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The Most Private of Makeovers

From The New York Times
November 28, 2004
By MIREYA NAVARRO

THE 39-year-old yoga instructor was like a lot of women these days: she was unhappy with her body and thought that a little sculpturing by a plastic surgeon would help. But her goal was not the usual smoothing out of facial wrinkles or expanding her bust.

Instead she wanted to achieve her beauty ideal in the most private part of her anatomy her genitals.

"I was very, very self-conscious about the way I looked," said the woman, who lives in Boston and spoke on the condition that her name not be used, to protect her privacy. "Now I feel free. I just feel normal."

As millions of women inject Botox, reshape noses, augment breasts, lift buttocks and suck away unwanted fat, a growing number are now exploring a new frontier, genital plastic surgery. They are tightening vaginal muscles, plumping up or shortening labia, liposuctioning the pubic area and even restoring the hymen, sometimes despite their doctors' skepticism about the need for such cosmetic measures.

Procedures that once were reserved for problems like incontinence, congenital malformations or injuries related to childbirth are now being marketed by some gynecologists and plastic surgeons as "vaginal rejuvenation," surgical techniques to enhance sexual satisfaction and improve the looks of the genitals.

Even doctors who do not advertise say they get inquiries from patients every month.

"There's remarkably amazing patient interest in this," said Dr. V. Leroy Young, chairman of the emerging trends task force for the American Society of Plastic Surgeons. "This is at that early stage where there's a lot of enthusiasm for it." Dr. Young said his group, the largest organization of plastic surgeons, has not yet started tracking how many doctors are making "gynecologic cosmetic care" or "vaginal rejuvenation" their specialty, but he said that anecdotal evidence suggests that while the numbers may be relatively small compared with other surgeries, demand for genital procedures is growing rapidly.

The most popular of those are tightening of the vaginal muscles, or vaginoplasty, and reduction of the labia minora, called labiaplasty. Doctors who perform the surgeries, which are usually done on an outpatient basis in less than two hours and can cost from $3,500 to $8,000, say that the reasons for the procedures are not always purely cosmetic; some women with large labia, the surgeons said, suffer discomfort wearing tight pants or during activities like bicycle riding.

But primarily, doctors say, aggressive marketing and fashion influences like flimsier swimsuits, the Brazilian bikini wax and more exposure to nudity in magazines, movies and on the Internet are driving attention to a physical zone still so private that some women do not dare, or care, to look at themselves closely.

"Now women shave," said Dr. Gary J. Alter, a plastic surgeon and urologist with offices in Beverly Hills, Calif., and Manhattan who has come up with his own "labia contouring" technique. "Now they see porn. Now they're more aware of appearance."

Dr. Bernard H. Stern, a gynecologist in Fort Lauderdale, Fla., began to focus exclusively on genital cosmetic surgery four years ago and said he had seen his business quadruple this year, to four to five surgeries a day on patients who come from all over the United States and abroad.

"It is lucrative and it has patient appreciation," said Dr. Stern, who has a Web site and runs ads in strip club magazines.

Other doctors who perform genital surgeries as part of broader medical practices say they are seeing at least a handful of patients a month concerned with the aesthetics of the vagina.

Some procedures, like hymen reconstruction, are relatively rare and confined to a minority of women who need to conform to religious or ethnic rules on virginity, doctors said. A greater number of patients complain of stretched vaginal muscles because of childbirth and aging, or inner labia that are too big, too uneven or unsightly.

"The women feel undesirable or unpretty," Dr. Stern said. "Even if nobody sees it, they see it."

The yoga instructor from Boston, who flew to Dr. Alter in Beverly Hills for a labiaplasty four years ago, said she was "asymmetrical": part of her inner vaginal lips extended about half an inch beyond the outer labia.

"The only women I could compare myself to was women in pornographic movies," she said. "They were tiny and dainty and symmetrical. Nobody looked like me."

