SINCE the dawn of its days as a medical specialty, plastic surgery has been marching inexorably down women's bodies, straightening, slimming, tucking as it goes, restoring the appearance of youth to features sagging with age and smoothing those marked by eccentricity.
Plastic surgery's southward expansion has now entered territory long thought sacred. Today, the vagina and its neighbors -- the labia majora, the labia minora, the clitoral hood -- are the latest bit of feminine real estate considered to be blighted by age or otherwise in need of renovation, beautification and rejuvenation.
Across the country, post-pubescent and peri-menopausal women alike are having their vaginas tightened, their mons pubis liposuctioned, their labial folds nipped and their clitoral hoods tucked. Most are seeking to restore what plastic surgeons are calling "a more youthful look" to this long-secreted corner of the female anatomy and often to improve their sex lives in the process. (In some cases, women with few pretensions to virginity are surprising their partners by having their hymens surgically restored.)
Other women, bothered by the imperfect proportions of their genitalia, undergo surgery just to bolster their self-image -- a boost that often pays sexual dividends as well.
"I was the type who always wanted to have the lights down low" when having sex, says Holly, a 50-year-old medical assistant who recently had surgery to trim her labia minora and who asked that her last name not be used to maintain her privacy. "Just being comfortable with my body, this was huge for me. I was able to be sexually confident."
Even as the small but growing group of genital plastic surgeons devise new and better surgical techniques, they acknowledge the standards women hope to achieve are set mostly by adult film actresses, strippers and nude denizens of the Internet.
"I know what women want," says Dr. David L. Matlock of Los Angeles, an obstetrician turned plastic surgeon who has been a pioneer in devising and popularizing the procedures. He knows, he says, because so many of his patients tote their husband's or boyfriend's magazines into his office and point to photos almost as explicit as the before-and-after ones posted on many surgeons' websites.
More traditional plastic surgeons and gynecologists may be reluctant to endorse such procedures, but the demand is undeniable. Vulvar and vaginal plastic surgery is one of the fastest-growing areas in plastic surgery, say some in the field.
Many of the techniques have been practiced for decades by obstetricians and gynecologists to repair childbirth-related injuries, and by urologists and reconstructive surgeons who repair birth defects or perform sex-reassignment surgery. But in the late 1990s, a few surgeons began offering the procedures as a means to enhance the aesthetic appearance of women's genital organs and, in some cases, to improve sexual function.
Today, in a field that assiduously tracks the demand for tummy tucks, butt lifts and breast implants, there is no data to gauge the scale of demand for these procedures. But there are signs that genital plastic surgery has appeared on the radar screens of social trend-watchers and the medical profession itself.
Next year, the American Society of Plastic Surgeons expects to begin collecting data on the number of vulvar and vaginal procedures its members are performing. Several practitioners of the new procedures, including a pair of Los Angeles plastic surgeons, have been profiled on cable TV shows pitched to viewers hungry for news of the beautiful and famous. And members of the American College of Obstetricians and Gynecologists have begun grumbling that it's an issue on which they need to weigh in.
But Dr. V. Leroy Young, who chairs the Emerging Trends Task Force of the American Society for Aesthetic Plastic Surgery, says the true gauge of these procedures' popularity may lie precisely in the fact that, far from either coast, conservative heartland women are paying doctors like him to perform them.
Young performs about two to three vulvar procedures a month on women who "would never dare ask the question at a church social," but who can now learn about such procedures on the Internet and on TV. "It's right here in middle America," says Young, whose practice is based in Creve Coeur, Mo., a suburb of St. Louis.
Southern California -- the seat of the adult entertainment industry -- is undeniably the birthplace of this fledgling field of surgical alteration.
In 2000, many Americans learned about a new procedure called labiaplasty when a porn star known as Houston had her labia-reduction surgery filmed and distributed to subscribers, then later auctioned off the excised flesh over the Internet.
Sharon Mitchell, executive director of the Adult Industry Medical Healthcare Foundation in Sherman Oaks and Woodland Hills, says few of today's adult film actresses are having the surgery because so many are already very young. But Mitchell, an adult film actress for 25 years before she earned a doctorate in human sexuality, says the adult film industry's emphasis on youth, as well as its growing audience among beauty-conscious women, is almost certainly driving the upsurge in the surgery.
And many women take the standards set by sex workers very much to heart, say doctors performing the surgeries.
"I hear it time and time again," says Dr. Gary Alter, a urologist-turned-plastic-surgeon who operates out of offices in Beverly Hills and New York City. "The woman says, 'I thought I was normal and I watch these movies with my boyfriends and now I feel like I must be a freak.' They feel they're the only ones in the world."
