Women’s experience and perspectives toward genital cosmetic surgery: A qualitative study

doi:10.21203/rs.3.rs-1437100/v1

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Research Article

Women’s experience and perspectives toward genital cosmetic surgery: A qualitative study

https://doi.org/10.21203/rs.3.rs-1437100/v1

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Background

Nowadays female genital cosmetic surgery (FGCS) has become quite popular, which has led to a broad variety of medical and social implications. After these surgeries, most women experienced anxiety, depression, and other psychiatric conditions. The present study was carried out in order to explore women’s perspective and experience toward genital cosmetic surgery based on their context and cultural aspects.

Methods

This study is a qualitative content analysis and collected data were analyzed through the approach introduced by Graneheim and Lundman (2004) after interview with nine women who experienced genital cosmetic surgeries in the city of Erbil, Kurdistan-Iraq in 2021-2022.

Results

After semi-structured interviews which carried out with participants, the main themes, including “husband satisfaction” and “self-confidence” have been extracted. Some relevant subthemes and meaning units like “ugly appearance”, “anxiety related to husband undesirable intercourse”, and “dyspareunia” were retrieved from the participants’ stories, and the related conclusions of each theme were explored.

Conclusion

Study findings suggest that female genital cosmetic surgery improves the women’s body image and sexual function and the couples’ sexual satisfaction, especially that of husbands. Because of people sociocultural aspects in Kurdistan region, they need to be more aware of female sexual needs and marital relationship. To investigate the issue more, conduction of further studies is recommended.

Female genital cosmetic surgery

female genitalia

female sexuality

sexual pleasure

Female genital cosmetic surgery (FGCS), also known as vulvoplasty, refers to a surgical procedure through which the vulvovaginal anatomy is altered. This cosmetic surgery is performed for women with no apparent functional or structural abnormality; therefore, it is not carried out for clinical purposes like gender affirmation surgery, incontinence, vaginal prolapse, reversing female genital cutting, previous obstetric or straddle injury, interference in athletic activities, pain with intercourse, or clinically diagnosed female sexual dysfunction [1].

Over recent years, FGCS has become quite popular, which has led to a broad variety of medical and social implications. FGCS encompasses a group of non-medically indicated cosmetic surgical procedures which are aimed at altering the external and internal appearance and structure of female genitalia [2]. To be more specific, it includes orgasm-shot, augmentation of G-spot, vaginal rejuvenation, mons pubis liposuction, vaginoplasty (also known as vaginal reconstruction), hymenoplasty, and labiaplasty (trimming the labia minora and less commonly labia majora). According to US 2013 statistics, labiaplasty with a rise of 44% in 2013 was reported to be the fourth most common cosmetic surgical procedure, following liposuction, breast augmentation and rhinoplasty [3]. From 2003 to 2013, the rate of labiaplasty increased 3 times in Australia and 4 times in the UK [4]. According to the statistics published by Australian government, requests for rebatable vulvoplasty increased from 640 in 2001 to more than 1500 in 2013, which is an increase of about 140% [5]. However, they did not report an associated increase in genital disease diagnoses [6]. An unknown number of surgeries are conducted in private hospitals and clinics; therefore, these figures cannot be the accurate number of vulvoplasties performed [5].

Following the sharp increase in the demand for FGCS and the general practitioners’ (GP) need for advice regarding FGCS, a resource guide for health professionals titled, ‘Female Genital Cosmetic Surgery: A resource for general practitioners and other health professionals’ was published by the Royal Australian College of General Practitioners on 31 July 2015. GPs are the first point of contact with the healthcare system; therefore, they have a significant and pivotal role in training girls and women regarding the various genital appearances and the risks associated with genital surgery. After vulvoplasty, most women experience anxiety, depression, and other psychiatric conditions; therefore, informed GPs can enhance the women’s health outcomes by tackling these modifiable psychosocial factors like [7]. In this regard, gynecologists and gynecological nurses need to be equipped with sufficient knowledge to recognize women with these complications [8, 9].

The present study was carried out in order to explore women’s perspective and experience of and expectations toward genital cosmetic surgery based on their context and cultural aspects. For this purpose, the study was an attempt to investigate into this question: “What is the meaning of cosmetic surgery in term of genital repair according to participant’s understanding?”

