HOW EXPOSURE TO IMAGES OF A VARIATY OF NATURAL VULVAS AFFECTS
THE FEMALE GENITAL SELF-IMAGE:
A study in women who requested labiaplasty
BY
LOTTE GRANSIER, B.Sc
5744334THESIS
Final version: 6.798 wordsSubmitted in partial fulfillment of the requirements
for the degree of Master of Science in Health Psychology;
specialization Clinical Psychology
University of Amsterdam, May 2015
Advisors:
Mrs. E.T.M. Laan, Ph.D
Mr. M. Spiering, Ph.D
ABSTRACT
The number of labiaplasties performed in women who are dissatisfied with the appearance of their genitals has increased tremendously over the last decade. Women’s dissatisfaction with their genital appearance might be culturally constructed by excessive exposure to idealized modified vulvar images in the media. This study examined if exposure to images depicting a variety of natural, unaltered vulvar images leads to a more positive genital self-image in women who requested labiaplasty. In the experimental condition a variety of natural vulvar images were shown and in the control condition women were exposed to images of neutral objects. In 18 women genital self-image was measured before and after the intervention. Exposure to natural vulvar images did not result in a more positive genital self-image. Women who requested labiaplasty had a lower genital self-image than women who did not seek to have their labia altered, and they experienced worse sexual functioning, more sexual distress and higher levels of anxiety on a day to day basis. All in all, in women who requested labiaplasty, exposure to pictures of natural vulva’s did not lead to a more positive genital self-image
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TABLE OF CONTENTS
I
NTRODUCTION_______________________________________________________________ 4
METHOD____________________________________________________________________ 9
Participants and Research Design _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ 9 Materials _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 9 Procedure _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 11 Statistical Analysis_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 12RESULTS____________________________________________________________________ 13
Participant Characteristics _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 13 The Effect of Exposure to Natural Vulvas on the FGSIS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 15 Correlations with the FGSIS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _15DISCUSSION_________________________________________________________________ 16
REFERENCES_________________________________________________________________ 20
APPENDIX A: Information Brochure and Informed Consent LR-Study_________________24
APPENDIX B: Cover Letter___________________________________________________ 29
APPENDIX C: Questionnaires ________________________________________________ 30
APPENDIX D.I: Images of Unaltered Vulvas, Experimental Condition_________________ 38
APPENDIX D.II: Images of Neutral Objects, Control Condition_______________________ 38
APPENDIX E: Preparation Plan________________________________________________39
APPENDIX F: Worksheet_____________________________________________________41
`I do not like the asymmetrical appearance or the way the inner lips protrude from the outer lips.`
This quote is of a woman who requested labiaplasty, because she was dissatisfied with the appearance of her labia minora (Veale et al., 2013). Women tend to have a more negative genital self-image than men (Morrison, Bearden, Ellis, & Harriman, 2005; Ålgars et al., 2011). Bramwell and Moreland (2009) reported that half of the women in their sample felt that their genitals were not always normal in appearance, and that approximately a third felt that their labia were at odd times too large. In a survey in Dutch women, 43% found the appearance of their labia minora to be important, 14% regarded their labia minora to be abnormal, and 7% had considered labiaplasty (Koning, Zijlmans, Bouman, & van der Lei, 2009).
Labiaplasty is the most common Female Cosmetic Genital Surgery (FCGS) procedure. FCGS is surgery of the vagina, vulva and surrounding structures. Labiaplasty is the surgical alternation of the labia minora. In this procedure the labia minora are usually reduced in size (Goodman, 2009). In public hospitals in the United Kingdom the number of performed labiaplasties quintupled between 2001 and 2010 (National Health Service, 2012, in Crouch, Deans, Michala, Liao, & Creighton, 2011). The increasing availability of this procedure in the cosmetic private sector indicates that labiaplasty is a booming business in Western society (Liao & Creighton, 2007).
The increase in number of labiaplasties is not due to a growing number of medical indications for FCGS, such as genital cancer, vulvar intraepithelial neoplasia, repair or reversal of female genital cutting, or adrenogenital syndrome (ACOG, 2007; Hodgkinson & Hait, 1984; Cain, Iglesia, Dickens, & Montgomery, 2013). It rather seems to be a cultural trend, whereby elective indications (not medically indicated) are predominant (Cain et al.). These elective indications are divided into functional and aesthetic. The functional reasons comprise physical vulvar complaints that are attributed to enlarged labia minora and are referred to as ‘hypertrophy’ of the labia minora. These women may suffer from local irritation during sports or when wearing tight clothes, from vulvodynia and/or superficial dyspareunia, or have problems with personal hygiene (Rouzier, Louis-Sylvestre, Paniel, & Haddad, 2000). Women without any physical complaints who request labiaplasty for aesthetic reasons are dissatisfied with the appearance of their labia minora (Paarlberg & Weijenborg, 2008). Aesthetic reasons comprise protrusion of the labia minora, their shape, colour, and/or asymmetry (Braun, 2010).
The reported reasons of women who request labiaplasty for aesthetic or functional reasons varied from 13 – 87% for aesthetics reasons, and 32% – 76% for functional reasons (Alter, 2008; Miklos, & Moore, 2008; Rouzier et al., 2000; Crouch et al., 2011; Goodman et al., 2010; Veale, Eshkevari, Ellison, Cardozo, Robinson, & Kavouni, 2013). Women may use a functional reasons rather than aesthetics to legitimize their request for surgery, because medical practitioners and insurance companies have difficulty with the performance of labiaplasty for strictly aesthetic reasons (Bramwell, Moreland, & Garden, 2007; Paarlberg &
5 Weijenborg, 2008). A qualitative retrospective study of Bramwell et al. (2007) revealed that the main reason to undergo labiaplasty was because these women wanted a ‘normal’ genital appearance. Also, the most prominent motive for labiaplasty expressed by women on online communities was dissatisfaction with the appearance of their genitals and the emotional discomfort that this dissatisfaction causes (Zwier, 2014). Veale et al. (2013) examined the psychological characteristics and motivations of women considering labiaplasty and compared them to a control group, which consisted of women who did not desire labiaplasty. They found that the labiaplasty group reported greater dissatisfaction toward the appearance of their vulva compared to the control group. The labiaplasty group also experienced more interference in life, especially in sexual life, discomfort, and distress in general, they reported lower sexual satisfaction, and a greater frequency of avoidance behaviors than the control group. It seems that labiaplasty for aesthetic reasons prevails and that dissatisfaction with one’s appearance is associated with emotional and psychosexual distress.
