Why some opt for an upgrade
Throughout history, women have adorned or altered their appearance to appear more attractive and desirable. Today we curl, roll, set, perm, and straighten our hair. We paint our fingernails and toenails. We tattoo our faces and bodies. We wear jewelry around our necks, on our fingers, and in our ears. Never mind the clothes we purchase, design, or create to adorn our bodies.
The genitals are no exception to this rule of adornment. Hair removal, piercings, tattoos, and yes, even surgery are all things that many women choose to do in the interest of making their private parts more attractive. It’s interesting to note that some women spend an inordinate amount of time and energy “enhancing” the appearance of their external genitalia when the average guy would probably flunk even the simplest quiz regarding the appearance of his partner’s parts. Face it, how many guys even notice when you make a major change to the hair on your head? These enhancements usually say more about how we want to look than about any preferences the men in our lives seem to have.
The Bare Necessities: What You Should Know Before Grooming Your Pubes
Changing trends in hairstyles are not limited to the hair on your head. As a gynecologist, I get a firsthand view of what’s trendy when it comes to pubic hair. Today less is more, and many of the women I see alter their pubic hair in some way, whether it’s just a trim or complete removal.
But sparse pubic hair wasn’t always the style. During the 15th century, abundant pubic hair was a sign of not only sexuality but also good health. Someone with a Brazilian in 1450 hadn’t just been to the beach but more likely had a sexually transmitted disease. Syphilis was the STD du jour back then, and the only treatment was mercury injections, which had the nasty side effect of making hair fall out. All of it. If you were lucky enough to escape syphilis, you probably contracted pubic lice. And without the option of stocking up on anti-lice shampoo from the corner drugstore, you would simply shave everything off. Enter the merkin: a pubic hair wig that men and women pasted on to hide their vulvar baldness due to syphilis or lice.
Why Do We Have Pubic Hair?
Before central heating, pubic hair was what kept the genitals warm. The obvious evolutionary advantage here is that people with warm genitals are more likely to take their clothes off, and men are more likely to maintain an erection. Evolutionarily, the other function of pubic hair was to draw attention to the genitals. (Evidently it is not just the modern man who seems to need a map to ensure he is heading in the right direction.) The natural oil in hair also provides skin lubrication and decreases friction during intercourse. I’ve seen some pretty nasty “rug burn” from rubbing while bare.
Why Do Women Choose to Remove It?
Today’s styles range from full bush to completely hairless. While most hairstyles follow the fashion of the day, some women remove public hair for religious reasons. Others say that baldness increases sensation during sex and that they feel it is more “hygienic.” But most simply prefer the way it looks when they have little pubic hair. Pubic hair spilling out the sides of a bathing suit is a major Glamour “don’t.” But I’m a gynecologist, not a stylist, so I’m going to focus on the medical aspects.
What Is the Best Way to Remove Pubic Hair?
If you do choose to lose the pubes, a multimillion-dollar industry has evolved around pubic fashion, giving you no shortage of options. Waxing, shaving, electrolysis, clipping, chemical depilatories, and laser removal are all at your disposal.
Keep in mind that, with the exception of clipping, red bumps commonly result no matter what method you choose, particularly in African American women. Professional waxing and electrolysis result in the least amount of irritation, allergy, or complications, but these methods can be expensive . . . not to mention painful. Some women use a topical anesthetic (Emla cream, available by prescription) to reduce the agony.
In spite of what seems to be the proliferation of waxing salons on practically every corner, the overwhelming majority of women simply shave their pubic hair and consider the task no different than shaving the hair on their legs or in their armpits.
My only word of warning is this: before choosing a method of permanent hair removal, such as electrolysis, keep in mind that next year the bush may be in style again and you may be forced to invest in a modern-day merkin!
Hairstyles
Let me tell you, when it comes to pubic hairstyle, I have seen it all:
Natural: Full bush, forest
Trimmed: hair shortened in length, but not removed or shaped
Shaped: Removal of the hair that would be sticking out of a bathing suit, but otherwise left alone
“Fancy” shapes: Hearts, arrows, and initials
Landing strip: a thin “runway” right down the middle
Brazilian: Bare and bald, “Hollywood Bare”
From both my observation and research, how women choose to style their pubic hair seems to be associated with age, socioeconomic status, religion, race, and yes, sexual behavior. The 20- to 30-year-old crowd is the most likely to go bald (intentionally anyway), and the more disposable income they have the more they tend to go to a waxing salon, as opposed to doing it on their own at home. For the record, most women I see are either au natural or somewhat shaped.