Research design

The present study was a qualitative content analysis conducted by a qualitative research method between September 2021 and February 2022. Content analysis method is a subjective interpretation of the content of the text which is carried out by classifying the codes and identifying the themes. Content analysis is appropriate for the present research because it is a good analysis method that can easily accommodate a large amount of data. The collected data were analyzed through the approach introduced by Graneheim and Lundman (2004) [10]. Using this approach, the following steps were used to analyze the collected data:

1. Transcribing the interviews verbatim and reading through the text several times to obtain a sense of the whole;

2. Dividing the text into condensed meaning units;

3. Abstracting the condensed meaning units and labeling with codes;

4. Sorting codes into categories and subcategories based on comparing their similarities and differences; and

5. Formulating themes as the expression of the latent content of the text.

Study procedures

After permission was obtained from the interviewees, all interviews were recorded with an MP3 player device. Interviews were listened to several times and typed verbatim, and the data were studied in order to better understand the meaning units in the interviews and identify initial codes that were extracted. The extracted codes were also classified into themes and subthemes based on their similarities, leading to the extraction of two main themes and several subthemes. The accuracy and robustness of data (validity, reliability, and the ability to transfer confirmation) were examined utilizing the criteria proposed by Cuba and Lincoln (1985) [11]. For data validation, interaction with and closeness to the participants as well as peer review and comparison were taken into account. Data reliability was assessed by experts, and appeals were made by the participants and outside observers.

Sample size and sampling technique

Nine women who experienced genital cosmetic surgeries in the city of Erbil, Kurdistan-Iraq were selected by the researchers. The inclusion criteria for sample selection of the study were women who underwent genital cosmetic surgery for at least three months, possibility of accessing their addresses and phone numbers, completely vigilant at the time of data collection, and willing to participate in the study. This research tried to qualify individuals with maximum diversity in terms of age and type of cosmetic surgery.

The sample size was based on data saturation and redundancy. Sample selection was found to be a tough task because most of the cases refused to participate in the study due to privacy and personal concerns. Another issue was that there were a few cases in the units or clinics of genital cosmetic surgery. Also, some of the participants were not willing to answer some of the researchers’ questions, and sometimes they provided short answers. They aged between 21 to 50 years, 7 of them were employed and office workers, the remainder were housewives. Seven women were married, one was divorced but had a fiancé, and one of them was unmarried. Informed consent was obtained from all participants. The participants were assured that they will be anonymous, they will be free to abandon the interview at any time, and they can avoid answering any questions. Required data were collected via semi-structured interviews which were carried out through face-to-face interview techniques by one of the researchers.

At the beginning of the interview, some open-ended questions were asked in order to encourage the participants to freely speak about personal experiences of their favorite subjects. Examples of the initial questions included: “How were you feeling before the surgery?” and “Why did you decide to perform this surgery?” Based on the individual experiences related by the participants, follow-up probing questions were asked from each participant in order to fully understand their experiences. The follow-up probing questions included: “What do you mean?”, “Explain”, and “Give an example”.

To understand the women’s experience of genital cosmetic surgery and also to figure out their understanding of and reasons for doing such surgical interventions, semi-structured interviews were carried out with them, which led to the emergence of the main themes, including “husband satisfaction” and “self-confidence”. Moreover, relevant subthemes and meaning units were extracted from the direct quotations which were retrieved from the participants’ stories, and the related conclusions of each theme were explored.

The first main theme: Husband Satisfaction

Based on the data extracted from the interviews, the main theme was “Husband Satisfaction” which included three subthemes, namely “ugly appearance”, “anxiety related to husband undesirable intercourse”, and “dyspareunia”.

The majority of the participants complained about their husband’s dissatisfaction with their intercourse, which made them feel anxious. They also stated that this condition made their relationship with their husband problematic, which in turn had negative effects on their life. Moreover, they were anxious about their marital relationship and satisfying their husband’s special needs. As they revealed, the ugly genital appearance was one of the causes of this problem. For example, Participant No. 1 stated:

“After my first childbirth, my genital area tore, but the midwife didn’t suture it, so I frequently experienced infection for nearly 7 years. Especially, I felt that gases came out of my vagina during intercourse, and my husband always complained about its appearance and grumbled. So, I decided to do genital cosmetic surgery after consulting with a gynecologist who guided me through and told me that nowadays many women in the world have such problems, but they resolved their problems through surgery. She also said that some women do such interventions just to change their body image. She suggested me surgery as the best way to get rid of my problem. Now after genital repair and such surgery, my partner is satisfied, but I’m in pain during intercourse”.

In the same regard, Participant No. 2 mentioned:

During my last delivery, I had laceration in my vagina and vulva when I was in the hospital. My midwife sutured it, but after I was discharged and while working at home, it opened and caused pain and infection for almost 3 years. However, last year another physician sutured and repaired it for the second time. Unfortunately, after two days, I fell off from a chair and it ruptured and caused sever pain again for several days. This time, I reject to repair it again because I have no luck. My husband complains, but I cannot change the condition, what can I do?

Moreover, Participant No. 5 mentioned a wonderful subject which reflected the subtheme of ugly appearance leading to female circumcision or delivery. In this regard, she narrated:

“I was married, but neither my husband nor I was satisfied with our intercourse, because when I was a small girl, my parents took me to a circumciser and she cut half of my genital labia in an irregular shape, so I did genital cosmetic surgery to repair it and decrease my husband’s complaints without notifying myself like some Kurdish women. We should remain silent and say yes to our husbands all the time”.

