked to provide their demographic information, followed by details of their labiaplasty procedure and satisfaction with this procedure. They were then asked to rate their current levels of genital appearance satisfaction, sexual satisfaction, and psychological wellness. Then, they were asked to recall their levels of genital appearance satisfaction, sexual satisfaction, and psychological wellness prior to undergoing labiaplasty so that we could examine any perceived changes in these psychological outcomes from before labiaplasty to the time they completed the questionnaire. A blank copy of the questionnaire is available as Supplementary Material at www.aestheticsurgeryjournal.com.
Demographics
Participants were asked their age, height, weight, ethnicity, sexual orientation, and highest level of education achieved. They were also asked whether they currently had a sexual partner, and whether they had any children.
Motivations for Labiaplasty and Labiaplasty Surgery Details
Participants were firstly asked to recall their reasons for undergoing a labiaplasty as an open-ended response. These were rated by two independent raters and four categories16 were agreed upon, namely “appearance,” “functional,” “sexual,” and “psychological.” Participants were then asked to provide the month and year of their labiaplasty procedure, whether they claimed Medicare (Australia’s national health service) entitlements for their procedure, and whether they had any other procedures performed at the same time as their labiaplasty (with details). They were also asked whether they had undergone any other cosmetic procedures besides labiaplasty in their lifetime and to provide details of these procedures if applicable.
Satisfaction with Labiaplasty
Satisfaction with the surgical result was measured using three items. The first two items addressed current satisfaction with labial appearance and labial function on a 7-point Likert scale ranging from 1 (extremely dissatisfied) to 7 (extremely satisfied). The third item addressed how strongly participants agreed that they had achieved their goals for surgery on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). In addition, they were asked whether they had any complications (and to provide details if so) and whether they underwent any revision surgeries.
Genital Appearance Satisfaction
Satisfaction with genital appearance was measured using the standardized 11-item Genital Appearance Satisfaction (GAS) scale.17 Participants rated how often they agreed with each item (eg, “I feel that my labia are too large”) on a 4-point Likert scale ranging from 0 (never) to 3 (always). Scores were summed to produce a total score which could range from 0 to 33, with higher scores indicating greater genital appearance dissatisfaction. Internal consistency for the present sample was acceptable (Cronbach’s α = .86 for current GAS scores and α = .84 for before labiaplasty scores).
Sexual Satisfaction
Participants were asked to rate their level of satisfaction with their sex life on a 7-point Likert scale ranging from 1 (strongly dissatisfied) to 7 (strongly satisfied). Only participants who had a sexual partner at the time of completing the questionnaire (n = 40, 83.3%) were asked to provide a response to this item for the current satisfaction rating and only participants who had had a sexual partner in their lifetime before undergoing labiaplasty (n = 46, 95.8%) were asked the before satisfaction item.
Psychological Well-Being
Participants were asked to rate their levels on three aspects of psychological wellness: (1) self-esteem; (2) life satisfaction; and (3) psychological well-being, which all ranged from 1 (very low) to 5 (very high). Overall mean total scores were calculated which ranged from 1 to 5, and higher scores indicated higher psychological wellness. Internal consistency for the present sample was acceptable (Cronbach’s α = .83 for current psychological wellness scores and α = .86 for before labiaplasty scores).
