The contribution of online content to the promotion and normalisation of female genital cosmetic surgery: A systematic review of the literature

Abstract

Background:
Women considering female genital cosmetic surgery (FGCS) are likely to use the internet as a key source of information during the decision-making process. The aim of this systematic review was to determine what is known about the role of the internet in the promotion and normalisation of female genital cosmetic surgery and to identify areas for future research.

Methods:
Eight social science, medical, and communication databases and Google Scholar were searched for peer-reviewed papers published in English. Results from all papers were analysed to identify recurring and unique themes.

Results:
Five papers met inclusion criteria. Three of the papers reported investigations of website content of FGCS providers, a fourth compared motivations for labiaplasty publicised on provider websites with those disclosed by women in online communities, and the fifth analysed visual depictions of female genitalia in online pornography. Analysis yielded five significant and interrelated patterns of representation, each functioning to promote and normalise the practice of FGCS: pathologisation of genital diversity; female genital appearance as important to wellbeing; characteristics of women's genitals are important for sex life; female body as degenerative and improvable through surgery; and FGCS as safe, easy, and effective. A significant gap was identified in the literature: the ways in which user-generated content might function to perpetuate, challenge, or subvert the normative discourses prevalent in online pornography and surgical websites.

Conclusions:
Further research is needed to contribute to knowledge of the role played by the internet in the promotion and normalisation of female genital cosmetic surgery.

Full text

R E S E A R C H A R T I C L E Open Access
The contribution of online content to the
promotion and normalisation of female
genital cosmetic surgery: a systematic
review of the literature
Hayley Mowat
1
, Karalyn McDonald
1
, Amy Shields Dobson
2
, Jane Fisher
1
and Maggie Kirkman
1*
Abstract
Background: Women considering female genital cosmetic surgery (FGCS) are likely to use the internet as a key
source of information during the decision-making process. The aim of this systematic review was to determine
what is known about the role of the internet in the promotion and normalisation of female genital cosmetic
surgery and to identify areas for future research.
Methods: Eight social science, medical, and communication databases and Google Scholar were searched for
peer-reviewed papers published in English. Results from all papers were analysed to identify recurring and
unique themes.
Results: Five papers met inclusion criteria. Three of the papers reported investigations of website content of
FGCS providers, a fourth compared motivations for labiaplasty publicised on provider websites with those
disclosed by women in online communities, and the fifth analysed visual depictions of female genitalia in online
pornography. Analysis yielded five significant and interrelated patterns of representation, each functioning to
promote and normalise the practice of FGCS: pathologisation of genital diversity; female genital appearance as
important to wellbeing; characteristics of women’s genitals are important for sex life; female body as degenerative
and improvable through surgery; and FGCS as safe, easy, and effective. A significant gap was identified in the
literature: the ways in which user-generated content might function to perpetuate, challenge, or subvert the
normative discourses prevalent in online pornography and surgical websites.
Conclusions: Further research is needed to contribute to knowledge of the role played by the internet in the
promotion and normalisation of female genital cosmetic surgery.
Keywords: Female genital cosmetic surgery, Systematic review, Internet, Labiaplasty, Women’shealth
Background
There is increasing evidence that women are pursuing
surgical modification of the vulva for cosmetic reasons.
Popular surgical procedures include, but are not limited
to, reduction of the labia minora and clitoral hood, tight-
ening of the vagina, ‘plumping’of the labia majora, lipo-
suction of the mons pubis, and ‘G-spot’collagen injections
[1, 2]. In Australia, data captured by Medicare, the na-
tional publicly-funded universal healthcare insurance
scheme, indicate that the number of claims for labia
reduction increased threefold in the decade from 2001 –
2010 [3]. These data do not capture the total number of
labiaplasties occurring across the country because medical
necessity must be demonstrated in order to claim surgical
costs under the Medicare scheme; procedures sought
without medical indication are paid for privately [4, 5] and
are not recorded in national registers.
The apparent popularity of female genital cosmetic
surgery (FGCS) procedures in recent years has triggered
* Correspondence: maggie.kirkman@monash.edu
1
Jean Hailes Research Unit, Monash University, Melbourne, Australia
Full list of author information is available at the end of the article
© 2015 Mowat et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Mowat et al. BMC Women's Health (2015) 15:110
DOI 10.1186/s12905-015-0271-5
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a flurry of critical academic engagement in the topic.
