|Year : 2018 | Volume
| Issue : 4 | Page : 257-263
Knowledge and attitude of women on genital cosmetic surgery at University College Hospital, Ibadan, Nigeria
Oluwasomidoyin Olukemi Bello, Olatunji O Lawal
Department of Obstetrics and Gynaecology, Urogynaecology Unit, University College Hospital, Ibadan, Nigeria
|Date of Web Publication||21-Dec-2018|
Dr. Oluwasomidoyin Olukemi Bello
Department of Obstetrics and Gynaecology, Urogynaecology Unit, University College Hospital, Ibadan
Source of Support: None, Conflict of Interest: None
Background: Female genital cosmetic surgery (FGCS) is performed in other to restore or enhance the female genitalia. Materials and Methods: This is a cross-sectional study assessing the knowledge and attitude of 310 women attending gynaecology clinic towards FGCS at University College Hospital, Ibadan, Nigeria. Data were analysed using SPSS 20. Results: Mean age of respondents was 33.28 ± 7.68 years. Majority were married (76.1%) in monogamous family (87.7%) and almost half (49.7%) were multipara. About 56.1% had vaginal delivery of which 84.5% had perineal tear or/and episiotomy. Overall, 27.7% had heard about FGCS and 84.2% had positive attitude towards the procedure. Respondents' age, marital status and occupation were associated with their knowledge and attitude to FGCS. Women with skilled occupation were more likely to have the knowledge and positive attitude to FGCS. Conclusion: The knowledge of FGCS was low; however, majority had positive attitude towards it because of its associated sexual and psychological satisfaction.
Keywords: Attitude, female genital cosmetic surgery, knowledge, psychological satisfaction, sexual satisfaction
|How to cite this article:|
Bello OO, Lawal OO. Knowledge and attitude of women on genital cosmetic surgery at University College Hospital, Ibadan, Nigeria. Niger Postgrad Med J 2018;25:257-63
|How to cite this URL:|
Bello OO, Lawal OO. Knowledge and attitude of women on genital cosmetic surgery at University College Hospital, Ibadan, Nigeria. Niger Postgrad Med J [serial online] 2018 [cited 2019 Jan 24];25:257-63. Available from: http://www.npmj.org/text.asp?2018/25/4/257/248210
| Introduction|| |
Female genital cosmetic surgery (FGCS) involves series of procedures designed to restore or enhance the female genitalia. These include ‘labiaplasty, clitoral unhooding, monsplasty, vaginoplasty, hymenoplasty, G-spot augmentation, frenuloplasty, perineoplasty, fat injections and combination of any of these procedures’; however, labiaplasty is the most common.,,,, These cosmetic medical procedures are done to eliminate functional problems such as laxity of vagina with sexual dissatisfaction and create aesthetically appealing external genitalia. FGCS has substantial psychological benefits for women who are particular about the appearance of their genitalia, and most of the women with severe distortion reported decreased pain or discomfort with daily activity and sexual intercourse after FGCS., There is an increasing demand for FGCS in developed countries with a 49% increase in the United States in 2014 while Australia and United Kingdom reported a 3-5 fold increase in demand over a 10 year period., This increase is attributed to sociocultural reasons with exposure to female state of undressing in the media, which defines the appearance of female genitalia.,,
However, women who express dissatisfaction with their genital appearance seek FGCS due to aesthetic dissatisfaction with labia, uneasiness when wearing clothes, discomfort when taking part in sporty activities, relationship difficulty and painful or difficult sexual intercourse.,,
In the Genitourinary Unit of the Department of Obstetrics and Gynaecology, University College Hospital (UCH), Ibadan, 3 women presented for FGCS on account of sexual dissatisfaction due to laxity of the vagina over a 3-month period – July to September, 2016. However, the popularity of the procedure is expected to increase as knowledge of the benefits increases. Thus, this study aimed to describe knowledge and attitude of women to FGCS in UCH, Ibadan, Nigeria.
| Materials and Methods|| |
This was a cross-sectional study amongst 310 sexually active women at Gynaecology Clinic of UCH, Ibadan. Ethical approval was obtained from the Oyo State Research Ethical Review Committee with a protocol number AD 13/497/299 on the 19 December 2016, and a written informed consent was obtained from each respondent.
