Female genital cosmetic surgery is on the rise. The number of labiaplasties performed in the UK has increased at least five-fold in the last decade. This week sees the release of  Centerfold, an animated documentary exploring issues surrounding real women’s choice to have the procedure.

The film has already won a Best Animation award at the 2012 Scinema Festival of Science Film and seems set for further acclaim. I went along to the official launch, and its accompanying panel discussion, to get a sense of the controversy surrounding the topic.

Labiaplasty, is a surgical procedure in which the labia minora (the inner set of lips surrounding the vagina) are cut down to achieve reduction in size or better symmetry. Centrefold covers the operation and the emotional reactions of the female protagonist tastefully but unflinchingly. The commentary is taken from interviews with three women discussing their experience of the surgery and its aftermath.

The panel consisted of director Ellie Land, two collaborating physicians, a psychoanalyst and an artist. Apparently a plastic surgeon, intended to represent the private sector, had earlier backed out. If he or she had feared a bloodbath they would probably have been right.

Why are so many women going under the knife?

There was broad agreement on the reasons for the rising incidence of the procedure. The greater availability of pornography was the first factor cited. The prevailing fashion within the sex industry is undoubtedly for small labia often internal to the labia majora (outer lips). With more women and girls coming into contact with pornography, often at an early age, an unrealistic impression can be created of a limited variation in appearance of female genitalia. The problem is even more acute with genitals than with breasts, noses or other body parts, because of the lack of everyday opportunities for comparison. This can lead to a sense of abnormality, particularly amongst the young or vulnerable.

The trend for hairlessness was also recognised as contributory. By shaving pubic hair around the vulva, women’s labia are more likely to come into contact with clothing and become irritated. This is particularly true of those who cycle or ride horses.

A third factor is the increasingly mainstream acceptance of cosmetic enhancement. Acres of print have been dedicated to the pernicious impact of celebrity culture and American attitudes to beauty, so I will not repeat well-worn arguments here. However it does seem to ring true that, in a society where cosmetic surgery, on various parts of the body, is an acceptable way for men and women to spend their money, there is no obvious reason why genitals should escape the knife. So, seemingly, they do not.

What the panel thought

While the cause of the rise in requests seemed to be little grounds for argument, this was not true for the correct response of the medical profession. The debate, as with all cosmetic surgery, surrounds the ethics of physicians agreeing to people’s demands for their appearance to be changed. There is also argument over what extent there are non-cosmetic justifications for labiaplasty in particular.

The two consulting physicians, Dr Creighton, a consultant gynaecologist, and Dr Liao, a psychologist, were partners in crime. The two shared authorship of a number of papers. Of particular interest was an article they published in British Journal of Obstetrics and Gynecology, which concluded that there was no significant difference in the size of labia between those seeking reduction and the normal population. For them, this seemed to settle the argument. The desire for labia reduction was then characterised as a psychological problem of low self-esteem or poor body image. Even in the case of demonstrable physical discomfort they claimed that symptoms were often exaggerated in order to obtain NHS treatment.

At this point it is probably worth noting that the normal values they used for comparison are not widely recognised (no standard anthropometrics exist). My personal feeling is that, as the study was conducted in an NHS facility, they were probably more likely to attract patients less empowered and more prone to psychological problems than the private sector. In truth, pretty much everyone admits that the topic is woefully under researched.

As a psychoanalyst and a feminist, Susie Orbach was visibly torn between two doctrines. Her belief in female empowerment and body ownership conflicted with the sense that women’s aspirations were being shaped by an unhealthy (masculine) view of beauty. However, when pressed she came down against cosmetic surgery, favouring therapy as the ideal treatment.

The only serious dissenting voice came from the audience. The lone private plastic surgeon in the room hesitantly raised her hand to present an alternative view. She admitted to performing three labiaplasties a week on women. All of her clients were over sixteen (cases as young at 12 had been mentioned) and had been offered psychological assessment. She claimed most of the women she saw were older often coming after childbirth. She strongly challenged the researchers’ assertion that age and pregnancy has no effect on vaginal appearance.

Interestingly, Ellie Land later told me that the process of making the film had actually broadened her mind. Despite starting out on the project hostile to the procedure she now had considerably more sympathy for the women who chose to undergo it. She also spoke of the difficulty she experienced finding women to volunteer their reflections, and mentioned that she had failed to find anyone with a truly negative experience.

Are labiaplasties justified?

As the meeting concluded, I was feeling  conflicted. I was certainly appalled at the willingness of surgeons, private and public, to perform operations as a “quick fix” for self-esteem issues. On the other hand I was disturbed by the characterisation of all women seeking this form of cosmetic surgery as suffering from mental illness. Many of the panel seemed to have been disturbed by the idea that people feel the need to conform to a particular aesthetic, especially when this became mixed up with gender politics. However, a sense of beauty in art, design and personal appearance does not seem to me to be something it would be possible, nor desirable, to exorcise for society.

I do believe men and women should be able to take ownership over their bodies and make whatever changes they desire, providing they can pay for it. The important point is that these decisions need to be born out of positive intention. It is extremely disturbing that vulnerable people are being allowed to undergo surgery without psychological profiling simply to earn or save money for particular establishments.

More research is unquestionably needed into the physiological range of labia sizes and the affects that abnormal appearance might have. It does seem that the private sector is very under-regulated. It seems ridiculous that private surgeons are not required to release statistics on the number or type of operations they perform. The lack of follow up after surgery was mentioned and this is also worrying.

The Great Wall of Vagina

The only panellist I haven’t mentioned so far is the artist Jamie McCartney. His major contribution sat silently at the back of the room occasionally drawing a fascinated eye. Jamie’s mission over the past few years has been to cast and display as many women’s vulvae as possible. He then composes these moulds into panels forming The Great Wall of Vagina. Viewing the mesmerising result one is struck by the redundancy any attempt at conformity in the face such huge variety in the shape, size and proportion of female’s privates.

Art can often silently communicate what hours of reasoned debate cannot. It seemed to me, staring into the array of alabaster vulvae, that beauty lies in diversity. We should all try to enjoy the bodies we are born with (or which later present themselves to us) before we try to change them.

This text was originally written for the Wellcome Trust Blog (20/07/12)