Complications of Hair Removal
Burns from wax that is too hot, ingrown hairs, and chafing are all possible consequences of hair removal. While many women tell me that they shave because it feels “cleaner” and more hygienic, the truth is that hair removal may increase the risk of some skin infections. In surgery, any shaving is done just minutes before the surgeon makes a skin incision since it has been shown that shaving the day before surgery increases the chance of wound infection.
A study released in March 2013 suggested that the irritation from hair removal may be responsible for an increased vulnerability to acquiring vulvar molluscum contagiosum, a common sexually transmitted virus that causes a skin eruption.
But if hair removal goes wrong? Not to worry! Consider this:
“Botched Brazilian? Misbehaved shave? Kitty Carpet™ ‘reusable downstairs toupee’ to the rescue!” This is an actual product! I can’t make this stuff up!
And accidents can happen. One of my patients, Emily, decided to wax her pubic hair the day before her son’s bar mitzvah. For those of you who are not Jewish, let me tell you that there is no tradition that requires the mother of the bar mitzvah boy to have groomed pubic hair. The wax was way too hot, and Emily ended up with second-degree burns on her vulva. She may well be the only mother of a bar mitzvah boy who has ever attended her son’s service wearing a skirt and no underpants.
According to The Journal of Urology, self-inflicted cuts and infections from grooming pubic hair accounted for 1,089 ER visits between 2002 and 2012.
Embellishments
Hair Dye
Botox and face-lifts are not the only way women camouflage their true age. Pubic hair dye is alive and well in more salons and pharmacies than you know. (Yes, that’s what’s going on behind those closed doors!) For you do-it-yourselfers, Smart Bikini Colour and Betty Beauty (“for the hair down there”) comes in an array of colors. For example, Smart Bikini comes in hot chocolate, cool blond, amber flame, intense red, and for those really special occasions, carmine pink.
But beware! Terri, a 48-year-old attractive blonde, called my office frantically one afternoon and insisted on an emergency appointment. When she walked in the door, it was obvious she was in a lot of pain. A quick exam revealed that her vulva was blistered, bright red, and so swollen she was unable to pee. She admitted that she had been dying her pubic hair to match the hair on her head. “My husband doesn’t know I’m not a real blonde,” she explained. Midway through the dye job, she got distracted and left it on too long.
I inserted a catheter, applied a burn salve, gave her some pain medication, and sent her home. Four weeks later, I saw her for a follow-up visit and was not surprised to see that she was now a brunette—top and bottom.
Genital Piercing
Now, I happen to love a bauble as much as the next girl, but the idea of genital jewelry has never really appealed to me. Having said that, many women don’t limit the holes in their body to their ears.
Female genital piercing has been around for thousands of years, although exactly how long, is difficult to say since plenty of myths seem to be woven into histories of piercing.
Piercing in modern Western culture became fashionable with the punk movement and among some gay and S&M subcultures, but now this fashion has become quite mainstream.
Why do women pierce their genitals? Well, it’s clearly not to show off a gift from a lover, since no one gets to see it except the lover—that would be kind of like getting a gift of a beautiful diamond ring that you only get to wear to bed.
Clitoral hood piercing is by far the most popular such adornment. I’ve also seen piercings of the inner and outer labia. The very brave actually pierce the clitoris, but bleeding and nerve damage often result.
Many women who pierce their genitals do so not for the sake of appearance but to improve sexual stimulation. Since for many women orgasms occur only with clitoral stimulation, a clitoral hood piercing increases the chance of having an orgasm during vaginal intercourse. In surveys, some women reported having their first orgasm only after getting pierced. (Those women evidently do not own vibrators.)
