Functional need or personal choice: Medical professionals’ understanding and framing of performing female genital cosmetic procedures

Abstract

Background:

Female genital cosmetic procedures (FGCPs) are becoming increasingly common but remain highly stigmatised and contested. This raises the question of how healthcare professionals justify performing FGCPs in such a context.

Objectives:

To understand how medical professionals (MPs) justify their involvement in FGCPs within a context of social and professional scrutiny.

Design:

Qualitative interview study using discursive thematic analysis.

Methods:

We conducted 11 in-depth interviews with plastic surgeons and gynaecologists performing FGCPs in Belgium and the Netherlands.

Results:

MPs employ two main discursive framings to justify performing FGCPs. The women’s health framing depicts FGCPs as addressing issues that were considered functional and fulfilling “genuine” medical needs, while the women’s choice framing emphasises a woman’s autonomy to make decisions about her body, even in the absence of functional concerns. Both framings are shaped by and rely on a series of juxtapositions which MP negotiate in their framings: functional versus aesthetic; patient choice versus medical decision-making; and medical versus cultural.

Conclusion:

MPs frame FGCPs in terms of women’s health and choice, helping to legitimise them as ethical care. These framings, however, obscure key tensions – between function and aesthetics, autonomy and clinical judgement, and medical versus cultural motivations. Examining these discursive dynamics reveals how FGCPs are made acceptable within a contested field.

Plain language summary

How doctors explain and justify performing female genital cosmetic surgery

Female genital cosmetic procedures (FGCPs), like labiaplasty, are becoming more common, but they are still controversial and often seen as taboo. This study explores how doctors who perform these surgeries explain and justify their work in such a debated area. We interviewed 11 plastic surgeons and gynaecologists in Belgium and the Netherlands. They explained their involvement in two main ways: some said the procedures help with real medical problems (a “women’s health” approach), while others focused on respecting women’s right to choose what happens to their bodies (a “women’s choice” approach). However, these explanations are not always straightforward. We found that what counts as a “medical need” is sometimes based on appearance, and while doctors say they support patient choice, they also guide or limit that choice. Cultural influences are also judged differently depending on whether the patient is from a Western or non-Western background. These ways of talking about FGCPs help make the practice seem acceptable, even though they cover up deeper tensions about beauty, medicine, culture, and ethics. Understanding these justifications helps us see how FGCPs are made to appear legitimate, even when the reasons behind them are complex and sometimes contradictory.

Highlights

• MPs use two discursive framings to justify FGCPs.

• The women’s health framing depicts FGCPs as solutions for genuine medical needs.

• The women’s choice framing emphasises women’s bodily autonomy.

• MPs differ on what qualifies as indication for FGCPs.

• MPs stress bodily autonomy but impose limits on FGCPs.

Introduction

Female genital cosmetic procedures (FGCPs) encompass a range of surgical and non-surgical interventions aimed at modifying the external and/or internal female genitalia for aesthetic or functional reasons and include labiaplasty or labia minora reduction, labia majora augmentation, clitoral hood reduction, G-spot amplification, perineoplasty, and vaginoplasty. ¹ Labiaplasty is the most commonly performed surgical form of FGCP. According to the International Society of Aesthetic Plastic Surgery, ² labiaplasty procedures increased by 14.8% (from 164,667 to 189,058) between 2019 and 2023 among reporting member countries, though this figure only reflects countries that submitted sufficient data and may not capture global patterns comprehensively. ² Studies indicate that women’s motivations for seeking FGCPs are usually related to concerns with labial appearance, physical discomfort with clothing and/or exercise, physical and/or emotional difficulties with sex-life, and general self-consciousness. ³

Despite their increasing prevalence, FGCPs remain controversial. ⁴ Bonell et al. ⁵ described this as the “cosmetic surgery paradox”: (especially) women are expected to conform to impossible beauty standards, but if they do so via surgery, they are blamed for being superficial, insecure, or looking “unnatural.” While this paradox applies to cosmetic surgery more generally, stigma is especially pronounced for genital surgeries. ⁶ Sasson et al. ⁷ inked this to cultural norms that associate the vulva with modesty and virginity, making any desire to alter its appearance seem immodest or overly sexual.

The increasing popularity of FGCPs has also drawn growing public attention and media debate.^8,9 Critics are concerned that women, and especially young girls, may be unfamiliar with the natural diversity of genital anatomy, and thus vulnerable to idealised images of the vulva, which may be digitally or surgically altered. ¹⁰ Furthermore, there are concerns that individuals with self- and body-image issues, a history of sexual violence, or psychological conditions such as body dysmorphic disorder (BDD), are especially susceptible to undergo FGCPs or cosmetic procedures more generally.^11,12 Additionally, some experts have highlighted the lack of rigorous research on the long-term outcomes of FGCPs, including their effects on sexual function and childbirth. ¹³

These concerns have prompted professional and regulatory bodies in countries such as the United States, the United Kingdom, Canada, Australia, New Zealand, Switzerland, and the Netherlands to issue guidelines on FGCPs.^14–19 However, even where such protocols exist, they are typically non-binding.

In the absence of clear guidelines on FGCPs, decisions about whether and how to perform these procedures often rest on the personal judgement of medical professionals (MPs), whose interpretations of medical necessity, ethical responsibility, and patient autonomy can vary widely. This raises a broader question, not only about what professionals do, but how they explain and justify their actions. Rather than focusing solely on practices or opinions, this study examines the discursive strategies professionals use to frame their decisions. These framings are not neutral: they reflect and shape broader ideas about what is normal, ethical, or medically legitimate. Drawing on feminist theory and Foucault’s concept of discourse, we analyse these justifications as meaning-making practices – tools through which professionals assert authority, draw boundaries, and navigate morally ambiguous terrain.