The sample size was calculated using the Kish and Leslie formula: n = z2 pq/d2, where n – desired sample size, z – standard normal deviation of 1.96 which corresponds to 95% confidence interval (CI), P = 0.95, with a total of 292 women calculated, and to allow for 5% non-response rate, a total of 310 women were recruited.
An interviewer-administered questionnaire was used to obtain information from the respondents from 2 January 2017 to 30 June 2017 in a private area in the consulting room to ensure confidentiality. The questionnaire was adapted and developed from previous studies on FGCS and labiaplasty. This tool was pre-tested amongst 20 eligible consenting women in Family Planning Clinic, UCH, Ibadan.
The questionnaire explored their demographic characteristics, obstetric history, knowledge and attitude to FGCS. Data were entered and analysed using IBM Statistical Package for Social Sciences Statistics for Windows, Version 20.0 (Armonk, NY, USA). The question ‘ever heard of FGCS’ and its indications were used to assess knowledge. Respondents who answered ‘Yes’ to ‘ever heard of FGCS’ and could identify at least three correct indications were considered knowledgeable about the procedure. Attitude towards FGCS was assessed on a 5-point Likert scale (strongly disagree = 1, disagree = 2, unsure = 3, agree = 4 and strongly agree = 5) using 7 questions with each carrying the same weight. Respondents whose attitudinal mean score was lower than the total mean score were categorised as negative attitude while those greater or equal to the mean score were categorised as having a positive attitude. Logistic regression was used to determine factors associated with the knowledge and attitude of the women towards FGCS. Statistical significance was set at P < 0.05 and 95% CI. Inclusion criteria included all consenting women who are sexually active. Sexually active was defined by having had peno-vaginal sexual intercourse at least once in the past 6 months.
| Results|| |
Mean age of respondents was 33.28 ± 7.68 years and ranged 20–55 years with majority (46.5%) aged 30–39. Most of the respondents (236, 76.1%) were married and 87.7% were in monogamous family settings. A higher proportion (227, 73.2%) had tertiary education and 41.9% were involved in skilled occupation [Table 1].
|Table 1: Sociodemographics and obstetric characteristics of the respondents|
Click here to view
The mean age at coitarche was 18.75 ± 6.74 years with majority (164, 52.9%) having their sexual debut between 15 and 20 years. Almost half (154, 49.7%) were multipara and 174 (56.1%) had delivered per vagina. Of those who had vaginal delivery, more than two-third (72.4%) had more than one vaginal delivery and majority (147, 84.5%) had had perineal tear or/and episiotomy during delivery [Table 1].
A little above a quarter (86, 27.7%) had ever heard of FGCS, but majority (84.2%) have a positive attitude towards it. Almost half (39, 45.3%) of them had been aware of it for more than 2 years. The most common source of information was through medical personnel (36, 41.9%) while about a third (33.7%) heard from friends and colleagues. However, only 21 (24.4%) of those that were aware of FGCS know someone that had undergone the procedure [Table 2].
|Table 2: Descriptive analysis of respondents' knowledge and attitude of female genital cosmetic surgery|
Click here to view
Age, educational status, marital status, occupation, parity and perineal tear/episiotomy during delivery were found to be associated with their knowledge of FGCS. Almost half (52, 48.6%) of women with the knowledge of FGCS were 20–29 years (P < 0.001) and one-third (75, 33.0%) with tertiary education were also knowledgeable (P = 0.001). Furthermore, marital status (P < 0.001), having a skilled occupation (P = 0.006), parity (P = 0.001), having had perineal tear and/or episiotomy during delivery (P = 0.049) were significantly associated with the knowledge of FGCS [Table 3].