While you might assume that the woman who has a pierced nose, pierced tongue, and 12 holes in her ears is the most likely to also have a pierced clitoral hood, that is far from the case. Many women who have a genital piercing don’t have any other piercings but are just trying to spice up their love lives. Some critics believe that genital piercing is motivated by masochism—after all, what could seem more masochistic than driving a needle through the most sensitive part of your anatomy? But evidently, if pain is what you’re after, genital piercing isn’t really what you want because it doesn’t really hurt that much, no more than piercing an ear or a navel—or so I am told.
The Risks of Genital Piercings
Most physicians oppose piercing anywhere but the earlobe. Not just because a ring through the nose looks just fine on a pig but really unattractive on a human, but because of the possibility of a complication. For starters, even “professional” piercers are often unregulated and therefore not required to know anything about anatomy or sterile technique. It is therefore no surprise that every year a significant number of labial piercings end disastrously owing to serious infections, bleeding, nerve damage, or scarring. If equipment isn’t being sterilized at a piercing studio, the procedure could also pass on any number of diseases, including hepatitis, HIV, and other STDs. The Red Cross has a 12-month waiting period before accepting a blood donation from someone who has been pierced, sending a clear message about the increased risk of infection. Is it worth potentially losing your labia—or your life for that matter—to make a fashion statement?
If you decide to forge ahead, at a minimum, make sure the piercer is a member of the Association of Professional Piercers to ensure that he or she is trained in sterile technique and knows basic first aid. Make sure the piercer wears gloves, uses a fresh needle, and cleans the area with antiseptic. To minimize the chance of infection, choose stainless steel, niobium, or titanium jewelry. Avoid sex, pools, hot tubs, and tight clothing until the piercing has healed. And avoid telling your mother—forever.
The ultimate complication I am aware of was a case that was presented at a sexual medicine conference of a woman who was receiving oral sex. She evidently made a sudden movement and her clitoral hood piercing got caught in her lover’s teeth, (brace yourself ladies!) causing her clitoris to partially tear off. Thankfully, doctors were able to reattach the tissue. I suspect she did not reattach her jewelry.
Vajazzling: A Special Gift for the Woman Who Has Everything
If you have never heard of Vajazzling (yes, it’s a verb), visit http://www.vajazzling.com to expand your clearly limited education. Vajazzling is defined as “the act of applying glitter and jewels to a woman’s bikini area for aesthetic purposes.” You will find information on this site so that you too can “start Vajazzling your business,” “treat yourself to a Swarovski experience,” and learn “how to stand out against competitors” by learning to apply hearts, stars, and other designs to your vulva. You will even discover a tutorial on combining a tattoo with Vajazzling for added effect. No pubic hair required.
Tattoos
Vulvar tattoos, while not as mainstream as hair removal, are accepted by many teens, young adults, and yes, midlife women. Tattoos on the vulva present the same issues as tattoos on other parts of the body, including infection, scarring, and regret. The only thing less fun than getting a tattoo on the pubic area is removing a tattoo on the pubic area. However, unlike the tattoo on your arm, there is always the option of letting your pubic hair grow over RALPH—I WILL LOVE YOU FOREVER once Ralph is out of the picture.
A study published in the Journal of Sexual Medicine in 2012 looked at sexual behavior and vulvar “modification” and found that women who had tattoos and piercings were more likely to have intercourse at an early age, more likely to have frequent intercourse, and more likely to have oral sex than women without embellishment.
Dr. Streicher’s SexAbility Survey
Men were asked if they found a tattoo on a woman’s genitals sexy:
13.2 percent said, “Absolutely!”
34.8 percent said it was a turnoff
51.9 percent said they didn’t care and were just happy to be invited to the party
Cosmetics
I would be willing to bet that when your mother gave you your first lipstick, she did not mention that there was also makeup for your other lips. My Own Pink Button is a cosmetic to pink up your labia and clitoris, which is evidently something that some women feel makes them more attractive.
For those who aren’t interested in making their genitals pinker but feel compelled to make their genitals lighter, there is Pink Daisy Labia Bleaching Cream and Biofade vulvar bleaching cream. I can’t imagine why someone would purchase those products, but evidently someone is doing just that.