While much has been written about patients’ motivations for FGCPs, less is known about how MPs decide whether and under what conditions to perform these procedures. Existing research, primarily quantitative, has begun to map out the factors that influence clinical attitudes and decision-making. Survey studies suggest that while many professionals regard FGCPs as rarely medically necessary, they often do not object to performing them if they perceive the patient’s request as autonomous and well-informed.^20,21 However, not all FGCPs are viewed equally; procedures like hymenoplasty or G-spot amplification are seen as more ethically problematic, either for reinforcing patriarchal norms or lacking scientific legitimacy, making practitioners more hesitant to perform them.^20,21

Aesthetic norms also appear to shape clinical judgements. Reitsma et al. ²² found that male plastic surgeons were especially likely to recommend labiaplasty and rated smaller labia as more “natural” and “attractive.” Across specialties, male physicians were more inclined to suggest surgery than female colleagues, suggesting that personal aesthetic preferences and gendered ideals of normality can shape medical decisions.

While these studies highlight important trends in clinical attitudes and influences, they primarily rely on surveys and do not examine how MPs themselves articulate or justify their involvement in FGCPs. One of the few qualitative studies in this area is by Kirkman et al., ²³ who investigated how health professionals and beauty therapists in Australia understand women’s motivations for FGCPs and the broader cultural concerns surrounding these procedures. While they include some discussion of professional ethics and clinical discomfort, their focus remains primarily on interpretations of patient desire rather than on how practitioners justify their own participation.

Our study builds on previous work by focusing specifically on how MPs frame their involvement in the contested field of FGCPs. We show that practitioners typically justify their role either by presenting genital concerns as legitimate health issues or by appealing to the principle of bodily autonomy. However, we also identify key tensions within these framings – between functionality and aesthetics, patient autonomy and clinical judgement, and medical versus cultural procedures. In doing so, the study contributes to feminist and sociological debates on beauty practices, genital modifications, neoliberal conceptions of choice, and the ethics of medical intervention.

Materials and methods

Participant recruitment and research method

We conducted a qualitative interview study using discursive thematic analysis. The reporting of this study conforms to the Consolidated Criteria for Reporting Qualitative (COREQ) Research guidelines. ²⁴

Semi-structured in-depth interviews were conducted with seven plastic surgeons (six Belgian, one Dutch), three gynaecologists (two Belgian, one Dutch), and one plastic surgeon’s consultant (Belgian; see Table 1) who carry out FGCPs. While all participating MPs had encountered labiaplasty as part of their standard training as either gynaecologist or plastic surgeon, MP8, MP10, and MP11 sought specialised training abroad with renowned genital cosmetic surgeons. MP10 was practising in both the Netherlands and Belgium at the time of the interview. MP7 and MP8 were working solely in Belgium but had previous experience in the Netherlands.

Table 1.

Overview participants.

Participant	Gender	Country	Profession	Procedures
MP1	F	Belgium	Consultant working for plastic surgeon	Labiaplasty, laser depilation
MP2	F	Belgium	Plastic surgeon	Labiaplasty, clitoral hood reduction
MP3	M	Belgium	Plastic surgeon	Labiaplasty, clitoral hood reduction
MP4	M	Belgium	Gynaecologist	Vaginal laser treatment
MP5	M	Belgium	Plastic surgeon	Labiaplasty, clitoral hood reduction, penis enlargement
MP6	M	Belgium	Plastic surgeon	Labiaplasty
MP7	M	Belgium	Gynaecologist	Labiaplasty
MP8	M	Belgium	Plastic surgeon	Labiaplasty, clitoridotomy, vaginal rejuvenation, G-shot, O-shot, vaginal laser treatment, revision surgery, penis enlargement, scrotal surgery
MP9	F	Belgium	Plastic surgeon	Labiaplasty, clitoral hood reduction
MP10	F	Netherlands	Gynaecologist	Labiaplasty, vaginal tightening, clitoral hood reduction, femilift
MP11	F	Netherlands	Plastic surgeon	Labiaplasty, vaginal laser treatment, lipofilling labia majora, liposuction venus hill, pubis lift

MP: medical professional.

No prior relationship existed between the interviewers and participants; all contact was initiated for the purposes of this study. Respondents were identified by browsing the internet for providers of FGCPs and were subsequently contacted via email with information about the research project and an invitation to participate. Participants were informed about the researchers’ academic backgrounds and the study’s aim to understand how MPs perceive and justify FGCPs.

A semi-structured interview guide was constructed, focusing on several key areas: current trends in genital cosmetic procedures (GCPs), the reasons why people seek such procedures, and the MPs’ opinions on various GCPs. Additionally, it explored which types of GCP the professionals (do not) perform and the reasons behind these decisions; which patients they accept or refuse and why; and their views on whether there should be regulation of GCP (see Supplemental Appendix A for interview guide). Interviews were conducted online or in the clinicians’ offices, lasted an average of 65 min, were audio recorded, and transcribed verbatim. No one other than the researcher and participant was present during the interviews. Participant quotations are presented throughout the Findings to illustrate themes, and each quotation is identified with the corresponding participant number. Quotations were translated from Dutch to English by the researchers.

The project received ethical approval from the Medical Ethics Committee at University Hospital Brussels (EC-2023-376). All participants received an information sheet outlining the purpose and procedures of the study. The researcher reviewed this information with each participant prior to the interview, ensuring that participants had the opportunity to ask questions and seek clarification. Written informed consent to participate was obtained from all participants before data collection commenced.

Scope of the study

This study focuses on procedures sought by cisgender women. While genital modification practices also affect trans and intersex individuals – and may involve overlapping surgical techniques – they are typically situated in different clinical, legal, and socio-political contexts. ²⁵ These include questions around gender identity recognition, access to care, and non-consensual interventions in early life. None of the interviewees discussed working with trans or intersex patients, and their inclusion would require a different analytical lens.

Although the study aimed to explore FGCPs broadly, discussions centred predominantly on labiaplasty, followed by vaginoplasty. This focus reflects the clinical prominence of labiaplasty as the most commonly performed. Non-surgical procedures (e.g., laser tightening) were mentioned less frequently and are therefore less central to the analysis.

