INTRODUCTION
The outlook towards sexual affairs has eased out in many countries over the recent few decades. However, women still find it difficult to talk about their intimate and private parts.[ 1 ] The overall hesitation to discuss the private parts suggests that many females are ignorant about the related advances in that field. Female genital cosmetic surgery (FGCS) is fairly a recent evolution in the field of cosmetic and plastic surgery and is gaining popularity in the developed countries. There is a growing request for FGCS in Western countries with United States reporting a 49% increase in 2014, while Australia and United Kingdom revealed a 3–5-fold escalation in the demand over the past 10 years.[ 1 , 2 ]
FGCS also known as vulvoplasty is commonly defined as any vaginal or labial surgical alteration of anatomy that offered for solely aesthetic reasons or for treatment of normal changes that occur throughout the life span.[ 3 ] It involves multiple surgical procedures planned to restore or enhance the female genitals. These procedures include labiaplasty, clitoral unhooding, monsplasty, vaginoplasty, hymenoplasty, G-spot augmentation, frenuloplasty, perineoplasty, fat injections and combination of any of these procedures; however, labiaplasty is the leading demand.[ 1 , 2 , 4 , 5 ] FGCS also provides a significant psychological satisfaction for women who are very specific about the appearance of their intimate parts. Most of the females with awful deformation revealed less pain or discomfort with enthusiastic routine life and sexual gratification after FGCS.[ 1 , 6 ]
FGCS is done to abolish functional difficulties such as lax perineum associated with sexual frustration and to create cosmetically appealing genitals. The Australian Government has reported an increase in requests for FGCS from 640 in 2001 to more than 1500 in 2013.[ 7 ] However, in the developing countries, the discussion and need for FGCS is still considered to be a social taboo. Many women may request for FGCS, who have disappointment about their genital appearance, difficulty when participating in sports activity, relationship issues and painful or difficult coitus. Nevertheless, these women in the Third World countries are not even aware about such procedures and the benefits and advantages of it.
The present study aims at ascertaining the awareness, outlook and attitude of female genital cosmetic surgeries in the female patients attending the outpatient department in one of the private healthcare institutes of India.
MATERIAL AND METHODS
It was a cross-sectional study conducted in a tertiary healthcare centre over a period of 6 months after obtaining the Institutional Ethics Committee approval dated 28 July 2021. A total of 526 patients participated, and written informed consent was obtained from all participants. A questionnaire was developed to get details from the candidates, in a private consulting room to ensure confidentiality. The questionnaire was formulated and adapted based on the previous study on FGCS.[ 8 ] The enquiry about the following procedures was done during the study, namely, perineoplasty, labiaplasty, hymenoplasty, labia majora augmentation, G-spot amplification.
Knowledge about FGCS was reported positively if the candidate answered ‘yes’ to ‘ever heard of FGCS’ and could recognise minimum of three indications of doing the procedure. The patients were then explained about each of the above-mentioned five procedures, and their attitude towards it was assessed. Evaluation of attitude towards FGCS was done using a 5-point Likert scale (strongly agree: 5, agree: 4, unsure: 3, disagree: 2, and strongly disagree 1) using five questions each having 1 mark. Positive attitude for FGCS was considered if women scored ≥3. Sexually active woman was delineated as one having penovaginal coitus at least once in 6 months. The data of the patients were collected, compiled and analysed using MS Excel worksheet. Statistical analysis was done using percentages.
RESULTS
Five hundred and twenty-six patients reporting to the outpatient department for various other gynaecological problems were surveyed after informed valid consent and the following information was obtained from them. Table 1 shows very poor knowledge (26.23%) of FGCS amongst the study population. Most of them have received the information from social media (56.5%). The duration of knowledge about FGCS is more than 2 years in many patients (51.4%). However, only 5.79% of the patients know someone who has undergone FGCS. After adequate counselling and giving information, about 82.88% of patients had positive attitude towards FGCS.
Table 1: Knowledge and attitude of patients towards female genital cosmetic surgery
Age distribution is shown in Table 2a . Educational status is shown in Table 2b . Occupation is shown in Table 2c . Marital status, sexual partnership, age at the onset of coitus are shown in Tables 3a , 3b and 3c respectively. Parity, mode of delivery and number of vaginal deliveries and episiotomy/perineal tear during vaginal delivery are shown in Tables 4a , 4b and 4c and 4d respectively. Knowledge and attitude towards particular female genital cosmetic surgery procedure is shown in Table 5 .