Previous empirical research has shed light on a range of
aspects relevant to the phenomenon, from factors that
may influence the decision of individual women to seek
FGCS [5] to mainstream media representations of fe-
male genitalia [6, 7]. Other scholars have sought to the-
orise the complex ethical debates around the practice of
FGCS, specifically in relation to the heavily critiqued
practice of female genital cutting/mutilation [8–10]. The
focus of such debates, and subsequently this review
paper, is not the use of surgery to address functional dif-
ficulties but the rise in demand for aesthetically-driven
procedures and the extent to which the distinction be-
tween the two has become increasingly blurred. In the
absence of formal, standardised medical indications for
these procedures [11], the identification of ‘pathological’
and ‘normal’is subjective. Plastic surgeons are significantly
more likely than other physicians to regard larger labia
minora as “distasteful and unnatural”,malesurgeonsmore
so than their female counterparts [12].
There is evidence that women’s external genitalia are
highly diverse [13]. However, the practice of FGCS ap-
pears to be underpinned by a desire for a particular
homogenous genital aesthetic, namely a “tight”vagina
[14] and “clean slit”[15, 16] or “Barbie Doll”[7, 17]
vulva, in which the labia minora are not visible. The
normalisation of these ideals has been linked to various
potential influences, including the popularity of pubic
hair removal [17], long-held negative societal attitudes
toward female genitalia [6, 18], and limited aesthetic diver-
sity in magazines, both mainstream and pornographic
[7,19].Bramwell’s [6] analysis of women’s magazines
found that the vast majority of images depicted the fe-
male pubic area as flat or a smooth curve. Of the 8 %
of images that showed any indentations or extrusions,
such detail was attributable to the bunching of clothing
rather than genital detail [6]. Schick and colleagues [7]
noted a similar trend amongst Playboy Magazine cen-
trefolds, reporting that none of the images portrayed
prominent labia minora, nor did they represent realistic
colour variation, with genitalia uniformly portrayed as
pink or pale red.
Whereas traditional media have long been understood
to influence female beauty ideals [20] and attitudes to-
wards cosmetic surgery [21], recent studies suggest that
the internet plays a larger role. For example, Walden and
colleagues [22] found the internet to be an important tool
in the decision-making process for women considering
breast augmentation. Given that many women are reluc-
tant to discuss concerns about their genitalia with health
care practitioners [23, 24], the anonymity afforded by the
internet may make it an even more powerful reference
point for those considering genital surgical modification.
Indeed, a recent study found the internet and pornography
to be the two major media influences on consideration of
labiaplasty among Australian women [25]. Internationally,
Michala and colleagues [26] found that the internet was a
primary source of information for older adolescents pre-
senting for labiaplasty in their Greek sample. Further, a
survey conducted in The Netherlands found that women
who used the internet as their source of information about
labia reduction surgery assessed the procedure as more ac-
ceptable and considered having the surgery more often
than women who obtained information from other
sources, such as mainstream media, peers or a physician
[27]. In light of these findings, and the pervasiveness of
online marketing of FGCS, it is important to gain a better
understanding of the information that is circulating in the
online sphere about female genitalia and female genital
cosmetic surgery. This systematic review was designed to
do so by synthesising existing research on female genital
cosmetic surgery and the internet.
Method
Inclusion criteria
Papers were eligible for inclusion if they were published
before September 2014, in English, in peer-reviewed
journals, and reported empirical research (using qualita-
tive or quantitative methods) about online representations
of female genital appearance or female genital cosmetic
surgery.
Search strategy and selection of papers
Eight social science, medical, and communication data-
bases (Medline, CINAHL, ProQuest, Scopus, Sociological
Abstracts, Social Science Citation Index, Communication
and Mass Media Complete, and PsycInfo) were individu-
ally searched using the terms “social media”OR “social
network*”OR internet OR youtube OR twitter OR tumblr
OR facebook OR “online communities”OR “bulletin
board”OR web*ORwiki OR blog*ORemail; in conjunc-
tion with: genital*ORlabia*ORvulv*ORvagin*ORcli-
tor*ORhymenop*. Where applicable, the relevant subject
terms for each database were also included. Google
Scholar was searched using the terms “female genital*”,
labiaplasty,internet. Reference lists of located articles
were hand-searched for other potentially relevant titles.
Following the removal of duplicates, records were
assessed for suitability in accordance with the PRISMA
guidelines [28], first by title, then by abstract. To determine
final inclusion, articles were obtained and read in full.