Statistical Analysis
The data were analyzed using IBM SPSS (version 23.0; IBM SPSS, Inc, Chicago, IL). Paired samples t tests were used to examine changes in participants’ current ratings for genital appearance satisfaction, sexual satisfaction, and psychological well-being compared to their recalled ratings before labiaplasty. Multiple linear regression was used to examine whether participant characteristics predicted satisfaction with labiaplasty outcomes. As there was a wide range in postoperative follow-up time (3-204 months), the effect of time on labiaplasty outcomes was also examined by splitting the sample according to the median length of follow-up time (24 months). Thus, “short” (≤24 months) and “long” (>24 months) follow-up groups were compared. Independent samples t tests were used to examine differences between these two groups in their satisfaction with labiaplasty. Mixed ANOVA, 2 (group: short, long) × 2 (time: recalled, current), were used to investigate differences between the two groups for their recalled to current ratings for genital appearance satisfaction, sexual satisfaction, and psychological well-being. Paired samples t tests were used to analyse significant group × time interaction effects, indicating that the two groups differed over time. A value of P < .05 was considered to be statistically significant
RESULTS
Sample Characteristics and Surgery Information
Participants ranged in age from 19 to 60 years (mean, 39.4 years; SD, 11.6 years). Participant motivations for labiaplasty were classified into four main categories and over half (n = 28, 58.3%) provided responses which encompassed more than one category. The most common motivation for labiaplasty was “appearance concern” (n = 33, 71.7%), followed by “physical discomfort” (n = 29, 63.0%), “physical and/or emotional concerns with sexual relationships” (n = 10, 21.7%), and “general psychological distress” (n = 8, 17.4%). In terms of their labiaplasty procedures, nineteen of the participants (40.4%) claimed Medicare entitlements. This meant that their procedure was “medically indicated,” but specific guidelines on what constituted a medically necessary procedure were never provided by Medicare.18 After November 2014, the Medicare guidelines were altered to specify that clinically relevant indications for labiaplasty included “non-inflammatory disorders of the vulva and perineum, congenital disorders and to repair or reconstruct normal female anatomy following trauma, harmful traditional practices or pathologic processes.”18,19 However, all of the women in our sample who claimed Medicare entitlements reported undergoing labiaplasty prior to this guideline change. Seven women (14.6%) reported that they had other procedures performed at the same time as their labiaplasty and these included breast augmentation (n = 3), clitoral hood reduction (n = 1), vaginoplasty (n = 1), tubal ligation (n = 1), umbilical hernia repair (n = 1), and dilation and curettage (n = 1). Eighteen (39.1%) had undergone other cosmetic procedures besides labiaplasty in their lifetime. The most popular procedure was breast augmentation (n = 9), followed by botulinum toxin injections (n = 4), abdominoplasty (n = 3), fillers (n = 2), rhinoplasty (n = 2), liposuction (n = 2), microdermabrasion (n = 1), otoplasty (n = 1), blepharoplasty (n = 1), intense pulse light (IPL; n = 1), and mole removal (n = 1).
Satisfaction with Labiaplasty
As seen in Table 2, the vast majority of participants were satisfied with their current labial appearance and function. In addition, most agreed that their goals for having a labiaplasty were achieved. However, ~10% to 17% of participants were in the “slightly”/”moderately”/”extremely” dissatisfied range for these measures of satisfaction (Table 2). Some of these participants utilized the open-ended response section at the end of the questionnaire to explain the reasons underlying their dissatisfaction and these included: unfulfilled expectations with labial appearance (n = 3), experiencing significant pain and discomfort after surgery (n = 3), and perceived incompetence by the physician who performed the procedure (n = 2). When the effect of time since surgery on satisfaction was examined, there were no significant differences between the short and long follow-up groups for all of labial appearance satisfaction, t(39) = 0.04, P = .996, d = 0.01, function satisfaction, t(39) = 0.66, P = .516, d = 0.21, and surgical goals achieved, t(39) = 0.68, P = .500, d = 0.21.
Participant Satisfaction with Labiaplasty Outcomes (n = 48)
| Variable | Extremely satisfied n (%) | Moderately satisfied n (%) | Slightly satisfied n (%) | Neither satisfied or dissatisfied n (%) | Slightly dissatisfied n (%) | Moderately dissatisfied n (%) | Extremely dissatisfied n (%) |
|---|---|---|---|---|---|---|---|
| Appearance satisfaction | 22 (45.8) | 10 (20.8) | 5 (10.4) | 3 (6.3) | 3 (6.3) | 3 (6.3) | 2 (4.2) |
| Function satisfaction | 31 (64.6) | 6 (12.5) | 1 (2.1) | 3 (6.3) | 2 (4.2) | 2 (4.2) | 3 (6.3) |
| Goals achieveda | 28 (58.3) | 9 (18.8) | 5 (10.4) | 1 (2.1) | 2 (4.2) | 1 (2.1) | 2 (4.2) |
| Variable | Extremely satisfied n (%) | Moderately satisfied n (%) | Slightly satisfied n (%) | Neither satisfied or dissatisfied n (%) | Slightly dissatisfied n (%) | Moderately dissatisfied n (%) | Extremely dissatisfied n (%) |
|---|---|---|---|---|---|---|---|
| Appearance satisfaction | 22 (45.8) | 10 (20.8) | 5 (10.4) | 3 (6.3) | 3 (6.3) | 3 (6.3) | 2 (4.2) |
| Function satisfaction | 31 (64.6) | 6 (12.5) | 1 (2.1) | 3 (6.3) | 2 (4.2) | 2 (4.2) | 3 (6.3) |
| Goals achieveda | 28 (58.3) | 9 (18.8) | 5 (10.4) | 1 (2.1) | 2 (4.2) | 1 (2.1) | 2 (4.2) |
a Likert scale anchors were “agree” rather than “satisfied” for this item.
