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Survey of male perceptions regarding the vulva Donna Mazloomdoost, MD; Catrina C. Crisp, MD, MSc; Lauren B. Westermann, DO; Janine M. Benbouajili, MA; Steven D. Kleeman, MD; Rachel N. Pauls, MD OBJECTIVE: The purpose of this study was to characterize male preferences of vulvar appearance, their awareness of labiaplasty, and their knowledge of genital anatomy. STUDY DESIGN: Men 18-80 years old were recruited via emails sent by an Internet provider to participate in a 27-question web-based survey. The questionnaire included images and queried demographics, men’s familiarity with vulvar anatomy, preferences regarding labial appearance, and awareness of labiaplasty. Two deployments to >150,000 email addresses were sent. Demographic data were described using frequencies for categoric variables and mean measures of central tendency for continuous variables. Logistic regression models were used to analyze associations between demographics and responses. RESULTS: Two thousand four hundred three men responded to the
survey. After excluding incomplete and ineligible surveys, 1847 surveys were analyzed. The median age of respondents was 55 years. The majority was white (87%), married (68%), employed (69%), and had completed high school or beyond (97%). One-third of the respondents lived in the South, with the other regions nearly equally represented. A significant majority, 95%, reported having been
sexually active with women, and 86% felt comfortable labeling the vulvar anatomy. With regard to preferences, more respondents considered smaller labia attractive compared to large labia; yet 36% of the men remained neutral. Men also showed a preference for partially or completely groomed genitals compared to natural hair pattern. Whereas 51% of participants believed the appearance of a woman’s labia influenced their desire to engage in sexual activity, 60% denied it affected sexual pleasure. Only 42% of men were familiar with labiaplasty, and 75% of all respondents would not encourage a female partner to change her genital appearance. Multivariable analysis revealed younger age to be associated with preferences for small labia and complete genital hair removal, as well as familiarity with labiaplasty. CONCLUSION: In this national survey, men demonstrated familiarity
with the female anatomy, but many did not feel it impacted sexual desire or pleasure. Moreover, the majority lacked strong preferences for a specific vulvar appearance and would not encourage a female partner to alter her genital appearance surgically. Key words: cosmetic, genitoplasty, labia, labiaplasty, male perception, vulvar appearance
Cite this article as: Mazloomdoost D, Crisp CC, Westermann LB. Survey of male perceptions regarding the vulva. Am J Obstet Gynecol 2015;213:.
F
emale genital plastic surgery (FGPS) refers to a composite of procedures aimed to alter the vulva or vagina, often performed for nonmedical indications.1 FGPS has become increasingly popular.2 According to the American Society for Aesthetic Plastic Surgery, 5070 labiaplasty procedures were performed in the United States in 2013, a 44% increase from 2012.3 In response to this perceived increase, the American Congress of Obstetricians and
Gynecologists released a committee opinion in 2007 stating: “Women should be informed about the lack of data supporting the efficacy of these procedures and their potential complications.”1 Furthermore, the committee opinion expressed that patient concerns may be reduced through reassurance that a wide variety of normal genital appearances exist.4 Available literature, however, is lacking regarding patient motives for seeking
From the Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology (Drs Mazloomdoost, Crisp, Westermann, Kleeman, and Pauls), and Hatton Research Institute (Ms Benbouajili), TriHealth/Good Samaritan Hospital, Cincinnati, OH. Received Dec. 19, 2014; revised April 27, 2015; accepted May 28, 2015. Supported by the TriHealth Medical Education Research Fund. The authors report no conflict of interest. Presented as a poster at the 41st Annual Scientific Meeting of the Society of Gynecologic Surgeons, Orlando, FL, March 22-25, 2015. Corresponding author: Donna Mazloomdoost, MD. [email protected] 0002-9378/$36.00 ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2015.05.063
FGPS. Media images, Internet advertising, physical discomfort, impedance of sexual activity, and dissatisfaction with appearance have been cited as indications.5-8 Recently, research has evaluated female opinions of their own vulvar appearance as well as patient and physician definitions of normal anatomy to shed light on these issues.4,9 In both US and European population surveys, most women were satisfied with their vulvar appearance; nevertheless, approximately 7% would consider labiaplasty.6 Female perception may be only part of the impetus driving this demand. It is speculated that male attitudes play a role in female decision-making, yet there is a paucity of data regarding male perceptions.7,10 Due to potential influences on a woman’s desire to pursue cosmetic interventions, we sought to understand male perceptions regarding the vulvar anatomy. Specifically, we explored male preferences with respect to appearance,
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FIGURE 1
Labia of varying size
M ETHODS This was an Internet-based crosssectional survey study administered through a secure online server at SurveyMonkey (Palo Alto, CA). Institutional Review Board approval was granted by TriHealth, Cincinnati, OH. Funding was obtained through an educational research grant from the E. Kenneth Hatton Medical Education Research Fund, TriHealth, Inc. Males between the ages of 18 and 80 in the United States were eligible and recruited via email addresses obtained through an Internet-based provider, Infogroup Inc (Omaha, NE). Infogroup is an Internet marketing resource that obtains email addresses from partnered company websites. Individuals providing these email addresses are >18 years old and have agreed to inclusion without compensation. To prevent duplication, a time and date stamp, Internet provider address, and a source Uniform Resource Locator are recorded and stored during data completion. The survey was designed through SurveyMonkey to allow only one response per computer, and participants could only access the survey via the emailed link. A goal response rate of 600 completed surveys was deemed appropriate for this descriptive study. To account for invalid email addresses and a predicted survey response rate of 1-3%, Infogroup estimated, based on their previous experience, that approximately 150,000 email addresses would be required, with a second email blast 1 week after the initial deployment. All email addresses were kept confidential by Infogroup. The email addresses were selected to obtain a representative age range and geographic sampling of men. The emails were distributed on Aug. 13, 2014, with a second deployment on Aug. 20, 2014. The email subject was titled, “Survey opportunity,” and the body of the message explained the purpose of the study, contained a link to the survey, and provided a notice that images
Images of the various labial sizes that were shown to the participants. Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
would be included. The participants were informed that their participation was voluntary and confidential and that consent would be provided by completing the survey. Upon accessing the link, a cover letter explained all the information to the participants again. The survey remained active for 2 months; responses were collected for analysis at that time. Participants could access the questionnaire only once. The survey, which consisted of 27 questions and included images, was designed by the authors to query men’s familiarity with vulvar anatomy, preferences regarding labial appearance, and awareness of labiaplasty. The survey was pretested with a sample of 30 men, and suggested changes to image labels
and language were incorporated into the final version. Eight demographic questions initiated the survey. The participants were then asked about familiarity with naming the external female genital anatomy and were provided an image to label the anatomy. The image was an artist rendition of the female vulva with arrows pointing towards the following structures: clitoris, urethra, labia minora, labia majora, vagina, and anus. They were provided with a list of anatomic names that included the labeled structures and 2 structures not labeled (the Mons and Skene’s glands) to prevent any guidance in selecting the anatomic labels. The participants were also surveyed regarding their history of sexual activity
FIGURE 2
Labia of varying hair pattern
Images of the various hair patterns that were shown to the participants. Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
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ajog.org with female partners, lifetime sexual partners, and the influence of a woman’s genital appearance on their desire for and pleasure with sexual activity. Six images were reproduced with permission.11 All images were of unaltered female genitalia. Three images were selected to represent varying labial sizes (Figure 1); 3 others represented varying hair patterns (Figure 2). The men were asked to rate the images as attractive/ appealing, neutral, or unattractive/ unappealing. The groups of images were followed by 1 question asking about preference of labial size and genital hair patterns. The respondents had the opportunity to select from the following choices for labial size: small, large, no preference, and “I don’t know.” Similarly, they were given the following options for hair pattern: natural, trimmed/ partially groomed, partially removed, complete removal, and no preference. Finally, the survey concluded with 4 questions regarding familiarity with FGPS and whether the participant would encourage a female partner to alter her genital appearance or pursue surgery if her appearance was different from his preference. Statistical analysis was carried out using SPSS software (version 22.0; SPSS Inc, Chicago, IL). Descriptive statistics were calculated for continuous and categoric data. The c2 test was used to analyze the relationship between demographics and responses (2-tailed, a ¼ .05). Simple logistic regression was used to further analyze significantly associated variables. Multiple logistic regression models were employed to determine which variables had the strongest association with responses.
