NHS-funded cosmetic surgery on female genitalia increased from 400 to 1,100 procedures between 2002 and 2008. Most operations were to reduce protuberance of labia minora from between the labia majora.

Morphology of female genitalia may vary. A woman may be aware of such variability from seeing other people’s bodies or looking at pictures and films. These may contribute to a concept of what is normal and in part to women’s anxieties about their own bodies.

The authors looked at differences in female genitalia from three genres of imagery: online pornography, textbooks and feminist publications.

A sample of three frequently visited pornographic websites was used to give a selection of 98 static images of good enough quality for measurements. Anatomy textbooks were used that showed images of the vulva; three photographs and 26 line drawings.

A total of 126 images of the vulva were taken from feminist publications – the authors of these stated that they aimed to show diversity of vulvas.

The protuberance of the labia minora from within the labia majora on static and video images was measured by one of the authors visually on a five point scale where 1 was estimated to be ≤ 10 mm and 5 to be > 40 mm. Another author rated a random 10% of the samples which showed high correlation (0.98) with the first rater.

Five quantitative measures were taken: clitoral hood length, distance from clitoral hood to urethra, labia minora length, labia majora length and perineum length. Not all images were standardised, so ratios of measurements were used to compare images.

For labial protuberance, online pornography and anatomy textbooks skewed towards the less-protruding end of the range (around 10 mm); the high-protruding range (up to 40 mm) was represented by feminist publications. The online pornography and feminist images differed significantly.

All five measurements of genital morphology were correlated with each other at the level of the whole sample and within the online pornography sample (p < 0.001).

The latter sample demonstrated a less varied range of morphologies compared with the other two. Medical illustrations showed reduced proportions and feminist publications the largest.

The authors stress that this paper makes no suggestion about body norms nor postulates a causal link to labioplasty, but suggest there are differences in body images which in part may contribute to a woman’s own beliefs about genital morphology, in the same way the media portrayals of female body shape have been linked to a normative ideal of thinness.

In assessing and reassuring women who request genital surgery, it is important to understand what the norm is. One study has looked at the variation in female genitalia but this was based on 50 premenopausal women undergoing gynaecological procedures not involving external genitalia.¹

GPs may be used to dealing with men who present with anxieties about erectile difficulties and penis size; however, we may be less able to deal with women with anxieties about genital morphology as they tend not to present as often. This paper helps us to understand some of the causes of these anxieties and aids our own understanding of the norm.

Dr Richard Ma

• Howarth H, Sommer V, Jordan FM. Visual depictions of female genitalia differ depending on source. Medical Humanities 2010; 36:75-79