Data analysis

We conducted a discursive thematic analysis, ²⁶ using NVivo 14 (developed by Lumivero), to identify not just content-based themes, but also the discursive patterns through which MPs construct and legitimise their involvement in FGCPs. Each researcher inductively coded two interviews. The researchers then compared and discussed the codes to identify links and develop initial codes. These initial codes were collected into a preliminary coding scheme, which guided the analysis of the subsequent interviews, although new (potential) codes were constantly added and revised. After all interviews had been coded, the researchers again discussed their codes and a final thematic map was developed collaboratively, encompassing main- and sub-themes that provide a comprehensive understanding of MPs’ perspectives on the acceptability and ethics of FGCP, and how these perspectives influence their actions (see Supplemental Appendix B for thematic map). Transcripts were not returned to participants, and participants did not provide feedback on the findings, in line with our discursive and interpretive analytic approach.

Our study followed the principles of reflexive thematic analysis, for which the positivist notion of data saturation is not considered a meaningful or theoretically coherent criterion. ²⁷ Instead, we drew on the concept of information power, ²⁸ which holds that the adequacy of a sample depends on the richness and relevance of the data in relation to the study aims. By the 11th interview, the dataset provided sufficient informational depth to address our research questions.

Study sites

While no comprehensive prevalence data exist, MPs in both Belgium and the Netherlands report rising demand for FGCPs – a trend echoed in increasing insurance reimbursements.^29–31 In the Netherlands, professional associations of gynaecologists and plastic surgeons published two position articles on cosmetic genital procedures, for example detailing physical, psychological and age-related (contra)indications for labium reduction and genital aesthetic surgery more generally.^14,32 Belgium, by contrast, lacks any formal guidelines.

Regarding coverage, the Netherlands’ mandatory basic health insurance does not reimburse procedures performed purely for cosmetic reasons. ³³ For instance, labiaplasty is only covered in cases of severe deformity caused by mutilation, disease, accident, or medical error. ³⁴ Belgium’s system, overseen by the National Institute for Health and Disability Insurance, also restricts coverage to cases of medical necessity. ³⁵ However, exceptions exist for procedures addressing “functional problems,” a term that remains loosely defined. ³⁶ This includes surgeries such as ear, nose, and eyelid corrections, which may be reimbursed not because they are medically necessary in a narrow sense, but because they are thought to alleviate psychosocial distress (e.g., children being bullied for protruding ears). This broader interpretation of functionality – where psychological and social well-being are considered part of health – also underpins how some MPs justify labiaplasty, as we explore further in the results section. In practice, the vagueness of the term grants doctors considerable discretion in determining whether a procedure qualifies for reimbursement.

Researchers’ positionality

Interviews in Belgium were conducted by Hannelore Van Bavel and those in the Netherlands by Anne-Mette Hermans. Our analytical approach is informed by our backgrounds in gender studies, medical anthropology, and the social sciences, and is grounded in a feminist poststructuralist perspective that understands bodies, norms, and diagnostic categories as produced through discourse rather than fixed biological facts.

Both authors identify as white European women in their early 30s and have extensive experience conducting qualitative interviews, including on sensitive health-related topics. Van Bavel’s background is in social anthropology and gender studies; her research examines the coloniality and global circulation of discourse on “female genital mutilation/cutting,” the unintended effects of anti-FGM/C interventions in East Africa and the United Kingdom, and the meanings and regulation of FGCPs in Belgium, the Netherlands and Kenya. Hermans, trained in the humanities and social sciences, has researched cosmetic procedures for nearly a decade and has also personally considered undergoing one herself. Both authors adopt a critical stance towards the growing normalisation of cosmetic procedures and the pressures on women to conform to socially constructed, consumerist body ideals.

Results

We identified two main themes that shed light on how MPs who perform FGCPs navigate the contentious field of FGCPs. The first theme explores their awareness of criticisms of GCPs, including how they perceive the heightened controversy around these surgeries compared to other forms of cosmetic intervention. The second theme focuses on how professionals justify their involvement in FGCPs. Within this theme, we identified two key discursive strategies: the “women’s health” framing, which positions FGCPs as addressing functional problems rather than purely cosmetic concerns, and the “women’s choice” framing, which emphasises patients’ bodily autonomy. These discursive strategies reveal how professionals navigate tensions between clinical legitimacy, ethical responsibility, and individual agency, while also highlighting the conditions under which they may place limits on patient choice.

Awareness of criticism of GCPs

The rapid increase in FGCPs has been accompanied by criticism. The responses of the participants showed that they were all familiar with, and had at times been on the receiving end of, these criticisms. While participants remarked upon scepticism towards cosmetic surgery in general, they felt that GCPs are particularly contentious. MP10 felt that colleague-gynaecologists looked at FGCP with disdain:

“Most people find it, yes, a bit the cesspit of our profession and a bit sad that you do it. [. . .] So, it is viewed very negatively within my professional group [. . .].” (MP10 – F – GYN – NL)

When asked what kind of critiques (conductors of) FGCPs receive, participants listed the following: FGCPs are sought to conform to beauty standards; protruding vulva lips are a normal anatomical feature and should therefore not be surgically altered; MPs might perform FGCPs for financial gain; and FGCPs should not be carried out on minors, as they are often insecure about their bodies and therefore unsuitable candidates for such procedures.