As mentioned above, ‘hypertrophy’ and protrusion of the labia minora shouldn’t be seen as a pathologic condition (Puppo, 2011; Rouzier et al., 2000). The labia minora vary in size. They can be almost invisible, they may protrude from the labia minora, and they can be asymmetrical. The width of the labia minora varies between 7 to 50 mm (M = 21.8, SD = 9.4) in the female population (Lloyd, Crouch, Minto, Liao, & Creighton, 2005). The study of Veale et al. (2013) showed that the women who requested labiaplasty all had a labia minora width that was within this range. There is also no evidence of any relationship between the size of the labia minora and sexual dysfunctioning (Bramwell et al., 2007) or between labia minora size and physical discomfort (Reitsma, Mourits, Koning, Pascal, & van der Lei, 2011).
There are a number of studies that claim that labiaplasty results in high patient satisfaction. Authors stated that labiaplasty reduces physical discomfort, and has a positive effect on sexual functioning (Alter, 2008; Goodman et al., 2000; Mirzabeigi et al., 2012). Unfortunately, these studies were methodologically poor, had no control group, no follow-up and/or had a retrospective design. The benefits of labiaplasty are therefore still questionable. Moreover, labiaplasty carries risks and might do more harm than good. Complications1 occur in 4.4% – 8.5% of the labiaplasty procedures (Alter, 2008; Goodman et al., 2010) and it
cannot be ruled out that incisions in the labial tissue may impair sexual functioning. Goldstein and Berman (1998) argued that similar to male erectile tissue, female genital vascular tissue might play an important role in sexual response. Several studies confirm that the labia minora contain sexually responsive vascular tissue (Shafik, Shafik, & Ahmed, 2004; Yang, Cold, Yilmaz, & Maravilla, 2006; Schober, 2010). This tissue becomes engorged with blood during sexual arousal. Because of this engorgement, the labia minora become turgid, thickened and everted. Research also shows that the labia minora have considerable numbers of free
1 Complications are i.a., visible scarred edge; clitoral hood overhang; change in pigmentation; frenulum distortion; fistula and sinus
formation; elevation and overtightening of the introitus; local hematoma; infection; wound dehiscence; dyspareunia and pain (Cain, et.al., 2013; Likes, Sideri, Haefner, Cunnigham & Albani, 2008).
nervous endings and sensory receptors (Martin-Alguacil et al., 2011). The labia minora are especially highly innervated along the edges, which gives them a specific sensitivity that is important for sexual arousal (Schober, 2010). Thus it is expected that any labial incision may disrupt female genital response. It may reduce the tissue’s erotic sensitivity and vascular response to sexual arousal, which in turn can lead to sexual dysfunctioning. The outcome of a study that examined the association between the size of vulvar excision and sexual functioning in women with vulvar intraepithelial neoplasia supports this hypothesis (Likes, Stegbauer, Tillmans, & Pruett, 2007). In 77% of cases an excision of the labia minora was made, and more extensive excision was associated with poorer sexual functioning, especially with respect to decreased sexual arousal and satisfaction.
A surgical intervention in a healthy sexual organ carries risks. Therefore, women who have a negative genital self-image should have other options than surgery to deal with these feelings of insecurity. The aim of this study is to test efficacy of a psychological intervention to enhance genital self-image in women who consider labiaplasty for aesthetic reasons.
Women’s dissatisfaction with their genital appearance and request for labiaplasty can be attributed to a number of factors. Historically, certain negative cultural representations of women’s genitals throughout Westerns societies contributed to genital dissatisfaction. According to Braun and Wilkinson (2010) the female genital is seen as inferior to the penis, disgusting, sexually inadequate, and is considered as an organ that should be kept hidden. These kind of negative representations may create an image of the female genitals which is defective and should be improved by, for example, cosmetic surgery.
In addition to the negative representations of female genitals, women today are exposed to modified idealized vulvas in both media and pornography. These idealized vulvas have labia minora which do not protrude the labia majora. Since women are rarely confronted with the natural variety of vulvas (Crouch et al., 2011) these images might construct their idea of average and acceptable genital appearances. Analyses of the representation of vulvas in women’s magazines demonstrated that the most common appearance of the vulva was of a smooth curve, or the position of the model was such that the vulva was almost invisible (Bramwell, 2002). Schick, Rima and Calabrese (2009) analyzed 183 photographs in Playboy Magazine that clearly depicted the model’s mons pubis. Results showed that the labia minora were only visible in 7% of the photographs. In only 1% of the photographs the labia minora were depicted as protruding beyond the labia majora. Another study compared images of vulvas from online pornography and feminist publications (Howarth, Sommer, & Jordan, 2010). This study also confirmed that labia protuberance and variance in vulvar appearance was significantly less in the images from online pornography. Inadequate exposure to idealized modified vulvar images in media and pornography may add to women’s negative genital self-image.
The current study investigates whether exposure to a variety of natural vulvar images positively affects the genital self-image in women who consider labiaplasty. The psychological intervention among
7 women who request labiaplasty will thus consist of exposure to a variety of natural, unaltered vulvar images. The intervention is based on the idea that exposure to these variations should convince women that their genital appearance is not abnormal, which will improve their genital self-image.
Recent research of Moran and Lee (2013) showed that exposure to modified vulvar images changes women’s perception of what is normal and ideal. Women who first viewed the modified images, rated the modified target vulvas as more normal than the natural vulvas. This rating was different from the women who first viewed the natural vulvas and rated the modified target vulvas as less normal. Another study examined the effect of counseling for women who requested labiaplasty (Özer, Laan, van Lunsen, Burger, & van der Horst, 2011). They found that counselling was an effective method to address aesthetic question of normality and to increase the knowledge about one’s genitals. The counselling consisted, among other things, of psycho-education, including exposure to images of natural vulvas. After counselling, 35% of the women refrained from labiaplasty. Even though counselling appeared effective, it is unknown which ingredients of the counselling procedure were responsible for this reduction in labiaplasty requests.
Previous research of Hesselink (2012) and Snijders (2013) investigated the effect of exposure to natural vulvar images, using a pretest posttest design. They randomly assigned the female participants to a photo condition, a mirror condition, a photo-mirror condition, and a control condition. In the photo condition the participants were exposed to a variety of natural vulvar images. In the mirror condition the participants were asked to look at their vulva with a mirror and describe it in neutral terms. The photo-mirror condition consisted of both procedures of aforementioned conditions. Finally, participants in the control condition were exposed to images of neutral objects. A significant increase in genital self-image was found for both the photo condition as well as the combined mirror condition. The effect was the strongest for the photo-condition. Since the sample size was too small (N = 31) for statistical reliability Martoredjo and Laan (2015) replicated the study with only the photo and control condition and a larger sample size. Results again showed that in the photo condition posttest genital image was more positive compared to pretest genital self-image, and compared to posttest genital self-image of the women in the control condition.
