The number of labia minora reduction or labiaplasty procedures performed across the world has risen in the last decade with consistent reports of high patient satisfaction and minimal complications. Motivations to pursue labiaplasty commonly include dissatisfaction with genital appearance, and discomfort while wearing tight clothing and during physical or sexual activity., Previously identified outcomes of labiaplasty include improving women's perceptions towards their genital appearance. Additionally, women who have undergone labiaplasty commonly report moderate to large improvements in self-confidence, physical comfort, and relief surrounding their genital appearance.
Women who undergo labiaplasty to address dissatisfaction with their genital appearance often experience improvements in sexual experiences owing to factors such as a reduction in physical discomfort (due to the reduction in labia minora size) as well as decreased self-consciousness., With enhancements in sexual satisfaction, one may expect that there would be accompanying improvements in overall relationship satisfaction and quality. Certainly, labiaplasty has been advertised as a potential means for women to improve their intimate relationships. Furthermore, a desire to enhance overall intimate relationship satisfaction, not only related to sexual enjoyment, is cited as a reason for some women to pursue labiaplasty., Despite these links, intimate relationship satisfaction has rarely been investigated in the context of labiaplasty. To the authors’ knowledge, only one study has examined relationship satisfaction, and this used a controlled prospective study design and employed a quantitative standardized measure. Contrary to expectation, the results showed no significant improvement in relationship satisfaction from prelabiaplasty to 6 months postlabiaplasty.
With interpersonal relationships, particularly intimate relationships, playing a crucial role in overall life satisfaction, this concept is worthy of further exploration in the context of labiaplasty. Given the complexity of human intimate relationships, quantitative standardized measures will have limitations in capturing these experiences. As such, a qualitative approach can be helpful in gaining an in-depth insight into this complex and largely underinvestigated area in labiaplasty research. Thus, the aim of this study was, for the first time, to preliminarily explore women's perceptions of the impacts of labiaplasty on their intimate relationship quality by means of qualitative interviews.
METHODS
Participants
Participants were 15 adult women between 1 and 72 months postlabiaplasty (mean [standard deviation], 28.2 [24.3] months). Note that this sample size of 15 is considered to be a moderate to large sized study in a qualitative research design where data saturation was reached, that is, all themes had been found and the conduct of further interviews would not have yielded any further themes. Also, an upper limit of 72 months postlabiaplasty was chosen because impacts on relationship outcomes are likely to be realized over a much greater length of time compared with, for example, aesthetic outcomes. Eligible participants included women aged 18 years or over, who were proficient in English and had undergone a labiaplasty procedure. Further details about this sample of participants have been reported previously.
Procedure
Participants who had undergone labiaplasty were contacted by reception staff at 2 clinics (authors C.H. and J.O., who conducted the procedures, were not involved in contacting participants). Patients who expressed interest to reception staff about the study were directed to contact author G.S. to obtain further information about the study, provide consent, and to schedule an interview. Once informed consent was obtained, both in writing and verbally, interviews were conducted between January and April 2019 by author G.S., an experienced researcher trained in conducting qualitative interviews. The interviewing researcher was not involved in any aspect of the treatment of the participants. Ethics approval for the study was obtained from the Monash University Human Research Ethics Committee.
Interviews
The semistructured interview questions and prompts were developed by author G.S. while consulting with the broader research team and were based on previous qualitative research in other types of aesthetic surgery. The interview guide was designed for participants to discuss the outcomes of their labiaplasty procedure in relation to any changes they felt in their engagement of relationships, quality of existing relationships, and partner perceptions (see Appendix, available online at www.aestheticsurgeryjournal.com, for a complete interview guide). All interviews were conducted over the telephone at a time of the participant's choosing and were audio recorded. The semistructured interviews were between 20 and 55 minutes in duration (mean, 28.1 [8.4] minutes). Audio recordings were transcribed verbatim by an external and confidential transcription service. Thematic analysis of the transcripts was performed by A.N.F. and Y.M. following the approach outlined by Braun and Clarke. Codes were developed and grouped into themes based on both deductive and inductive analysis approaches to allow for the identification of codes aligned with the research questions as well as the identification of codes as they emerged in the interview transcripts. The developed codes and themes were discussed and agreed upon by all authors.