Some participants felt that GCPs are not much different from other cosmetic procedures, and that the criticisms on FGCPs thus stem from “conservative attitudes” and societal taboos surrounding sex and female genitalia. MP10, for example, said that gynaecologists oppose GCPs out of conservatism:

“Gynaecologists are inherently very traditional, very conservative. There are also many female gynaecologists who [. . .] refer to themselves: ‘I don’t have a problem with it, so why do you have a problem with it?’” (MP10 – F – GYN – NL)

Additionally, MP8 reflected on the taboo on altering female genitalia:

“I find it odd that so much is swept under the carpet when it comes to normal cosmetic surgery, yet aesthetic genital surgery is viewed with such suspicion. [. . .] I think that [female genitalia] are almost something magical, from which [babies] are born and which is a centre of sexual pleasure for both parties. It mustn’t be touched. It’s like a treasure chest that shouldn’t be worked on or something.” (MP8 – M – PS – BE)

It is noteworthy that this taboo extended even to the practices of MPs themselves. They mentioned, for example, that they would keep physical examinations as brief as possible, ensure that only female staff are present, and avoid taking photos – something they would normally do for other surgeries. MP3, for instance, reflected on this by saying:

“I take photos of all my surgeries. Over the past twenty-eight years, I’ve taken, I don’t know, 14,000, 16,000 photos. But not of these types of operations. In fact, I should be doing it because my insurance is gradually starting to require it. But it’s actually, yes, embarrassing to take photos of those. So, in fact, I don’t have any photos of them.” (MP3 – M – PS – BE)

Discursive framings to defend, rationalise or justify FGCPs

In the context of FGCPs being a contentious issue, MPs used two main discursive framings to justify performing these procedures: the women’s health framing and the women’s choice framing. The woman’s health framing emphasises that most women seek FGCPs for functional reasons, and these functional complaints, much like other women’s health issues, are often not taken seriously. Thus, FGCPs are framed as medical treatments. The woman’s choice framing, on the other hand, emphasises that women have the right to make decisions about their own bodies regardless of medical (non-)necessity. Both framings rely on a series of juxtapositions – functional versus aesthetic; patient choice versus medical decision-making; and medical versus cultural – which are considered and negotiated in MPs’ framings.

The women’s health framing

The women’s health framing challenges the notion that women undergo FGCPs to conform to beauty standards. Instead, it asserts that most women pursue these procedures due to functional issues that cause what participants consider genuine (medical) problems and thus deserve to be taken seriously. For example, when discussing vaginal tightening procedures, the interviewees emphasised that these procedures alleviate functional issues. MP10, for example, stated:

“Regarding vaginal tightening, those who come in always present with [physical] complaints. They never come in saying. . . Well, sometimes they do mention that it looks like a gaping hole, but that’s more of a side issue. They always come with [physical] complaints.” (MP10 – F – GYN – NL)

Similarly, labiaplasties were widely considered to be sought for functional complaints caused by protruding inner labia, rather than for aesthetic reasons:

“Women in their 70s say, yes, I still love cycling, but my skin is thinning with age, and those long flaps are constantly getting chafed and torn. How it looks cosmetically is not my main concern; I just want to be free of these [physical] complaints.” (MP10 – – F – GYN – NL)

The MPs thus constructed their work as providing medical solutions for functional complaints.

The women’s health framing was especially present in the responses of the Dutch participants. Both criticised sceptics of FGCP for not taking women’s genital concerns seriously. They constructed this scepticism as an example of how, in the Netherlands, women’s health issues are too often overlooked or not taken seriously.

“It remains a serious problem, especially because, I think, women’s health issues are underemphasized in the Netherlands. So, the GP thinks it’s nonsense, the gynaecologist thinks it’s nonsense. [. . .] Women have nowhere to turn.” (MP11 – F – PS – NL)

“The problem in the Netherlands is that gynaecologists are not trained in issues related to the vagina, so if you have a minor but bothersome problem, like losing urine when coughing or jumping on a trampoline, such a gynaecologist or GP will dismiss you with, ‘Yes, yes, you’ll have to live with it.’” (MP10 – F – gyn – NL)

MP11, a Dutch plastic surgeon who was working in both the Netherlands and Belgium at the time of the interview, felt that women’s concerns about their genital health were not taken as seriously in the Netherlands as they were in Belgium. She attributed this difference to the Calvinistic mindset prevalent in the Netherlands, which she described as a mentality where people are expected not to complain and to simply accept their situation. Additionally, she noted that in Belgium, it is much more common to regularly visit a gynaecologist, which she believed helps reduce taboos and makes it easier to discuss sexual and reproductive health issues openly. Both Dutch participants emphasised the importance of normalising discussions about FGCPs to reduce stigma, ensure women’s concerns are taken seriously, and prevent them from suffering in silence.

Defining “functional.”

The women’s health framing challenges the assumption that FGCPs are primarily sought for cosmetic or aesthetic reasons. It seems to operate on the implicit assumption that functional reasons for genital surgeries are more socially acceptable. For the participants, some procedures were without a doubt functional. Vaginal tightening, for instance, was frequently framed as an unambiguous example – it happens internally and is not visible, which participants saw as making it inherently unrelated to appearance.

However, the distinction between functional and aesthetic became more problematic with procedures like labiaplasty. Participants’ varied interpretations of what constitutes “functional” reasons for labiaplasty suggest that this boundary is both complex and subjective. Perspectives differed significantly on two key questions central to defining the “functional,” namely (a) what qualifies as a functional issue, and (b) how one can determine if someone meets these criteria.

With regard to what qualifies as a functional issue, all participants primarily conceptualised functional complaints in terms of physical discomfort and/or pain, often attributing this to labial length. They noted that long (inner) labia could cause pain and discomfort during activities such as cycling, wearing tight clothes, and penetrative sex (where the labia could become entrapped in the vagina). Others expanded the traditional definition of “functional” to include psychological and/or social discomfort arising from aesthetic concerns about one’s genitalia. They argued that aesthetic issues should be considered “functional” if they lead to people avoiding places like saunas or sports clubs, shying away from sexual activities, or avoiding gynaecological exams because of these concerns. For example, MP11 stated:

“If you have functional complaints from your labia, you’re 14 years old and you no longer dare to go to hockey or sports, you don’t feel comfortable showering. You become isolated, right? Then I intervene [. . .].” (MP11 – F – PS – NL)

In terms of psychological impact, some participants suggested that aesthetic concerns could be a medical issue, even in the absence of physical pain or social limitations. Citing the World Health Organization’s definition of health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” ³⁷ they suggested that any factor impacting well-being, thus including aesthetic concerns about one’s genitals, could be considered a medical issue. For instance, MP6 stated:

“The aesthetic aspect, strictu sensu, according to the definition of health by the World Health Organization, includes well-being and feeling good in your own body, which falls within the field of health. So, it is actually also medical.” (MP6 – M – PS – BE)

Adopting a broad definition of “functional” (including physical, psychological, and social aspects), many participants thus conceptualised FGCPs as always being, at least partially, functional and/or medical. It follows that some interviewees expressed reservations about labelling their work as cosmetic.

