Information and advice for health practitioners

Significant variation exists in labia size, symmetry, shape and colour between individuals. Medical textbooks largely do not address the natural diversity of labia, and only include diagrams of vulvas with labia minora that do not protrude beyond the labia majora. These diagrams do not represent the standard or ‘normal’ labia. Labia minora have been recorded at lengths between 5-100mm, and the American College of Obstetricians and Gynaecologists (ACOG) specifies that measures outside this range do not indicate abnormality². Furthermore, 30–50% of all women have labia minora that are longer than the labia majora³.

It is important to note that there is no clinical definition of normal labia. Clinical labia minora hypertrophy remains poorly defined, and there are no established cutoff values⁴.

The labia perform important functions, including:

• protecting the urethra and vagina
• contributing to sexual arousal
• providing sensation and lubrication during sex 

It is not clear how these functions are affected by labiaplasty or other forms of female genital cosmetic surgery. 

It is increasingly common for general practitioners to encounter female patients with concerns about the normality of their genital appearance.

Such concerns may be motivated by a variety of factors, including:

• idealised representations and limited diversity of genitalia found within pornography, medical images and images accessible on the internet 
• changes in hair removal practices that expose more of the labia 
• limited access to accurate information about female genital anatomy and its natural diversity
• information and images used by cosmetic surgeons in advertisements for labiaplasty
• existing social pressures and expectations relating to appearance of the labia

When approached by patients with concerns about the appearance of their labia, it is recommended that health professionals provide counselling about the diversity that exists³. The Labia Library is a useful tool to support these conversations. The Labia gallery features photographs of labia across a wide range of ages, skin tones, gender identities and experiences (such as vaginal childbirth), which show just how different labia can be. It also includes images of vulvas after gender affirming surgery and six months of testosterone therapy, which may be helpful for trans patients pre- or post-gender affirming care in demonstrating that there is no standard or normal version of labia. More information on providing affirming trans healthcare can be found at Auspath.

It is important to note that while, for many patients, exposure to images that show the diversity of vulvas will be sufficient to alleviate their concerns, this is not the case for everyone. The concerns of patients experiencing high levels of anxiety regarding the appearance of their labia should not be minimised or dismissed.

If a patient is still experiencing anxiety after receiving information about the diversity of labia (or was already aware of this information), it may be helpful to complete psychometrics, such as the Depression, Anxiety and Stress Scale (DASS), and provide a referral to a sexual health psychologist.

Increase in concerns regarding labial appearance has led to a rise in demand for labiaplasty in Australia and other countries around the world. Some people request these procedures to address congenital anomalies or injuries, or issues that cause them a lot of pain. However, labiaplasty is most commonly performed for cosmetic reasons. Research shows that the majority of women seeking genital cosmetic surgery have labia within the documented physiological range⁵.

The Canadian Society of Obstetricians and Gynaecologists (SOGC) advises that, for patients requesting female genital cosmetic surgery that is not medically indicated, counselling which focuses on the natural diversity of vulvas and physiological changes over the lifespan should be prioritised⁵. The Labia Library website is a useful resource to support this approach. It includes information about labial diversity and unmodified photographs of labia to demonstrate just how different they can be. Providing information about the diversity of labia is often effective at addressing patients’ concerns about their genital appearance. Studies have found that women who are considering labiaplasty and are shown images that demonstrate labial diversity preoperatively choose to proceed with surgery less frequently .

If patients are already aware of this diversity, or still desire cosmetic surgery after receiving this information, it is important to treat their decisions with respect (as with requests for any other type of cosmetic surgery) and be aware that they are trying to balance a range of social pressures to achieve the best outcomes for their individual circumstances.

Functional concerns can also motivate individuals to consider labiaplasty. The Royal Australian College of General Practitioners (RACGP)⁶ advises that care should be taken not to ‘medicalise’ symptoms such as chafing and discomfort from grooming processes and clothing. These are common and may be addressed with simple education and reassurance, without the need for surgical intervention.

Simonis³ provides a list of questions that can help explore the cause and impact of functional concerns, including:

• What sort of exercise gear do you wear?
• Do you remove your pubic hair? If so, what technique do you use?
• How do you feel about your genital appearance?
• How is this impacting your life and relationships?

Further information on managing patients who are requesting female genital cosmetic surgery can be found in the RACGP Female genital cosmetic surgery: a resource for general practitioners⁶ and the SOGC clinical practice guideline⁵.

Professional medical bodies in the United States⁷, Canada⁵ and Australia⁶ advise that there is limited scientific evidence to support the short- and long-term safety and effectiveness of female genital cosmetic surgery, and inadequate clinical guidelines associated with these procedures. All emphasise the lack of evidence for claims of improvement in self-image, self-esteem or sexual function and note potential adverse outcomes². These include:

• scarring
• numbness
• pain
• discolouration of the labia
• reduced or loss of sexual sensations
• dyspareunia
• permanent disfigurement

The Canadian Society of Obstetricians and Gynaecologists (SOGC) advises that female genital cosmetic surgery should generally be discouraged in patients under 18 years of age⁵. The long-term impacts of labiaplasty are still poorly understood and the risk of harm for adolescents is even more significant. The anatomy of the vulva and labia continually changes throughout adolescence and early adulthood, with the labia minora often becoming more prominent in appearance. As a result, children and adolescents who undergo labiaplasty are more likely to require multiple surgeries, which increases the potential for scarring and sensitivity loss. 

According to the Royal Australian College of General Practitioners (RACGP), patients seeking labiaplasty who are younger than 18 should be referred to a specialist adolescent gynaecologist⁶. 

Education regarding the natural diversity of labia should also be provided and is an important starting point to address genital body image anxiety⁸. Studies have found that with appropriate education and counselling, concerns regarding labial appearance can be managed without surgery in the majority of girls⁵. The Labia Library website can help support this. It contains a photo gallery that depicts a diverse range of vulvas and includes useful and accessible health information that can be reviewed at home.

Resources specifically for parents are also available if they are concerned about their child’s appearance.

American College of Obstetricians and Gynecologists (2020) ACOG Committee Opinion 795: Elective female genital cosmetic surgery 

Society of Obstetrics and Gynaecology Canada (2022) SOGC Clinical Practice Guideline 423: Female genital cosmetic surgery and procedures. 

Royal Australian College of General Practitioners (2015) Female genital cosmetic surgery: a resource for general practitioners and other health professionals. 

Women’s Health Victoria (2018) “I never realised they were so different”: understanding the impact of the Labia Library