Young women’s genital self-image and effects of exposure to pictures of natural vulvas

Abstract

Introduction: Many women have doubts about the normality of the physical appearance of their vulvas. This study measured genital self-image in a convenience sample of college-educated women, and assessed whether exposure to pictures of natural vulvas influenced their genital self-image.

Method: Forty-three women were either shown pictures of natural vulvas (N = 29) or pictures of neutral objects (N = 14). Genital self-image was measured before and after exposure to the pictures and two weeks later. Sexual function, sexual distress, self-esteem and trait anxiety were measured to investigate whether these factors influenced genital self-image scores after vulva picture exposure.

Results: A majority of the participants felt generally positively about their genitals. Having been exposed to pictures of natural vulvas resulted in an even more positive genital self-image, irrespective of levels of sexual function, sexual distress, self-esteem and trait anxiety. In the women who had seen the vulva pictures, the positive effect on genital self-image was still present after two weeks.

Discussion: The results of this study seem to indicate that even in young women with a relatively positive genital self-image, exposure to pictures of a large variety of natural vulvas positively affects genital self-image. This finding may suggest that exposure to pictures of natural vulvas may also lead to a more positive genital self-image in women who consider labiaplasty.

Keywords:

• Genital self-image
• labiaplasty
• natural vulvas
• self-esteem
• sexual function

Introduction

Research in the past decade has revealed that women’s genital self-image is related to engagement in specific sexual behaviors such as receptive cunnilingus, as well as to more general sexual function [1–5]. Particularly anxiety about exposing parts of the body during sexual activity is found to be associated with poor sexual functioning [5]. Genital self-image is also found to be associated with gynaecological screening behavior [6,7]. Negative perceptions of genitals are specifically related to embarrassment about size, smell, and/or appearance [8–10]. This embarrassment may prompt women to postpone necessary gynaecological examinations [2,6,7] and may be related to an increase in the number of women undergoing elective genital surgeries [7,11,12].

Figures from general hospitals show that the number of requests for labiaplasty is on the rise in the Western World [12]. Given that most labia surgeries are performed in private clinics, the exact number of surgeries per year is not known, but possibly the demand in these clinics is also increasing [13]. Labia minora reduction is the most common type of vulvar surgery [14]. As it is unlikely that labia minora size has increased in recent years, and no information has recently emerged that labia minora size is related to a particular condition, it may be assumed that this increase is due to an increasing dissatisfaction of women with the appearance of their labia minora, perhaps accompanied by a greater knowledge about the availability of labia surgery [15,16]. Indeed, most of the labia minora reductions are performed in women who are dissatisfied with the appearance of their genitals [16–18] or in women who believe that their vulva does not look “normal” [19]. Research concerning effects of labia minora reductions is scant and weighted towards the description of surgical techniques and postoperative high satisfaction rates [20], but very little long term, controlled, or prospective data are available regarding safety or psychosexual consequences [13].

Labia minora vary greatly in size, shape and color [21]. However, in most media that depict women’s vulvas (erotic magazines, women’s magazines, internet, porn movies), labia minora are not protruding the labia majora [22,23]. These images are either digitally manipulated or show models that have undergone a labia minora reduction or women who naturally have smaller labial size [24], and therefore do not provide a realistic image of natural vulvas [23]. Unrealistic views about the appearance of women’s genitals may be amplified by make-over programs promoting plastic surgery. For instance, one US study found viewing frequency of makeover television programs to be positively related to perfectionism and body dissatisfaction [25]. Also, viewing of such programs was positively related to past attainment of cosmetic surgery [26] and was related to a greater interest in having plastic surgery relative to women not exposed to such programs [27]. If poor genital self-image is related to being exposed to unrealistic images of vulvas, exposure to images that provide a realistic image of natural vulvas may result in a more positive genital self-image [28,29], and perhaps, in the long run, in a reduction in the current demand for labiaplasty.