Assessment of quality
Given that all eligible papers were likely to report analysis
of texts or images, we sought standardised criteria, tools,
or frameworks to use in assessing their quality, but found
nothing designed for the purpose. Two authors (HM and
KM) independently assessed the quality of each study
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using Kmet’s [29] assessment tool for quantitative and
qualitative studies. Discrepancies were discussed among
three authors (HM, KM, and MK) and resolved. The
quantitative and qualitative checklists comprise, respect-
ively, 14 and 10 questions (see Tables 2 and 3), each of
which assesses against a criterion. If the item meets the
criterion it is scored 2, if it partially meets the criterion it
is scored 1, and if it fails to meet the criterion it is scored
0. If a criterion is assessed as “not applicable”, 2 points are
deducted from the final total (maximum possible = 28).
Calculated scores were defined as strong (>80 %), good
(70–80 %), adequate (50–70 %), or limited (<50 %).
Data analysis
Results reported in all papers were analysed thematically.
As themes were identified in each paper, a structure of
themes and sub-themes was developed. Each paper was
reassessed against the developing thematic structure to
ensure the best fit and to establish relationships among
themes and concepts. In addition to the results reported
and conclusions drawn by the authors of each paper, re-
viewers used all identified themes in analysing the con-
tent of any included data excerpts, in order to achieve
the most comprehensive account of the literature.
Results
The search strategy yielded five eligible papers, each
reporting on a single study. Details of the selection
process are outlined in Fig. 1. A summary of papers is
presented as Table 1.
Four of the five studies were conducted by researchers
based in high-income Western countries: the Netherlands
[30, 31], the United Kingdom [31, 32], and Australia [33].
The remaining study was conducted in a low-income
country, Nigeria [34]. Four studies explored internet con-
tent that had been produced across multiple countries in
the Anglophone West [30–33], reflecting both the globa-
lised nature of the internet and also that this particular
form of genital surgery may be prominent in Westernised
societies and cultures. One paper reported research of
sites based in a single country (Australia) [33].
Liao and colleagues [32] report results of a content
analysis of 10 FGCS provider websites, based in the
United States and United Kingdom, with a specific
emphasis on the breadth, depth, and quality of clinical
information provided. Moran and Lee [33] limited
their sample to four websites belonging to Australian
labiaplasty clinics but used the techniques of multimodal
critical discourse analysis to examine how both the textual
Fig. 1 Flow diagram of study selection process, based on the PRISMA statement [28]
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and visual content of the sites contributed to the normal-
isation of FGCS. Writing from Nigeria, Ashong and Batta
[34] analysed the textual content relating to FGCS on 11
websites for FGCS provider clinics based in the United
States, the United Kingdom, Belgium, Canada, and Brazil.
The authors were particularly interested in integrity of the
information supplied, and the overall trend towards the
commercialisation of female genitalia through medicine,
arguing that “the hype surrounding cosmetic or aesthetic
genital surgery is a damaging distraction particularly when
[Africa] is waging a battle against female genital mutila-
tion”[34]. Zwier’s [30] paper reported the only study of so-
cial media content, comparing motivations for labiaplasty
disclosed by 78 women posting in online communities with
those publicised by 40 labiaplasty provider websites. In a
report of the sole study to examine online representations
of female genitalia without specific reference to FGCS,
Howarth and colleagues [31] compared visual depictions of
female genitalia in online pornography to those depicted in
anatomy textbooks and feminist publications (print and
online) to assess how patterns of representation might in-
fluence public perceptions of ‘normality’.
Quality assessment
Tables 2 and 3 provide summaries of the quality assess-
ment of reviewed papers and the rating assigned to each
paper. Four of the five articles were rated as of Strong
quality. Despite assessing the quality of Ashong and Bat-
ta’s [34] paper as Limited, we chose to include it for two
reasons. First, there is a scarcity of African perspectives
in Western academic debates about FGCS, a gap that is
particularly pertinent given the parallels between FGCS
and female genital cutting/mutilation. Further, their find-
ings were consistent with those reported in the other
four papers.
Themes
Five interrelated themes were identified. These were:
pathologisation of genital diversity (identified in 5 papers),
female genital appearance as important for wellbeing (4
papers), characteristics of women’s genitals as important
for sex life (4 papers), the female body as degenerative and
improvable through surgery (3 papers), and FGCS as safe,
easy, and effective (3 papers).
Table 1 Summary of reviewed papers
Author Year
Country of Origin
Aim Method Sample Quality rating, limitations
Ashong & Batta
2012 [34]
To explore the content of
Western female genital
cosmetic surgery
provider websites.
Qualitative. Textual
analysis, methods not
described in detail.
11 international FGCS provider
websites (6 USA , 2 UK, 1 Canada,
1 Belgium, 1 Brazil). Does not specify
which pages from each
site were analysed.