Extreme Makeover: Vagina Edition
It’s one thing to glue a few crystals on your mons or dye your pubic hair pink for kicks. It’s quite another thing to undergo plastic surgery to change the appearance of your genitals. Along with the “less is more” pubic hair trend comes the ability to clearly see what things look like, and as with every other part of the body, women tend to be really critical of their appearance.
When I first went into practice, I never had a single patient request cosmetic genital surgery. Now it is a request I get at least once a week. While many women are motivated by the perception that surgery will result in improved sexual pleasure, others simply don’t like the appearance of their genitals. A desire for improved “self-esteem” is often expressed, and there is no question that comfort with one’s genitals is associated with sexual confidence and enjoyment. It is not unusual for women to have surgery in midlife, when they find themselves between relationships and want to “reinvent” themselves.
In general, there are two categories of genital plastic surgery—external or internal.
External Genital Procedures
The most common form of external plastic surgery that women undergo is a labioplasty, or surgery to the labia. Usually, women choose this procedure when they perceive their labia minora to be too long, too thick, or asymmetrical. Some women, when reassured that their labia are slightly longer than average but perfectly normal, still want a “trim” based on their idea of what is attractive. Some women are reluctant to let their partners see them since they think their labia are “too floppy,” and therefore they avoid being sexually intimate.
Some women do have excessively long labia, a condition referred to as labial hypertrophy. Labial hypertrophy is defined as labia that are longer than four centimeters and extend well beyond the labia majora. When measuring labia, in case you are so inclined, you should spread the labia outward (like a butterfly) and measure from the base to the tip of the triangle. While many women want surgery solely for cosmetic reasons, some women with excessively long labia have difficulty with vaginal irritation, urine spraying in all directions, and discomfort during sports or sex.
Dr. Streicher’s SexAbility Survey
When asked how they felt about their labia,
45.5 percent of women said, “I don’t think about my labia.”
11.5 percent said, “I wish they were shorter.”
35.4 percent said, “I love my labia just the way they are.”
7.6 percent said, “I have a labia?”
When the men weighed in and were asked what they thought about their wife’s/partner’s labia:
31% responded: “I don’t think about her labia.”
2.5% responded: “I wish they were shorter.”
57.1% responded : “I love her labia just the way they are.”
8.9% responded: “She has a labia?”
Both gynecologists and plastic surgeons perform labioplasty, but not every gynecologist or plastic surgeon does the procedure. If you are interested, not only do you need to ask your doctor if he or she performs this procedure, but how often and using what technique. Some simply trim the labia. Others take out a wedge of tissue in order to keep an anatomically correct shape and labial edge. Some women desire clitoral hood reduction as well.
As with any cosmetic procedure, in order to get the result you have in mind, you need to clearly communicate with your doctor! Furthermore, I strongly advise that your discussion with your doctor include a mirror so that you point to exactly what you want changed.
Most women who undergo labioplasty are very satisfied with the results and are glad they went through with it, even if it means a month of no sex, bike riding, or tight clothes.
Women who requested labioplasty in one study gave the following motivations for the surgery:
Aesthetic dissatisfaction (87 percent)
Discomfort in clothing (64 percent)
Discomfort in playing sports (26 percent)
Uncomfortable sex (43 percent)
Internal Genital Procedures
Labial shortening isn’t the only vaginal cosmetic procedure that women request. Vaginal tightening surgery, also known as “vaginal rejuvenation,” is increasingly popular and includes procedures that are designed to reduce the size of the opening of the vagina, or the introitus, and in some cases bring together lax musculature along the length of the vagina to make things tighter during intercourse.
Women who have had many children, large children, or vaginal tears at the time of delivery often are left with a relaxed or scarred introitus. A vaginal opening that gaps due to childbirth usually has no effect on sexual function and response. Nevertheless, some women find a gaping vaginal opening aesthetically displeasing or less sexually satisfying and want the vaginal opening to be tightened. This procedure, called perineoplasty, involves making a small incision at the bottom of the vaginal opening, taking out a small V-shaped segment of skin, and restoring the opening of the vagina to a prepregnancy appearance. While I am occasionally asked to do a vaginal tightening, the majority of the time I do this as part of a more extensive surgery, such as repair of a dropped bladder or rectum or an incontinence procedure.