|Table 3: Relationship between respondents' sociodemographics and obstetric characteristics with knowledge of female genital cosmetic surgery|
Click here to view
Respondents' educational level, marital status, family settings, occupation and age at coitarche were significantly associated with their attitude towards FGCS. More than three-quarter (197, 86.8%) of the respondents with tertiary education had positive attitude (P = 0.039), as well as the married respondents (190, 80.5%) and those with semi-skilled occupation (97, 89.0%) having a positive attitude towards FGCS with P = 0.001 and P = 0.013, respectively. Women with early coitarche of <15 years had a higher proportion of them with positive attitude to FGCS [P = 0.007; [Table 4]].
|Table 4: Relationship between respondents' sociodemographics and obstetric history with attitude towards female genital cosmetic surgery|
Click here to view
In the multivariate analysis, factors associated with respondents' knowledge of FGCS were their age, marital status, occupation and parity. Respondents within 20–29 years' age category were eight times more likely to have the knowledge of FGCS (odds ratio [OR] = 8.042, 95% CI = 1.803–35.874) while married respondents were five times less likely to be knowledgeable about FGCS (OR = 0.184, 95% CI = 0.074–0.456). Furthermore, those with skilled occupation were six times more likely to have the knowledge of FGCS (OR = 6.230, 95% CI = 1.379–6.540), and primipara respondents were about four times more likely to be knowledgeable about it (OR = 3.733, 95% CI = 1.427–9.764) [Table 5].
|Table 5: Multivariate analysis of knowledge of the study population on female genital cosmetic surgery|
Click here to view
In relation to their attitude, the married women were five times less likely to have positive attitude towards FGCS (OR = 0.182, 95% CI = 0.055–0.607) while those who had their first sexual intercourse at <15 years of age were about thirteen times more likely to have positive attitude towards it (OR = 12.913, CI = 1.332–125.158). Women involved in skilled and semi-skilled occupation were about four times more likely than those of them involved in unskilled occupation to have positive attitude towards FGCS (OR = 3.929, CI = 1.137–13.579 and OR = 4.073, CI = 1.235–13.433, respectively) [Table 6].
|Table 6: Multivariate analysis of attitude of the study population on labiaplasty|
Click here to view
| Discussion|| |
This study revealed a low level of knowledge of FGCS, though majority of the women have a positive attitude towards it. This is similar to the result from an international survey which examined the knowledge and attitude of women towards the appearance of their genitals and documented a very low knowledge of FGCS. This could be because most women do not particularly pay much attention to their genital appearance as compare to their facial appearance. Moreover the genital area is mostly covered with clothing and not exposed so most women are not aware of the normal look let alone know about genital cosmetic surgery. However, to the best of our knowledge, there is no documented study on the awareness, knowledge and perception of normal genital appearance amongst women in Nigeria.
Although FGCS is popular in developed countries, only 27.7% have ever heard of it amongst the women studied. Thus, this showed that most women in Ibadan, Nigeria, do not know about FGCS.
It is a well-known fact that mass media, especially social media, have the ability to increase public awareness in any area, but majority of the women in this study were informed about FGCS by medical personnel. This is contrary to report from several studies where most women gained the knowledge through the social media., On the other hand, 97% of the general practitioners studied in Australia reported that women of all ages had enquired about how a normal genitalia looks while 65% had seen patients who requested for FGCS. This might be because the genitalia (vulva and vagina) is believed to be a private part that should not be discussed openly or viewed as a taboo or disgusting to talk about in our environment.
Age, marital status, parity and occupation of the women were associated with their knowledge of FGCS. A higher proportion of women aged 20–29 years were knowledgeable about FGCS which is in line with previous report that majority of the procedures of the FGCS were performed amongst women of ages 16–35 years. These younger respondents were found to be eight times more likely to know about it. This might be because younger women pay more attention to how ‘they look down there’. This substantiates other studies which showed that young ladies have heightened concern about their ‘genital look’ while older women centre their attention on ‘facial appearance’., Moreover, married women were less likely to know about FGCS; this could be because the unmarried will be more particular about their genitals and prefer to look more attractive to their prospective partners and thus more likely to explore procedures for sexual reasons. Another reason is that some of the married women might still want to have more babies, therefore, at present may not want to alter the looks of their genitals. A similar pattern was observed by Veale et al. in which majority of the women who seek or underwent FGCS were majorly singles.