R ESULTS After 2 email deployments, a total of 2403 participants responded to the survey. The first deployment delivered 144,501 email messages, with an estimated open rate of 13.7%. The second deployment delivered 190,620 email messages, with an estimated open rate of 12.6%. The larger second deployment included the original email messages and additional email messages to account for invalid email addresses in the first
TABLE 1
Demographics of survey respondents (n [ 1847) Characteristic
n (%)
Median age, y (interquartile range)
55 (16)
Age category, y 18-24
36 (1.9)
25-44
333 (18.0)
45-64
1058 (57.3)
65-80
420 (22.7)
Race Black/African American
66 (3.6)
White
1613 (87.3)
Native American
16 (0.9)
Hawaiian or Pacific Islander
9 (0.5)
Asian
31 (1.7)
Other
44 (2.4)
Preferred not to answer
68 (3.8)
Ethnicity Hispanic
77 (4.2)
Not Hispanic
1714 (92.8)
Preferred not to answer
56 (3.0)
Level of education Less than high school
16 (0.9)
High school graduate
204 (11.0)
Some college
455 (24.6)
College graduate
512 (27.7)
Some graduate school
125 (6.8)
Graduate school
493 (26.7)
Preferred not to answer
42 (2.3)
Relationship status Single
331 (17.9)
Married
1250 (67.6)
Separated and/or divorced
161 (8.7)
Widowed
34 (1.8)
Preferred not to answer
71 (3.8)
Employment status Full-time
1117 (60.5)
Part-time
155 (8.4)
Unemployed
456 (24.7)
Preferred not to answer
119 (6.4)
Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
(continued)
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TABLE 1
Demographics of survey respondents (n [ 1847) (continued) Characteristic
n (%)
Income category $85,001
751 (40.7)
Preferred not to answer
324 (17.5)
US region Northeast
527 (28.5)
South
616 (33.4)
Midwest/Central
333 (18.0)
West
371 (20.1)
Area population 500,000
600 (32.5)
Do not know
167 (9.0)
Sexually active with women in the past Yes
1755 (95.0)
No
57 (3.1)
Preferred not to answer
35 (1.9)
Number of sexual partners 0
36 (1.9)
1-2
315 (17.1)
3-5
294 (15.9)
6-10
328 (17.8)
>10
722 (39.1)
Preferred not to answer
152 (8.2)
Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
deployment. Due to the confidential nature of responses, we were unable to adequately estimate the proportion of email messages that were delivered or viewed and therefore could not ascertain a true response rate. Of the 2403 participants, 556 had to be excluded because the reported age was outside the eligibility range or because the survey was not completed in its entirety; therefore, 1847 survey responses were analyzed.
The median age of respondents was 55 years (interquartile range, 16). Over half of respondents (57%) were 45-64 years old; 2% were 18-24 years old; 18% were 25-44 years old, and the remaining 23% were >65 years old. The majority was white (87%), not Hispanic (93%), completed high school or beyond (97%), married (68%), employed (69%), and had a household income of >$65,000 (55%). The respondents were
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distributed almost evenly with regard to region of habitation; the largest proportion lived in the southern United States (33%). Approximately one-third (32%) reported living in urban areas with populations >500,000 (Table 1). A significant majority (95%) reported currently being or having ever been sexually active with women; the largest proportion of respondents (39%) reported >10 lifetime partners. Eighty-six percent felt “very” or “somewhat” familiar with naming the female anatomy. When asked to label the anatomic diagram, the majority correctly labeled the female genital anatomy, with the clitoris and anus being correctly labeled most often (92% and 93%, respectively; Table 2). The participants were asked to rate their opinion of the images of various sized labia. Regarding the images most viewed as attractive, 43% of the respondents rated small labia as attractive/ appealing; 43% rated middle-sized labia as attractive/appealing, and 24% rated large labia as attractive/appealing.With respect to finding the images unattractive or unappealing, men most often reported viewing the large labia this way (46%), followed by the middle-sized labia (20%), and finally the small labia (16%) (Figure 3). However, over onethird of the respondents (36%) were neutral towards the appearance of all 3 images. Additionally, when specifically queried whether they had a preference of labial size, over half reported no preference (54%; Table 2). Men also rated their preferences for hair pattern of the female genitalia. They most often reported the partially groomed image as appealing/attractive (67%) compared with the images of complete hair removal (47%) and natural hair pattern (37%; Figure 3). When specifically asked regarding any preference for hair pattern, 16% responded that they would prefer a natural hair pattern; 39% preferred partial removal of hair; 24% preferred complete hair removal, and 19% reported no preference (Table 2). Fifty-one percent of men reported that the appearance of a woman’s genitalia would influence his desire to
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ajog.org engage in sexual activity with that woman. Notwithstanding, 60% responded that the appearance would not impact their pleasure with sexual activity (Table 2). Regarding FGPS, only 42% of respondents were familiar with these procedures. When they reported familiarity, they most often learned about it via a nonsocial networking Internet site, followed by information from a female friend (data not shown). Overall, 75% of respondents would not encourage a female partner to alter the appearance of her genitalia, even if the appearance was not his preference, and only 10% stated they would encourage a female partner to pursue surgical alteration (Table 2). Using c2 tests of association and simple logistic regression, the relationship between demographic variables and responses were tested. Responses that were analyzed were (1) the perception that small labia or complete hair removal is attractive, (2) the perception that large labia or natural hair pattern is unattractive, (3) a response of “yes” to encouraging changing vulvar appearance or pursuing surgical alteration, and (4) reporting familiarity with FGPS. After this initial analysis, variables significantly associated were entered into multiple logistic regression models. Both age and the number of lifetime sexual partners remained significantly associated with reporting the image of small labia as attractive. When compared to respondents 65 years older, younger respondents 18-24 years old were approximately 3 times more likely to find the small labia attractive (Table 3). Additionally, respondents with >10 lifetime sexual partners were most likely to find small labia attractive compared to respondents with zero sexual partners (Table 3). In contrast to this, with regards to the large labia, the number of lifetime sexual partners negatively correlated with finding the image of large labia unattractive. Specifically, men who reported >10 lifetime sexual partners were less likely to report the large labia as unattractive, compared to those reporting zero partners (P ¼ .003; odds ratio [OR],
TABLE 2
Familiarity with female genital anatomy and preferences (n [ 1847) Responses
n (%)
Perceived familiarity with female genital anatomy Very familiar
607 (32.9)
Somewhat familiar
983 (53.2)
Neither familiar nor unfamiliar
176 (9.5)
Somewhat unfamiliar
51 (2.8)
Very unfamiliar
30 (1.6)
Correctly labeled anatomic components
a
Anus
1726 (93.4)
Clitoris
1707 (92.4)
Vagina
1545 (83.6)
Urethra
1444 (78.2)
Labia minora
1170 (63.3)
Labia majora
1163 (63.0)
Appearance of a woman’s genitalia influences your desire to engage in sexual activity Yes
949 (51.4)
No
787 (42.6)
I do not know
111 (6.0)
Size of a woman’s labia affects your pleasure with sexual activity Yes
389 (21.5)
No
1117 (60.5)
I do not know
332 (18.0)
Would encourage partner to change the appearance of her genitalia Yes
149 (8.1)
No
1386 (75.0)
I do not know
312 (16.9)
Would encourage partner to get surgery to change the appearance of her genitalia Yes
178 (9.6)
No
1376 (74.5)
I do not know
293 (15.9)
Familiar with female genital plastic surgery
a
Yes
777 (42.1)
No
924 (50.0)
I do not know
146 (7.9)
Survey questions that ask respondents to label the components of the female genital anatomy were optional. Percentages that are given include those respondents who skipped the question to keep a consistent denominator of 1847, which is the total number of respondents who completed all required survey questions.
Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
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FIGURE 3
Male preferences of labial size and hair pattern
CI, 0.17e0.68), compared to zero sexual partners. Men living in the South (P ¼ .01) and those employed full time (P ¼ .02) were more likely to encourage a female partner to change her genital appearance. Likewise, men from Southern states were more likely than those living in the Northeast (P ¼ .01) or Midwest (P ¼ .02) to encourage a female partner to pursue surgical alteration. Finally, education, age, and geographic location were associated with familiarity with labiaplasty (Table 3). Men with higher education and younger age were more likely to be familiar, while those who lived in the Midwest were least familiar with labiaplasty.
C OMMENT
Responses of the participants to the attractiveness of (top) various labial sizes and (bottom) hair patterns. Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
0.33; 95% confidence interval [CI] 0.16e0.68; data not shown). Thus, it appears that while men with more sexual partners found small labia attractive, they did not find large labia unattractive. When considering the image of complete hair removal, younger age, greater income, and more lifetime partners were found to have an association with finding this pattern attractive (Table 3). Similarly, age and number of sexual
partners were found to be correlated with reporting natural hair pattern as unattractive (data not shown). Men 1824 years of age were more likely to rate natural hair pattern as unattractive, when compared with men >65 years old (P ¼ .03; OR, 2.22; 95% CI, 1.08e4.55). Additionally, reporting >10 lifetime partners was associated with a lower likelihood of finding natural hair pattern unattractive (P ¼ .002; OR, 0.34; 95%
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In a large national survey of male perceptions regarding vulvar appearance, the majority of men were knowledgeable about the female genital anatomy. Vulvar aesthetics were deemed to impact sexual desire in approximately half of all subjects but did not impact pleasure with sexual activity in the majority. While smaller and more groomed labia were described as attractive more often, particularly by younger men, many remained neutral about labial appearance. Finally, most men were unfamiliar with labiaplasty and would not encourage a female partner to pursue this. Contrary to other findings, we were able to demonstrate that the majority of men correctly labeled the female genitalia.12 This could be related to the fact that our respondents were, on the whole, older than those in other studies or that the multiple choice format might have increased the likelihood that respondents would choose the correct answer. Overall, the labia were least likely to be labeled correctly compared with other components of the female genitalia, which is interesting given the subject of the survey. We are unable to explain this finding, but perhaps unfamiliarity with the labia has led to less interest in learning about labiaplasty. It also could mirror the lack of strong preference in these males towards a particular labial appearance. Also of note, a large
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ajog.org majority of respondents were able to correctly label the clitoris, suggesting men are familiar with important structures related to the sexual pleasure of women. While many of the men did not exhibit strong preferences regarding hair patterns, groomed labia were deemed attractive most often. These findings are consistent with pubic hair removal practices performed by today’s women.13 It is important to note that these preferences were not an overwhelming majority and that men who reported more lifetime sexual partners were less likely to find the natural hair pattern unattractive. Possibly as a byproduct of the trend toward labial grooming, more attention has focused on the size and symmetry of these structures. Despite publications stressing the wide variation of normal genital anatomy,1 the popularity of FGPS has continued to rise.3 Although women are motivated by functional implications, aesthetic causes, such as appearance, account for almost half of the impetus driving this demand.14 We demonstrated that many males surveyed did not have strong preferences regarding labial size and did not believe this factor impacts sexual desire or pleasure. This may reassure women who are considering FGPS for such indications. However, we recognize that not all variations of vulvar appearances were evaluated, which could affect these results. Although younger men showed a preference for smaller labia, this trend was not seen in the older populations, possibly suggesting this perception to be related to social trends, such as what is seen in the media, and this influence might decrease with age. Furthermore, while the smaller labia may have been selected as attractive by a larger proportion of men, men who were sexually active and reported multiple lifetime partners were less likely to deem the large labia as unattractive. Though a small proportion of men were familiar with FGPS, younger men and those with higher degrees of education were more likely to report familiarity. Considering that men who
TABLE 3
Results of multiple logistic regression models n (%)
Odds ratio (95% confidence interval)
65-80
130 (31)
1 [Reference]
45-64
476 (45)
1.63 (1.24e2.14)
< .001c
25-44
173 (52)
2.26 (1.61e3.16)
< .001c
18-24
19 (53)
3.15 (1.52e6.54)
.002c
Category
P valuec
Responses of “attractive/appealing” to picture of small labiaa,b Age category, y
No. of sexual partners 0
5 (14)
1 [Reference]
1-2
113 (36)
4.15 (1.54e11.14)
.005c
3-5
120 (41)
5.17 (1.92e13.91)
.001c
6-10
144 (44)
5.70 (2.12e15.27)
.001c
>10
367 (51)
7.62 (2.88e20.17)
< .001c
49 (32)
3.55 (1.28e9.85)
.02c
Prefer not to answer Responses of “attractive/appealing” to picture with hair completely removeda,b Age category 65-80
130 (31)
1 [Reference]
45-64
476 (45)
1.90 (1.45e2.49)
< .001c
25-44
173 (52)
2.55 (1.82e3.58)
< .001c
18-24
19 (53)
4.25 (2.01e9.01)
< .001c
Income category $85,000
363 (48)
2.70 (1.02e7.20)
.046c
Prefer not to answer
144 (44)
2.66 (0.99e7.17)
.05c
No. of sexual partners 0
5 (14)
1 [Reference]
1-2
113 (36)
3.19 (1.36e7.47)
.01c
3-5
120 (41)
2.76 (1.18e6.46)
.02c
6-10
144 (44)
3.76 (1.61e8.79)
.002c
>10
367 (51)
4.32 (1.87e9.96)
.001c
49 (32)
2.28 (0.94e5.55)
.07c
Prefer not to answer
Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
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TABLE 3
Results of multiple logistic regression models (continued) Category
n (%)
Odds ratio (95% confidence interval)
243 (49)
1 [Reference]
P valuec
Response of “yes” regarding familiarity with labiaplastyd,e Level of education Graduate school Some graduate school
62 (50)
0.96 (0.64e1.45)
.86
College graduate
221 (43)
0.73 (0.56e0.95)
.02c
Some college
169 (37)
0.56 (0.42e0.74)
< .001c
High school graduate
60 (29)
0.43 (0.30e0.63)
< .001c
Less than high school
5 (31)
0.58 (0.18e1.88)
.37
Prefer not to answer
17 (40)
0.58 (0.28e1.21)
.15
Age category, y 65-80
143 (34)
1 [Reference]
45-64
462 (44)
1.55 (1.21e1.99)
.001c
25-44
155 (46)
1.89 (1.38e2.59)
< .001c
18-24
17 (47)
2.62 (1.26e5.43)
.01c
Hispanic No
707 (41)
1 [Reference]
Yes
44 (57)
1.79 (1.10e2.91)
.02c
Prefer not to answer
26 (46)
1.29 (0.71e2.35)
.40
US region Midwest
114 (34)
1 [Reference]
Northeast
222 (42)
1.35 (1.01e1.82)
.04c
South
270 (44)
1.41 (1.05e1.88)
.02c
West
171 (46)
1.47 (1.06e2.02)
.02c
No. of sexual partners 0
1 [Reference]
1-2
103 (33)
0.97 (0.44e2.13)
.95
3-5
118 (40)
1.39 (0.64e3.05)
.41
6-10
143 (44)
1.59 (0.73e3.46)
.24
>10
351 (49)
1.93 (0.90e4.15)
.09
51 (34)
1.09 (0.48e2.50)
.83
Prefer not to answer a
11 (31)
Percentages were calculated from the number of respondents in each category who selected “attractive/appealing” divided by the total number of respondents in that category; b Employment status was also included in the model, but the variable was not significant at a ¼ .05; c Significant at a ¼ .05; d Percentages were calculated from the number of respondents in each category who selected ‘yes’ divided by the total number of respondents in that category; e Area population and income categories were also included in the model, but the variables were not significant at a ¼ .05.
Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
reported familiarity with labiaplasty often learned of this via the Internet, it is possible that younger and more educated men have greater ability to
navigate this resource and were therefore more likely to learn about such procedures. Additionally, men who lived in the Midwest were least likely to be
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familiar with these procedures, possibly secondary to their geographic social culture. Perhaps individuals in the Midwest are less exposed to advertisements regarding labiaplasty, or there is less focus on cosmetic surgery compared with other regions. Such local cultural norms may also explain the reason that men in the South are more likely to encourage alterations of the genitalia. One of the key strengths of our study is the large number of respondents of varied ages and geographic distribution. The majority of our respondents (75%) were 25-64 years old, representing a population of interest to women who are considering FGPS, as such women are most often 28-35 years old.15-17 Our study population was also representative of men from all over the United States, with varying income and education levels. Furthermore, providing the questionnaire via an Internet modality helped to preserve the anonymity of the responses, thereby, increasing the chances that men would answer honestly. As with any Internet-based survey, there are limitations inherent to the method of delivery. Selection bias may have impacted our results, as only men who agreed to be contacted via Infogroup were surveyed. Therefore, generalization of these results may be limited to men familiar with Internet navigation. Unfortunately, to limit the survey length, we did not query regarding the respondent’s level of Internet usage. Although Infogroup does retain this information, it was associated with additional costs. In addition, over half of respondents were 45-64 years old, possibly biasing the results due to this distribution. Given the nature of the survey delivery, we were unable to provide information about those who declined to participate. Similarly, a true response rate could not be calculated. Furthermore, to produce a survey with minimal burden, a limited number of images were used, possibly impacting our findings. Finally, we recognize that our respondents were predominantly white, educated, and sexually active. Though this might limit the generalizability of our results, all geographic areas,
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ajog.org age groups, and marital status were represented. In this large national survey, men were generally unaware of FGPS and would not suggest their female partner to pursue it. Although some preferences regarding vulvar anatomy were noted, there was no strong propensity towards any particular appearance. This information is reassuring and can help guide the counseling of patients interested in FGPS. REFERENCES 1. American College of Obstetricians and Gynecologists. Vaginal “rejuvenation” and cosmetic vaginal procedures. ACOG Committee Opinion no. 378. Obstet Gynecol 2007;110: 737-8. 2. Lowenstein L, Salonia A, Shechter A, Porst H, Burri A, Reisman Y. Physicians’ attitude toward female genital plastic surgery: a multinational survey. J Sex Med 2014;11:33-9. 3. American Society for Aesthetic Plastic Surgery (ASAPS). 2012 Statistics. Available at: http://www.surgery.org/media/news-releases/ rising-demand-for-female-cosmetic-genital-surgery-
begets-new-beautification-techniques. Accessed Nov. 21, 2014. 4. Yurteri-Kaplan LA, Antosh DD, Sokol AI, et al. Interest in cosmetic vulvar surgery and perception of vulvar appearance. Am J Obstet Gynecol 2012;207:428.e1-7. 5. Reitsma W, Mourits MJ, Koning M, Pascal A, van der Lei B. No (wo)man is an island: the influence of physicians’ personal predisposition to labia minora appearance on their clinical decision making: a cross-sectional survey. J Sex Med 2011;8:2377-85. 6. Koning M, Zeijlmans IA, Bouman TK, van der Lei B. Female attitudes regarding labia minora appearance and reduction with consideration of media influence. Aesthet Surg J 2009;29: 65-71. 7. Liao L-M, Michala L, Creighton S. Labial surgery for well women: a review of the literature. BJOG 2010;117:20-5. 8. Bramwell R, Morland C, Garden AS. Expectations and experience of labial reduction: a qualitative study. BJOG 2007;114:1493-9. 9. Lloyd J, Crouch NS, Minto CL, Liao LM, Creighton SM. Female genital appearance: “normality” unfolds. BJOG 2005;112:643-6. 10. Schick VR, Calabrese SK, Rima BN, Zucker AN. Genital appearance dissatisfaction: implications for women’s genital image
self-consciousness, sexual esteem, sexual satisfaction, and sexual risk. Psychol Women Q 2010;34:394-404. 11. Karras N. Petals. San Diego, CA: Crystal River Publisher; 2003. 12. Volck W, Ventress ZA, Herbenick D, Hillard PJ, Huppert JS. Gynecologic knowledge is low in college men and women. J Pediatr Adolesc Gynecol 2013;26:161-6. 13. Herbenick D, Schick V, Reece M. Pubic hair removal among women in the United States: prevalence, methods, and characteristics. J Sex Med 2010;7:3322-30. 14. Zwier S. “What Motivates Her”: motivations for considering labial reduction surgery as recounted on women’s online communities and surgeons’ websites. Sex Med 2014;2: 16-23. 15. Crouch N, Deans R, Michala L-M, Liao L, Creighton S. Clinical characteristics of well women seeking labial reduction surgery: a prospective study. BJOG 2011;118:1507-10. 16. Veale D, Eshkevari E, Ellison N, et al. Psychological characteristics and motivation of women seeking labiaplasty. Psychol Med 2014; 44:555-66. 17. Miklos JR, Moore RD. Labiaplasty of the labia minora: patients’ indications for pursuing surgery. J Sex Med 2008;5:1492-5.