In the present study the effect of exposure to natural vulvas was examined in women with a request for labiaplasty. Such a study has not been done before. In this study a pretest and posttest comparison of genital self-image was obtained in women exposed to the photo condition and in women allocated to the control condition. As in the study of Martoredjo and Laan (2015), the photo condition consists of a variety of 44 natural vulvar images and the control condition consists of 44 images of neutral objects.
There are several factors that can influence genital self-image. Research points out that women with a positive body-image have fewer sexual problems (Ackard, Kearney-Cooke, & Peterson, 1999; Satinsky, Reece, Dennis, Sanders, & Bardzell, 2012; Seal, Bradford, & Meston, 2009). For women, a positive genital self-image is also positively related to sexual esteem, sexual satisfaction, and sexual functioning, and
negatively related to body/genital-image self-consciousness during sexual activity, and levels of sexual distress and sexual anxiety (Berman, Berman, Miles, Pollets, & Powell, 2003; Herbenick, & Reece, 2010; Morrison, Bearden, Ellis, & Harriman, 2005; Schick, Calabrese, Rima, & Zucker, 2010). In addition, there are indications that genital self-image may be related to the trait neuroticism. Neuroticism is defined as emotional (in)stability, and people who score high on the trait neuroticism tend to experience more negative emotions (Tamir, 2005). Neuroticism is negatively correlated with body satisfaction (Swami & Carvalho 2011; Swami, Hadji-Michael, & Furnham, 2008). This study therefore investigated to what extent sexual dysfunctioning, sexual distress, and an anxious disposition influences the efficacy of the intervention.
It was expected that participants in the photo condition will have a more positive genital self-image at posttest compared to pretest, and compared to posttest genital self-image of participants in the control condition.
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METHOD
Participants and Research Design
The study examined 18 women who requested labiaplasty and had arranged a referral to visit a gynaecologist for this matter. Initially, the sample size was determined on 38 participants with power analyses from the program G*Power. In the study of Martoredjo et al. (2015) an effect size Cohen’s f = .24 was found for the within-between interaction effect. For a mixed ANOVA with an effect size of f = .24, a power of .82, 38 participants were needed for a significant result at α < .05. Due to logistical difficulties in recruiting patients from different medical centres only 18 participants were tested.
The exclusion criteria were being younger than 18 years and unable to understand the Dutch language. The age limit was introduced, because Dutch guidelines recommend that the procedure should not be carried out in women younger than 18 years (Paarlberg & Weijenborg, 2008). Before participation written consent was obtained. Participation was voluntarily and participants did not received any compensation. Participants were recruited at the Academic Medical Centre (AMC), Amsterdam, the Deventer Hospital, Deventer, the Gelre Hospital, Apeldoorn, the Isala Clinics, Zwolle, the Jeroen Bosch Hospital, Den Bosch, the Sint Lucas Andreas Hospital (SLAZ), Amsterdam, and Ter Gooi Hospital, Blaricum. The study was approved by the Medical Ethical Committee of the AMC and of all participating centres.
This study has an experimental design with two conditions and female genital self-image as the dependent variable. In the experimental condition the manipulation – exposure to unaltered, natural vulvar images – was applied. In the control condition images of neutral objects were presented. Participants were randomly assigned to the two conditions.
Materials
Photo’s – The experimental condition (EC) consisted of exposure to a PowerPoint presentation depicting a
variety of 44 unaltered, natural vulvar images (Appendix D.I). These images were selected from the book Petals of Nick Karras, which contains a wide variety of vulvar images, depicting the large variability in the appearance of the vulva. The presentation started with an instruction slide, which stated: “These are vulvas of normal women. None of these vulvas have been altered surgically or with Photoshop. Please pay attention to the images.” This slide was presented for 25 seconds. Then, the actual presentation with the 44 images of vulvas commenced. Each image was presented for 5 seconds. The last slide stated: “The presentation ends now. You can now summon the test leader.” The total duration of the presentation was 4 minutes and 10 seconds.
The control condition (CC) consisted of exposure to a PowerPoint presentation with 44 images of neutral objects (Appendix D.II). The presentation started with an instruction slide, which stated: “Images will be presented to you now. Please pay attention to the images.” This slide was presented for 25 seconds. Then,
the actual presentation with the 44 images of neutral objects commenced. These images were each presented for 5 seconds. The last slide states: “This was the presentation. You can now summon the test leader.” The total duration of the presentation was 4 minutes and 10 seconds.
Genital self-image – The Female Genital Self Image Scale (FGSIS) is a scale for assessing genital self-image
(Herbenick, & Reece, 2010). The scale consists of 7-items assessing women’s feelings and beliefs about their own genitals. Items are scored on a 4-point response scale, which ranges from strongly disagree to strongly
agree. The scores on the 7-items are summed to obtain a total score ranging from 7 to 28. Higher scores
indicate a more positive genital self-image. The reliability of the scale is sufficient, with a Cronbach alpha of .88 to .91 (Herbenick, & Reece, 2010; Herbenick et al., 2011). The construct validity of the scale is also satisfactory. The factor loadings range from .65 to .86 and the corrected item-to-total correlations range from .55 to .77 (Herbenick, & Reece, 2010). The FGSIS was translated into Dutch by two independent translated into Dutch by two independent individuals. When the translators disagreed, the final text was arrived at after an extended discussion. The final version was backtranslated by a native English speaker; no substantial loss of information was observed.
Sexual function – The Female Sexual Functioning ( FSFI) is a multidimensional scale for assessing sexual
function in women (Rosen et al., 2000). The questionnaire consists of 19 items and has a 6 domain structure, which include desire, subjective arousal, lubrication, orgasm, satisfaction, and pain. Each item is rated on a 5- or 6-point response scale. The total score ranges from 2 to 36. Higher scores indicate better sexual function. The FSFI has strong psychometric qualities. The factor structure, the test-retest reliability and internal consistency (Cronbach’s alpha values of .82 and higher) are satisfactory. The discriminant validity is also sufficient such that the questionnaire discriminates between women with and without sexual complaints (Rosen et al., 2000; Wiegel, Meston, & Rosen, 2005). Additionally, the psychometric validity and the reliability of the Dutch translation is also found to be good (ter Kuile, Brauer, & Laan, 2006). The questionnaire was only administered to participants who had been sexually active in the last 4 weeks.