Limited (8/20): lack of rigorous
data analysis or theoretical
connection.
Nigeria
Howarth, Sommer &
Jordan 2010 [31]
To determine if visual
depictions of female
genitalia differ across 3
sources (online pornography,
anatomy textbooks, and
feminist publications: online,
print).
Quantitative. Comparison
of measurements of
vulval features from
screen and book photos
or illustrations.
253 images (98 from 3 free online
pornography websites, 29 from
<92 human anatomy textbooks,
126 from feminist publications:
2 books, 1 website).
Strong (18/22): limited by
unclear sampling strategy and
failure to differentiate sources
of individual images.
United Kingdom,
The Netherlands
Liao,Taghinejadi &
Creighton 2012 [32]
To investigate the clinical
information on female
genital cosmetic surgery
provider websites.
Quantitative. Content
analysis.
10 international FGCS provider
websites (5 UK, 5 USA).
Strong (18/18).
United Kingdom
Moran & Lee 2013 [33] To examine how the textual
and visual content of the
Australian labiaplasty provider
websites normalises the
practice of FGCS.
Qualitative. Multimodal
critical discourse analysis.
4 Australian FGCS provider
websites: all textual and visual
content on home pages, (cosmetic
surgery in general), and content
related to labiaplasty from entire
site.
Strong (18/20): limited by only
partial use of verification
procedures and reflexivity.
Australia
Zwier 2014 [30] To compare motivations for
considering labiaplasty
expressed by women on
online communities with
those indicated on the
websites of an international
sample of surgery providers.
Quantitative. Content
analysis.
40 international English- or Dutch-
language FGCS provider websites
(Australia, Canada, Ireland, the
Netherlands, New Zealand, South
Africa, UK, USA). 78 posts in which
women (28 Dutch, 25 US, 25 UK)
wrote about their reasons for
labiaplasty, drawn from 4 online
communities with recent threads
about labiaplasty (1 Netherlands, 2
USA, 1 UK). Ages disclosed by
posters ranged from 12 to 61 years.
Strong (21/22): limited by
inconsistency of sample. A
selection of Dutch, US and UK
websites would have enabled
more accurate comparison
between content of online
communities and websites.
The Netherlands
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Pathologisation of genital diversity
All studies found that vulval diversity is pathologised in
cyberspace, with the concomitant promotion of a homo-
genised “clean slit”[15, 16] vulva as ideal and desirable.
Pathologisation occurred textually, with providers using
medical terminology and disparaging language to pos-
ition certain characteristics as abnormal or undesirable,
and through visual representations on these websites
and in online pornography.
Three papers reported FGCS surgical provider websites
employing a range of disparaging language to signify which
genital characteristics or features ought to be considered
undesirable. For instance, pubic fat is described as “un-
sightly”, vaginas as potentially “loose”,andlargelabiaas
“protuberant”,“oversized”,“awkward”,and“unappealing”
[32–34]. In addition to such overtly pejorative descriptions,
Liao and colleagues [32] noted that sampled FGCS provider
websites made latent associations between larger labia, ugli-
ness, and poor personal hygiene.
Findings from four studies support the conclusion that
vulval diversity is pathologised by the presentation of
certain characteristics as unnatural or diseased. Two studies
identified FGCS provider websites using medical termin-
ology to construct protruding labia minora, amongst other
genital characteristics, as pathological and thus requiring
surgical correction [32, 33]. A third paper quoted excerpts
from surgical websites in which such medical rhetoric
was visible, but this was not specifically addressed or
interrogated by the authors [34]. Liao and colleagues
[32] and Moran and Lee [33] noted that, although
terms such as ‘labial hypertrophy’may appear to the lay
consumer to refer to established medical conditions,
they lack formal scientific definition. In particular, in
the case of ‘labial hypertrophy’, Liao and colleagues [32]
suggest that the lack of specificity allows surgeons to
apply the label to women without any clinical indication.
Three papers found provider websites proffering potential
causes of these supposedly undesirable features, such as
ageing, childbirth, or weight gain [32–34]. It was noted
that a discussion of causes further positions genital varia-
tions outside the limited ideal as abnormalities or defects
in need of surgical correction [33].