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Survey of male perceptions regarding the vulva Donna Mazloomdoost, MD; Catrina C. Crisp, MD, MSc; Lauren B. Westermann, DO; Janine M. Benbouajili, MA; Steven D. Kleeman, MD; Rachel N. Pauls, MD OBJECTIVE: The purpose of this study was to characterize male preferences of vulvar appearance, their awareness of labiaplasty, and their knowledge of genital anatomy. STUDY DESIGN: Men 18-80 years old were recruited via emails sent by an Internet provider to participate in a 27-question web-based survey. The questionnaire included images and queried demographics, men’s familiarity with vulvar anatomy, preferences regarding labial appearance, and awareness of labiaplasty. Two deployments to >150,000 email addresses were sent. Demographic data were described using frequencies for categoric variables and mean measures of central tendency for continuous variables. Logistic regression models were used to analyze associations between demographics and responses. RESULTS: Two thousand four hundred three men responded to the
survey. After excluding incomplete and ineligible surveys, 1847 surveys were analyzed. The median age of respondents was 55 years. The majority was white (87%), married (68%), employed (69%), and had completed high school or beyond (97%). One-third of the respondents lived in the South, with the other regions nearly equally represented. A significant majority, 95%, reported having been
sexually active with women, and 86% felt comfortable labeling the vulvar anatomy. With regard to preferences, more respondents considered smaller labia attractive compared to large labia; yet 36% of the men remained neutral. Men also showed a preference for partially or completely groomed genitals compared to natural hair pattern. Whereas 51% of participants believed the appearance of a woman’s labia influenced their desire to engage in sexual activity, 60% denied it affected sexual pleasure. Only 42% of men were familiar with labiaplasty, and 75% of all respondents would not encourage a female partner to change her genital appearance. Multivariable analysis revealed younger age to be associated with preferences for small labia and complete genital hair removal, as well as familiarity with labiaplasty. CONCLUSION: In this national survey, men demonstrated familiarity
with the female anatomy, but many did not feel it impacted sexual desire or pleasure. Moreover, the majority lacked strong preferences for a specific vulvar appearance and would not encourage a female partner to alter her genital appearance surgically. Key words: cosmetic, genitoplasty, labia, labiaplasty, male perception, vulvar appearance
Cite this article as: Mazloomdoost D, Crisp CC, Westermann LB. Survey of male perceptions regarding the vulva. Am J Obstet Gynecol 2015;213:.
F
emale genital plastic surgery (FGPS) refers to a composite of procedures aimed to alter the vulva or vagina, often performed for nonmedical indications.1 FGPS has become increasingly popular.2 According to the American Society for Aesthetic Plastic Surgery, 5070 labiaplasty procedures were performed in the United States in 2013, a 44% increase from 2012.3 In response to this perceived increase, the American Congress of Obstetricians and
Gynecologists released a committee opinion in 2007 stating: “Women should be informed about the lack of data supporting the efficacy of these procedures and their potential complications.”1 Furthermore, the committee opinion expressed that patient concerns may be reduced through reassurance that a wide variety of normal genital appearances exist.4 Available literature, however, is lacking regarding patient motives for seeking
From the Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology (Drs Mazloomdoost, Crisp, Westermann, Kleeman, and Pauls), and Hatton Research Institute (Ms Benbouajili), TriHealth/Good Samaritan Hospital, Cincinnati, OH. Received Dec. 19, 2014; revised April 27, 2015; accepted May 28, 2015. Supported by the TriHealth Medical Education Research Fund. The authors report no conflict of interest. Presented as a poster at the 41st Annual Scientific Meeting of the Society of Gynecologic Surgeons, Orlando, FL, March 22-25, 2015. Corresponding author: Donna Mazloomdoost, MD. [email protected] 0002-9378/$36.00 ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2015.05.063
FGPS. Media images, Internet advertising, physical discomfort, impedance of sexual activity, and dissatisfaction with appearance have been cited as indications.5-8 Recently, research has evaluated female opinions of their own vulvar appearance as well as patient and physician definitions of normal anatomy to shed light on these issues.4,9 In both US and European population surveys, most women were satisfied with their vulvar appearance; nevertheless, approximately 7% would consider labiaplasty.6 Female perception may be only part of the impetus driving this demand. It is speculated that male attitudes play a role in female decision-making, yet there is a paucity of data regarding male perceptions.7,10 Due to potential influences on a woman’s desire to pursue cosmetic interventions, we sought to understand male perceptions regarding the vulvar anatomy. Specifically, we explored male preferences with respect to appearance,
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ajog.org
FIGURE 1
Labia of varying size
M ETHODS This was an Internet-based crosssectional survey study administered through a secure online server at SurveyMonkey (Palo Alto, CA). Institutional Review Board approval was granted by TriHealth, Cincinnati, OH. Funding was obtained through an educational research grant from the E. Kenneth Hatton Medical Education Research Fund, TriHealth, Inc. Males between the ages of 18 and 80 in the United States were eligible and recruited via email addresses obtained through an Internet-based provider, Infogroup Inc (Omaha, NE). Infogroup is an Internet marketing resource that obtains email addresses from partnered company websites. Individuals providing these email addresses are >18 years old and have agreed to inclusion without compensation. To prevent duplication, a time and date stamp, Internet provider address, and a source Uniform Resource Locator are recorded and stored during data completion. The survey was designed through SurveyMonkey to allow only one response per computer, and participants could only access the survey via the emailed link. A goal response rate of 600 completed surveys was deemed appropriate for this descriptive study. To account for invalid email addresses and a predicted survey response rate of 1-3%, Infogroup estimated, based on their previous experience, that approximately 150,000 email addresses would be required, with a second email blast 1 week after the initial deployment. All email addresses were kept confidential by Infogroup. The email addresses were selected to obtain a representative age range and geographic sampling of men. The emails were distributed on Aug. 13, 2014, with a second deployment on Aug. 20, 2014. The email subject was titled, “Survey opportunity,” and the body of the message explained the purpose of the study, contained a link to the survey, and provided a notice that images
Images of the various labial sizes that were shown to the participants. Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
would be included. The participants were informed that their participation was voluntary and confidential and that consent would be provided by completing the survey. Upon accessing the link, a cover letter explained all the information to the participants again. The survey remained active for 2 months; responses were collected for analysis at that time. Participants could access the questionnaire only once. The survey, which consisted of 27 questions and included images, was designed by the authors to query men’s familiarity with vulvar anatomy, preferences regarding labial appearance, and awareness of labiaplasty. The survey was pretested with a sample of 30 men, and suggested changes to image labels
and language were incorporated into the final version. Eight demographic questions initiated the survey. The participants were then asked about familiarity with naming the external female genital anatomy and were provided an image to label the anatomy. The image was an artist rendition of the female vulva with arrows pointing towards the following structures: clitoris, urethra, labia minora, labia majora, vagina, and anus. They were provided with a list of anatomic names that included the labeled structures and 2 structures not labeled (the Mons and Skene’s glands) to prevent any guidance in selecting the anatomic labels. The participants were also surveyed regarding their history of sexual activity
FIGURE 2
Labia of varying hair pattern
Images of the various hair patterns that were shown to the participants. Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
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ajog.org with female partners, lifetime sexual partners, and the influence of a woman’s genital appearance on their desire for and pleasure with sexual activity. Six images were reproduced with permission.11 All images were of unaltered female genitalia. Three images were selected to represent varying labial sizes (Figure 1); 3 others represented varying hair patterns (Figure 2). The men were asked to rate the images as attractive/ appealing, neutral, or unattractive/ unappealing. The groups of images were followed by 1 question asking about preference of labial size and genital hair patterns. The respondents had the opportunity to select from the following choices for labial size: small, large, no preference, and “I don’t know.” Similarly, they were given the following options for hair pattern: natural, trimmed/ partially groomed, partially removed, complete removal, and no preference. Finally, the survey concluded with 4 questions regarding familiarity with FGPS and whether the participant would encourage a female partner to alter her genital appearance or pursue surgery if her appearance was different from his preference. Statistical analysis was carried out using SPSS software (version 22.0; SPSS Inc, Chicago, IL). Descriptive statistics were calculated for continuous and categoric data. The c2 test was used to analyze the relationship between demographics and responses (2-tailed, a ¼ .05). Simple logistic regression was used to further analyze significantly associated variables. Multiple logistic regression models were employed to determine which variables had the strongest association with responses.