“I’m going to put ‘cosmetic’ in quotation marks, because most people who come for [labia corrections], about 90% come because they have hypertrophic labia that cause bleeding, irritation, pain, and discomfort during cycling, horseback riding, and sports. And it is mainly for that reason they wish for the procedure.” (MP6 – M – PS – BE)

There seems to be a connection between context, framing, and the definition of functionality. Dutch participants, who work in a context where FGCPs are largely, or even only, considered acceptable for functional reasons, emphasised women’s health and adopted a broad understanding of functionality, which includes social impact. Similarly, MP6, a Belgian plastic surgeon, also draws on functionality as he has an exclusivity contract with a public hospital, which restricts him to performing only functional surgeries. This may explain why he has a very expansive interpretation of what “functional” means, encompassing physical, psychological, and social impacts. This broad definition allows him to perform all labiaplasties. As he put it:

“That’s something you’re allowed to know about me: I consider [labiaplasties functional]. [. . .] I charge [the Belgian health insurance] for it.” (MP6 – M – PS – BE)

MP6 thus draws on the same kind of reasoning the Belgian health insurance applies to certain procedures, such as ear corrections for children experiencing bullying. Although labiaplasty is not explicitly included, practitioners like MP6 adopt a similar rationale to justify and secure reimbursement for FGCPs.

Determining and establishing functional complaints

Participants explained that determining whether a patient seeks FGCP for aesthetic or functional reasons typically involves understanding her motivations and conducting a physical examination of her genitalia. For both labiaplasty and vaginal tightening, the first indication is usually the functional complaints expressed by the patient.

Beyond the functional complaints described by patients, MPs also use physical examinations to assess whether an FGCP is indicated. MP10 noted that vaginal widening or prolapse symptoms can be visibly identified, such as a “gaping hole” appearance in cases of vaginal widening or a low-hanging cervix in cases of prolapse. Regarding vaginal rejuvenation procedures using laser techniques, MP4 explained that he measures the thickness of the vaginal wall to establish whether a treatment is indicated:

“We can also easily measure the entire wall using ultrasound. Pre-menopause, it’s usually six to nine millimetres thick – not just the mucosa, but also the muscle layer, essentially the entire wall. Post-menopause, the thickness drops to one to three millimetres. I measure it [because it] gives an important indication of whether the patient is a suitable candidate for lasering.” (MP4 – M – GYN – BE)

In the case of labiaplasty, during the physical examination, the focus is on evaluating the length and/or protrusion of the inner labia, as most participants believed there is a connection between these physical traits and the likelihood of experiencing functional issues.

“We often see that women experience discomfort not just aesthetically, but also physically [. . .]. If, for instance, the labia minora are, let’s say, around four, five, or six centimetres long, it can really cause some discomfort: during intercourse, while cycling, or when engaging in certain sports.” (MP1 – F – consultant – BE)

MPs felt confident in their ability to visually assess during the physical examination whether a woman’s claim of seeking labiaplasty for functional reasons was “valid.”

In Belgium, this assessment also serves a financial purpose, as the national health insurance reimburses labiaplasties performed for functional reasons. This may incentivise women to emphasise functional complaints and places the responsibility on MPs to assess the validity of these claims. MP11, for example, observed:

“You have a number of women who are very familiar with these complaints but, I think, might exaggerate them a bit to add a functional reason to the aesthetic correction. [. . .] We do have the deontological boundary to say, yes, okay, you don’t like this, and it might be that it presses a bit on your bicycle saddle, but a small labium that extends half a centimetre beyond the larger labium, I really cannot justify making the community pay to correct that.” (MP5 – M – PS – NL)

Both Dutch participants recalled existing guidelines on when labiaplasty might be indicated. They believed these guidelines set a threshold of 5 cm protrusion beyond the outer labia but were not entirely certain. They noted that the guideline lacks clarity on how measurements should be taken (such as where to begin and how much to stretch the labia) and fails to account for individual variations in what is considered ‘too long’ relative to body size. MP10 observed, “If someone is very small and petite, even 2 cm could be too much. I focus more on balance.” She further noted that the guideline is somewhat arbitrary: “And because a decision had to be made, gynaecologists in the Netherlands just settled on. . . some say 4 cm, others say 5 cm” (MP10 – GYN – NL). As a result, both Dutch participants choose not to follow the guideline and instead use the protrusion of the inner labia as indication for labiaplasty.

Belgian participants similarly used terms such as “too large,” “excess tissue,” or “hypertrophy” (from Greek, “excessive growth”), and associated such “hypertrophied” labia with functional complaints. When asked when labia are “too large” or “hypertrophied,” some vaguely remembered classifications and indications but could not recall the specifics. MP9, for example, said she did not remember the exact criteria, but summarised it as the labia minora extending beyond the labia majora:

“Um. . . I must honestly say that I don’t know those classifications by heart, but it’s mainly when the labia minora extend beyond the labia majora, and there are gradations of how far they extend.” (MP9 – F – PS – BE)

Other participants said that there is no scientific standard or measurement that specifies at what length the labia might cause functional issues. In the absence of such standard, these participants determined labial hypertrophy based on whether the woman reports functional complaints. MP6, for example, explained:

“That boundary. . . it doesn’t really exist. If you search for it, there are indeed gradations. I think the gradation mainly lies in the functional hindrance it causes. [. . .] But real clear classifications of ‘this or that is too much or too little’, [those don’t exist].” (MP6 – M – PS – BE)

MP6 thus appeared to use tautological reasoning: he determines whether there can be a functional problem by observing whether there is “labial hypertrophy,” and in the absence of a clear medical threshold, he determines labial hypertrophy based on whether the woman reports functional complaints.