Participant Satisfaction with Labiaplasty Outcomes (n = 48)
| Variable | Extremely satisfied n (%) | Moderately satisfied n (%) | Slightly satisfied n (%) | Neither satisfied or dissatisfied n (%) | Slightly dissatisfied n (%) | Moderately dissatisfied n (%) | Extremely dissatisfied n (%) |
|---|---|---|---|---|---|---|---|
| Appearance satisfaction | 22 (45.8) | 10 (20.8) | 5 (10.4) | 3 (6.3) | 3 (6.3) | 3 (6.3) | 2 (4.2) |
| Function satisfaction | 31 (64.6) | 6 (12.5) | 1 (2.1) | 3 (6.3) | 2 (4.2) | 2 (4.2) | 3 (6.3) |
| Goals achieveda | 28 (58.3) | 9 (18.8) | 5 (10.4) | 1 (2.1) | 2 (4.2) | 1 (2.1) | 2 (4.2) |
| Variable | Extremely satisfied n (%) | Moderately satisfied n (%) | Slightly satisfied n (%) | Neither satisfied or dissatisfied n (%) | Slightly dissatisfied n (%) | Moderately dissatisfied n (%) | Extremely dissatisfied n (%) |
|---|---|---|---|---|---|---|---|
| Appearance satisfaction | 22 (45.8) | 10 (20.8) | 5 (10.4) | 3 (6.3) | 3 (6.3) | 3 (6.3) | 2 (4.2) |
| Function satisfaction | 31 (64.6) | 6 (12.5) | 1 (2.1) | 3 (6.3) | 2 (4.2) | 2 (4.2) | 3 (6.3) |
| Goals achieveda | 28 (58.3) | 9 (18.8) | 5 (10.4) | 1 (2.1) | 2 (4.2) | 1 (2.1) | 2 (4.2) |
a Likert scale anchors were “agree” rather than “satisfied” for this item.
Approximately a quarter of participants (n = 11, 22.9%) reported that they experienced complications after their labiaplasty and these included extreme pain/discomfort (n = 5), wound dehiscence (n = 3), sutures coming out (n = 3), lump at incision site (n = 2), infection (n = 1), and “poor outcome” not otherwise specified (n = 1). Five participants (10.4%) reported that they underwent revision surgeries.
Psychological Outcomes of Labiaplasty
As seen in Table 3, there were significant changes in all psychological outcome measures (genital appearance satisfaction, sexual satisfaction, and psychological well-being). More specifically, the participants were significantly more satisfied with their genital appearance and sex lives, and experienced greater psychological well-being at the time they completed the questionnaire compared to their recalled levels prior to labiaplasty. When the effect of time since surgery on psychological outcomes was examined, there was a significant group (short, long follow-up) × time (recalled, current) interaction effect for genital appearance satisfaction, F(1, 34) = 12.54, P = .001, η2 = .05, but not for sexual satisfaction, F(1, 32) = 1.13, P = .295, η2 = .03, or psychological well-being, F(1, 39) = 0.06, P = .815, η2 < .01. For genital appearance satisfaction, although both follow-up groups reported significant improvements in their levels of satisfaction, the short follow-up group reported a greater improvement from their recalled levels (mean, 26.11; SD, 5.33) to current levels (mean, 4.42; SD, 4.31), t(18) = 16.45, P < .001, d = 4.47, than the long follow-up group (recalled: mean, 19.18; SD, 6.44; and current: mean, = 5.82; SD, 6.20; t(16) = 6.66, P < .001, d = 2.11).
Comparisons of Participants Recalled Ratings before Labiaplasty and Current Ratings on Psychological Outcome Measures (n = 48)
| Variable | Range | Before mean (SD) | Current mean (SD) | P-value | Cohen’s d |
|---|---|---|---|---|---|
| Genital appearance dissatisfaction | 0-33 | 22.81 (6.59) | 5.69 (5.41) | <.001 | 2.84 |
| Sexual satisfaction | 1-7 | 4.51 (1.89) | 5.38 (1.82) | .009 | 0.47 |
| Psychological well-being | 1-5 | 3.12 (0.76) | 3.73 (0.62) | <.001 | 0.88 |
| Variable | Range | Before mean (SD) | Current mean (SD) | P-value | Cohen’s d |
|---|---|---|---|---|---|
| Genital appearance dissatisfaction | 0-33 | 22.81 (6.59) | 5.69 (5.41) | <.001 | 2.84 |
| Sexual satisfaction | 1-7 | 4.51 (1.89) | 5.38 (1.82) | .009 | 0.47 |
| Psychological well-being | 1-5 | 3.12 (0.76) | 3.73 (0.62) | <.001 | 0.88 |
SD, standard deviation.