R ESULTS After 2 email deployments, a total of 2403 participants responded to the survey. The first deployment delivered 144,501 email messages, with an estimated open rate of 13.7%. The second deployment delivered 190,620 email messages, with an estimated open rate of 12.6%. The larger second deployment included the original email messages and additional email messages to account for invalid email addresses in the first
TABLE 1
Demographics of survey respondents (n [ 1847) Characteristic
n (%)
Median age, y (interquartile range)
55 (16)
Age category, y 18-24
36 (1.9)
25-44
333 (18.0)
45-64
1058 (57.3)
65-80
420 (22.7)
Race Black/African American
66 (3.6)
White
1613 (87.3)
Native American
16 (0.9)
Hawaiian or Pacific Islander
9 (0.5)
Asian
31 (1.7)
Other
44 (2.4)
Preferred not to answer
68 (3.8)
Ethnicity Hispanic
77 (4.2)
Not Hispanic
1714 (92.8)
Preferred not to answer
56 (3.0)
Level of education Less than high school
16 (0.9)
High school graduate
204 (11.0)
Some college
455 (24.6)
College graduate
512 (27.7)
Some graduate school
125 (6.8)
Graduate school
493 (26.7)
Preferred not to answer
42 (2.3)
Relationship status Single
331 (17.9)
Married
1250 (67.6)
Separated and/or divorced
161 (8.7)
Widowed
34 (1.8)
Preferred not to answer
71 (3.8)
Employment status Full-time
1117 (60.5)
Part-time
155 (8.4)
Unemployed
456 (24.7)
Preferred not to answer
119 (6.4)
Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
(continued)
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TABLE 1
Demographics of survey respondents (n [ 1847) (continued) Characteristic
n (%)
Income category $85,001
751 (40.7)
Preferred not to answer
324 (17.5)
US region Northeast
527 (28.5)
South
616 (33.4)
Midwest/Central
333 (18.0)
West
371 (20.1)
Area population 500,000
600 (32.5)
Do not know
167 (9.0)
Sexually active with women in the past Yes
1755 (95.0)
No
57 (3.1)
Preferred not to answer
35 (1.9)
Number of sexual partners 0
36 (1.9)
1-2
315 (17.1)
3-5
294 (15.9)
6-10
328 (17.8)
>10
722 (39.1)
Preferred not to answer
152 (8.2)
Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
deployment. Due to the confidential nature of responses, we were unable to adequately estimate the proportion of email messages that were delivered or viewed and therefore could not ascertain a true response rate. Of the 2403 participants, 556 had to be excluded because the reported age was outside the eligibility range or because the survey was not completed in its entirety; therefore, 1847 survey responses were analyzed.
The median age of respondents was 55 years (interquartile range, 16). Over half of respondents (57%) were 45-64 years old; 2% were 18-24 years old; 18% were 25-44 years old, and the remaining 23% were >65 years old. The majority was white (87%), not Hispanic (93%), completed high school or beyond (97%), married (68%), employed (69%), and had a household income of >$65,000 (55%). The respondents were
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distributed almost evenly with regard to region of habitation; the largest proportion lived in the southern United States (33%). Approximately one-third (32%) reported living in urban areas with populations >500,000 (Table 1). A significant majority (95%) reported currently being or having ever been sexually active with women; the largest proportion of respondents (39%) reported >10 lifetime partners. Eighty-six percent felt “very” or “somewhat” familiar with naming the female anatomy. When asked to label the anatomic diagram, the majority correctly labeled the female genital anatomy, with the clitoris and anus being correctly labeled most often (92% and 93%, respectively; Table 2). The participants were asked to rate their opinion of the images of various sized labia. Regarding the images most viewed as attractive, 43% of the respondents rated small labia as attractive/ appealing; 43% rated middle-sized labia as attractive/appealing, and 24% rated large labia as attractive/appealing.With respect to finding the images unattractive or unappealing, men most often reported viewing the large labia this way (46%), followed by the middle-sized labia (20%), and finally the small labia (16%) (Figure 3). However, over onethird of the respondents (36%) were neutral towards the appearance of all 3 images. Additionally, when specifically queried whether they had a preference of labial size, over half reported no preference (54%; Table 2). Men also rated their preferences for hair pattern of the female genitalia. They most often reported the partially groomed image as appealing/attractive (67%) compared with the images of complete hair removal (47%) and natural hair pattern (37%; Figure 3). When specifically asked regarding any preference for hair pattern, 16% responded that they would prefer a natural hair pattern; 39% preferred partial removal of hair; 24% preferred complete hair removal, and 19% reported no preference (Table 2). Fifty-one percent of men reported that the appearance of a woman’s genitalia would influence his desire to
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ajog.org engage in sexual activity with that woman. Notwithstanding, 60% responded that the appearance would not impact their pleasure with sexual activity (Table 2). Regarding FGPS, only 42% of respondents were familiar with these procedures. When they reported familiarity, they most often learned about it via a nonsocial networking Internet site, followed by information from a female friend (data not shown). Overall, 75% of respondents would not encourage a female partner to alter the appearance of her genitalia, even if the appearance was not his preference, and only 10% stated they would encourage a female partner to pursue surgical alteration (Table 2). Using c2 tests of association and simple logistic regression, the relationship between demographic variables and responses were tested. Responses that were analyzed were (1) the perception that small labia or complete hair removal is attractive, (2) the perception that large labia or natural hair pattern is unattractive, (3) a response of “yes” to encouraging changing vulvar appearance or pursuing surgical alteration, and (4) reporting familiarity with FGPS. After this initial analysis, variables significantly associated were entered into multiple logistic regression models. Both age and the number of lifetime sexual partners remained significantly associated with reporting the image of small labia as attractive. When compared to respondents 65 years older, younger respondents 18-24 years old were approximately 3 times more likely to find the small labia attractive (Table 3). Additionally, respondents with >10 lifetime sexual partners were most likely to find small labia attractive compared to respondents with zero sexual partners (Table 3). In contrast to this, with regards to the large labia, the number of lifetime sexual partners negatively correlated with finding the image of large labia unattractive. Specifically, men who reported >10 lifetime sexual partners were less likely to report the large labia as unattractive, compared to those reporting zero partners (P ¼ .003; odds ratio [OR],
TABLE 2
Familiarity with female genital anatomy and preferences (n [ 1847) Responses
n (%)
Perceived familiarity with female genital anatomy Very familiar
607 (32.9)
Somewhat familiar
983 (53.2)
Neither familiar nor unfamiliar
176 (9.5)
Somewhat unfamiliar
51 (2.8)
Very unfamiliar
30 (1.6)
Correctly labeled anatomic components
a
Anus
1726 (93.4)
Clitoris
1707 (92.4)
Vagina
1545 (83.6)
Urethra
1444 (78.2)
Labia minora
1170 (63.3)
Labia majora
1163 (63.0)
Appearance of a woman’s genitalia influences your desire to engage in sexual activity Yes
949 (51.4)
No
787 (42.6)
I do not know
111 (6.0)
Size of a woman’s labia affects your pleasure with sexual activity Yes
389 (21.5)
No
1117 (60.5)
I do not know
332 (18.0)
Would encourage partner to change the appearance of her genitalia Yes
149 (8.1)
No
1386 (75.0)
I do not know
312 (16.9)
Would encourage partner to get surgery to change the appearance of her genitalia Yes
178 (9.6)
No
1376 (74.5)
I do not know
293 (15.9)
Familiar with female genital plastic surgery
a
Yes
777 (42.1)
No
924 (50.0)
I do not know
146 (7.9)
Survey questions that ask respondents to label the components of the female genital anatomy were optional. Percentages that are given include those respondents who skipped the question to keep a consistent denominator of 1847, which is the total number of respondents who completed all required survey questions.
Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
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FIGURE 3
Male preferences of labial size and hair pattern
CI, 0.17e0.68), compared to zero sexual partners. Men living in the South (P ¼ .01) and those employed full time (P ¼ .02) were more likely to encourage a female partner to change her genital appearance. Likewise, men from Southern states were more likely than those living in the Northeast (P ¼ .01) or Midwest (P ¼ .02) to encourage a female partner to pursue surgical alteration. Finally, education, age, and geographic location were associated with familiarity with labiaplasty (Table 3). Men with higher education and younger age were more likely to be familiar, while those who lived in the Midwest were least familiar with labiaplasty.
C OMMENT
Responses of the participants to the attractiveness of (top) various labial sizes and (bottom) hair patterns. Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
0.33; 95% confidence interval [CI] 0.16e0.68; data not shown). Thus, it appears that while men with more sexual partners found small labia attractive, they did not find large labia unattractive. When considering the image of complete hair removal, younger age, greater income, and more lifetime partners were found to have an association with finding this pattern attractive (Table 3). Similarly, age and number of sexual
partners were found to be correlated with reporting natural hair pattern as unattractive (data not shown). Men 1824 years of age were more likely to rate natural hair pattern as unattractive, when compared with men >65 years old (P ¼ .03; OR, 2.22; 95% CI, 1.08e4.55). Additionally, reporting >10 lifetime partners was associated with a lower likelihood of finding natural hair pattern unattractive (P ¼ .002; OR, 0.34; 95%
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In a large national survey of male perceptions regarding vulvar appearance, the majority of men were knowledgeable about the female genital anatomy. Vulvar aesthetics were deemed to impact sexual desire in approximately half of all subjects but did not impact pleasure with sexual activity in the majority. While smaller and more groomed labia were described as attractive more often, particularly by younger men, many remained neutral about labial appearance. Finally, most men were unfamiliar with labiaplasty and would not encourage a female partner to pursue this. Contrary to other findings, we were able to demonstrate that the majority of men correctly labeled the female genitalia.12 This could be related to the fact that our respondents were, on the whole, older than those in other studies or that the multiple choice format might have increased the likelihood that respondents would choose the correct answer. Overall, the labia were least likely to be labeled correctly compared with other components of the female genitalia, which is interesting given the subject of the survey. We are unable to explain this finding, but perhaps unfamiliarity with the labia has led to less interest in learning about labiaplasty. It also could mirror the lack of strong preference in these males towards a particular labial appearance. Also of note, a large
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ajog.org majority of respondents were able to correctly label the clitoris, suggesting men are familiar with important structures related to the sexual pleasure of women. While many of the men did not exhibit strong preferences regarding hair patterns, groomed labia were deemed attractive most often. These findings are consistent with pubic hair removal practices performed by today’s women.13 It is important to note that these preferences were not an overwhelming majority and that men who reported more lifetime sexual partners were less likely to find the natural hair pattern unattractive. Possibly as a byproduct of the trend toward labial grooming, more attention has focused on the size and symmetry of these structures. Despite publications stressing the wide variation of normal genital anatomy,1 the popularity of FGPS has continued to rise.3 Although women are motivated by functional implications, aesthetic causes, such as appearance, account for almost half of the impetus driving this demand.14 We demonstrated that many males surveyed did not have strong preferences regarding labial size and did not believe this factor impacts sexual desire or pleasure. This may reassure women who are considering FGPS for such indications. However, we recognize that not all variations of vulvar appearances were evaluated, which could affect these results. Although younger men showed a preference for smaller labia, this trend was not seen in the older populations, possibly suggesting this perception to be related to social trends, such as what is seen in the media, and this influence might decrease with age. Furthermore, while the smaller labia may have been selected as attractive by a larger proportion of men, men who were sexually active and reported multiple lifetime partners were less likely to deem the large labia as unattractive. Though a small proportion of men were familiar with FGPS, younger men and those with higher degrees of education were more likely to report familiarity. Considering that men who
TABLE 3
Results of multiple logistic regression models n (%)
Odds ratio (95% confidence interval)
65-80
130 (31)
1 [Reference]
45-64
476 (45)
1.63 (1.24e2.14)
< .001c
25-44
173 (52)
2.26 (1.61e3.16)
< .001c
18-24
19 (53)
3.15 (1.52e6.54)
.002c
Category
P valuec
Responses of “attractive/appealing” to picture of small labiaa,b Age category, y
No. of sexual partners 0
5 (14)
1 [Reference]
1-2
113 (36)
4.15 (1.54e11.14)
.005c
3-5
120 (41)
5.17 (1.92e13.91)
.001c
6-10
144 (44)
5.70 (2.12e15.27)
.001c
>10
367 (51)
7.62 (2.88e20.17)
< .001c
49 (32)
3.55 (1.28e9.85)
.02c
Prefer not to answer Responses of “attractive/appealing” to picture with hair completely removeda,b Age category 65-80
130 (31)
1 [Reference]
45-64
476 (45)
1.90 (1.45e2.49)
< .001c
25-44
173 (52)
2.55 (1.82e3.58)
< .001c
18-24
19 (53)
4.25 (2.01e9.01)
< .001c
Income category $85,000
363 (48)
2.70 (1.02e7.20)
.046c
Prefer not to answer
144 (44)
2.66 (0.99e7.17)
.05c
No. of sexual partners 0
5 (14)
1 [Reference]
1-2
113 (36)
3.19 (1.36e7.47)
.01c
3-5
120 (41)
2.76 (1.18e6.46)
.02c
6-10
144 (44)
3.76 (1.61e8.79)
.002c
>10
367 (51)
4.32 (1.87e9.96)
.001c
49 (32)
2.28 (0.94e5.55)
.07c
Prefer not to answer
Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
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TABLE 3
Results of multiple logistic regression models (continued) Category
n (%)
Odds ratio (95% confidence interval)
243 (49)
1 [Reference]
P valuec
Response of “yes” regarding familiarity with labiaplastyd,e Level of education Graduate school Some graduate school
62 (50)
0.96 (0.64e1.45)
.86
College graduate
221 (43)
0.73 (0.56e0.95)
.02c
Some college
169 (37)
0.56 (0.42e0.74)
< .001c
High school graduate
60 (29)
0.43 (0.30e0.63)
< .001c
Less than high school
5 (31)
0.58 (0.18e1.88)
.37
Prefer not to answer
17 (40)
0.58 (0.28e1.21)
.15
Age category, y 65-80
143 (34)
1 [Reference]
45-64
462 (44)
1.55 (1.21e1.99)
.001c
25-44
155 (46)
1.89 (1.38e2.59)
< .001c
18-24
17 (47)
2.62 (1.26e5.43)
.01c
Hispanic No
707 (41)
1 [Reference]
Yes
44 (57)
1.79 (1.10e2.91)
.02c
Prefer not to answer
26 (46)
1.29 (0.71e2.35)
.40
US region Midwest
114 (34)
1 [Reference]
Northeast
222 (42)
1.35 (1.01e1.82)
.04c
South
270 (44)
1.41 (1.05e1.88)
.02c
West
171 (46)
1.47 (1.06e2.02)
.02c
No. of sexual partners 0
1 [Reference]
1-2
103 (33)
0.97 (0.44e2.13)
.95
3-5
118 (40)
1.39 (0.64e3.05)
.41
6-10
143 (44)
1.59 (0.73e3.46)
.24
>10
351 (49)
1.93 (0.90e4.15)
.09
51 (34)
1.09 (0.48e2.50)
.83
Prefer not to answer a
11 (31)
Percentages were calculated from the number of respondents in each category who selected “attractive/appealing” divided by the total number of respondents in that category; b Employment status was also included in the model, but the variable was not significant at a ¼ .05; c Significant at a ¼ .05; d Percentages were calculated from the number of respondents in each category who selected ‘yes’ divided by the total number of respondents in that category; e Area population and income categories were also included in the model, but the variables were not significant at a ¼ .05.