RESULTS
The participants were 15 adult women (a moderate to large sample size for qualitative research where data saturation was reached) whose ages ranged from 18 to 52 years (mean, 36.7 [12.7] years). Other demographic characteristics and findings from the women have been described previously. The major themes that emerged from the interviews included increased confidence to engage in relationships and perceptions of partners on labiaplasty results.
Impact on Entering New Relationships
Entering New Relationships
There were a number of impacts on women's intimate relationships which should be considered in the context of their relationship status at the time of the procedure as well as at interview (Supplemental Table 1, available online at www.aestheticsurgeryjournal.com). Postsurgery, almost half of the women (n = 7, 46.7%) reported experiencing greater confidence in dating and entering new intimate relationships, and this extended across the age range (18-52 years). Those who had started seeking new relationships or entered new relationships after undergoing labiaplasty reported feeling comfortable with new partners seeing their genitals (n = 3, 20.0%).One participant reported having better relationships with men after the procedure which extended to greater optimism about having children as a result of her newfound confidence and the stability of her current relationship.
“… definitely felt like I would be able to be comfortable with getting into a relationship or … just trying those things.” (Participant 5, aged 23 years, 72 months postoperative)
“… with my new boyfriend I just have a lot more confidence.” (Participant 4, aged 50 years, 60 months postoperative)
“I used to feel like I wasn’t a woman … I felt less. And now that I can … it makes me feel more confident. I have better relationships with men now. Before I was like always second guessing myself … I really felt like I will never be able to have kids … I’m in a very good relationship right now.” (Participant 6, aged 28 years, 11 months postoperative)
No Significant Change
Of the participants who noted no significant changes to their existing relationship or their approach to dating, 2 were married (n = 2, 13.3%) at the time of their procedure and reported no significant changes to their relationship dynamic. Four participants (26.7%) reported no specific changes in sentiments regarding entering relationships; 3 of these women were not in a relationship at the time of the interview and 1 of them entered a long-term relationship after her procedure.
Partner Perceptions of Labiaplasty Results
Over half of the women (n = 8, 53.3%) reported concerns regarding their partners’ perceptions towards their decision to undergo labiaplasty. The women reported worrying about whether their partners would notice any scarring from the procedure and subsequent judgment around having the procedure. Some women discussed wanting their partners to accept them and their new appearance as “normal” and not altered.
“I do worry that if I’m with a guy … they might be able to see the scars and maybe think I’ve had a sex change or something … I would have to explain to them … I didn’t like the way it looked. I do worry about that.” (Participant 10, aged 35 years, 18 months postoperative)
“I was nervous a bit if he was able to tell that I had anything done—just because I didn’t want to say anything.” (Participant 5, aged 23 years, 72 months postoperative)
Five out of the 8 participants in this theme were in a relationship at the time of undergoing labiaplasty. One of these 5 participants reported that her partner at the time appeared not to notice a change, despite concerns about how they would view or judge labiaplasty more broadly.
“I mean he [partner] doesn’t know and I don’t think I’d tell him because … I would feel uncomfortable telling him … I think he would just ask why I had the surgery.” (Participant 4, aged 50 years, 40 months postoperative)
DISCUSSION
To the authors’ knowledge, this study is the first to qualitatively explore outcomes of labiaplasty on intimate relationship quality and satisfaction. Most women reported feeling more confident entering relationships after labiaplasty. Interestingly, some women expressed concerns about how their sexual partners—present and future—would perceive and respond to them undergoing labiaplasty. These themes not only identified novel areas of consideration for aesthetic surgeons when consulting prospective patients, but also provide some in-depth insights into the experiences of women's intimate relationships.
For around half of the women, labiaplasty appeared to alleviate concerns about entering relationships. Notably, this was the case for older teenagers through to those aged in their fifties, illustrating the impact of labiaplasty on relationships across the age spectrum. Women mostly reported increased confidence to engage in new relationships. From our previous research with this sample, prior to undergoing labiaplasty, some actively avoided entering relationships due to concerns about genital appearance, with a number of the youngest women involved avoiding relationships entirely. Thus, undergoing labiaplasty appeared to give them an opportunity to experience an important part of life that they felt was not available to them previously. To expand on this, one woman expressed that she felt capable of entering into a relationship and, for the first time, bearing children as a result of her labiaplasty surgery.