The pathologisation of vulval diversity does not occur
solely through language. The findings reported in all five
papers indicate that online visual representations of fe-
male genitalia can be a powerful indicator of socially
desirable and undesirable genital characteristics. Four
studies reported the presence of before-and-after labia-
plasty image galleries on FGCS provider websites, with
the frequency ranging from 25 to 60 % of the websites
in each sample [30, 32–34]. Two papers reported de-
tailed analysis of these images, with authors concluding
Table 3 Quality Assessment Matrix, Qualitative Studies [29]
Study Ashong &
Batta [34]
Moran &
Lee [33]
Question/objective sufficiently described? Yes Yes
Study design evident and appropriate? Partial Yes
Context for the study clear Yes Yes
Connection to a theoretical framework/
wider body of knowledge
Partial Yes
Sampling strategy described relevant
and justified
Partial Yes
Data collection methods clearly described
and systematic
Partial Yes
Data analysis clearly described and
systematic
No Yes
Use of verification procedures to establish
credibility
No Partial
Conclusions supported by the results? No Yes
Reflexivity of the account No Partial
Table 2 Quality Assessment Matrix, Quantitative Studies [29]
Study Howarth, Sommer &
Jordan [31]
Liao, Taghinejadi &
Creighton [32]
Zwier
[30]
Question/objective sufficiently described? Yes Yes Yes
Study design evident and appropriate? Yes Yes Yes
Method of subject/comparison group selection described and appropriate? Partial Yes Partial
Subject (and comparison group) characteristics sufficiently described? Partial Yes Yes
Outcomes well defined and robust to measurement/misclassification bias? Means
of assessment reported?
Yes Yes Yes
Sample size appropriate? Partial Yes Yes
Analytic methods described/justified and appropriate? Yes Yes Yes
Some estimate of variance is reported for the main results? Yes N/A Yes
Controlled for confounding? Partial N/A Yes
Results reported in sufficient detail? Yes Yes Yes
Conclusions supported by the results? Yes Yes Yes
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that the images serve to pathologise natural vulval di-
versitybycontrasting‘before’examples, all of which fell
within the range of labial dimensions observed in the
female population, with standardised ‘after’images of
vulvas with no visible labia minora [32, 33].
Howarth and colleagues [31] found the range of female
genitalia depicted in three popular free online pornog-
raphy websites (N= 98 images) to be significantly less
protuberant and less varied than the range found in the
female population. The authors also analysed a sample
of images drawn from feminist-oriented publications
(one website and two books) (N= 126 images) which
they considered to be a closer reflection of the range of
variation amongst women [31]. However, because the
authors did not make any distinction in this sub-sample
between the images sourced online and those from print
publications, we cannot draw any definitive conclusions
about the range of female genitalia depicted on this
website.
Female genital appearance as important for wellbeing
Results from four studies indicate a strong discursive
connection between female genital appearance and well-
being. This connection was often drawn by commercial
FGCS providers in order to promote their services but
was also supported and reinforced by women’s own ac-
counts of their motivations and experiences. Four papers
identified FGCS provider websites drawing an unques-
tioned connection between female genital appearance and
psychological or emotional wellbeing or distress [30, 32–
34]. Specifically, provider websites were found to suggest
that female genitals that are deemed to be aesthetically
unpleasing cause a woman shame and embarrassment,
leading to “devastating effects on her life”[34].
Zwier’s [30] analysis found that 98 % of provider web-
sites promoted FGCS as a solution to emotional discom-
fort such as feeling “freakish”or ashamed about one’s
genital appearance. Indeed, it was reported that FGCS
websites were more likely to emphasise surgery as a so-
lution to emotional problems than to physical pain or
functional issues [30]. Liao et al. [32] found 100 % of
provider websites in their sample suggested several “social
and psychological advantages”of a modified vulval appear-
ance through FGCS, such as improved self-confidence
and a “sense of freedom”.
Using the techniques of critical discourse analysis,
Moran and Lee [33] interrogated this connection, conclud-
ing that surgical websites frame emotional or psychological
distress as an inevitable by-product of possessing certain
genital characteristics, rather than a societal failure to rec-
ognise such variation as natural or acceptable. For example,
websites claimed that “suitable candidates for labial re-
juvenation surgery”are women “who experience psy-
chological distress due to appearance of their labia”and
that “enlarged or exposed labia causes much stress about
the appearance of the inner and outer lips of the vagina”
[33]. The authors also draw attention to the subtle ways in
which this connection is reinforced through common id-
ioms on surgical websites, as women reviewing the sites
are encouraged to care for their “skin, body and soul”,
“optimise your health, wellbeing and appearance”,and
to “look and feel your very best”[33].
Zwier’s [30] analysis of women’s accounts of motiva-
tions for FGCS, as disclosed in online communities, sug-
gests that this connection may have significant cultural
resonance with women. This was the only study among
the reviewed papers to explore user-generated content.