Mazloomdoost. Male perceptions of vulvar anatomy. Am J Obstet Gynecol 2015.
reported familiarity with labiaplasty often learned of this via the Internet, it is possible that younger and more educated men have greater ability to
navigate this resource and were therefore more likely to learn about such procedures. Additionally, men who lived in the Midwest were least likely to be
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familiar with these procedures, possibly secondary to their geographic social culture. Perhaps individuals in the Midwest are less exposed to advertisements regarding labiaplasty, or there is less focus on cosmetic surgery compared with other regions. Such local cultural norms may also explain the reason that men in the South are more likely to encourage alterations of the genitalia. One of the key strengths of our study is the large number of respondents of varied ages and geographic distribution. The majority of our respondents (75%) were 25-64 years old, representing a population of interest to women who are considering FGPS, as such women are most often 28-35 years old.15-17 Our study population was also representative of men from all over the United States, with varying income and education levels. Furthermore, providing the questionnaire via an Internet modality helped to preserve the anonymity of the responses, thereby, increasing the chances that men would answer honestly. As with any Internet-based survey, there are limitations inherent to the method of delivery. Selection bias may have impacted our results, as only men who agreed to be contacted via Infogroup were surveyed. Therefore, generalization of these results may be limited to men familiar with Internet navigation. Unfortunately, to limit the survey length, we did not query regarding the respondent’s level of Internet usage. Although Infogroup does retain this information, it was associated with additional costs. In addition, over half of respondents were 45-64 years old, possibly biasing the results due to this distribution. Given the nature of the survey delivery, we were unable to provide information about those who declined to participate. Similarly, a true response rate could not be calculated. Furthermore, to produce a survey with minimal burden, a limited number of images were used, possibly impacting our findings. Finally, we recognize that our respondents were predominantly white, educated, and sexually active. Though this might limit the generalizability of our results, all geographic areas,
SGS Papers
ajog.org age groups, and marital status were represented. In this large national survey, men were generally unaware of FGPS and would not suggest their female partner to pursue it. Although some preferences regarding vulvar anatomy were noted, there was no strong propensity towards any particular appearance. This information is reassuring and can help guide the counseling of patients interested in FGPS. REFERENCES 1. American College of Obstetricians and Gynecologists. Vaginal “rejuvenation” and cosmetic vaginal procedures. ACOG Committee Opinion no. 378. Obstet Gynecol 2007;110: 737-8. 2. Lowenstein L, Salonia A, Shechter A, Porst H, Burri A, Reisman Y. Physicians’ attitude toward female genital plastic surgery: a multinational survey. J Sex Med 2014;11:33-9. 3. American Society for Aesthetic Plastic Surgery (ASAPS). 2012 Statistics. Available at: http://www.surgery.org/media/news-releases/ rising-demand-for-female-cosmetic-genital-surgery-
begets-new-beautification-techniques. Accessed Nov. 21, 2014. 4. Yurteri-Kaplan LA, Antosh DD, Sokol AI, et al. Interest in cosmetic vulvar surgery and perception of vulvar appearance. Am J Obstet Gynecol 2012;207:428.e1-7. 5. Reitsma W, Mourits MJ, Koning M, Pascal A, van der Lei B. No (wo)man is an island: the influence of physicians’ personal predisposition to labia minora appearance on their clinical decision making: a cross-sectional survey. J Sex Med 2011;8:2377-85. 6. Koning M, Zeijlmans IA, Bouman TK, van der Lei B. Female attitudes regarding labia minora appearance and reduction with consideration of media influence. Aesthet Surg J 2009;29: 65-71. 7. Liao L-M, Michala L, Creighton S. Labial surgery for well women: a review of the literature. BJOG 2010;117:20-5. 8. Bramwell R, Morland C, Garden AS. Expectations and experience of labial reduction: a qualitative study. BJOG 2007;114:1493-9. 9. Lloyd J, Crouch NS, Minto CL, Liao LM, Creighton SM. Female genital appearance: “normality” unfolds. BJOG 2005;112:643-6. 10. Schick VR, Calabrese SK, Rima BN, Zucker AN. Genital appearance dissatisfaction: implications for women’s genital image
self-consciousness, sexual esteem, sexual satisfaction, and sexual risk. Psychol Women Q 2010;34:394-404. 11. Karras N. Petals. San Diego, CA: Crystal River Publisher; 2003. 12. Volck W, Ventress ZA, Herbenick D, Hillard PJ, Huppert JS. Gynecologic knowledge is low in college men and women. J Pediatr Adolesc Gynecol 2013;26:161-6. 13. Herbenick D, Schick V, Reece M. Pubic hair removal among women in the United States: prevalence, methods, and characteristics. J Sex Med 2010;7:3322-30. 14. Zwier S. “What Motivates Her”: motivations for considering labial reduction surgery as recounted on women’s online communities and surgeons’ websites. Sex Med 2014;2: 16-23. 15. Crouch N, Deans R, Michala L-M, Liao L, Creighton S. Clinical characteristics of well women seeking labial reduction surgery: a prospective study. BJOG 2011;118:1507-10. 16. Veale D, Eshkevari E, Ellison N, et al. Psychological characteristics and motivation of women seeking labiaplasty. Psychol Med 2014; 44:555-66. 17. Miklos JR, Moore RD. Labiaplasty of the labia minora: patients’ indications for pursuing surgery. J Sex Med 2008;5:1492-5.
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