Exploring the motivations for pursuing operative labiaplasty in Chinese patients

Abstract This study aimed to investigate the motivations for Chinese patients seeking operative labiaplasty. Data was collected from January 2018 to December 2019 using a standardized questionnaire, which examined factors influencing patients’ motivations, including aesthetic and functional reasons, as well as psychological factors. Of the 216 patients who responded to the questionnaire within 24 months, 22.2% cited cosmetic reasons, while 38.4% reported functional discomfort. Both functional and aesthetic reasons were cited by 35.2% of patients, while 4.2% reported psychological troubles. It is noteworthy that patients who sought surgical intervention for physical complaints did so as a personal decision, and only 6.3% of patients seeking labiaplasty for cosmetic reasons were influenced by their sexual partner. Additionally, 7.9% and 66.7% of patients with other motivations were influenced by their male spouse, while 2.6% and 33.3% were influenced by the media. In conclusion, this study suggests that most Chinese patients seek labiaplasty for functional reasons, with few being influenced by sexual partners or media. Impact statement What is already known on this subject? The growing demand and interest in labiaplasty surgery has been widely acknowledged. Existing reports from western countries have highlighted that aesthetic concerns are the primary motivations behind patients' requests for this surgical intervention. However, there is limited information available regarding the factors influencing Chinese patients' decisions to undergo labiaplasty, as China has a large population. Therefore, the specific reasons behind Chinese patients' requests for labiaplasty are not well understood. What do the results of this study add? This clinical study focuses on the perspectives of eastern women regarding labia reduction surgery, contributing to the existing literature on this topic. Notably, this study is one of the few that examines the request for surgical reduction of hypertrophy of the labia minora and highlights that not all patients undergo surgical intervention purely for personal reasons. What are the implications of these findings for clinical practice and/or further research? The implications of these findings for clinical practice and further research are significant. Given the increasing demand for labiaplasty, gynecologists in Australia, Western Europe, the United States, and New Zealand are likely to encounter a rising number of women seeking labial reduction surgery. Similarly, labiaplasty has become an increasingly popular cosmetic surgery procedure in China. This study's results differ from previous research, which suggested that functional concerns were the primary motivation for women seeking to undergo labiaplasty. The request for pursuing labiaplasty is influenced not only by personal preferences but also by external factors. Therefore, a comprehensive evaluation before considering the procedure is crucial, and if practitioners are unsure, multidisciplinary specialized evaluation should be considered.


Introduction
It is well recognised that the interest and demand for labiaplasty have increased in recent years.Some reports from Western countries have indicated that the major motivations for requesting surgery were aesthetic concerns.However, as a country with a very large population, limited information is available regarding Chinese patients' reasons for seeking labiaplasty.Moreover, we still know very little about the specific factors that influence their decisions to undergo labiaplasty.The traditional sex culture in China still has a certain impact on women.Therefore, the aim of this study is to figure out the motivations and influencing factors for pursuing operative labiaplasty in Chinese patients.

Methods
This retrospective review was performed on all patients who sought labia minora reduction surgery at our clinic from January 2018 until December 2019.The investigation was carried out by three postgraduates and two residents, who received training to introduce research methods, questionnaire design and distribution, and data acquisition processes.After the patients finished their consultation, an investigator would show them a Quick Response Code to scan by cell phone, which linked to the questionnaire without recording their personal information to maintain confidentiality.If the patients were confused about the content, researchers had to clarify the questions to ensure their understanding.After the patients completed and anonymously submitted the questionnaire, the system would collect the data, which researchers could analyse and statistically evaluated.
Based on published articles, we concluded several items to restructure a simple version of the questionnaire, which consisted of two parts: Part I-patients were asked their age, highest level of education completed and whether they had ever had a sexual partner in their lifetime; Part II-their motivations and influencing factors for seeking labiaplasty (Appendix).Motivations included the following scenarios: aesthetic reasons, functional impairment, both aesthetic and functional reasons, and psychological factors.Patients were also asked whether this was a self-requirement or was influenced by others, such as friends, family, sexual partners, or media.