Interestingly, the primiparous women were more knowledgeable about FGCS. This might be because most primiparous women would have had an episiotomy and/or perineal tear following vaginal delivery in our environment. Seeking for knowledge on resumption of sexual intercourse and sexual satisfaction after delivery may have exposed them to female cosmetic procedures because of the laxity of the vagina following vaginal deliveries., Shaw et al. in 2013 also reported that the labia continue to remodel with childbirth/parity. Furthermore, most of these primiparous women are of younger age and fall within the age group of <35 years in which there is preponderance of FGCS.
In this study, respondents with skilled occupation were six times more likely to have knowledge about FGCS. This result is expected considering the fact that majority of the respondents in this study had at least tertiary level of education and this is in support with other studies that showed most women who seek FGCS are either middle or upper social class.
Furthermore, a higher proportion of the population studied had a positive attitude towards FGCS. This is probably because African women like to adopt the Western cultures. Conversely, this is different from the report of Koning et al. in which more than half of those studied strongly disagreed to labiaplasty although other types of FGCS were not considered.
Predictors of positive attitude towards FGCS were marital status, occupation and age at coitarche. Marital status was found to be associated with respondents' attitude towards FGCS. Even though some married respondents had positive attitude towards FGCS, they were five times less likely than the unmarried respondents. This is definitely expected since the married women also had low knowledge of FGCS. Similarly, some studies reported a higher proportion of single ladies willing and undergoing FGCS which shows that they possess positive attitude towards it, and this further reflects that they are particular about their genital appearance., In addition, it is not surprising that age at coitarche is a predictor of positive attitude towards FGCS because majority of the women studied had their sexual debut at <20 years. Furthermore, majority of the women in this study are involved in skilled occupation, depicting that they are quite educated hence their positive attitude towards FGCS. However, women in developing countries have been reported to undergo different vaginal practices such as ingestion of substances, intravaginal cleansing or douching and insertion of herbal preparations for sexuality in other to increase pleasure for the man and the woman and achieve desired vaginal state despite the associated side effects and undesired consequences. Thus, having a medically approved surgical procedure will be well accepted amongst the learned and the general women population, but there is a need for adequate knowledge of the normal look of the genitalia including the physiological changes expected with increasing age and vaginal deliveries as well as the merit and consequences of the FGCS procedure. Likewise, several studies have reported the safety and improved genital appearance with sexual satisfaction following FGCS without debilitating side effects when done by experts.,,, Nevertheless, it is imperative that all women who seek out for FGCS be adequately counselled and examined with the procedure only carried out if a medical indication is established because of the potential complications such as bleeding, infection and scarring although these are uncommon.,
To our knowledge, this is probably the first published study in Nigeria that assessed the knowledge and attitude of women towards FGCS, but we will like to state our limitations. First, the study did not explore if the women underwent female genital mutilation (FGM) which may be used to assess and define precisely if it influenced their attitude to FGCS because FGM has been documented to be associated with sexual dissatisfaction and sometimes necessitating corrective genital surgery. This was not explored because FGM is often performed at a younger age and the woman might not be aware of it except the vulva and vagina of each respondent are examined. Furthermore, FGM has been banned in Nigeria and the cultural, religious and social norms which could influence a woman's attitude were not explored. However, it is good to note that women's attitude, expectation of sexual satisfaction and aesthetic genital look desire can be affected by their culture, beliefs and social status. In addition, the extent to which the findings from the study can be generalised is limited due to the fact that it is a hospital-based study, but a community survey would be more representative. However, these limitations do not affect the reliability of the findings of the study.
| Conclusion|| |
The women in this study had positive attitude towards FGCS, but the knowledge about the procedure is low. Factors associated with the women's knowledge were age, marital status, occupation and parity while age at coitarche, occupation and marital status were factors associated with their attitude towards FGCS. Women should be educated on the normal look of the genitalia and the expected physiological changes as well as the benefits and complications of FGCS so as to improve their knowledge.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nappi RE, Liekens G, Brandenburg U. Attitudes, perceptions and knowledge about the vagina: The international vagina dialogue survey. Contraception 2006;73:493-500.