Furthermore, Participant No. 6 who aged 50 years with 7 children relate:

“Throughout all of my married life, I was unhappy with our intercourse because my husband was always nagging to me and said I was like a dry stick because I am one of hundreds of girls who was circumcised during childhood, which I thought was one of the reasons for his nagging. He closed his eyes to my real world as a woman and human and didn’t understand my condition. I also experienced frequent perineal lacerations, leading to 7 childbirths, which caused more problems for me. Anyway, I’m better now because I did surgery, and my physician repaired my genital parts, and both my husband and I are comfortable and I feel better”.

As revealed by the participants, women’s ability to satisfy their spouse effected their married life and relationship. They tried to retrieve the normal shape and size of their genital organ to satisfy their spouse’s desire.

The second main theme: Self-confidence

Some of the participants revealed their experience of prolapse of uterus or collection of fatty tissue in the genital area after delivery, leading to the extraction of subthemes, entitled “self-satisfaction, love, and attention”. In this regard, one of the participants talked about having pain and discomfort which had led to delivery complications and made her attend the gynecologist for surgery and repair her perineal area to improve comfortability for normal life and intercourse so as to gain her partner’s attention. She further added:

“After my childbirth, my uterus came down, so that I could feel it when I sat. This condition made me uncomfortable too much. I had pain which led to both uterine prolapse and hemorrhoid. To resolve my complications, I did surgery, and now I am satisfied with sexual activity with my husband. Unlike the past, I think he loves me more because he speaks with me more cordially”.

Participant No. 7 was divorced and she wanted to marry again, so she prepared herself for marriage by doing some plastic and cosmetic surgery to remove her fatty tissue from her abdomen and genital area following her fiancé’s request. Hymen is culturally very important for both partners, and it increases sexual satisfaction during their first intercourse. In this regard, she continued:

“After the proposal and engagement, my fiancé asked me to repair my genitalia, especially my hymen through hymenoplasty to be like before my first marriage. So, after I attended a physician, she repaired my vagina and did hymenoplasty. Now I’m feeling more confident, and I’m ready for marriage”.

Participant No. 4 who was an unmarried 23-year-old girl stated:

I want to marry, but I was thinking of doing labiaplasty before marriage, so I did it because I experienced circumcision during my childhood, leading to irregular size of my labia.

Regarding love and attention after genital repairing, Participant No. 9 revealed:

I’ve got 5 children. After delivery of each of them, I had many problems with urination and intercourse. My husband complained about dissatisfaction with our intercourse. I felt that he didn’t love me, because of our sexual problems. Those problems affected our married life and decreased my self-steam, especially during intercourse.

In the same regard, another participant stated:

“Immediately after my last childbirth, the physician sutured my episiotomy and used cosmetic technique for suturing and repaired it because I asked her to repair my perineal area, because it was the main reason for marriage problems between me and my husband after our previous childbirth. This cosmetic surgery raised love between us. I believe if the woman fails to satisfy her husband during sexual intercourse, they will face many problems in their married life”.

According to these narrations, Kurdish culture plays an important role in married life and dyadic relationship because man in cultures like Arab and Middle Eastern countries is the first person in family and woman should be responsible to provide his satisfaction in their married life without notifying her human right and sexual needs.

Based on the analysis of the interviews, satisfying husbands and increasing self-confidence were found to be two significant reasons for the women’s efforts to change their body shape and size through genital cosmetic surgery. Also, their statements revealed their anxiety or sexual distress because of the abnormal shape of their genital parts like labia and irregular perineal scars or recurrent infection and pain after childbirth. As mentioned in the findings section, the participants wanted to resolve their sexual difficulty, provide their spouses with sexual satisfaction, and decrease the level of their anxiety and stress regarding continuation of their normal married life. Similar to this finding, Brotto et al. (2019) in their study concluded that some women might downplay any negative or judgmental attitudes that could be perceived as contributing to their requests. However, they examined the psychological characteristics of women seeking FGCS (female genital cosmetic surgery) and revealed that the influence of personal negative judgements and evaluations, perceived partner-related dissatisfaction, and perceived negative evaluations by them play a highly significant role in initiation of FGCS [12]. Moreover, the report of the American Society of Plastic Surgeons (2016) revealed that the number of people seeking cosmetic surgery continues to rise because they want to change their abnormality into normality [13].

