A cosmetic surgical procedure to alter women's genitals is rising in popularity thanks in part to the porn industry, even as many questions loom about unknown medical and social consequences.

Labiaplasty involves “trimming” or reshaping the labia minora, usually to make them smaller or more symmetrical.

Labiaplasty is the second-fastest growing form of cosmetic surgery, according to the American Society for Aesthetic Plastic Surgery. The procedure was performed 5,070 times in 2013, a 44 percent increase over 2012. It's difficult to determine how many were performed prior to 2012; that was the first year ASAPS tabulated the surgery in its annual statistics.

101 Vagina, an art exhibition and book, began touring North America April 5. Part of its mission is to counteract the negative body image accompanying the rise of labiaplasty and other cosmetic surgeries. Photo courtesy of 101 Vagina.

Too Little Research

Labiaplasty is not new. It and other vaginal procedures have been used historically as forms of reconstructive surgery. It was, however, performed mainly when deemed medically necessary by the American College of Obstetricians and Gynecologists for conditions such as labia hypertrophy (a type of overgrowth), congenital conditions, or chronic irritation.

It is only within the last few years labiaplasty has been adopted – and advertised - by the cosmetic surgery community. And little formal training exists. Dr. Sean Rice, a Toronto-based plastic surgeon, told CBC News that he learned the procedure from conferences.

Research on labiaplasty is even less developed. Almost no studies have been done looking at long-term outcomes or complications, and a number of the studies that have been done focus mainly on patient satisfaction measures. In fact, when researchers at the University College London Elizabeth Garrett Anderson Institute of Women’s Health in the U.K. attempted in 2009 to conduct a systematic review of the literature, what they were able to find was “extremely rudimentary and precluded the use of the recommended methodology.” Even the rubric for patient satisfaction of extant studies “mostly reflected anecdotes or were based on providers questioning recipients as to how they felt about the intervention after it had taken place.”

The fact that labiaplasty is an elective surgery combined with the absence of research has led several major medical organizations to oppose the procedure, including the ACOG and the Society of Obstetricians and Gynecologists of Canada.

Some have gone farther, arguing that the desire for aesthetic vaginal surgeries is eerily reminiscent of the female genital mutilation crisis in other countries. One of the key factors the World Health Organization uses in defining FGM is its lack of health benefits – a feature FGM shares with many labiaplasties.

Nor does labiaplasty always produce satisfactory results. One case report from the Aesthetic Surgery Journal describes two women who sought corrective surgery after their labiaplasties because of deformities in their clitoral hoods they said had not been present prior to the procedure.

Porn's Unique Role

An important difference between labiaplasty and FGM is the matter of consent. But consent may not be free of societal considerations. The WHO points out that FGM tends to be perpetuated by cultural tradition where it is practiced, noting that “social pressure to conform to what others do and have been doing is a strong motivation to perpetuate the practice.”

Plastic surgeons certainly do their work with greater precision and care than is exhibited in most FGM rituals. And there is definitely less social pressure in North America regarding vaginal aesthetics.

But that could be changing, thanks in part to the increased availability of pornography. Reviews on sites such as RealSelf.com seem to confirm the correlation: Jennygirl wrote, for instance, "Now I look like a Playboy model down there."

Adult entertainer Andre Shakti told the CBC her exposure to porn made her insecure about her own labia. Though she doesn't want labiaplasty anymore, she had considered it for years. "I was basing the idea of typical on what I’d seen in porn because I didn’t know differently. When I found out about the surgery at 19, it was always there at the back of my mind, ‘when I can afford it, I’ll do it,'” she said.

Celebrities such as Sharon Osbourne have also admitted having vaginal surgery recently, adding to its cultural currency.

Plastic surgeons are using these pressures to conform in their own advertising. The Manhattan Center for Vaginal Surgery proclaims “Neatness Counts.” Even EHow has jumped on the bandwagon with an article explaining how men can suggest labiaplasty to their spouses.

The porn industry, of course, is not directly advocating women get aesthetic vaginal surgeries. To some extent, what is considered attractive in pornography is merely a reflection of broader cultural trends.

However, porn has a unique role in defining modern cultural perceptions of vaginal aesthetics: there are few other outlets in which men or women can actually see what another person's vagina looks like.

And porn is increasingly becoming a predominant venue for vaginal comparison, especially among teens and young adults.

It has only been in the last decade that streaming and downloading videos and pictures could be done with ease. According to statistics compiled by the advocacy group Family Safe Media, 90 percent of 8-to-16 year olds have viewed porn online, and 80 percent of 15-to-17 year olds have had “multiple hard core exposures.” Many of these viewers develop expectations about sex – including aesthetics – long before having it.

There is extensive literature detailing various ways in which media exposure influence body image, but little work has been done specifically to investigate media effects on conceptions of female genitalia. In 2013, one experiment out of Australia’s University of Queensland School of Psychology suggested that images of altered vaginas could indeed influence women's beliefs about what's normal.

Three groups of women were shown images of modified vaginas, unmodified vaginas, or no images. Then all were shown images of a mix of modified and unmodified vaginas. The control group was 18 percent less likely to rate the modified vulvas as normal than those who initially saw the altered vaginas, and 13 percent less likely to rate them as society's ideal.

If labiaplasty is being spurred by exposure to an unrealistic ideal, how does one counteract it?

One effort is being headed by photographer Philip Werner, whose book and art project, 101 Vagina, seeks to break down “the taboo around vaginas and body image shame generally.”

The reach of the fine arts and the medical communities is limited, though, and societal restrictions on sexually explicit material in popular media outlets will continue to make porn the de facto source for vaginal comparisons.

For the moment, opportunities for women to be exposed to realistic examples of other vaginas remain few and far between. On this point, the promoters of labiaplasty have the advantage.