Sexual distress – The Female Sexual Distress Scale-Revised (FSDS-RV) measures sexual related personal
distress experienced by women (Derogatis, Clayton, Lewis-D’Agostino, Wunderlich & Fu, 2008). The scale consists of 13 items, with a 5-point response scale for each item ranging from never to always. The total sum score ranges from 0 to 52, with a higher score indicating a higher level of sexual distress. The Dutch translation of the test has a good discriminant validity, high test-retest reliability (correlation coefficient of .93) and a high degree of internal consistency (Cronbach's coefficient alpha of .97; ter Kuile et al., 2006). A
11 score of 11 or higher on the FSDS-R in combination with a score of 26.55 or lower on the FSFI is indicative of sexual dysfunctioning (Derogatis et al., 2008).
Anxious disposition – The subscale Trait Anxiety of the State-Trait Anxiety Inventory – Dutch Y (STAI-DY) was
used to assess trait anxiety. Trait anxiety is the overall tendency to react with anxiety and correlates strongly with neuroticism (Schreider, Carver & Briges, 1994). The Trait Anxiety subscale is an unidimensional measure with 20 items. Each item is rated on a 4-point intensity scale, ranging from almost never to almost always. The total sum score ranges from 20 to 80, with a higher score indicating greater anxiety. The test-retest reliability is satisfactory. The internal consistency is sufficient with Cronbach’s alpha of .73 to .95 (Van der Ploeg, Defares & Spielberger, 1980). The Trait Anxiety subscale can be administered independently of the entire questionnaire.
Motives for labiaplasty – The questionnaire Motives for Labiaplasty (MfL) assesses if the participant
considered labiaplasty for aesthetic and/or functional reasons. This is a self-constructed questionnaire, which consists of four items. Each item has a 5-point response scale, ranging from entirely not applicable to entirely
applicable.
Item 1: Are you considering labiaplasty for aesthetic reasons? (You do not like the appearance of your labia.)
Item 2: Are you considering labiaplasty for functional reasons? (Your labia elicit discomfort.)
Item 3: Are you considering labiaplasty because your vulva hurts regularly? Item 4: Do you expect the vulvar pain to decrease after labiaplasty?
Item 3 was included in order to determine what proportion of the participants with functional impairment also experienced vulvar pain. Item 4 was included because women who expect labiaplasty to reduce their vulvar pain will probably be persistent in their request for labiaplasty, even though there is no evidence for a relationship between the size of the labia and the amount of physical discomfort (Reitsma, Mourits, Koning, Pascal, & van der Lei, 2011).
Procedure
Upon each referral for labiaplasty received at the outpatient gynaecology clinic of each of the participating clinics, the physician assistant notified the research assistants of the AMC, the hospital that initiated this study, by email. Then the physicians assistants sent the confirmation of the appointment, together with the information brochure, the informed consent (Appendix A) and the cover letter (Appendix B) of the study to the potential participant (Appendix E). Nine days after this was mailed to the patient, she was phoned by the
research assistant to inquire whether she would be interested to participate in the study, and to check eligibility. For patients who decided to participate, the appointment for the study was scheduled an hour prior to the gynaecologist appointment in the corresponding clinic. The research assistant traveled to the clinic to perform the actual testing.
Prior to giving informed consent, participants were informed about the study details and procedure and were assured anonymity and confidentiality (Appendix F). The participants were tested in a private research room at the outpatient clinic. The study was presented to the participant as: “The reasons for considering labiaplasty.” They were informed that they would be asked to fill in a number of questionnaires on the computer and would be exposed to a variety of natural vulvar images or to images of neutral objects.
The participants first completed the FGSIS, the GAS, the FSDS-RV, the STAI-DY, and the MfL, and when they were sexually active they also complete the FSFI (Appendix C). After the intervention all participants completed the FGSIS for the second time.
Statistical Analyses
For all the participant characteristics a Fisher’s exact test or the Likelihood Ratio test was performed to examine if the characteristics significantly differ per condition. These test were chosen instead of the Pearson’s Chi-squared test because of the small sample size of the study.
To examine the baseline of the FGSIS scores, the pretest FGSIS data of this study were compared with the pretest FGSIS data of the study of Martoredjo and Laan (2015) with a Mann-Withney test. In order to verify that the covariates and the pretest FGSIS data do not differ per condition at baseline, independent t-tests and a Mann-Withney test were executed. Non-parametric t-tests were used when the assumptions for parametic testing were violated.
To examine the effect of the intervention on the FGSIS total scores a 2 Group (experimental/control) x 2 Time (pretest/posttest) ANOVA was conducted. To check the assumption of normality and homogeneity of variance for the mixed ANOVA, Kolmogorov-Smirnov and Levene’s tests were performed for the pre- and posttest FGSIS data.
In advance three separate 2 Group x 2 Time ANCOVAs were planned, to examine the effect of the intervention, while controlling for the possible effects of the covariates. Since the sample size was smaller than originally planned (N = 18 instead of N = 38) the ANCOVAs were not performed, because of a tremendous loss of statistical power. Bivariate correlation analyses between the covariates and the pretest FGSIS data were performed instead, to examine the linear relationship between these variables. Pretest FGSIS scores were chosen for these analyses because these contain less bias than posttest scores, due to testing effects.
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RESULTS
Participant Characteristics
The period of recruitment was from January 2014 until November 2014. The participants were recruited at the AMC, the Gelre Hospital, the SLAZ, and the Isala Clinics. Of the approached labiaplasty patients, 75% participated in the study (N = 18). Their average age was 29.6 years (SD = 9.95, range 18-48). The majority (83%) had a Dutch ethnic background and their sexual orientation was predominantly heterosexual (94%). Ten of the participants were in a relationship, with an average duration of eleven years and three months (SD = 7.0, range 1.3-20.2). Eleven participants were sexually active during the last four weeks and 36% of them had combined FSFI (< 26.55) and FSDS-R (> 11) scores indicative of sexual dysfunction. Of all the participants 78% experienced sexual distress. In Table 1 the participant characteristics and experience are listed. These characteristics and experiences did not significantly differ between conditions (all ps > .33).
Table 1.
Participant Characteristics and Experiences in Percentages, per Condition (EC, CC) and in Total.