Most of those who undergo cosmetic surgeries are female because they become psychologically anxious if they are rejected by their partners or society due to abnormality in their body. Similarly, the results of the present study reflected the participants’ anxiety about both the ugly appearance of their genital areas caused by congenital anomaly, circumcision, or delivery and their husbands’ dissatisfaction with intercourse. In comparison with the past, increasing Kurdish women’s interest in and tendency toward plastic surgery, especially genital cosmetic, is an important reason to get the ideal form of their body and change their body image in order to be accepted by their partners and the society. Another reason for doing such surgeries is to save their married life which might make them scared a lot if it is endangered. Another probable reason is that they care more about their spouses and their dyadic relationship than themselves. Similar to these findings, research has shown that there has been an increase in genital cosmetic surgeries due to a sharp rise in the anxiety associated with perceived vulvar anomalies. Other reasons for such surgeries in the Western culture and media include hairless, undefined vulvas that have no protruding labia minora and irregular shape of labia minora or large labia majora [14, 15].

In addition, being a barbie doll is the women’s preference and perception of ‘normality’ to be accepted and considered sexy by their partners and the society. In this regard, women rate vulvar images as more ‘normal’ and ‘representative of society’s ideal’ with digital and surgical modifications [14]. As reported by Brotto et al. (2019), another reason for which some women might seek FGCS is to improve their sexual function. Moreover, sexual difficulties have been reported to affect up to a third of women across ages, and psychological factors, such as depression, anxiety and body image, are strong predictors of women’s sexual response and satisfaction especially in their married life [12].

The results of the present study further revealed that most of the women had abnormal outcomes after childbirth. Experience of vaginal tear and laceration as well as incomplete suturing the perineal wound by midwives lead to many physical and emotional complications for vulvoplasty-seeking women. On the other hand, such women become anxious not only due to physical problems like pain and discomfort during sitting and daily activities but also because of their inability to have normal sexual function due to pain. Another reason for their anxiety has been reported to be “ugly appearance” of their genital area in the eyes of their partner. Such women feel that their married life is in danger, so they feel they have to do these cosmetic surgeries to save their dyadic relationship. In line with these findings, research has shown that sexual satisfaction is an important component of sexual health, a sexual right, and an outcome of sexual wellbeing [16].

According to the results of a study conducted by Rowen et al. (2018), an appropriate (satisfying and safe) sexual relationship is one of the most important dimensions that has the highest effect on marital satisfaction. Thus, the improvement of sexual satisfaction could improve marital satisfaction [17]. Improving self-confidence after genital cosmetic surgery was another concept extracted from the women’s quotations and stories. As revealed by their experience, doing labiaplasty or hymenoplasty changed their body image and gave them self-esteem in their marriage. Similarly, the results of the study conducted by Eftekhar et al. (2021) showed that gynecologic cosmetic surgery led to significant improvement in the women’s body image, sexual functioning, and sexual satisfaction. They also concluded that sexual functioning was related to and a significant predictor of both own and partner’s sexual satisfaction [18]. Moreover, Goodman et al. (2016) showed that female genital cosmetic surgery results in both ‘partner’s satisfaction’ and ‘enhancement of sexual function’. They also found positive outcomes where 97% of the women reported overall satisfaction, and a majority of them indicated sexual and emotional enhancement after female genital cosmetic surgery [19].

The findings suggest that female genital cosmetic surgery improves the women’s body image and sexual function and the couples’ sexual satisfaction, especially that of husbands. Improving these factors might lead to a healthier and more pleasurable marital relationship. Because of people sociocultural aspects in Kurdistan region, they need to be more aware of female sexual needs and marital relationship. To investigate the issue more, conduction of further studies is recommended.

Ethics approval and consent to participate

The study was carried out in accordance with the Declaration of Helsinki. It was approved by the Ethics Committee of Howler Medical University (No. 8960054 dated 15th September 2021). Informed consent was obtained from all individual participants included in the study. Participants were assured of the confidential nature of the information gathered. All data collected were anonymized using unique study identifiers.

Acknowledgements

The authors would like to all the participants and coordinator of the center for cosmetic surgery at Erbil Kurdistan, Iraq.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Authors’ contributions

TJP, AAS, and WH contributed to the study conception and design. Data collection was conducted by TJP, and WH. Data analysis were performed by TJP, KS, and AAS. All authors contributed to the interpretation of the findings. The first draft of the manuscript was written by TJP, AAS, and KS. All authors contributed to the revision of the manuscript and approved the final manuscript.

Consent to publication

Not applicable.

Conflict of interest

None of authors declare conflict of interest.

Funding

This study was not funded by any funding bodies.

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No competing interests reported.

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You are reading this latest preprint version

Women’s experience and perspectives toward genital cosmetic surgery: A qualitative study

Status:

Version 1

Abstract

Introduction

Patients And Methods

Research design

Study procedures

Sample size and sampling technique

Findings Of The Study

The first main theme: Husband Satisfaction

The second main theme: Self-confidence

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1