The women’s choice framing

Although participants generally foregrounded a women’s health framing, they also positioned cosmetic procedures as (informed) decisions for cosmetic reasons. They explained that few women would initially share their appearance concerns; most would begin by mentioning functional complaints. However, during the consultation, it often became clear that the appearance aspect was as bothersome as the experience of physical complaints. Some participants felt that women might claim functional reasons because they find it more acceptable or easier to justify, likely due to the taboo surrounding and stigmatisation of GCPs. MP3 illustrates this point by expressing scepticism about the legitimacy of these functional complaints:

“I have the impression that patients feel they have to say that [they have problems with cycling or sex] because they’ve read it somewhere. [. . .] Can you have problems cycling because of large labia? Then we men should all have problems cycling because we have something else hanging there! [laughs] So in my opinion, that is a fallacy.” (MP3 – M – PS – BE)

Despite some hesitation regarding the legitimacy of functional complaints, the Belgian participants generally did not see this as problematic, instead emphasising individuals’ freedom to choose FGCPs. Indeed, to justify FGCP in the absence of functional complaints, MPs used the woman’s choice framing, which emphasises that it is ultimately a woman’s choice what to do with her body.

“That is the ethics of an aesthetic procedure: let the patient decide for themselves.” (MP5 – M – PS BE)

The importance of women’s “own choice” is highlighted by the fact that one participant performed labiaplasties despite not personally understanding why someone would choose to undergo the procedure. This plastic surgeon indicated that he is not a proponent of labiaplasties, describing them as delicate surgeries with considerable risks due to the bacteria and moisture in the area. Additionally, he could not understand why women would want to operate on their genitals and did not believe it was ever for functional reasons. However, his motivation for performing labiaplasties was the potential to increase patients’ happiness, underscoring the importance he places on respecting personal choice over his own views:

“To me, it’s one big question why women want to have genital surgery. [. . .] So that’s basically my motivation: can I make someone happy? And sometimes I do operations where I wonder: is this really necessary? (MP3 – M – PS – BE)

Participants thus emphasised that their goal is to make people happy and respect patient choice. MP8 reflected on how financial pressures and empty surgery slots can influence decision-making, suggesting that practitioners, including himself, may lean on the principle of “patient’s informed choice” to justify performing procedures that carry elevated risks or questionable necessity:

“If you have available time in your operating theatre next week and someone comes in who smokes ‘a few cigarettes,’ then you say, ‘You know you’re at higher risk of complications, right?’ – ‘Yes.’ – ‘Yes, you know you should really quit?’ – ‘I don’t know if I can.’ – ‘Well, I’ve told you.’ And then they still end up on the list.” (M8 – M – PS – BE)

Gatekeeping/limitations on women’s choice

While participants emphasised that the decision to undergo a procedure lies with the patient, most set boundaries regarding the types of procedures they are comfortable performing and the patients they are willing to treat. For example, some participants mentioned that they would not accept clients who wanted an aesthetic resembling a prepubescent vulva, as they found this morally questionable or objectionable. Consequently, they only agreed to perform surgeries that would result in a “natural” and “adult” looking vulva.

“But I find it a bit disturbing. . . that vaginas should look. . . I would almost call it ‘girlish.’ I find that disturbing. And that was a trend for a while, and there was a huge demand for vaginas to look as young as possible, almost pre-pubescent. I said, sorry, I don’t participate in that.” (MP6 – M – PS – BE)

Furthermore, some MPs would refuse patients if they felt their expectations were unrealistic. In such cases, they believed it was necessary to be “paternalistic” and “protect women from themselves,” which seems to contradict the earlier emphasis on respecting women's choices.

“But I think every tradeswoman or tradesman has to be a bit paternalistic. If someone asks a plasterer to plaster their wall with 2 mm of plaster and the tradesman knows it needs at least 8 mm or it will fall off, then you don’t say: ‘I’ll do what the customer asks, customer empowerment!’ No no no, I do, of course, what the customer asks, but within the range that I know has a good chance of making them happier. So, I definitely refuse patients.” (MP5 – M – PS –BE)

MPs also placed limits regarding on whom they would conduct FGCPs. These limitations seemed to, often implicitly, be linked to ideas around (the capacity for) autonomous choice. Some mentioned that patient–-clients had to want it themselves, rather than being under pressure from a third person:

“Sometimes you see this clearly: a man and a woman come in, and the woman says, ‘I don’t need it, but my husband says I should get my breasts enlarged.’ I say: ‘Madam, you don’t need different breasts, you need a different husband.’ [. . .] There should be no pressure.” (MP3 – M – PS – BE)

Some participants stated that they would not perform FGCP on minors because minors are still changing physically. They also noted that teenagers are often insecure during this stage of life, making it unwise to carry out genital or any cosmetic procedures at this time.

“There is, of course, a whole group of teenagers, almost all teenagers I think, who are very insecure about their bodies, and you shouldn’t do a labia reduction in such a phase. You shouldn’t do a nose correction. You shouldn’t do breasts. You should first let such a child grow up.” (MP1 – F – GYN – NL)

Besides concerns about coercion and age, some MPs mentioned they would not proceed with an FGCP, if they believed the patient was experiencing mental health issues. This could be related to a current life situation, such as infidelity or divorce.

“If I have someone with me who has just gotten divorced and their husband has left them for someone else, I would rather say: ‘Look, madam, wait six months.’ Because she might want to change something thinking ‘maybe it’s because of that [that my husband left me].’” (MP1 – F – consultant – BE)

Yet, participants were also wary of broader patterns of dissatisfaction or unhappiness.

“So I definitely refuse patients. If I think that a severe psychological issue is being projected onto a physical feature, then I pause and try to convince the person: you’re actually dealing with a psychological trauma, shouldn’t I refer you to a psychologist?” (MP5 – M – PS – BE)

Additionally, they would refrain from performing the procedure if they felt the patient had a history of sexual abuse, which played a role in them seeking this specific procedure.