Nevertheless, the other half of the women reported no change in their relationship quality after labiaplasty; some of these women were already involved in marriages/long-term partnerships and were comfortable in these relationships. This divide in the current study's sample may explain why very limited previous quantitative research found no significant increase in intimate relationship quality/satisfaction from pre- to postlabiaplasty. That is, the improvements experienced by some women after labiaplasty were negated by those who did not, resulting in a nonsignificant overall effect. Such a comparison between quantitative and qualitative findings potentially suggests the importance of using both approaches within the same study (ie, mixed methods) when investigating complex psychological outcomes of aesthetic surgery. Clearly, more research needs to be conducted given the limited quantitative and qualitative research in this intimate relationship area. In terms of clinical implications, the current results possibly suggest that if prospective patients report concerns about entering intimate relationships to their treating team, labiaplasty has the potential to alleviate such concerns.
Clearly, the perceptions of partners are a key component of relationship quality, and we investigated how women believed their partners perceived their decision to undergo labiaplasty. A novel theme emerged, with more than half of the women expressing concerns that their partner would notice scarring on their genitalia, and with 1 woman being greatly concerned that such scarring would be believed to be from a “sex change” or gender-affirming surgery. While enhancing partner satisfaction is a reported motivation for labiaplasty, there may be concerns that these partners have negative perceptions of aesthetic surgery. There appears to be stigma surrounding labiaplasty amongst some women, as seen in a previous study where greater opposition was seen when considering labiaplasty compared to aesthetic surgery of the breast or of an unspecified sexual organ. It could be that the women in the current study held similar beliefs and were worried about potential partners sharing the same sentiments. Although the acceptance of aesthetic surgery appears to have increased in recent times, visible changes may not be as easily accepted as “natural” outcomes. While signs of having undergone labiaplasty such as physical changes and scarring are probably very unlikely to be noticed by sexual partners, some women still expressed concerns about them being noticed. Due to the novelty and importance of this finding, it will be the subject of future investigation—do photographs of vulva that have undergone labiaplasty appear different from those that have not? Can people (particularly men) tell if a woman has had labiaplasty? Such research, prompted by the current study's innovative findings, will be able to be discussed with preoperative patients. In this way, patients will have an evidence-based understanding of how likely it actually is that a sexual partner can tell that they have had labiaplasty by looking at their genitals.
This study has some limitations which are important to consider. Patients with more favorable outcomes were probably more likely to self-select and participate in the study, potentially making our findings less generalizable to the wider patient population. However, generalizability is not the goal of qualitative research. Instead, we were able to gain a valuable deeper understanding into an important outcome in intimate relationship quality through this preliminary report. Future research should still aim for larger sample sizes. Additionally, while this study was able to recruit and interview patients with varying degrees of time since their procedure, there may have been some difficulty recalling certain outcomes for those who had undergone their procedure in the more distant past. Nevertheless, the longer time since surgery may have allowed the women to reflect more broadly on their intimate relationship quality outcomes. Another limitation was that given the potentially sensitive nature of the interview topic, the women may have refrained from providing some insights due to feelings of embarrassment. However, the women appeared to engage well in the interviews. Despite these limitations, the qualitative approach described here adds an in-depth account of the perceptions and experiences of women who have undergone labiaplasty which can help inform prospective patients and surgeons to continue to maximize satisfaction.
CONCLUSIONS
These findings provide some novel insights into the intimate relationship outcomes of women who undergo labiaplasty and create an important platform for research in the area. Some women will likely experience greater confidence in their intimate relationships, particularly if they were concerned about entering into relationships prior to labiaplasty, while others will perceive no change. Furthermore, there may still be some stigma associated with undergoing labiaplasty and concerns for some women that any indicators of surgery (eg, scarring) will be judged negatively by sexual partners. Understanding the nuances of these interpersonal relationship outcomes will be crucial to inform patients and provide evidence-based recommendations and care.
Supplemental Material
This article contains supplemental material located online at www.aestheticsurgeryjournal.com.
Acknowledgments
Sincere thanks are extended to all of the women who participated in this study. The authors would also like to thank Pascale Maynard for her valuable assistance with the earliest stages of this research. Ms Fernando and Ms Mehta made an equal contribution to this work as co–first authors.
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