EC (n = 9) CC (n = 9) Total (N = 18)
% (n) % (n) % (n)
Educational level
Elementary school 11% (1) 0% (0) 6% (1)
Lower secondary education 0% (0) 0% (0) 0% (0)
Post secondary education 33% (3) 33% (3) 33% (6)
Tertiary education 22% (2) 33% (3) 28% (5) Community college 22% (2) 22% (2) 22% (4) University 11% (1) 11% (1) 11% (2) Ethnic background Dutch 89% (8) 89% (8) 89% (16) Other 11% (1) 11% (1) 11% (2)
Sexual orientation towards
Only women 0% (0) 11% (1) 6% (1)
Mainly women, but sometimes men 0% (0) 0% (0) 0% (0)
Women and men equally 0% (0) 0% (0) 0% (0)
Mainly men but sometimes women 11% (1) 11% (1) 11% (2)
Only men 89% (8) 78% (7) 83% (15)
Relationship
Yes 67% (6) 44% (4) 56% (10)
No 33% (3) 56% (5) 45% (8)
Sexually active (last four weeks)
Yes 78 % (7) 44% (4) 61% (11)
No 22% (2) 56% (5) 39% (7)
Decreased sexual functioning
Yes 29% (2) 50% (2) 36% (4) No 71% (5) 50% (2) 64% (7) Sexual distress Yes 78% (7) 78% (7) 78% (14) No 22% (2) 22% (2) 22% (4) Sexual dysfunction Yes 29% (2) 50% (2) 36% (4) No 71.% (5) 50% (2) 64% (7)
When asked about the reasons for requesting labiaplasty (Table 2): 66.6% reported that dissatisfaction with the appearance was partly to entirely applicable to them (aesthetic reason) and 94.5% reported that discomfort was somewhat to entirely applicable to them (functional reason). For 83.3% of the participants painful labia were regularly, partly to entirely, the reason for requesting labiaplasty. The same percentage expected that labiaplasty would, somewhat to completely, reduce this pain.
Table 2.
Reasons for Requesting Labiaplasty in Percentages, per Condition (EC, CC) and in Total.
EC (n = 9) CC (n = 9) Total (N = 18)
% (n) % (n) % (n)
Aesthetic reasons
Entirely not applicable 44% (4) 22% (2) 33% (6)
Somewhat not applicable 0% (0) 0% (0) 0% (0)
Partly applicable / partly not applicable 22% (2) 56% (5) 39% (7)
Somewhat applicable 11% (1) 22% (2) 17% (3)
Entirely applicable 22% (2) 0% (0) 11% (2)
Functional reasons
Entirely not applicable 0% (0) 0% (0) 0% (0)
Somewhat not applicable 0% (0) 0% (0) 0% (0)
Partly applicable / partly not applicable 11% (1) 0% (0) 6% (1)
Somewhat applicable 0% (0) 56% (5) 28% (5)
Entirely applicable 89% (8) 44% (4) 67% (12)
Pain reasons
Entirely not applicable 0% (0) 11.1% (1) 6% (1)
Somewhat not applicable 22% (2) 0% (0) 11% (2)
Partly applicable / partly not applicable 0% (0) 22% (2) 11% (2)
Somewhat applicable 33% (3) 33% (3) 33% (6)
Entirely applicable 44% (4) 33% (3) 39% (7)
Expectation pain reduction
Entirely not applicable 11% (1) 11% (1) 11% (2)
Somewhat not applicable 11% (1) 0% (0) 6% (1)
Partly applicable / partly not applicable 0% (0) 56% (5) 28% (5)
Somewhat applicable 67% (6) 0% (0) 33% (6)
Entirely applicable 11% (1) 17% (3) 22% (4)
Genital self-image of the women in the control condition was equal to genital self-image of the women in de experimental condition (means and SD of FGSI scores are listed in Table 3). Genital self-image of the women in the present study was significantly lower (M = 15.11, SD = .75) than genital self-image of the women in the study of Martoredjo and Laan (2015) (M = 20.79, SD = .42), with U = 69.00, p < .001, r = .65. There were also no significant differences in FSFI, FSDS-R, STAI-DY scores between the experimental and control condition.
15
The Effect of Exposure to Natural Vulvas on the FGSIS
The FGSIS test results are listed in Table 3. The assumptions of parametic testing were not violated. The FGSIS pretest and posttest data were normally distributed and there was homogeneity of variance. The 2 Group x 2 Time ANOVA revealed no significant main effect for Group, F(1, 16) = 0.00, p = 1.00, ηp2 > .001 and no significant main effect for Time, F(1, 16) = .209, p = .654, ηp2 = .013. The predicted interaction among Group and Time was not significant, F(1,16) = .093, p =.764, ηp2 = .006.
Correlations with the FGSIS
In Table 4 the means and standard deviations of the covariates – sexual functioning (FSFI), sexual distress (FSDS-R) and anxious disposition (STAI-DY) – are listed. The data of the covariates were normally distributed. All assumptions for Pearson’s correlation analyses were met. The test results are listed in Table 5. Intercorrelations for the FGSIS pretest scores with the covariates showed that women with a low genital self-image reported decreased sexual functioning, more sexual distress, and higher levels of anxiety on a day to day basis. In addition, women who experienced decreased sexual functioning also reported more sexual distress, and scored higher on the anxious disposition. Similarly, women who experienced more sexual distress also reported higher levels of anxiety.
Table 5.
Correlations for Scores on the FSFI, FSDS-R, STAI-DY, and Pretest FGSIS.
*p < .05, two-tailed. **p < .01, two-tailed.
Table 3.
Means (and Standard Deviations) for the pre- and Posttest Scores on the FGSIS per Condition.
Experimental
Condition Control Condition
(n = 9) (n = 9)
Pretest 15.0 (2.8) 15.2 (3.6)
Posttest 14.9 (2.5) 14.7 (3.2)
Table 4.
Means, Standard Deviations and Total Number of Cases for the Scores on the FSFI, FSDS-R, and STAI-DY.
M SD N FSFI 25.6 1.9 11 FSDS-R 20.1 5.0 18 STAI-DY 47.5 1.9 18 FSFI FSDS-R STAI-DY Pretest FGSIS .674* -.678** -.848** FSFI -.916** -.768** FSDS-R .767**
DISCUSSION
This study investigated if exposure to a variety of natural, unaltered vulvar images has a positive effect on genital self-image in women who requested labiaplasty. The results revealed that for women who requested labiaplasty, exposure to natural vulvar images did not have an effect on genital self-image. Also, posttest genital self-image of these women was not more positive than genital self-image of the women who had been exposed to neutral images. Thus, the hypothesis that exposure to natural vulvar images would enhance genital self-image in women who requested labiaplasty, is rejected.