Comparisons of Participants Recalled Ratings before Labiaplasty and Current Ratings on Psychological Outcome Measures (n = 48)
| Variable | Range | Before mean (SD) | Current mean (SD) | P-value | Cohen’s d |
|---|---|---|---|---|---|
| Genital appearance dissatisfaction | 0-33 | 22.81 (6.59) | 5.69 (5.41) | <.001 | 2.84 |
| Sexual satisfaction | 1-7 | 4.51 (1.89) | 5.38 (1.82) | .009 | 0.47 |
| Psychological well-being | 1-5 | 3.12 (0.76) | 3.73 (0.62) | <.001 | 0.88 |
| Variable | Range | Before mean (SD) | Current mean (SD) | P-value | Cohen’s d |
|---|---|---|---|---|---|
| Genital appearance dissatisfaction | 0-33 | 22.81 (6.59) | 5.69 (5.41) | <.001 | 2.84 |
| Sexual satisfaction | 1-7 | 4.51 (1.89) | 5.38 (1.82) | .009 | 0.47 |
| Psychological well-being | 1-5 | 3.12 (0.76) | 3.73 (0.62) | <.001 | 0.88 |
SD, standard deviation.
As seen in Table 4, we also examined whether satisfaction with labiaplasty was related to participant characteristics (demographic information, motivations for labiaplasty, cosmetic surgery experiences, and psychological well-being). As the three satisfaction items employed in this study (labial appearance, labial function, and goals for surgery achieved) were strongly inter-correlated, mean scores were calculated and this variable was called “total satisfaction.” The other outcome measure was current genital appearance dissatisfaction, as measured by the GAS scale. From Table 4, none of the demographic characteristics or psychological well-being (current and before surgery) predicted either outcome variable. However, from the motivations category, functional and sexual motivations for labiaplasty positively predicted total satisfaction. In addition, from the cosmetic surgery experience category, having complications after labiaplasty negatively predicted total satisfaction and positively predicted current genital appearance dissatisfaction.
Standardized Regression Coefficients for Variables Predicting Satisfaction with Labiaplasty Outcomes (n = 48)
| Variables | Total satisfaction β | Current genital appearance dissatisfaction β |
|---|---|---|
| Demographic characteristics | ||
| Age | .32 | −.37 |
| BMI | −.01 | .10 |
| Sexual orientationa | −.08 | −.25 |
| Sexual partner statusb | .11 | −.13 |
| Childrenb | -.33 | .01 |
| Educationc | −.25 | .03 |
| Motivations for surgery | ||
| Appearanceb | .21 | .09 |
| Functionalb | .42* | −.34 |
| Sexualb | .34* | −.22 |
| Psychologicalb | .25 | −.17 |
| Cosmetic surgery experience | ||
| Other surgeries in lifetimeb | −.14 | .19 |
| Complications from labiaplastyb | −.43* | .47* |
| Psychological well-being | ||
| Before surgery | .12 | −.02 |
| Current | .24 | −.23 |
| Total adjusted R2 | .34* | .05 |
| Variables | Total satisfaction β | Current genital appearance dissatisfaction β |
|---|---|---|
| Demographic characteristics | ||
| Age | .32 | −.37 |
| BMI | −.01 | .10 |
| Sexual orientationa | −.08 | −.25 |
| Sexual partner statusb | .11 | −.13 |
| Childrenb | -.33 | .01 |
| Educationc | −.25 | .03 |
| Motivations for surgery | ||
| Appearanceb | .21 | .09 |
| Functionalb | .42* | −.34 |
| Sexualb | .34* | −.22 |
| Psychologicalb | .25 | −.17 |
| Cosmetic surgery experience | ||
| Other surgeries in lifetimeb | −.14 | .19 |
| Complications from labiaplastyb | −.43* | .47* |
| Psychological well-being | ||
| Before surgery | .12 | −.02 |
| Current | .24 | −.23 |
| Total adjusted R2 | .34* | .05 |
*P < .05.
