In ACOGs committee opinion on “Vaginal Rejuvenation,” which makes me cringe due to incorrect anatomical terminology, they say that labial hypertrophy may be caused by excess androgens. This is completely made up based on a case study where a woman took androgenic medication as a child and had “labial hypertrophy” as an adult. The authors explain this is an indication for labiaplasty. The authors do not note what constitutes hypertrophy in this case, which has been variably defined, even in the OB/GYN literature, as low as less than the mean found in normative studies. For all we know, this woman had average-sized or slightly above average-sized labia minora and the androgenic medications had an inhibitory effect on labia minora development.

Evidence:

1. None

Counter-evidence:

1. Histological studies of hormone receptors in vulvar tissue showing highest concentrations of estrogen receptors and low concentrations of androgen receptors in labia minora relative to other structures (clitoris, labia majora)
2. CAH — excess androgens during fetal development leads to enlarged clitoris and minimal to absent labia minora. In corrective surgery for CAH, they sometimes will actually craft labia minora from shaft skin as there is none.
3. Women on T — anecdotal. But ask anyone who has taken testosterone.
4. Whatever causes multiple endocrinology textbooks to contend that labia minora size is reflective of estrogen levels and to never say it is reflective of androgen levels.
5. No apparent correlation between labia hypertrophy and clitoromegaly — look at photos of vulvas.

Incentives for this statement:

1. There is a lot of money in making women feel insecure about their genitals. Telling them their morphology is due to excess male hormones makes it seem like more of a problem. In the peer-reviewed literature, they also say things like “may be due to excess masturbation,” which is also without evidence. In the ACOG opinion, they say, “may be due to mechanical irritation.”

ACOG acts like this opinion was made to oppose these surgeries. But really the opinion appears to be made to oppose an expensive training program, which is made obvious by the fact that they use a marketing term (and a misleading one) I believe is actually registered to one doctor in particular, though it has been used by many others (cringe). However, at the time of initial publication, it was mainly used by one. They endorse labiaplasties (and implicitly, clitoral hood reductions) as “treatment for hypertrophy,” where no objective definition of hypertrophy means this can be applied liberally to up to over half the female population in peer-reviewed literature. Meanwhile, ACOG has resisted efforts to standardize training and does not offer CME. Experts have been sounding alarms for over a decade now, over the prevalence of botched procedures done by OB/GYNs who do these without training, and ACOG continues to actually obstruct patient safety while approving these procedures, even, in a new opinion, for women under 18.

Published first in 2007, this was re-published in 2017 without correction. That means an entire committee signed off on this twice.

This is just one example.

And as we move into medical journals and textbooks, information from which is also used to make clinical decisions, there is of course an even lower standard for information quality. Authors can just make something up, and as long as it gets cited enough times, it’s true! Sometimes the discussion contradicts the result. Often the basic anatomy of the clitoris is described and labeled incorrectly, and that has to matter. How do claims that the clitoral glans is 1–2 cm long get past peer review? Also, maybe, just maybe, the mislabeling of the vestibule as labia minora in one article on labiaplasty indicates the authors shouldn’t be doing surgery at all.

One crazy claim I saw in an OB/GYN textbook recently said there is no correlation between the extent of vulvectomy and sexual dysfunction. Do you realize how crazy that is? This links to a study with an insignificant number of women who had vulvectomy involving their clitoris. The authors used a measure of sexual dysfunction that involved asking questions similar to those in the FSFI, like (from what I remember), “how satisfied are you with your relationship?” Asking questions about psychological factors obviously gets in the way of how surgery has affected someone physically. This is an upsetting claim because it defends the use of larger margins than may be necessary.