Explorative analyses indicated that women who requested labiaplasty seem to have a lower genital self-image than women who did not requested labiaplasty. This is in line with findings of the study of Veale et al. (2013) who reported that the women who requested labiaplasty experienced more dissatisfaction with the appearance of their vulva. Correlation analyses confirmed that women with a low genital self-image experienced decreased sexual functioning and more sexual distress. Correlation analyses furthermore showed that women with a low genital self-image experienced higher levels of anxiety on a day to day basis. These results are in line with the findings of Swami and Carvalho (2008) and Swami et al. (2011) who concluded that trait neuroticism is associated with higher body dissatisfaction.
There are several explanations for the ineffectiveness of the intervention on the genital self-image in women who requested labiaplasty. These women experience more anxiety on a day to day basis, based on the correlation between trait anxiety and the genital self-image. Consequently they also experience more negative emotions and are thus less susceptible to a change in perspective. In order to verify this hypothesis, covariate analyses, as planned in this study, should be conducted in follow-up research with a larger sample.
Schick, Calabrese, Rima, and Zucker (2010) also found that a lower genital self-image was associated with higher genital image self-consciousness during sexual activity. Higher self-consciousness during sexual activity might lead to cognitive distraction during sexual activity, which, in turn, has a negative effect on sexual functioning (Wiederman, 1996; Wiederman & Pryor, 1997, Dove & Wiederman, 2000). The content of cognitive distraction, predicted by a negative body-image, represents a sexual performance concern (Meana & Nunnick, 2006). It is reasonable to expect that women with sexual performance concerns have difficulty attaining and maintaining their sexual response (Meston, 2006; Wiederman, 2000). This way a low genital self-image becomes the precursor of decreased sexual functioning and distress.
Another explanation for the ineffectiveness of the intervention is that the women in the sample size could have had actual large labia minora, and were already convinced of this fact, that the images of unaltered vulvas could not overrule their feelings of abnormality. Future research can control for the influence of the labia size on the genital self-image by measuring them prior to the labiaplasty, and include the variable labia size in a covariate analyses.
17 Next to having abnormal labia there are also women who request labiaplasty because they suffer from body dysmorphic disorder (BDD). When suffering from BDD someone is preoccupied with their appearance without a clear noticeable abnormality (APA, 2000). The distorted perception itself makes them less receptive for a change in perspective when exposed to natural variations. It is therefore important in further research to screen for BDD, because including these patients in the study probably attenuates the general effect of the intervention.
Noteworthy, for 95% of the women functional complaints were at least a reason to undergo labiaplasty, and 83% of the women experienced regularly painful labia. The intervention was based on the idea that a negative genital self-image is influenced by the perception of having an ‘abnormal’ genital appearance. Exposure to the natural variations of vulvas should convince women that their genital appearance is normal, which in turn should improve their genital self-image. The influence of other factors, rather than aesthetic perception, on the genital self-image were not taken into account. It is not inconceivable that the experience of pain and other physical discomforts might also have a negative influence on how women evaluate their body parts. This might also be the case when these women experience sexual dysfunctioning. When these experiences of physical and sexual discomfort outweigh the dissatisfaction with the ‘abnormal’ appearance, when it comes to evaluating the genital self-image, then the intervention will not be effective. This hypothesis is at odds with the results of Martoredjo and Laan (2015) who found that the exposure to natural vulvar images, in women who did not consider labiaplasty, was effective irrespectively the degree of sexual dysfunctioning, sexual distress, and trait anxiety. It must be mentioned that these results might be biased due to the use of a relative healthy sample size.
The main methodological limitation of this study is the small sample size. According to the power analyses for the mixed analyses of variance 38 participants were needed, but this study only had 18 participants. Because of the small sample, the distinctiveness of this study is limited. Because of the statistical limitations the covariate analyses were also not performed. Therefore this study could not investigate to what extent sexual dysfunctioning, sexual distress, and an anxious disposition influenced the efficacy of the intervention. Future research needs a bigger sample size so that with greater certainty the ineffectiveness of the intervention in this population can be assessed and the effects of the covariates on intervention effect can be identified.
The fact that the sample only consisted of patients of medical centres made it difficult to recruit enough participants. Unfortunately the physician assistants of the gynaecology centres did not always notify the research assistants in time, when they received a referral for labiaplasty. Naturally, these patients could not be included in the study after counselling, or labiaplasty had taken place. Furthermore, some gynaecology centres not always knew in advance that patients were referred for a labiaplasty, in those cases these women also could not be included on time.
Secondly, the pretest-posttest design of the study might had a undesired effect on the genital self-image itself. Possibly provision of the pretest attenuated the effect of the intervention, because the pretest sensitized participants to the intervention (Kazdin, 2013). There were also several participants who noticed the repetition of the scale, probably because the FGSIS was offered in rapid succession. They could have interpreted this repetition as if their responses were checked. Because the interval was so small, they could have easily memorized their answers at the pretest. If this had occurred, then it may have hindered the effect of the intervention. In addition, it is remarkable that the women in both conditions reported a lower genital self-image, although not significantly, at posttest compared to pretest. The decline in genital self-image scores might be due to the questionnaires offered between the pre- and posttest. These questionnaires may have confronted women with a negative evaluation of their sexual functioning and their degree of sexual distress, this influencing subsequent their genital self-image. In future research the FGSIS pretest and the sexual functioning/distress scales can be administered two weeks before the intervention and the FGSIS posttest takes place. Hereby the possible effect of confrontation with one’s sex life on the genital self-image and the pretest sensitization effect can be diminished (Kazdin, 2013).
The third methodological limitation of the study is the generalizability of the results. The participating clinics were all medical centres. No patients from cosmetic clinics participated in the study. As a result, the characteristics of the sample size might deviate from the entire population of women who requested labiaplasty. In cosmetic clinics it is more likely that women undergo surgery predominantly for aesthetic reasons instead of functional reasons, which were mainly the reason for labiaplasty in this study. The intervention was probably not affective since it intervenes on the aesthetic and not the functional reasons. Further research is needed to examine the effect of exposure to a variety of natural vulvar images in women who requested labiaplasty predominantly for aesthetic reasons, to be found in cosmetic clinic populations.
One of the implications of the main finding of this study – genital self-image does not improve in women who requested labiaplasty when exposed to natural vulvar images – might be that the effective ingredient of the counselling procedure for labiaplasty request in the study of Özer et al. (2011), was not the exposure to images of natural vulvas. The fact that the exposure to natural vulvar images was effective for women who did not requested labiaplasty (Martoredjo & Laan, 2015) might also imply that women who already requested labiaplasty are less receptive to this psychological intervention.