BMI, body mass index (weight kg/height m2).
aCoding was 1 for exclusively heterosexual through to 7 for exclusively homosexual; b1 for no and 2 for yes; c1 for high school, 2 for trade/diploma/certificate, 3 for undergraduate, and 4 for postgraduate degree.
Standardized Regression Coefficients for Variables Predicting Satisfaction with Labiaplasty Outcomes (n = 48)
| Variables | Total satisfaction β | Current genital appearance dissatisfaction β |
|---|---|---|
| Demographic characteristics | ||
| Age | .32 | −.37 |
| BMI | −.01 | .10 |
| Sexual orientationa | −.08 | −.25 |
| Sexual partner statusb | .11 | −.13 |
| Childrenb | -.33 | .01 |
| Educationc | −.25 | .03 |
| Motivations for surgery | ||
| Appearanceb | .21 | .09 |
| Functionalb | .42* | −.34 |
| Sexualb | .34* | −.22 |
| Psychologicalb | .25 | −.17 |
| Cosmetic surgery experience | ||
| Other surgeries in lifetimeb | −.14 | .19 |
| Complications from labiaplastyb | −.43* | .47* |
| Psychological well-being | ||
| Before surgery | .12 | −.02 |
| Current | .24 | −.23 |
| Total adjusted R2 | .34* | .05 |
| Variables | Total satisfaction β | Current genital appearance dissatisfaction β |
|---|---|---|
| Demographic characteristics | ||
| Age | .32 | −.37 |
| BMI | −.01 | .10 |
| Sexual orientationa | −.08 | −.25 |
| Sexual partner statusb | .11 | −.13 |
| Childrenb | -.33 | .01 |
| Educationc | −.25 | .03 |
| Motivations for surgery | ||
| Appearanceb | .21 | .09 |
| Functionalb | .42* | −.34 |
| Sexualb | .34* | −.22 |
| Psychologicalb | .25 | −.17 |
| Cosmetic surgery experience | ||
| Other surgeries in lifetimeb | −.14 | .19 |
| Complications from labiaplastyb | −.43* | .47* |
| Psychological well-being | ||
| Before surgery | .12 | −.02 |
| Current | .24 | −.23 |
| Total adjusted R2 | .34* | .05 |
*P < .05.
BMI, body mass index (weight kg/height m2).
aCoding was 1 for exclusively heterosexual through to 7 for exclusively homosexual; b1 for no and 2 for yes; c1 for high school, 2 for trade/diploma/certificate, 3 for undergraduate, and 4 for postgraduate degree.
DISCUSSION
As the first retrospective study in Australian women of the psychological outcomes of labiaplasty, as well as the predictors of satisfaction with labiaplasty outcomes, we have provided some new insights. We showed that, like the few studies conducted in other countries, women in Australia also report improvements in their genital appearance satisfaction, sexual satisfaction, and psychological well-being after undergoing labiaplasty. We also showed, for the first time, that physical/functional motivations and sexual motivations for labiaplasty were related to greater satisfaction with surgical outcomes. In contrast, experiencing complications after surgery was related to lower satisfaction.
In terms of women’s initial motivations to undergo labiaplasty, like women in other countries,2,5,6,20 Australian women were motivated by primarily aesthetic concerns. Interestingly, the percentage of Australian women who had undergone other cosmetic procedures besides labiaplasty in their lifetime was considerably higher than in other studies16,20 potentially suggesting that a sizeable percentage of the women in our study were dissatisfied with the appearance of multiple body parts in addition to their labia. Although we did not specifically examine body dysmorphic disorder (BDD) symptoms in our questionnaire, it is possible that our sample included a higher percentage of women who met criteria for BDD,16,20 an issue which requires further investigation in the labiaplasty field.
The Australian women in our study were also generally very satisfied with the aesthetic and functional outcomes of their labiaplasty, with women who had undergone their procedure more than two years prior to study participation reporting comparable levels of satisfaction with more recent patients. However, the satisfaction percentages reported here were slightly lower than previous case series studies in other countries.4-8 It is possible that as our survey was conducted independently of medical practitioners and the women were not asked to provide any details about their practitioners, those who were less satisfied with their outcomes may have felt more comfortable to participate. As we did not collect any information about the medical practitioners, it is also possible that some of the women in our sample were treated by practitioners who were less experienced with labiaplasty surgery and thus the women were not as satisfied with the outcomes. This may also contribute to a surgical complication rate (23%) which was higher than most previous reports6,21 but comparable to Veale et al’s22 study (26%). It is also important to note that, in our study, complications were nominated by the women themselves independently rather than the collection of this information via their medical practitioner at a postoperative examination.