Table 2a: Age distribution of participants (n =526)
Table 2b: Educational status of the participants (n =526)
Table 2c: Occupation of the participants (n =526)
Table 3a: Marital status (n =526)
Table 3b: Sexual partnership (n =526)
Table 3c: Age at the onset of coitus (n =526)
Table 4a: Parity of the patients (n =526)
Table 4b: Mode of delivery (n =526)
Table 4c: Number of vaginal deliveries (n =249)
Table 4d: Episiotomy/perineal tear during vaginal delivery (n =249)
Table 5: Knowledge and attitude towards particular female genital cosmetic surgery procedure
Nearly 50% of the patients belonged to the age group of 30–39 years with a mean age of 34.6 years. However, participants belonging to the age category of 21–29 years had more knowledge (47.76%) and relatively more positive attitude (87.6%) towards FGCS procedures as compared to other age groups. More patients (25.3%) of the study population were professionally occupied, whereas only 2.85% of patients worked as unskilled workers. Professionally occupied patients (36.1%) had more knowledge. Positive attitude towards FGCS had a direct correlation with the increasing financial independence of the patients. Of the study population 57.8% were married; however, knowledge about FGCS was more or less same amongst all the study groups. Married patients (91.8%) were more inclined and showed a positive attitude towards FGCS followed by the single/unmarried participants (86.2%).
Of the study population, 86.7% were in monogamous relationship. However, knowledge (30%) and attitude (90%) towards FGCS was seen more in participants who were in polygamous relationship. Onset of coitus was more commonly seen in the age group of 21–25 years (41.1%), followed by 26–30 years’ age groups (36.5%). However, knowledge of FGCS was more commonly seen in patients who had onset of coitus below the age of 15 years (33.3%). Population who had early onset of coitus was more prone towards FGCS.
Of the study population 43.5% had two kids. Nevertheless, knowledge about FGCS was more in nulliparous patients (32.3%). Attitude towards FGCS was seen more in patients who had kids rather than nulliparous patients with more inclination in primiparous patients (92.6%).
Vaginal delivery including instrumentation had occurred in 47.3% of participants. Out of the 138 participants who were knowledgeable, maximum had vaginal birth (58). Patients with vaginal delivery (90.5%) and even with instrumental vaginal delivery (84.6%) were more willing towards FGCS. Most of the patients had 2 vaginal births (69.5%), and knowledge about FGCS also was seen more in these patients only (25.4%). The number of vaginal delivery did not influence much upon the inclination of the patients towards FGCS as almost all the patients had equal propensity towards FGCS. Of the population with vaginal delivery 79.5% had tear/episiotomy during vaginal birth; those patients (25.8%) only had more knowledge about FGCS. In spite of that, all the patients had similar readiness towards FGCS. Many patients were aware of more than one FGCS procedures during the study. Hymenoplasty was the most known procedure amongst the study population followed by labiaplasty. Nonetheless, after the proper counselling and knowledge about all the procedures, more participants had desire towards perineoplasty followed by labiaplasty.
DISCUSSION
Although known since ages,[ 9 ] the awareness of FGCS procedures in India is very low. This is probably because talking about private parts is still not socially acceptable and discussing various surgical procedures, related to genital parts and not medically indicated is yet not admissible. This study aims at finding the knowledge of Indian females on FGCS and their attitude towards it after thorough knowledge.
The study reported a pretty low magnitude of knowledge (26.2%) about FGCS amongst the study population, although most of the participants (82.9%) had a very positive attitude towards it as shown in Table 1 . This can be compared to a study[ 8 ] where knowledge amongst study population was 27.7% and attitude was 84.2%. This may be due to the more ignorant behaviour of females towards genital appearance as compared to facial appearance. Private parts are not exposed and covered with clothes, so most of the females in general population are not well versed with the natural appearance of genital parts, let alone the FGCS. Another international study who surveyed about the knowledge and attitude of females regarding the look of their private parts revealed a very poor knowledge and attitude towards it.[ 1 ]
Knowledge of such subjects is usually obtained by social media as the secrecy is maintained and the participants do not have to reveal their identity by any means when updating themselves. This has been proven by our study where most of the patients have information about FGCS from social media (56.5%) as described in Table 1 . This is also supported reports from other studies.[ 4 , 5 ] However, this is contradictory to a study[ 8 ] where patients had received details about the same from healthcare professionals. In the current study, only 5.8% of the study population know about someone who has undergone FGCS; however, a study conducted in Australia reported that nearly 65% of the patients requested for FGCS.[ 2 ] This is due to lack of openness to discuss about the genital parts in our society and the social pressure prohibiting females to talk about it in public.[ 10 ]
The various sociodemographic variables were related to the knowledge about FGCS. Knowledge was more amongst younger population (21–29 years) along with positive attitude towards it as depicted in Table 2a . This was comparable to reports in other studies[ 8 , 11 ] This can be substantiated by the fact that young females are more cautious about their genital appearances as well. This goes well with a study that showed young women are concerned about their genital look, whereas older females are more interested in their facial appearances.[ 2 , 12 ] Education and employment are also directly associated with the knowledge and attitude of participants towards FGCS as expressed by Tables 2b and 2c. In the present study, highly educated population and professionals have better understanding about FGCS and are more inclined towards it. This is similar to that reported in a study.[ 8 ] This can be explained by the fact that education improves our understanding about a particular matter and better profession gives us financial and mental independence to take decisions.