As the procedures have grown in exposure and popularity, a few mainstream gynecologists have sounded the alarm.
"You're basically taking a risk for no or very little benefit" with most of these surgeries, says Dr. Thomas G. Stovall, immediate past president of the Society of Gynecological Surgeons. Stovall warns that with labiaplasties and vaginal tightening, patients run the risk of developing infection and scar tissue, which can decrease sensation -- or worse, cause pain -- in the areas where incisions have been made.
As for the claim that vaginal tightening can enhance sexual gratification, Stovall insists "there is no scientific basis" to support it. "It might make it better for her partners," says Stovall, but the female patient is taking a risk without much prospect of personal benefit.
Feminists too have criticized the trend. Judy Norsigian, co-founder and author of the feminist health tract "Our Bodies, Ourselves," says women who have these surgeries are taking risks to adhere to standards of feminine beauty that are fleeting, unnatural and, ultimately, dictated by a society in which men are fixated on barely pubescent girls.
Norsigian and others have spoken out against Brazilian waxes, a popular hair removal trend that leaves all but a tiny wisp of pubic hair intact, as a reflection of that fetish. In turn, by making women's genitals more visible, the Brazilian wax trend has naturally led more women to take the risky next step of having their genitalia surgically altered, she says.
"We live in a country where people are always thinking up new things, new practices, new ways to make money," says Norsigian. "And if you can play upon an insecurity, you can get a lot of people to do a lot of things."
But many of the patients who pay from $7,000 to $18,000 to have their genitals nipped, tucked and rejuvenated aren't buying the arguments of those who would portray them as feckless pawns.
"I consider myself a feminist, and I feel this is so empowering," says Katie Sokey, a 36-year-old South Pasadena resident on whom Matlock recently performed laser vaginal rejuvenation. "It was a way to take charge of my own sexuality" after giving birth naturally to three strapping babies.
Why women risk it
Women seeking plastic surgery in the genital area vary in their motivations, say those in the field. Many are prompted strictly by aesthetics: They are, says Alter, "women who are in tune with what they should look like."
But a number of patients, including Sokey, turn to plastic surgeons with complaints about physical discomfort, whether from lengthy labia, weakened vaginal walls or a clitoris enlarged by steroids or hormone imbalance. And in many cases, these patients report their concerns have been dismissed, played down or greeted with an unsympathetic shrug from the obstetricians and gynecologists they consulted first.
Sokey had three children at home with a midwife and breast-fed them well into their toddler years. She laughs sheepishly at the thought that she has become a champion of vulvar plastic surgery. "I would have never thought I'd end up in a Beverly Hills plastic surgeon's office; this is not my world," she says.
But in the two years after the birth of her third child, Sokey says she consulted three physicians for symptoms that had grown more dramatic with each childbirth. Her vaginal walls felt loose, she felt a "bottoming-out" feeling when she ran or lifted the baby and the downward pressure of her reproductive organs, urinary bladder and rectum had caused her labia to swell so much that normal underwear rubbed and chafed. "Sex," she adds, "just wasn't as much fun," and feeling her marriage was in jeopardy, she went looking for help.
One gynecological surgeon told her she "had the vagina of a 50-year-old woman," and sent her home with orders to do more Kegels, a pelvic-squeezing exercise long recommended to reestablish vaginal tone after childbirth. Another suggested corrective surgery and the implantation of a pessary, a supporting device that would hold her uterus and other organs in place and prevent them from intruding into the vagina. But the physician cautioned that convalescence would be long and insisted Katie stop breast-feeding so that the weakened surface of her vagina would hold sutures. A third recommended a hysterectomy, which would have plunged Sokey into early menopause.
Sokey felt the options that obstetrics and gynecology had offered her ranged from ineffective to frighteningly radical. Her physical problems and the demands of motherhood were taking a toll on intimacy, even as her marriage, she discovered, was coming apart.
Sokey says she was overwhelmed with "the despair of going forth in the world of singlehood feeling broken and used up, and there was nothing I could do about it ... I felt very old."
When a friend suggested she go to Matlock, Sokey felt a twinge of hope. "It seemed overall like a gentler procedure," she says, and Matlock's staff assured her they had sent women in her situation home repaired, happy and hopeful. She went for Matlock's trademarked Laser Vaginal Rejuvenation package, an $8,000 procedure in which Matlock uses lasers and layers of sutures to make incisions along the front and back of vaginal walls, stitch the urinary bladder and rectum in place, remove excess tissue and tighten the vaginal opening.