A 34-year-old housewife from Long Island said a similar problem nagged her through adolescence, marriage and three children. Like other women interviewed for this article, she would speak only on the condition of anonymity because of the private nature of the subject and fear of ridicule.

"It never bothered my husband," she said, "but it was always like `Yuck!' All I know is that what I had I didn't like."

Just two years ago, she said, she could not find a doctor in her area with experience in labiaplasty or who would not play down the problem and try to keep her from seeking a surgical solution.

Last year she went online and found Dr. Edward Jacobson, a gynecologist in Greenwich, Conn., who performed a labiaplasty using a laser technique.

Now, she said, "I look down and I say, that's the way it should be."

But, some doctors warn, buyer beware. Vaginoplasties are often touted as a way to improve sexual satisfaction for women, but Dr. Thomas G. Stovall, president of the Society of Gynecologic Surgeons, the principal group for gynecologic surgeons with academic appointments, said there is no scientific data to back up the claim.

The opposite is true, he said; painful intercourse can result if the vaginal muscles are too snug.

Other possible risks from genital procedures are painful scarring or nerve damage that could result in loss of sensation or hypersensitivity, according to some doctors. But they added that the procedures have a low rate of complications and that their happy customers reject those qualms.

A 41-year-old police officer in Fort Lauderdale who saw Dr. Stern for vaginal surgery last June said that after having four children she thought her vaginal muscles needed improvement, both for her and for her partner.

Like many other genital surgery patients, the officer has had other plastic surgeries, including breast augmentation and liposuction.

"I just felt that I keep myself in shape everywhere else, and this would make me feel better," she said, adding that the surgery has given her more intense sexual enjoyment.

One patient, a 22-year-old college student from Toronto, said she had never had intercourse until after her labiaplasty because she felt "insecure and ugly" about excess labia tissue.

"It's just that when you feel bad about your body, especially this part of your body, it's kind of impossible to let your true feelings and passions show," she said.

Now, after the surgery last May, she said, "I have nothing to hide."

Some sex therapists are troubled that the emphasis on a youthful look in the doctors' ads are creating demand. And some pointed out that there are dissatisfied customers as well.

Dr. Laura Berman, director of a treatment clinic for female sexual dysfunction in Chicago, the Berman Center, said some of her patients complained that they ended up with pain or could no longer be sexually aroused after undergoing some of the procedures. Unlike most other cosmetic procedures, she said, genital plastic surgery has the potential to harm function.

"Any time you're having surgery that involves any kind of intervention in the genitals you're asking for trouble in regard with your sexual function," she said.

Dr. Berman, who this year completed a national survey on the effect of women's "genital self-image" on sexual function, said most women "walk around with a feeling of anxiety about their genitals" because women are not usually brought up feeling confident about that part of the body. "These surgeries kind of play into that," she added. She said her research showed that a woman's comfort level with her genitals affects her sexual enjoyment.

But she and other sex therapists say they recommend less drastic measures, like Kegel exercises to strengthen pelvic muscles, as a way to deal with any insecurities.

Some plastic surgeons, who note that there is no such thing as "normal" female genitals, are scratching their heads.

"It doesn't make a lot of sense to me, to be honest," said Dr. Young, of the American Society of Plastic Surgeons, who said he does a small number of labiaplasties in his practice in St. Louis. "I try to discourage most patients."

Even people in the pornographic film industry say there is no universal standard of beauty for genitals and that, in any event, men fantasize about the woman, not any one body part.

Mark Kernes, a senior editor with the trade magazine Adult Video News, said, "I really don't think most men care."

Some doctors said men would be flocking to their offices for their own genital surgery if such procedures as penile enlargement were not fraught with complications and unintended outcomes.

Dr. Alter, the plastic surgeon and urologist, who performs genital surgery on both women and men, said, "With female genital surgery it's predictable, and women are extremely happy."

The housewife on Long Island agreed. "I'm not saying you should do it on a whim," she said. "But if you think it'd make you feel better, why wouldn't you do it?"