Discussion
To the best of our knowledge, this is the first study to investigate the motivations for pursuing operative labiaplasty in China.Labia hypertrophy can be caused by various factors such as congenital conditions, repetitive pulling, or infection (see Figure S1).Our preliminary results show that the primary reason for Chinese patients to pursue labiaplasty surgery is functional discomfort, followed by functional and aesthetic concerns.In comparison to the West, Rouzier et al. (2000) found that most patients pursued surgery for aesthetic complaints, followed by discomfort during clothing and exercise, and dyspareunia.Additionally, Crouch et al. (2011) conducted a prospective study of 33 patients with physical or psychological concerns and found that most complaints were related to appearance or discomfort.
This review reveals that 4.2% of people are afflicted with psychological problems such as loss of self-esteem, anxiety, and negative body image.A large proportion of the participants in this study are well-educated (81.4% obtained a college degree).Nevertheless, Herbenick et al. (2011) considered that female genital self-image had nothing to do with educational background.Eastern women are more conservative in their characteristics compared to those in the West.They always consider this topic to be embarrassing and private, and they may be labelled as "bad women" if they choose to discuss it.As for those who were reluctant to complete the questionnaire, they tended to have a negative genital selfimage and, to some extent, a lack of confidence.In another study by Sharp et al. (2016), the appearance of the labia was the most commonly reported motivation for surgery, and relationship status was an important factor that influenced women's decisions to undergo surgery.Similarly, our results state that 63.9% of the participants have a sexual partner and 6.9% were influenced by their male spouse.Sharp et al. (2016) also demonstrated that these women felt anxious and avoided romantic relationships due to their sexual partner's response to the appearance of their labia.
In 2007, Bramwell (2007) conducted a retrospective qualitative study of six women who had undergone labiaplasty to investigate their expectations and experiences.The results revealed that all women felt that their genital appearance was "odd" and that they adhered strongly to cultural norms.Some surgeons consider that the indication for labiaplasty should be physical discomfort rather than appearance.Ackard (2000) reported on the results of a survey completed by 3627 women about body image, self-image, and sexual behaviours.They found that a positive self-image and body image were related to a higher level of sexual satisfaction.However, there is little research on the relationship between them, so we can only speculate that if women perceive dissatisfaction with their bodies, they are less likely to enjoy sexual pleasure.Thus, having a beautiful or "standard" vulva may provide a better functional experience.
Generally speaking, when patients consider labia reduction surgery, outside influence accounts for only 9.2% of cases, with most being affected by their sexual partner.The proportion of emotional problems as the reason for surgery accounts for a mere 4.2% of the participants, but these psychological troubles are all influenced by external factors, indicating that sexual partners and media have an impact on their motivations.
Undeniably, the media has an impact on aesthetic conceptions and culture.However, it should be stressed that there is no standard appearance of the vulva.Exposure to media images of female genitalia draws attention to their appearance.A "normal" genital appearance may come to mind via the internet, pornography, or advertising, leading women to believe that surgery is necessary to achieve the ideal appearance.
In this study, most of the patients were young women (mean age ¼ 31.0,SD ¼ 6.7), and only 2.3% reported being influenced by the media.In 2009, Markey and Markey (2009) examined predictors of young women's interest in cosmetic surgery and concluded that young women's body dissatisfaction is a predictor of cosmetic surgery, and they are more likely to internalise media messages about physical appearance issues.Sharp et al. (2015) noted that media exposure and peer influence on genital appearance dissatisfaction influenced the consideration of labiaplasty.However, this investigation was carried out in the community, and the sociocultural framework may have affected the results.
Previous research indicates that the motivations for pursuing labiaplasty may not only be a personal request but also have outside influences.According to a survey by Lowenstein et al. (2014), most practitioners (75%) recommend that their patients be referred for consultation with either a psychiatrist or a psychologist for a comprehensive evaluation before considering female genital plastic surgery (FGPS).Their study also reported that women who assume FGPS as an improvement of self-esteem may be more likely to be dissatisfied with their vulval appearance if they pick up information that is biased towards certain morphological characteristics.Furthermore, The International Society for the Study of Vulvovaginal Disease (ISSVD) Cosmetic Surgery Committee recommends that body dysmorphic disorder must be considered.If practitioners are unsure, a multidisciplinary specialised evaluation should be considered.

Conclusions
Labiaplasty is becoming increasingly prevalent among women in China.Most Chinese patients seek surgery for functional reasons, and a few are influenced by their sexual partners and the media.Not everyone undergoing surgical intervention does so for purely personal reasons, so it is necessary to perform a comprehensive evaluation prior to considering labial surgery.Future research should focus on surgical satisfaction and satisfaction with life associated with different motivations and should aim to determine how psychological functioning and sex influence motivations and satisfaction with labiaplasty outcomes.