Today, Sokey says she feels, simply, "rejuvenated." When she blew up a balloon for her son recently, she did not have to brace against the bottoming-out feeling. Her labia have returned to normal, making her choice of underpants a fashion decision again. And as she makes the first tentative steps back into single life, she says, "sex has been great." Matlock says his colleagues in the obstetrics and gynecology specialties have treated women -- and patients such as Sokey -- shabbily. He says he is listening to them and giving them options that many desperately want.
"If these were male problems, [the medical profession] would have looked at these symptoms and solved them long ago," Matlock says. His patients, he says, are voting with their feet -- and their pocketbooks because virtually none of the services he provides is paid for by insurance. "They all have gynecologists, but they're coming to me."
Even Stovall, of the Society of Gynecological Surgeons, acknowledges that many ob-gyn specialists are wary of asking about vaginal function after childbirth because women's sexuality is such a complex matter. "Most doctors don't have the expertise," he says, adding "since they don't have anything to address the problem, they'd just as soon not ask.
"That may be a problem," says Stovall. "But getting your vagina lasered is not going to solve that problem."
But for every woman like Sokey, there is probably at least one like Holly, the 50-year-old medical assistant from Southern California.
Holly conceived the idea that her labia didn't look right while in her late teens, just as she became sexually active. Looking furtively at adult magazines or at her friends convinced her "this didn't look normal."
For almost 30 years, her sense that her labia minora were too long "constantly made me sad and not [feel] good about myself." When she would confide the cause of her sexual shyness to a man, he would invariably tell her she was fine, but she never bought it. Now, with her labia reduced by Alter, "there's a little jump in my step because I just feel so good about myself."
A range of normalcy
A plastic surgeon must always consider whether a patient's request is reasonable or is a symptom of an unhealthy body image. To do so requires an understanding of what is normal and what is, by society's current definition, beautiful. When it comes to female genitalia, the standard of beauty, at least, is an evolving standard. And that leaves plastic surgeons little firm basis for deciding which patients are unstable and should be turned away.
Matlock is perhaps clearest in his definition of female genital beauty. The porn stars his patients most frequently hold up as exemplary, says Matlock, sport "a nice, clean look," with a smooth clitoral hood hugging the clitoris like "a piece of paper draped tightly around a pencil" and petite, wrinkle-free labia flanking a "slit-like introitus" (or vagina) that appears never to have endured the indignities of childbirth.
But that is hardly the norm among American women, and physicians such as Stovall argue that before they reach for plastic surgery, women should be made to understand that "there are a multitude of normal variations." In plastic surgery, however, that's often a tough sell -- not to mention a low priority. Young says he often tries to reassure women who seek him out that their genitals "are in the range of normal." Most often, he adds, "they don't want to hear it. They want the problem fixed."
Young echoes an often-heard conviction of plastic surgeons offering the new procedures: "I don't want to hear from a patient that they're doing it for someone else, that 'my husband or boyfriend said he doesn't like the way I look,' " he says. "That's a dead-end."
But he acknowledges there's at best a "subtle difference" between a woman seeking surgery to increase her own self-confidence and the one who does so in hopes of pleasing the man or men in her life.
Many women who come to Alter's office are more focused on improving the look of their genitals than correcting a defect in their function, he says. But he refuses to dismiss their concerns as a form of "body dysmorphia" -- the kind of wildly distorted body image that afflicts, for instance, those suffering the eating disorder anorexia nervosa.
For women whose sexuality is profoundly linked to self-esteem, Alter insists that improving appearance does improve sexual function, and helping women improve the quality of their lives is worth the risks that come with surgery.
"I hear people say, 'Who cares anyhow how someone looks down there?' " says Alter, who performs about 15 labia reduction surgeries, one of his specialties, a month. "My response is, 'You look down there and the other person who counts most of all, your partner, does, and that's enough. People do look down there, and no one likes to feel they're a freak.
"My view is that the operations I do are extremely safe, they have negligible risks and an incredibly high satisfaction rate. What's the problem?" Alter says.
The problem, says Mitchell of the Adult Industry Medical Healthcare Foundation, is that women, whether they are porn stars or would like to look like them, would do better to accept themselves -- to "dance naked in front of the mirror until they like what they see."
And those tempted to go under the knife after admiring the genital proportions of a porn star should remember, she adds, that there is more than just youth and beauty at work in adult films: There is considerable cinematic sleight of hand.
"It's still a fantasy, still a projection," says Mitchell, who notes that vaginal wrinkles or asymmetrical labia can be airbrushed as readily as a pimple. "This is still moviemaking, regardless of how cheap."