The author found that emotional discomfort is the most
commonly cited reason for desiring or pursuing FGCS,
discussed by 71 % of women; 42.5 % of women gave this
as their sole reason, with the remainder alluding to add-
itional motivations such as discomfort in tight clothing or
when exercising [30]. Zwier [30] reports the intense emo-
tions communicated by women in their online contribu-
tions; for instance: “I hate mine, hate, hate HATE it”.
Notably, two of the websites quoted in Ashong and
Batta’s [34] study suggested that the distress was related
to how a woman “perceives”her genital appearance, a
construction of the problem that was not evident in the
other papers reviewed. However, regardless of whether
the emotional distress is attributed to objective assessment
of genitalia or is mediated by the woman’s perception, all
four analyses of FGCS provider websites found the con-
tent of these sites to position FGCS as the logical solution
to emotional distress, with the sites asserting that surgery
will “restore”and “enhance”the self-confidence of women
who undergo it [30, 32–34].
Characteristics of women’s genitals are important for
sex life
Findings from four papers indicate that FGCS provider
websites commonly claim associations between pre-
operative genitalia and sexual dysfunction, with the
dysfunction described as primarily psychological [30,
32–34]. Although sexual dysfunction is attributed, in
some cases, to pain and discomfort, provider websites and
women’s online accounts both designate the primary
source of sexual dysfunction as shame, embarrassment,
and fear of adverse reactions from male sexual partners
[30, 32–34]. FGCS provider websites assert sexual dys-
function and thus that women’s sex lives will be improved
by undergoing labiaplasty or other genital cosmetic proce-
dures [32, 33].
Although it might be inferred that a woman’s sexual
satisfaction is being prioritised, three studies found that
FGCS provider websites promoted surgery as the solu-
tion to a male partner’s sexual dissatisfaction [32–34]. In
some instances, this was achieved by highlighting the
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reasons for potential dissatisfaction, with websites mak-
ing claims such as “the loose and unsatisfying feeling
that women feel can also be felt by their male partner
during intercourse”[34]. In others, it is stated that “the
sexual partner will feel a difference after labiaplasty”,or
“will clearly notice this change for the better”[33]. Liao
and colleagues [32] reported that some provider websites
recommended FGCS to benefit intimate relationships in
general because it improved interpersonal “disharmony
and resentment”. These assertions are reflected in the
anxieties evident in the women’s posts in online FGCS
communities, with 37.5 % reporting fear of negative re-
actions from sexual partners as a motivation for labia-
plasty [30]. A further 11 % wrote that they expected their
sexual enjoyment to be enhanced by the procedure [30].
The female body as degenerative, improvable through
surgery
Having established that a “tight”vagina and a “tidy”,
“youthful”vulva is represented online as the (Western)
ideal, three papers reported online content that contributes
to a cultural representation of a tenuous female body sus-
ceptible to degeneration, particularly through childbirth
and ageing, and improvable or restorable through surgery
[32–34]. Ageing or post-baby bodies are pathologised
through descriptors such as “loose”,“descending”or
“hanging”, all terms that carry unflattering connotations in
a society that valorises youth [33, 34]. Provider websites
recruit sexual partners to reinforce the need to reverse
genital deterioration by suggesting that they will notice
and dislike intimate parts of her body, visible only to them:
“a woman might have a face lift and look really young
until she goes to bed and a partner can see the evidence of
ageing there”[32]. Three papers note that FGCS provider
websites tend to depict almost exclusively young, slim,
Caucasian women [32–34].
Several surgery clinics are reported as promoting
“Mommy Makeover”packages, in which vaginal tighten-
ing and labia reduction surgeries are bundled together
with liposuction, tummy tucks, and breast augmentations
[32, 33]. These packages promise to restore a woman’s
“previously gorgeous body”[33]. The authors argue that
these promotional activities reframe the physical effects of
bodily processes such as pregnancy and childbirth as
undesirable conditions necessitating reversal through
medical intervention [33].
FGCS as safe, easy and effective
It was reported in papers from three studies that FGCS
provider websites claimed benefits and asserted the safety
of various FGCS procedures, without providing evi-
dence [32–34]. Liao and colleagues [32] found that pro-
vider websites tended to emphasise non-specific social
and psychological advantages, such as improved self-
confidence, relief of discomfort, and better hygiene.
Where specific medical claims were made, these were
not supported by reference to any clinical evidence.