It was already mentioned that there is no evidence for any relationship between the size of the labia minora and physical and sexual discomfort (Bramwell et al., 2007; Reitsma et al., 2011), and in addition, it turned out that a request for labiaplasty is associated with a negative genital self-image. Hereby, a negative genital self-image remains a risk factor for undergoing labiaplasty. It is therefore recommended to expose young women to a variety of natural vulvas as part of their sex education, in order to counterbalance the potential negative impact on the genital self-image by inadequate exposure to idealized, modified vulvas in
19 media. This way more women might
gain satisfaction with their own genitals
at a young age, whichmight make labiaplasty for them superfluous.
Based on the results of this study, it seems that exposure to a variety of natural, unaltered vulvar images has no direct positive effect on the genital self-image in women who requested labiaplasty in medical centres. Next to physical and sexual discomfort, women who requested labiaplasty also experience higher levels of anxiety on a day to day basis. This makes their request for labiaplasty complex and therefore difficult to influence. Nothwithstanding, exposure to a variety of natural vulvas has been shown to be effective in improving genital self-image of women who do not consider labiaplasty (Hesselink, 2012; Snijder, 2013; Martoredjo & Laan, 2015). In women who requested labiaplasty on the other hand, exposure to images of natural vulva’s did not lead to a more positive genital self-image.
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APPENDIX A: Information Brochure and Informed Consent LR-Study
INFORMATIEBROCHURE EN TOESTEMMINGSFORMULIER
VOOR DE STUDIE NAAR ‘MOTIEVEN DIE VROUWEN
HEBBEN VOOR HET LATEN UITVOEREN VAN EEN
LABIUMVERKLEINING’
LR studie
25 Geachte deelneemster,
Uw gynaecoloog doet, in samenwerking met andere Nederlandse gynaecologen, een
wetenschappelijk onderzoek bij vrouwen die een labiumverkleining overwegen. Met deze
informatiebrochure willen wij u informeren over dit onderzoek. Deelname aan het onderzoek is
geheel vrijwillig, zoals verder in deze brochure zal worden toegelicht. Voordat u beslist of u wilt
deelnemen is het belangrijk dat u weet waarom het onderzoek wordt uitgevoerd en wat deelname
voor u zal betekenen. Leest u daarom het onderstaande zorgvuldig door.
Waarom wordt dit onderzoek uitgevoerd?
De laatste jaren wenden steeds meer vrouwen zich tot de arts met het verzoek de binnenste
schaamlippen (de labia) te laten verkleinen, terwijl de gevolgen van deze ingreep op bijvoorbeeld
wondheling, pijnklachten en tevredenheid met het uiterlijk van de labia na de operatie niet goed zijn
onderzocht. In dit onderzoek kijken we welke motieven vrouwen hebben voor het laten uitvoeren van
een labiumverkleining.
Waarom ben ik uitgenodigd deel te nemen aan het onderzoek?
U heeft bij het maken van de afspraak met uw gynaecoloog kenbaar gemaakt dat u hinder ondervindt
van de grootte van uw binnenste schaamlippen. Veel vrouwen met soortgelijke klachten overwegen
hierbij een labiumverkleining. Wij hebben u uitgenodigd om meer inzicht te krijgen in de motieven
van vrouwen die een labiumverkleining willen laten uitvoeren en om vrouwen met deze klachten in
de toekomst beter te kunnen helpen.
Wat kan ik verwachten als ik deelneem aan het onderzoek?
Het onderzoek bestaat uit 1 visite van 1 uur, voorafgaande aan uw afspraak bij de gynaecoloog. Als u
zich hebt aangemeld wordt u naar een kamer gebracht waar u rustig kunt zitten. Indien u nog vragen
hebt, kunt u die op dat moment stellen. Nadat u officieel toestemming heeft gegeven om mee te doen,
krijgt u een aantal vragenlijsten voorgelegd. Deze hebben betrekking op de motieven achter de
labiumverkleining. Daarna krijgt u plaatjes te zien van neutrale voorwerpen of natuurlijke vulva’s en
tot slot moet u nogmaals één vragenlijst invullen.
Wat zijn de mogelijke nadelen of risico’s van deelname aan het onderzoek?
Er zijn geen risico's of ongemakken te verwachten.
Wat zijn de mogelijke voordelen van deelname?
Er is geen persoonlijk voordeel. Met dit onderzoek hopen wij de patiëntenzorg in de toekomst te
optimaliseren. Door deel te nemen draagt u bij aan de wetenschappelijke kennis omtrent motieven
van vrouwen om een labiumverkleining te overwegen.
Vrijwilligheid
Als u besluit af te zien van deelname aan dit onderzoek, zal dit op geen enkele wijze gevolgen voor u
hebben. Mocht u tijdens het onderzoek zelf besluiten uw medewerking te staken, dan zal dat
eveneens op geen enkele wijze gevolg voor u hebben.
Welke medisch-ethische toetsingscommissie heeft dit onderzoek goedgekeurd?
Voor aanvang van het onderzoek zijn de onderzoeksopzet, deze informatiebrochure en het
toestemmingsformulier beoordeelt en goedgekeurd door de wettelijk erkende Medisch Ethische
Toetsings-commissie van het Academisch Medisch Centrum te Amsterdam.
Verzekering
Aangezien aan deelname aan dit onderzoek geen risico’s verbonden zijn, heeft de Medisch Ethische
Commissie ontheffing verleend van de verplichting om voor deelnemers een speciale
schadeverzekering af te sluiten.
Vertrouwelijkheid van de onderzoeksgegevens
Tijdens het onderzoek worden gegevens over u verzameld. Deze gegevens blijven geheim. Uw
gegevens krijgen een code en uw naam wordt weggelaten. U zult uw naam dus nooit tegenkomen in
een rapport over het onderzoek. Alleen de onderzoeker en medewerkers die direct bij het onderzoek
betrokken zijn weten welke code u heeft. Een paar andere mensen kunnen uw medische gegevens
inzien. Deze mensen controleren of het onderzoek goed en betrouwbaar is. Mensen die uw medische
gegevens kunnen inzien zijn het onderzoeksteam, vertegenwoordigers van het AMC als
opdrachtgever van het onderzoek en vertegenwoordigers van de Inspectie voor de Gezondheidszorg.
