The vulval taboo

Western society considers itself free, liberal and nurturing of gender equality, yet women's genitalia remain a taboo subject. Women rarely say the word ‘vulva’, and instead describe their external genitalia using a vast array of different terms, often using euphemisms (e.g. ‘down below’) or incorrectly calling it ‘vagina’.1

The lack of appropriate vocabulary reflects a general lack of knowledge of female genital anatomy and function. Sex education focuses mainly on reproduction and hence on the vagina, an internal structure which most children have no experience of and can't see.2 A physiological analogy would be to teach the role of the throat in swallowing food without mentioning the tongue or mouth. A research paper examining female sexual terminology suggests that “societal silence regarding the role of the clitoris may act as a symbolic clitoridectomy”.2 This pervading ‘vulval taboo’ means that women are often not comfortable openly sharing genital insecurities.

Vulval vanity

In recent years the internet has become a source of information, and has brought female genitalia out of the shadows and into public scrutiny. Popular culture is increasingly sexualised with acceptance of nudity in the media, and popularity of skimpy, tightly fitting fashions. Images of hairless, minimalist pudenda on pornographic websites may skew women's views of their own genital normality, as well as changing men's expectations. This has contributed to a change in beauty ideals and introduced a culture of genital modification.3

The Brazilian effect

Society usually regards hairiness as unfeminine4 and women from different cultures have removed body hair in varying amounts since ancient times. However, it is only in recent decades that pubic hair removal has become a popular Western trend. Around 85% of British women report pubic hair removal.4 An American study found that total hair removal is fashionable among young women, and reasons for genital grooming include feelings of cleanliness, comfort, sex appeal and social normality.5 Some data suggest that women who totally remove pubic hair have better genital self-image scores and sexual function.6

Vulval accessorising has also become fashionable in the form of genital piercings, tattoos and ‘vajazzling’ (applying sequins and glitter to the pubis). Piercings of the labia or clitoral hood are increasingly common and around two in 1000 women in the UK are estimated to have a genital piercing. These are done for aesthetic or sexual reasons, or as a form of self-expression.7 Vulval grooming may be interpreted as a positive sign that women are becoming more comfortable exploring their genitalia.

Designer vaginas

The trend for pubic depilation has been accompanied by an increased demand for female genital cosmetic surgery (FGCS) and pubic hair removal may be partly responsible for uncovering genital insecurities.8 ,9

FGCS procedures change the structure and appearance of normal female genitalia.10 Most requests for FGCS appear to be motivated by aesthetics. However, women may request genital surgery due to symptoms relating to ‘large’ labia minora causing discomfort during sex, exercise, tampon insertion or when wearing tight clothes.11 Furthermore, some women with psychosexual difficulties may seek a surgical intervention perceiving that this will provide a definitive solution to their sexual problems. These difficulties may be better addressed by exploring the source of their psychological anxieties.9

Genital surgeons offer a huge variety of procedures including labiaplasty, G-spot amplification, clitoral hood reduction, revirgination and vaginal rejuvenation. The demedicalisation of some of these terms reflects the consumer-driven nature of the surgery. Labiaplasty, the partial excision of the labia minora, is the commonest procedure requested. The majority of FGCS is performed in private practice, although in 2010 around 10 000 labial reductions were performed on the National Health Service, which represented a five-fold increase in 10 years.7

FGM: the crime of cutting

Female genital mutilation (FGM) or ‘cutting’ is an ancient, deeply rooted practice performed mainly in communities in Africa, Asia and the Middle East. FGM occurs elsewhere in the world and migration has made it a global problem.

The World Health Organization defines FGM as procedures that involve the removal or partial removal of the external female genital organs for cultural or non-therapeutic reasons12 and further categorises FGM into four types (Table 1).

Traditionally, unskilled practitioners perform FGM on young children in basic surroundings using crude instruments with no anaesthetic and under restraint. FGM can lead to life-threatening and lifelong complications affecting physical, psychological and sexual function.12

The origins of FGM are unknown but its aims are to preserve virginity and control sexual behaviour of women. By eliminating the ‘masculine’ clitoris, FGM is believed to make a girl clean, pure and ‘smooth’. FGM is perceived to enhance a man's sexual pleasure.12 FGM reflects gender inequality and is often embedded in social and economic structures of a community. FGM guarantees marriageability, honour and security. The practice is supported without question by both genders, and families who abandon the practice risk condemnation and social ostracism.12

FGM is recognised by modern Western society as a form of child abuse and sexual violence. It is illegal in many countries. The Female Genital Mutilation Act 2003 (applicable in England, Wales and Northern Ireland) states that it is an offence for a person to excise, infibulate or otherwise mutilate any part of a girl's labia minora, majora and clitoris.10