“If someone tells me at 45: I was abused in my youth and you are the first person I’ve told. . . oopsie, now I’m going to call the GP: who can I recommend? Then I call the gynaecologist, who sees this more often, and ask: who in [the vicinity] can I recommend for further consultation?” (MP5 – M – PS – BE)

In all three cases, participants relied on their intuitive understanding of people and personal experience to identify coercion, emotional immaturity, and/or potential psychological issues. They generally felt confident in their assessments, as illustrated by MP9’s statement regarding recognising BDD:

“Yes, but you pick up on that very quickly, don’t you? Body dysmorphic disorder is quite straightforward; it’s an anxiety disorder, so these people are anxious by nature. You can see it as soon as they walk in – they’re already very anxious. [. . .] You ask them briefly what’s going on, and they say, ‘Yes, my labia are far too large. I think about it every day. It’s a daily worry, I can’t sleep because of it.’ [. . .] Most people, when you examine them, lie down and look to the left or right, a bit dissociated, but [people with BDD] stay sitting up, spread their legs as far as they can, and start pulling at themselves, you know. And that’s typical of BDD: the fidgeting.” (MP9 – F – PS – BE)

However, they also acknowledged occasionally missing signs. MP6, for instance, admitted that “very occasionally” he still “gets caught out,” meaning that he might operate on someone with low self-esteem who he believes might have been better served by seeing a psychologist.

With regard to coercion, the MPs seemed to understand it only in the most direct sense: a boyfriend, pimp, or a mother influencing or pressuring the woman. They did not spontaneously consider other forms of coercion, such as societal and cultural pressures (as has been suggested by feminists, e.g., Braun ²⁵ ). For instance, most did neither spontaneously mention beauty standards or cultural expectations that might compel a woman to seek out cosmetic procedures, nor did they consider how a woman’s own internalised beliefs about “normality” or “beauty,” shaped by these societal influences, could lead her to feel pressured into making certain decisions without any direct pressure from another person. When the interviewer suggested the role of beauty standards, MP5 responded:

“But is there really an ideal in society? It may be that a lot of pornography is easily accessible, but most women don’t think in terms of society.” (MP5 – M – PS – BE)

While the MPs did not spontaneously recognise societal and cultural pressures in the context of FGCPs, they were quick to acknowledge the role of such pressures with regard to other types of genital modifications, such as hymenoplasty, FGM, and male circumcision. Many commented that it is wrong to cut genitalia for “cultural” or religious reasons. Various participants believed that choice and bodily autonomy set FGCPs apart from what they consider unethical genital procedures. MP3, for example, said:

“Yes, but. . . when you talk about genital mutilation, I think of Africa, I think of children, [. . .] Muslims and so on. [. . .] What we are talking about [FGCPs] involves adult women who are competent to make decisions. That is totally different. So yes, mutilation is not the word here! It is someone who is competent asking for. . . something different. Not what happens there in Africa, for religious reasons.” (MP3 – M – PS BE)

Discussion

We found that gynaecologists and plastic surgeons were familiar with, and often encountered critiques of, FGCPs in both their personal and professional lives. Consistent with Sasson et al., ⁷ who highlight the heightened stigma surrounding GCPs, MPs felt that FGCPs are more contested than other types of cosmetic procedures, and attributed this to conservative gendered norms towards female genitalia and taboos on sex more generally. The MPs employed two discursive framings to justify their practice within the contentious field of FGCPs and to navigate the stigma faced by both patients and practitioners. The first, the women’s health framing, frames FGCPs as medical treatments addressing functional issues that participants emphasised were ‘genuine’ medical concerns. Critiques of FGCPs appeared to shape this framing: participants did not just state that women sought these procedures for functional reasons – they repeatedly insisted those concerns were legitimate. Notably, the term “function” was used broadly to include discomfort during sport, chafing in clothing, or diminished sexual confidence, rather than clinical or anatomical dysfunction. This expansive definition served a dual purpose: it validated women’s embodied distress and positioned FGCPs as legitimate medical care rather than elective cosmetic enhancement. While survey studies suggest that FGCPs are generally viewed as medically unnecessary,^20,21 our findings show how some professionals reframe necessity by expanding the meaning of “functional” impairment.

The second discursive framing, related to women’s choice, emphasises that, even in the absence of functional issues, the decision to undergo FGCPs ultimately lies with the woman. This perspective aligns with survey research showing that MPs generally did not object to performing FGCPs if the request came directly from the patient.^20,21 It also reflects a neoliberal logic in which individual autonomy is privileged, and health-related decisions are framed as matters of personal responsibility and consumer choice. ³⁸

Although we present the “health” and “choice” framings separately for analytical clarity, most practitioners moved fluidly between them in practice. A minority foregrounded FGCPs as unequivocally medical interventions, but the majority combined both framings – first emphasising functional motivations and then asserting that, even in cases driven primarily by aesthetics, women have the right to choose such procedures. This oscillation allowed practitioners to legitimise FGCPs on multiple grounds, enabling them to respond to diverse patient narratives while navigating the broader moral contestation surrounding these surgeries.

Both discursive framings revolve around juxtapositions. The women’s health framing juxtaposes functional and aesthetic concerns, and operates on the assumption that a clear line can be drawn between them. However, the results suggest that this distinction can be complex and subjective. This complexity was less pronounced in cases such as vaginal tightening, which was described as “invisible” and therefore not associated with aesthetic concerns, making its classification as functional less contentious. Labiaplasty, however, presented more complex challenges in defining functionality. Consistent with Kirkman et al., ²³ who found no clear consensus among MPs on indications for FGCPs, our findings revealed a spectrum of perspectives. While some MPs limited their understanding of functional issues to strictly physical problems, such as pain or discomfort, others adopted a broader perspective, recognising psychological distress or social difficulties related to appearance as valid functional concerns.