The goal of this type of surgery is to restore normal anatomy without making things too tight. Some women are curious if physicians need to know the measurement of the penis in their life prior to surgery. The answer is no; I neither ask for measurements nor take measurements. Surgeons simply use a “standard” guide to determine the size: if two fingers can fit with a bit of “wiggle room,” the opening will be just fine for most any penis.
Every ob-gyn has had the experience of the witty guy who requests “an extra stitch to tighten things up for me” while still in the delivery room or during a pre-op consultation. The only appropriate response, of course, is for the obstetrician to look piercingly at the guy’s crotch and inquire just how small he needs it.
Tightening of the actual vaginal walls (removal of excess internal tissue) is not generally performed for cosmetic purposes, but only if there is pelvic relaxation or prolapse of the bladder or rectum. Some experts will surgically tighten pelvic floor muscles, but most experts believe that pelvic physical therapy (as opposed to surgery) is a far more appropriate way to enhance sexual satisfaction if the vagina is perceived as being “too loose.” While using a local vaginal estrogen product has not been proven to “tighten” vaginal walls, it stands to reason that the increased blood flow, increased lubrication, and thickening of the tissue might make a difference.
Dr. Michael Goodman, a leading expert in female genital plastic surgery, has done extensive research into the motivations, complications, and outcomes of genital cosmetic surgery. According to one of his large studies, women’s motivations for genital plastic surgery include:
To look better
To enhance self-esteem
To feel more normal
“I feel discomfort” (with sex, sports, clothes, etc.)
Chafing
“I feel loose,” “I feel large,” etc.
To increase friction, enhance sex
Pleasure
To increase partner’s sexual pleasure
At the urging of sexual partner
Dr. Goodman’s research shows that self-esteem and sexual satisfaction are very dependent on a woman feeling comfortable with the appearance of her genitals. “Every published study on outcomes after female plastic genital surgery,” he says, “shows that in the hands of an experienced genital plastic/cosmetic surgeon, 95% of women undergoing external cosmetic procedures were happy with the results and 85–90% of women undergoing vaginal tightening reported enhancement of sexual function. A single study examining men’s experience showed that less than 80% of these women’s male partners noted enhanced sexual experience.”
While I have not personally done research in this area, I can tell you anecdotally that my patients who have chosen to have surgery are pleased with the results and express increased confidence and sexual satisfaction.
A few years ago a woman came to see me escorted by her husband, who requested a vaginal tightening. At my insistence, he reluctantly did not accompany her during the examination. Her vagina and vulva were completely normal, and I asked her why she wanted the procedure. She explained that “he wanted it” and she wanted “whatever he wanted.”
I declined to do the surgery and explained to him that she was completely normal and that any “tightening” would result in pain during intercourse. As he stormed out my office door he angrily said, “You must think I’m a real pencil dick!”
I agreed.
It goes without saying that no woman should ever be pressured into undergoing surgery by a partner.
With all of these genital surgical procedures, as in any surgical procedure, there is always the risk of a complication such as infection or bleeding. There is always the risk that you won’t be happy with the results. Unlike shaving, hair dye, or Vajazzling, there’s no going back if you go under the knife. Be sure before you proceed, and be sure you have a surgeon who is experienced.
What Are the Strangest Things Gynecologists Have Seen?
I am asked this question at cocktail parties on a regular basis: “What is the most unusual vaginal adornment, piercing, hairstyle, or tattoo that you’ve ever seen?”
After more than 20 years in clinical practice, I’ve seen my share of strange and wondrous things when women come in for their regular exam. Here’s a sampling from my practice as well as other doctors’:
• A “mange-moi” tattoo on the mons, right next to the clitoris, with a picture of the Rolling Stones logo
• A little square of hair left on the mons that looked like a Hitler mustache
• Sparkly “hair” spray
• Tattoos of “kissing” lips on the mons
• A tattoo on the mons of little eyes looking out
• A chain between a clitoral piercing and a labial piercing
• A tattoo of an ice cream cone on the pubic area
• A tattoo on the inner thigh consisting of an arrow pointing to the introitus and the words ENTER HERE