Shades of grey

Western society may appear hypocritical by criminalising traditional FGM whilst not condemning genital mutilation in the guise of FGCS. Both are performed under cultural pressure, although fundamental differences clearly do exist. FGM is almost always performed on non-consenting minors, it is associated with much greater harm and usually results in permanent removal of sexual function. The Female Genital Mutilation Act 2003 stipulates that no offence is committed if an operation is deemed necessary for physical or mental health. This may include “cosmetic surgery resulting from the distress caused by a perception of abnormality”. ‘Distress’ is a subjective term, so some legal ambiguity surrounding FGCS exists.10

Ethically, an adult woman of African descent requesting labial surgery in order to marry within her culture7 is, in some ways, comparable to a Western woman requesting a labial reduction in order to further her modelling career. If we condemn FGCS in the same way as FGM, then, arguably, we should similarly condemn other aesthetically driven cosmetic procedures such as breast augmentation, rhinoplasty, or even genital piercing – which is an example of Type 4 FGM. Perhaps all of these procedures reflect subjugation of women by a paternalistic society's narrow ideals of normality, beauty and desirability.3 ,13

The clean slit

The culturally constructed vulva is portrayed as a flat, smooth slit, prepubertal in appearance and almost devoid of sexual parts.3 Its hidden nature contrasts with the male phallus implying a passive, receptive role.14 This portrayal ignores the physical variety in sexually mature female anatomy, as well as the genital swelling that occurs during sexual arousal.15 Furthermore, pornographic images that sexualise child-like physical characteristics may risk depicting young girls as sexual objects.15

Current vulval ideals are likely to originate from historic attitudes towards femininity. Over the years, negative depictions of female genitalia as dirty, odourous, dangerous and polluting have resulted in the vulva often being a source of embarrassment and disgust.14 Indeed the word ‘pudendum’ derives from the Latin ‘to be ashamed’.14 Classical beauty is often symmetrical and minimalist, and historically, physical beauty was considered a reflection of inner virtue and goodness. Large, protrusive external genitalia were associated with sexual deviance, promiscuity and the female ‘grotesque’.9 ,15

Surgical psychotherapy

The cosmetic surgery industry is based on the narrative that changing one's looks can transform one's life.9 And although undergoing cosmetic surgery is a free choice, the FGCS industry may be seen to be exploiting the anxieties of vulnerable women. Promotional material describes normal variations in vulval appearances as pathological. Emphasis is given to problems such as odour, hygiene, chronic irritation and infections attributed to ‘labial hypertrophy’. Advertisements claim that lax and ageing vaginas fail to provide enough frictional forces for sexual gratification, which can create relationship disharmony.16

FGCS is sometimes justified as a means of female ‘empowerment’.17 FGCS marketing offers solutions that promise to enhance appearance, restore self-confidence and ‘revolutionise’ sex lives.16 This reflects a societal premise that female fulfilment is attained by optimising sexual performance.17

There are few high-quality data examining the efficacy and long-term outcomes following FGCS. Published data on FGCS mainly record outcomes using postoperative questioning or anecdotes from providers (e.g. “went on to marry professional golfer”).18 Physical, sexual and psychological consequences are unknown. FGCS represents interventions that serve no obvious medical benefit and risk complications of infection, chronic pain, dyspareunia, scarring and adhesions. The labia minora are densely innervated, hormone-sensitive and contain erectile tissue which facilitates engorgement during sexual arousal. Consequently, labiaplasty may disrupt vulval sensitivity and impair sexual function.10

The General Medical Council and the Advertising Standards Agency provide guidance on cosmetic surgery marketing with an emphasis on imparting honest, factual information and realistic outcomes. The FGCS industry is under no obligation to audit or publish complication rates. A recent study suggests that the official guidance appears to be systematically ignored.10 ,16

Reclaiming the vulva

Despite an increased openness towards sexuality, ignorance of the nature of female genital parts still exists in contemporary society.

As medical professionals we should encourage a positive and unembarrassed relationship with the vulva. We should educate our patients, male and female, about the variety in size, shape and colour of normal genitalia. Vulvas are as individual as faces and, as with faces, genital appearance may change over lifetime. We should not talk in euphemisms but introduce women to correct genital terminology. Resources such as the ‘labia library’ can help in this education process (http://www.labialibrary.org.au).

We can manage genital problems by exploring insecurities, providing reassurance, and discussing simple vulval health measures. If a woman discloses deeper anxiety, we should recommend psychological therapy. We must fully inform women about the risks and lack of evidence for genital surgery.

The authors of the article entitled ‘Kept under the hood, the neglect of the clitoris in common vernacular’ conclude that “reclaiming the clitoris may help women actively discover their own sexuality and be more independent in the sexual choices they make”.2 Perhaps better understanding and acceptance of their genitals may help women resist pressures to submit themselves or allow their daughters to undergo mutilation, whatever their cultural background.