Such claims included the assertion that G-spot injec-
tions “revolutionise many women’ssexlives”and that,
in the case of labiaplasty, “sensation may even be en-
hanced because of the new nerve endings and removal
of the tissue”[32].
Two papers reported on the success rates published
on surgery provider websites, finding that, where cited,
these were in the range of 90 –95 % [32, 33]. Liao and
colleagues [32] found that other sites boasted “an excel-
lent track record”or “the best results worldwide”.Two
website studies reported on the use of personal testimo-
nials on surgeon websites, with Liao and colleagues [32]
finding flattering personal testimonials on 30 % of the
websites in their study. Without similarly quantifying
what they found, Ashong and Batta [34] characterised
the testimonials on their sample sites as overwhelmingly
adulatory, praising the benefits of FGCS and the surgeon
and downplaying any potential adverse outcomes.
It was found in three studies that providers used med-
ical terminology to confer credibility on FGCS in general
and to legitimate specific surgical techniques and proce-
dures [32–34]. Half of all providers investigated by Liao
and colleagues [32] aligned themselves with the invented
field of “cosmetic gynaecology”. This was the only paper
to include a detailed interrogation of such language,
reporting the use of 72 different terms or labels for female
genital cosmetic surgery procedures across 10 provider
websites [32].
Authors of three papers expressed concern about risk
information on FGCS provider websites, arguing that
potential risks or adverse outcomes of surgery are mini-
mised or omitted entirely from website content [32–34].
Liao and colleagues [32] found that, although all sam-
pled sites mentioned risk in some form, risks were either
not specified (40 %) or limited to a list of standard surgi-
cal risks (60 %). Recovery expectations were idealised,
with websites advising potential patients to expect “mild
discomfort and swelling”and scars that will “disappear
completely after 1 –2 weeks”[34]. One paper reported
that only two of the 10 sites studied mentioned scarring
as a potential risk [32].
Information about potential surgical complications was
almost exclusively in the context of warnings against
“botched jobs”elsewhere, such as, “we have seen many
unfortunate examples of terrible scarred uneven results of
labiaplasty from other physicians”[32]. Accompanying
claims were made that there are “no complications or side
effects with any of our patients”[32]. Of 25 sites analysed
by three papers, only one website was reported as citing a
revision rate for its own clinic, giving a rate of 2 % for va-
ginal surgery [32].
Mowat et al. BMC Women's Health (2015) 15:110 Page 7 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Discussion
This systematic review examined findings from five stud-
ies exploring online content relating to female genital
appearance or female genital cosmetic surgery. Four of
the five studies analysed the content of FGCS provider
websites, and the consistency of their findings reveal the
ways in which providers of female genital cosmetic sur-
gery are promoting and normalising the practice of
FGCS online. The most prominent theme, the pathologi-
sation of vulval diversity, was also found in an analysis
of online pornography. The results of this review suggest
adverse implications for the women accessing these sites
and reveal sociocultural attitudes to female genitalia and
FGCS.
On female genital cosmetic surgery websites, the fe-
male body is pathologised by the medicalization and
denigration of the aesthetic appearance of certain vulval
features. Despite research indicating no significant asso-
ciation between pregnancy, childbirth, or natural ageing
and vulval measurements [13], FGCS provider websites
consistently assert that each causes undesirable deterior-
ation that requires surgical intervention. The representa-
tion of the female body as degenerative, and improvable
through surgery, sits within a broader Western culture
in which youth is valorised, ageing pathologised, and
concomitant self-surveillance and self-improvement are
strongly encouraged [35, 36].
These websites perpetuate a persistent and unquestioned
assumption that genital variation, beyond a restricted ideal,
results in psychological and sexual dysfunction. We do
not seek to discount the emotional distress and decreased
quality of life experienced by some women because of
internalised ‘self-loathing’associated with the appearance
of their genitalia. Indeed, the majority of women posting
in online communities cite this as a motivation for surgery
[30].However,bydiscursivelyframingthedistressasat-
tributable to the genitalia themselves, rather than to a per-
ceived failure to meet societal expectations [33], FGCS
provider websites reinforce the ideal of the culturally con-
structed “clean slit”or “Barbie doll”vulva against which
women must measure themselves [7, 15–17]. The deploy-
ment of such associations on provider websites fosters the
very psychological and sexual distress for which FGCS
procedures are recommended as solutions.