Uw onderzoeksgegevens worden 15 jaar na afloop van het onderzoek bewaard. Daarvoor geeft u
toestemming als u meedoet aan dit onderzoek. Als u dat niet wilt, kunt u niet meedoen aan dit
onderzoek.
Zijn er extra kosten of is er een vergoeding wanneer u besluit aan dit onderzoek mee te doen?
Aan het onderzoek zijn geen kosten verbonden en er wordt geen vergoeding geboden.
Hoe kan ik meedoen?
U hebt deze patiënteninformatie ontvangen samen met uw afspraak bij de gynaecoloog zodat u de tijd
heeft om na te denken of u wilt deelnemen. Een week nadat u deze informatie ontvangen hebt, wordt
u gebeld door iemand van het onderzoeksteam en zal u gevraagd worden of u wilt deelnemen aan het
onderzoek. Indien u besloten hebt om deel te nemen, komt u op het tijdstip dat aangegeven wordt in
de brief. Indien u niet wilt deelnemen, zal de afspraak voor het onderzoek worden geannuleerd en
komt u alleen naar uw reguliere afspraak bij de gynaecoloog.
27
Nadere inlichtingen
Voor het stellen van vragen en het inwinnen van nadere informatie over het onderzoek verwijzen wij
u naar mw. M. Haakman (m.t.haakman@amc.uva.nl), mw. L. Gransier
(l.gransier@amc.uva.nl), mw. dr. E.T.M. Laan (020- 5669111, sein 58152, e.t.laan@amc.uva).
Wilt u graag een onafhankelijk advies over meedoen aan dit onderzoek? Dan kunt u terecht bij een
onafhankelijke arts. U kunt dr. W.M. Ankum bereiken via 020-5669111, sein 58286, mail
w.m.ankum@amc.uva.nl of via de polikliniek Gynaecologie van het AMC (020-5663400).
Met vriendelijke groet,
E.T.M Laan
M.T. Haakman
L. Gransier
Toestemmingsformulier
Naam onderzoek: Labium reductie studie / LR studie
Titel onderzoek: Motieven die vrouwen hebben voor het laten uitvoeren van een labiumverkleining.
Naam instelling: Nummer deelnemer:
Hierbij verklaar ik mondeling en schriftelijk op de hoogte te zijn gebracht van het onderzoek. Ik heb de bijbehorende ‘Informatiebrochure voor deelnemers’ ontvangen en gelezen. Ik ben voldoende in de
gelegenheid gesteld vragen over het onderzoek te stellen en deze vragen zijn naar tevredenheid beantwoord. Ik begrijp dat deelname aan dit onderzoek vrijwillig is, ik heb het recht om op ieder moment deelname aan het onderzoek te beëindigen. Ik begrijp dat deze voortijdige beëindiging geen enkele nadelige invloed zal hebben op mijn verdere behandeling.
Ik begrijp dat alle persoonlijke gegevens vertrouwelijk zullen worden behandeld en dat mijn identiteit nooit openbaar zal worden gemaakt
Ik weet dat sommige mensen mijn gegevens kunnen zien. Die mensen zijn het onderzoeksteam, vertegenwoordigers van het AMC als opdrachtgever van het onderzoek en vertegenwoordigers van de Inspectie voor de Gezondheidszorg, zoals vermeld in de informatiebrief’.
Ik geef toestemming om mijn onderzoeksgegevens 15 jaar na afloop van dit onderzoek te bewaren’.
Op grond van het bovenstaande en op grond van de aan mij verstrekte informatie betreffende het onderzoek geef ik vrijwillig te kennen te willen deelnemen aan dit onderzoek.
________________________ ________________ ____________________
Naam van de deelnemer Datum Handtekening
Hierbij bevestig ik dat ik het onderzoek aan de deelnemer heb uitgelegd.
_________________________ ________________ ____________________ Naam van de onderzoekster die
verantwoordelijk is voor het verkrijgen van toestemming
Datum Handtekening
Een kopie van de getekende en gedateerde toestemmingsverklaring zal aan de deelnemer worden meegegeven
29
APPENDIX B: Cover Letter
Geachte mevrouw,
Uw gynaecoloog doet, in samenwerking met andere Nederlandse gynaecologen, een wetenschappelijk onderzoek bij vrouwen die een labiumverkleining overwegen. Het gaat over de motieven die vrouwen hebben voor het laten uitvoeren van een labiumverkleining. Voorafgaand aan uw eerste consult betreffende de labiumverkleining bij uw gynaecoloog is er één uur ingepland waar dit onderzoek kan plaatsvinden. In de bijgevoegde informatiebrochure vindt u nadere informatie over het onderzoek. Wij verzoeken u om deze informatie te lezen binnen een week na ontvangst. Over een week zal telefonisch contact met u worden opgenomen door iemand van ons onderzoeksteam om na te gaan of u wilt deelnemen. Wanneer u afziet van deelname zullen wij de afspraak voorafgaand aan uw gynaecologisch consult annuleren.
Bij voorbaat dank voor uw tijd.
Met vriendelijke groet, E.T.M. Laan
M.T. Haakman L. Gransier
APPENDIX C: Questionnaires
Op de volgende pagina’s vindt u een aantal vragenlijsten. Neemt u rustig de tijd om alles goed door te lezen en in te vullen. Slaat u alstublieft geen vragen over.
FEMALE GENITAL SELF IMAGE SCALE (FGSIS)
De volgende items gaan over hoe je je voelt over je eigen genitalia (de vulva en de vagina). Het woord vulva refereert aan de externe vrouwelijke genitalia (de delen die je aan de buitenkant kunt zien, zoals de clitoris, venusheuvel en schaamlippen). Het woord vagina refereert aan de binnenkant, ookwel het “geboortekanaal” genoemd (dit is ook het deel waar een penis in kan of waar een tampon kan worden ingebracht). Geef alsjeblieft aan hoe sterk je het met elke stelling eens of oneens bent.
Geef met een “X” in het desbetreffende hokje aan hoe sterk je het eens of oneens bent met elke stelling.
Sterk mee Oneens
Oneens Eens Sterk
mee Eens Ik voel me positief over mijn genitalia.
Ik ben tevreden met het uiterlijk van mijn genitalia.
Ik zou me comfortabel voelen mijn genitalia aan een seksuele partner te laten zien.
Ik vind dat mijn genitalia prima ruiken.
Ik denk dat mijn genitalia werken zoals ze bedoeld zijn te werken.
Ik voel me comfortabel een medische hulpverlener mijn genitalia te laten onderzoeken Ik schaam me niet voor mijn genitalia.