This blurred line between functional and aesthetic justification was especially evident in participants’ use of clinical language. Terms like “labial hypertrophy” were applied automatically to longer labia, implicitly pathologising anatomical variation, even while participants acknowledged that labia vary widely in size. There were no consistent criteria for this label; it was used to describe both physical protrusion and reported discomfort, regardless of labial length. In this way, the clinical term “hypertrophy” legitimised aesthetic preferences and subjective complaints as functional problems requiring intervention. Rather than serving as a precise diagnosis, it became a culturally loaded label that blurred cosmetic desire with clinical necessity. This reflects Braun’s ²⁵ observation that FGCPs are framed not as ways to enhance appearance, but as treatments that restore a presumed norm, thereby contributing to the medicalisation of women’s genital variation.

Institutional and policy contexts may influence how MPs define “functionality.” For example, Belgian national health insurance policy reimburses certain procedures, such as labiaplasty, if they are classified as addressing functional issues, which can incentivise MPs to categorise concerns as functional in order to secure reimbursement for patients. Similarly, public hospital employment contracts that restrict MPs from performing non-functional procedures can encourage broader interpretations of functionality.

We also identified a juxtaposition within the women’s choice framing: between patient-autonomy and medical decision-making. This framing emphasised women’s right to choose – even, in some cases, to the extent of fulfilling a woman’s request for a procedure the medic found incomprehensible. At the same time, participants described exercising gatekeeping by setting limits on the procedures they were willing to perform and the patients they would accept. For instance, some MPs refused to perform procedures that would result in a prepubescent-looking vulva, deeming such outcomes morally questionable. Others declined patients with unrealistic expectations, citing concerns that these individuals would likely remain dissatisfied and ultimately feel disappointed. Concerns also arose regarding patients’ ability to make autonomous decisions. Many participants said they would refuse to operate if they suspected pressure from a third party, or if the patient was a minor or had significant mental health issues. They relied on their intuitive understanding of people to identify signs of external pressure, mental health concerns, or histories of sexual abuse. However, they acknowledged that they sometimes missed these signs and lacked the necessary tools to consistently detect such factors.

Within the broader framing of women’s choice, a third juxtaposition emerged: the distinction between “medical” and “cultural” motivations. Participants consistently viewed procedures like hymen reconstruction, and FGM as culturally motivated and therefore ethically problematic. In contrast, they described FGCPs like labiaplasty as medically legitimate and not culturally driven. This reveals a clear double standard: cultural influences were acknowledged and critiqued in non-Western practices but largely ignored in Western ones – a pattern that has been widely critiqued in critical anthropological and postcolonial scholarship as reflecting colonial and racialised assumptions.^39–41 As feminist and anthropological scholars have shown, biomedicine is not culturally neutral, even if it presents itself as scientific and objective.^42,43 This is particularly evident in the case of labiaplasty, where cultural preferences for smaller labia have led to the pathologisation of longer labia under the clinical label “labial hypertrophy.”

Study limitations

This study draws on a small qualitative sample of MPs in Belgium and the Netherlands. While appropriate for an in-depth discursive analysis, the sample size does neither allow for robust comparisons between subgroups (e.g., by gender or specialty), nor was statistical generalisation intended. The sample includes more plastic surgeons than gynaecologists, reflecting the fact that plastic surgeons more commonly perform FGCPs in these settings. As with all interview-based research, participants may have presented their practices in ways that align with professional norms or manage potential scrutiny, which may have influenced how certain framings were articulated.

Future research could examine how these discursive framings operate in other national, legal, or institutional contexts, and how policy environments shape professional justifications. Although the study aimed to explore a broad range of FGCPs, the data centred primarily on labiaplasty and vaginoplasty. Further studies might focus more explicitly on less commonly examined procedures, including both surgical and non-surgical FGCPs.

Conclusion

MPs justify their involvement in FGCPs through two primary discursive framings: women’s health and women’s choice. These framings allow them to present FGCPs as either addressing genuine medical needs or respecting women’s autonomy. Yet these justifications rest on a series of unstable juxtapositions – between function and aesthetics, choice and authority, medical and cultural motivations – which, as our analysis shows, are not neutral but discursively produced. Aesthetic concerns are recast as functional impairments; patient choice is defended yet constrained; and cultural influence is pathologised in non-Western contexts but rendered invisible in Western ones.

These discursive framings do more than explain professional involvement; they work to stabilise and legitimise FGCPs by masking the deeper tensions they contain. Recognising these discursive manoeuvres is crucial to understanding how FGCPs come to be accepted as legitimate care and how deeper contradictions surrounding beauty, medicine, and ethics are managed rather than resolved. Moreover, the emphasis on “women’s choice” also works to render clinicians’ own role invisible: by presenting themselves as merely honouring patient autonomy, practitioners downplay how their consent to perform these surgeries helps establish certain body parts, that is, the labia, as appropriate sites for modification or removal. As one participant noted, men may also experience functional discomfort from their genitalia, such as testicles getting in the way while cycling, yet a request to remove them would never be considered clinically acceptable. The fact that labial reduction is readily sanctioned while comparable alterations in men are unthinkable highlights how deeply gendered assumptions shape what is regarded as a legitimate medical intervention. Moreover, the emphasis on choice also obscures the cultural beauty norms that give rise to these requests, norms that remain largely invisible in Western contexts even as cultural motivations are readily acknowledged and problematised in relation to genital modification practices in other cultures.

Supplemental Material

sj-docx-1-whe-10.1177_17455057261423384 – Supplemental material for Functional need or personal choice: Medical professionals’ understanding and framing of performing female genital cosmetic procedures

Supplemental material, sj-docx-1-whe-10.1177_17455057261423384 for Functional need or personal choice: Medical professionals’ understanding and framing of performing female genital cosmetic procedures by Hannelore Van Bavel and Anne-Mette Hermans in Women's Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057261423384 – Supplemental material for Functional need or personal choice: Medical professionals’ understanding and framing of performing female genital cosmetic procedures

Supplemental material, sj-docx-2-whe-10.1177_17455057261423384 for Functional need or personal choice: Medical professionals’ understanding and framing of performing female genital cosmetic procedures by Hannelore Van Bavel and Anne-Mette Hermans in Women's Health