Further, the construction of certain natural genital var-
iations as objectively abnormal and undesirable enables
‘corrective’surgery to be positioned as the logical and
empowering solution for affected women. Not only is
surgery posited as the best solution to distress about
one’s genitals, it is also promoted as an expression of
personal agency and empowerment, a representation that is
highly consistent with consumerist, neo-liberal, and post-
feminist discourse more generally [33, 37]. This discourse
functions in conjunction with the other themes identified
in the review papers, particularly the pathologisation of di-
versity and the connection of FGCS to emotional wellbeing.
After all, if certain genital features are objectively patho-
logical and undesirable, and if correcting these through sur-
gery is safe, easy, and beneficial to psychological health,
then the decision to undergo surgery is neither superficial
nor self-indulgent. Despite addressing what are primarily
aesthetic concerns, FGCS is repositioned as a matter of
reclaiming one’s self-confidence, life, and happiness, effect-
ively distancing it from the critiques of vanity so commonly
levelled at the practice of cosmetic surgery more generally
[38]. The themes identified by this review are largely con-
sistent with Braun’s [39] discussion, published as a book
chapter and therefore ineligible for review. Braun analysed
20 FGCS provider websites and found various ways in
which particular genital features and practices were patho-
logised or valorised; she concluded that the content of such
sites was “deeply problematic”for women [39].
In line with Braun’s [39] critiques, the studies in this
review found that the descriptions of sexual pleasure
and dysfunction on FGCS provider websites were het-
eronormative and androcentric, focusing almost exclusively
on heterosexual vaginal intercourse and the expectation
that a tighter vagina and particular vulval aesthetic will re-
sult in increased sexual pleasure for both parties. The de-
piction of diverse, healthy female genitalia as problematic
for male sexual partners and of FGCS as the only solution
(as opposed to amending sexual activities, changing part-
ners, or male-oriented surgery) reinforces an age-old view
of passive female sexuality, in which women exist solely to
appease the sexual desires of men [40]. That women are en-
couraged to surgically remove densely-innervated genital
tissueonlyaffirmsthismodel.
A primary critique of FGCS is the extent to which
these procedures are being performed in the absence of
any clinical data on safety or long-term effectiveness
[11]. This review found that many confident claims are
being made across FGCS provider websites. In lieu of
supporting evidence, providers foreground testimonials
and, in some cases, assert high success rates without any
indication of how these have been measured. Further,
complications or patient dissatisfaction are positioned as
the result of individual incompetence, not because surgeons
may be poorly trained, the procedures lack evidence of
safety and effectiveness, and the field as a whole is un-
regulated [41, 42].
Conclusion
This body of literature, albeit small, draws attention to
significant and interrelated patterns of online representa-
tion that function to pathologise natural genital variation
and promote and normalise a homogenous, surgically al-
tered ideal vulva to Western women. Although these
studies have been able to discern and highlight particular
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Content courtesy of Springer Nature, terms of use apply. Rights reserved.

patterns of representation, it should be acknowledged
that such representations are open to interpretation,
which will largely be influenced by individual viewer
characteristics. Studies suggest that online content, in-
cluding pornography and surgical websites, influences
women’s consideration and acceptance of FGCS [25, 27].
Further qualitative inquiry into how women are using
and interpreting such websites is warranted.
The majority of studies in this review analysed solely
‘non-social’media: surgical websites and online pornog-
raphy. However, the internet is not all direct marketing
and pornography. Rather, the key feature or benefit of
the internet is its capacity for diverse many-to-many
communication opportunities. We speculate that this
capacity may give people using social media the power
to challenge dominant representations and discourses in
cyberspace. Nevertheless, the sole study of espoused mo-
tivations for labiaplasty in online communities demon-
strates that many women appear to have internalised
derogatory patriarchal connotations of the vulva to an
extent that adversely affects their lives and wellbeing
[30]. In order to gain a fuller understanding of the role
of the internet in the promotion and normalisation of
FGCS, a detailed exploration of where and how individ-
uals contribute to online discussions around female
genital appearance and female genital cosmetic surgery
would be valuable.
Abbreviations
FGCS: Female genital cosmetic surgery.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
HM, MK, KM, AD and JF contributed to the design of the literature review,
and structure editing of the manuscript. HM conducted the literature search
and analysed the data, participated in the quality assessment and drafted
the manuscript. MK and KM participated in the quality assessment and
contributed to the analysis. All authors read and approved the final manuscript.
Acknowledgment
This work was supported by funding from the Australian Research Council
under Grant LP130100025.
Author details
1
Jean Hailes Research Unit, Monash University, Melbourne, Australia.
2
Institute
for Advanced Studies in the Humanities, University of Queensland, Brisbane,
Australia.
Received: 16 April 2015 Accepted: 24 November 2015
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