1. What’s Normal? Influencing women’s perceptions of normal genitalia: An experiment involving exposure to modified and non-modified images Claire Moran & Christina Lee The University of Queensland, Australia

2. #BlueJC We will discuss this paper at #BlueJC on Twitter. Join us and share your thoughts! Follow @BJOGTweets How #BlueJC works? – Leung E, Tirlapur S, Siassakos D, Khan K. BJOG. 2013 May;120(6):657-60. http://bit.ly/10VaiRZhttp://bit.ly/10VaiRZ Further information? – See Journal Club section at http://www.bjog.org/http://www.bjog.org/

3. Scenario At a gynaecology clinic, a woman was referred to you with menorrhagia. Genital examination was unremarkable and transvaginal ultrasound showed fibroid. You have suggested appropriate management. At the end of the consultation, she asked “my vagina does not look symmetrical, is it normal?”

4. Background Increasing popularity of labiaplasty – 5-fold increase within the NHS between 2001-2011 Most women believe that “normal” labia minora should not be visible beyond the labia majora Aesthetic concerns were the most common reason given for undergoing labiaplasty Crouch 2011, Yurteri-Kaplan 2012, Bramwell 2007

5. The Clinical Question Does exposure to modified vulvas determine our perception of what is a normal vulva?

6. Background How common is plastic surgery to the genitalia (e.g. labiaplasty) in your practice?

7. Description of Research ParticipantsWomen aged 18 to 30 in Australia Intervention Viewing of a series of images of surgically modified vulva OR Viewing of a series of images of non-modified vulvas Comparison Did not view any images of vulvas OutcomesRating of normality and “society’s ideal” (on a 4-point Likert scale) on a series of images of non-modified and surgically modified vulvas viewed Study designRandomised controlled trial

8. Flow chart of the study Agreed to participate (N=97) Modified images (n=33) Non-modified images (n = 33) Control (no images) (n=31)

9. Methods How did the researchers recruit participants? Are the participants recruited representative of the population? Are randomization, allocation concealment and attainment adequate in this study?

10. Ratings of “Normality” Condition exposured

11. Ratings of “Society’s Ideal” Condition exposured

12. Results Women pre-exposed to images of modified vulvas rated the modified vulvas as more normal (compared to those exposed to normal vulvas and the control) More women in all three groups rated the modified vulvas as the society’s ideal, but this difference was most obvious in women pre-exposed to images of modified vulvas

13. Results Can you briefly summarise the results of this study using your own words? What are the potential implications of the results of this study?

14. Authors’ conclsion Exposure to images of modified vulvas affects women’s perceptions of what is normal and desirable These may lead to requests for unnecessary surgery on normal genitalia, which could be changed by education and awareness about genital diversity and appearance

15. Discussion What is your opinion on restricting public display of images of modified sexual organs? How would you answer the question posed by the woman in the scenario?

16. Suggested reading Crouch NS, Deans R, Michala L, Liao LM, Creighton SM. Clinical characteristics of well women seeking labial reduction surgery: A prospective study. BJOG: An International Journal of Obstetrics & Gynaecology. 2011;118(12):1507-10. Yurteri-Kaplan LA, Antosh DD, Sokol AI, Park AJ, Gutman RE, Kingsberg SA, et al. Interest in cosmetic vulvar surgery and perception of vulvar appearance. American Journal of Obstetrics and Gynecology. 2012;207(5):428.e1. Bramwell R, Morland C, Garden AS. Expectations and experience of labial reduction: A qualitative study. BJOG: An International Journal of Obstetrics & Gynaecology 2007;114(12):1493-9.