In our study, women’s satisfaction with their surgical results also appeared to translate to improvements in their sexual satisfaction and psychological well-being, compared to their recalled levels prior to surgery. This was the case for women who had undergone labiaplasty more recently as well as those who were more than two years postoperative. It may be the case that with the physical changes made to women’s labia minora through surgery came improvements in their self-image, which, in turn allowed them to enjoy a more satisfying sex life, as well as more confidence in their lives in general.23,24
As one of the rare studies to examine predictors of satisfaction with cosmetic surgical outcomes, we found that motivations for labiaplasty of a physical/functional or sexual nature were related to greater satisfaction with outcomes. This result is probably unsurprising. The removal of labial tissue which causes irritation/discomfort while performing normal daily activities such as exercise and/or is pushed in during penetrative sex would likely be a great relief to women and considerably improve their quality of life. Interestingly, appearance motivations were not significantly related to greater satisfaction with surgical outcomes. As discussed above, aesthetic concerns appear to be the major motivator for women to undergo labiaplasty and so our results have implications for women who seek labiaplasty for predominantly appearance reasons. Some of the women in our study who took the opportunity to utilize the open-ended response section stated that they were dissatisfied with their surgical outcomes as their labia did not appear as they expected.23,24 These women may have expected complete amputation of their labia minora to generate a completely smooth genital surface, as reported in a previous qualitative study.25 However, when this was not fulfilled owing to the recommended conservative excision approach,26 the women were less satisfied. Alternatively, the particular surgical technique used to excise the labial tissue may have led to a “fuller” looking clitoral hood which can be “aesthetically unpleasant.”21,27 Clearly, aesthetic surgical outcomes are potentially more subjective than physical/functional outcomes. Thus, for women who are seeking labiaplasty for primarily aesthetic reasons, it may be important for clinicians to discuss how their labia are likely to appear after surgery so women know what to expect.
We also found that experiencing complications after labiaplasty was related to lower satisfaction with surgery outcomes. This result is hardly surprising and corresponds to the open-ended responses provided by some women that they were less satisfied owing to significant postoperative pain, as well as the perception that their procedure was performed incompetently. As Alter28 has previously recommended, surgeons should be competent in a range of labiaplasty techniques and be aware of the potential complications for each of these techniques in order to achieve the best possible outcome for each patient.
Like any study, the present study should be interpreted with some limitations in mind. Firstly, owing to the retrospective design of the study, we relied upon participant recall of psychological factors prior to labiaplasty in order to examine changes in these measures from pre- to post-surgery. For some women, this entailed recall of experiences from over a decade ago. Clearly, prospective study designs are required to better clarify the effect of labiaplasty on psychological outcomes, and, to our knowledge, only three prospective studies22-24 have been conducted to date. Thus, future research should involve prospective study designs with long-term follow-up periods. Another limitation was that our sample size was relatively small and may not have been representative of the wider population of women seeking labiaplasty owing to the study being advertised on cosmetic surgery forums. This advertising strategy may have led to the involvement of women with a greater interest in and experience with cosmetic surgery in general. Furthermore, it may have also led to the participation of women whose labiaplasty experiences were either extremely positive or extremely negative29 and thus their engagement with discussion forums on the topic of labiaplasty. A further study limitation was the lack of information collected regarding the labiaplasty surgical experience of the medical practitioners who performed the operations. Finally, in order to reduce participant burden, we developed rather short measures (occasionally single items) to assess some of the key psychological outcomes. Future studies should employ psychometrically validated measures for all outcome measures.
CONCLUSIONS
Our study results have provided novel insights into the psychological outcomes of labiaplasty, as well as factors which predict satisfaction with surgical outcomes, particularly in the Australian context. We identified that Australian women perceive that labiaplasty has a positive effect on their genital appearance satisfaction, sexual satisfaction, and psychological well-being. We also showed that functional and sexual motivations for labiaplasty are associated with greater surgical satisfaction, while post-surgery complications have a negative impact on surgical satisfaction. Our study results will potentially assist clinicians in their discussions with prospective patients, particularly around their expectations for surgical outcomes.
Supplementary Material
This article contains supplementary material located online at www.aestheticsurgeryjournal.com.
Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research, authorship, and publication of this article.
Acknowledgements
Sincere thanks are extended to all of the women who participated in this study and all of the individuals and organizations who assisted with the advertising of the study.