Sharp G, Tiggemann M, Mattiske J. Predictors of consideration of labiaplasty; an extension of the tripartite influence model of beauty ideals. Psychol Women Q 2015;39:182-93.
Braun V. Female genital cosmetic surgery: A critical review of current knowledge and contemporary debates. J Womens Health (Larchmt) 2010;19:1393-407.
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.
Simonis M, Manocha R, Ong JJ. Female genital cosmetic surgery: A cross-sectional survey exploring knowledge, attitude and practice of general practitioners. BMJ Open 2016;6:e013010.
Rouzier R, Louis-Sylvestre C, Paniel BJ, Haddad B. Hypertrophy of labia minora: Experience with 163 reductions. Am J Obstet Gynecol 2000;182:35-40.
Crouch NS, Deans R, Michala L, Liao LM, Creighton SM. Clinical characteristics of well women seeking labial reduction surgery: A prospective study. BJOG 2011;118:1507-10.
Moran C, Lee C. ‘Everyone wants a vagina that looks less like a vagina’: Australian women's views on dissatisfaction with genital appearance. J Health Psychol 2018;23:229-39.
Liao LM, Michala L, Creighton SM. Labial surgery for well women: A review of the literature. BJOG 2010;117:20-5.
Honigman R, Castle DJ. Aging and cosmetic enhancement. Clin Interv Aging 2006;1:115-9.
Veale D, Naismith I, Eshkevari E, Ellison N, Costa A, Robinson D, et al.
Psychosexual outcome after labiaplasty: A prospective case-comparison study. Int Urogynecol J 2014;25:831-9.
Klein MC, Kaczorowski J, Firoz T, Hubinette M, Jorgensen S, Gauthier R, et al.
A comparison of urinary and sexual outcomes in women experiencing vaginal and caesarean births. J Obstet Gynaecol Can 2005;27:332-9.
Shaw D, Lefebvre G, Bouchard C, Shapiro J, Blake J, Allen L, et al.
Female genital cosmetic surgery. J Obstet Gynaecol Can 2013;35:1108-12.
Rao N, Aparajita, Sharma N. Current trends in female genital cosmetic surgery. Apollo Med 2012;9:219-23.
Goodman M, Fashler S, Miklos J, Moore R, Brotto L. The sexual, psychological, and body image health of women undergoing elective vulvovaginal plastic/cosmetic procedures: A pilot study. Am J Cosmetic Surg 2011;28:219-26.
Martin Hilber A, Hull TH, Preston-Whyte E, Bagnol B, Smit J, Wacharasin C, et al.
A cross cultural study of vaginal practices and sexuality: Implications for sexual health. Soc Sci Med 2010;70:392-400.
Goodman MP, Placik OJ, Matlock DL, Simopoulos AF, Dalton TA, Veale D, et al.
Evaluation of body image and sexual satisfaction in women undergoing female genital plastic/Cosmetic surgery. Aesthet Surg J 2016;36:1048-57.
Kent D, Pelosi MA. Vaginal rejuvenation: an in-depth look at the history and technical procedure. AJCS 2012;29:89-96.
WHO study group on female genital mutilation and obstetric outcome, Banks E, Meirik O, Farley T, Akande O, Bathija H, et al.
Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006;367:1835-41.
Ministry of Health and Population, El-Zanaty and Associates, and ICF International. Egypt Demographic and Health Survey 2014. Cairo, Egypt and Rockville, Maryland, USA: Ministry of Health and Population; 2015. Available from: http://www.dhsprogram.com/pubs/pdf/fr302/fr302.pdf
. [Last accessed on 2018 Aug 29].
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]