Table 3a suggests that unmarried/single participants had more updates about the topic (27.58%). This is in accordance with other studies.[ 8 , 13 ] Unmarried females are more specific about their genital appearances as they want to be more precise about their future sexual encounters. Married women, on the other hand, want to conceive, hence more concerned about conception rather than sexual preferences. With no second doubts, participants in polygamous relationship will have more details and will be more acceptable about female genetic cosmetic surgeries due to their sexual experiences. This was also proven in our study as nearly 90% of patients in polygamous relationship had a positive attitude towards FGCS as depicted in Table 3b . Table 3c demonstrated that knowledge about FGCS was more commonly seen in patients who had their onset of coitus at the age of 21–25 years (31.48%), followed by 26–30 years (27.08%). This is the most common age groups in Indian standards to get married with the onset of coitus. This also similar to that reported in another study,[ 8 ] where 32.7% of the study population had onset of coitus at the age of 21–25 years. Positive attitude towards FGCS was seen more in the study population who had younger age at onset of coitus as has been reported in an earlier study.[ 8 ]
Nulliparous patients (32.29%) had great details about FGCS procedures, whereas primiparous (92.55%) patients had a more positive attitude towards FGCS in the current study as illustrated in Table 4a . This can be made clear by the fact that nulliparous patients are more peculiar about genital appearances as compared to parous patients, but after gaining information, even parous patients would like to go for the FGCS procedures. However, in a study[ 8 ] it was observed that 35.3% of primiparous patients had knowledge about the procedures and acceptability was also high (88.2%) in these patients. Due to the various changes that occur in the appearance of external gentiles and laxity of the vagina, more patients with vaginal delivery acquire particulars about FGCS procedures and also have increased willingness towards these procedures as described in Table 4b . This is demonstrated in our study where patients with vaginal delivery including instrumentation had more knowledge and added predilection towards FGCS procedures. Similarly, patients with episiotomy/perineal tears (25.75%) during vaginal deliveries will be more updated regarding FGCS procedures due to the scarring and sexual dissatisfaction as seen in Table 4d . This is also comparable with another study[ 8 ] where 19% of the patients with perineal tear or episiotomy had knowledge about FGCS.
When knowledge about particular FGCS procedure was obtained, more patients had information about hymenoplasty, followed by labiaplasty (Table 5 ). However, various studies carried out in Western countries have shown labiaplasty surgery to be most popular amongst FGCS procedures.[ 1 , 2 , 4 , 6 , 14 ] Perineoplasty followed by labiaplasty was amongst the more common procedure with the positive attitude towards FGCS probably because many patients in the study population had vaginal delivery leading to lax perineum and loose hanging labia minora.
It has been seen that women in developing countries use various vaginal herbs, do cleansing and douching of the vagina for sexual gratification to impress their partners irrespective of the various side effects.[ 15 ] Hence, having medically approved surgical methods will be better appreciated amongst the educated and common population. In spite of all these, there is a necessity of sufficient information about the normal appearance of external genitalia including the physiological changes that happen in a female body with growing age and vaginal deliveries and about the various risks and benefits associated with FGCS procedures. Many studies have shown better genital features with coital gratification safely after FGCS procedures.[ 2 , 13 , 16 , 17 ] However, FGCS procedures should be done only after adequate counselling and providing complete knowledge regarding the procedures including their complications.[ 7 , 18 ] The study provides an insight about the awareness that needs to be created in the Indian females about the FGCS procedures. However, the limitations of the study were that it was a hospital-based study at a private tertiary healthcare institute; a community survey would precisely give more in-depth information about the subject; however, the findings of this study cannot be ignored.
To conclude, it was observed that knowledge about FGCS depends a lot on the age, education profession, marital status, parity, vaginal deliveries, etc., However, when adequate information was presented to all these women, the majority of the population had a positive attitude towards the FGCS procedures. These women should be informed in detail about the merits and consequences of the FGCS procedures to take a valid informed decision about the FGCS procedures.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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