Indeed, in an uncontrolled study in Dutch women who were considering labia surgery, 35% opted to refrain from having the surgery after having received counseling that included accurate information about variation in the appearance of labia minora, the function of the labia minora, specifics of labia surgery and possible complications of surgery [30]. Verbal information about the appearance of labia minora was supplemented by exposure to photographs showing a large variety in the appearance of vulvas [31].

An unpublished study performed in 31 young Dutch college-educated women who did not consider labiaplasty provided preliminary support for the idea that exposure to photographs depicting a large variety in vulvar appearance would enhance genital self-image [32]. In addition, those women who viewed makeover programs more frequently were more likely to report a more negative genital self-image and more sexual distress.

The aim of the present study was to study genital self-image in young women using the Female Genital Self Image Scale (FGSIS), a valid and reliable measure of genital self-image [2,3,6]. A second aim was to assess whether exposure to pictures of natural vulvas depicting a large variety in vulvar appearance influences women’s genital self-image. To assess temporal stability, genital self-image was again assessed two weeks after picture exposure.

Given that sexual function [1,4], self-esteem [5] and trait-anxiety [33] are associated with overall body image, questionnaires were included that measure these constructs. We hypothesized that genital self-image of women in the vulva pictures condition is more positive after exposure to pictures of natural vulvas, and more positive than posttest scores of women in a neutral pictures condition. We explored whether potential effects on genital image of vulva picture exposure were conditioned by sexual function, sexual distress, self-esteem and trait anxiety.

Method

Participants

Recruitment for this study was done through posters at the Department of Psychology, University of Amsterdam, the Netherlands and through various websites. The study was described as an investigation of genital self-esteem in women. There were no exclusion criteria. The study was approved by the Medical Ethics Committee of the Academic Medical Center, University of Amsterdam, the Netherlands. Only psychology students of the University of Amsterdam were rewarded for participation with course credit. The other participants were not rewarded for participation. A pilot study with a slightly different design found an effect size of 1.27 for the difference between the vulva pictures condition and the neutral pictures condition [32]. Based on these data, an a priori power analysis was performed with α set at (0).05 and 1−β at (0).95, revealing a required sample size of 33.

Materials

Pictures in both conditions were presented one at a time in a fixed order for five seconds each, on a 17-inch computer screen, using a PowerPoint presentation [32]. The PowerPoint presentation of the vulva pictures condition consisted of 44 photographs, taken from Nick Karras’ Petals [31], of vulvas that had not undergone plastic surgery, neither were the photo’s digitally modified. Close ups of the, approximately life size, vulva pictures were shown frontally (sometimes slightly varying in angle), and were diverse with respect to labia minora size, the depicted women’s age and ethnicity, without other body parts being visible. Both shaven and unshaven pictures were presented. The PowerPoint presentation of the neutral pictures condition consisted of 44 photographs of very diverse themes such as household objects, art, nature, animals and architecture.

Genital self-image was measured using the Female Genital Self Image Scale (FGSIS) [2,3,6]. This questionnaire consists of seven items that are answered on a 4-point scale ranging from “strongly disagree” to “strongly agree”, with higher scores representing a more positive genital self-image. FGSIS items assess vulvar appearance, smell, and function, and comfort with one’s vulva in interpersonal situations (all items are listed in Table 1). The total score is the sum of these seven items, with a range of 7 (very negative genital self-image) to 28 (very positive genital self-image). Three independent parties translated the original FGSIS into Dutch. Disagreements between translators were resolved through discussion. A native English speaker back translated the final version, and no substantial loss of information was observed. The reliability (Cronbach’s α) of the FGSIS total score of the Dutch translation is 0.73.

Table 1. Means (and standard deviations) for each of the FGSIS items at pretest.

FGSIS items	Mean	SD
1. I feel positively about my genitals	3.02	0.56
2. I am satisfied with the appearance of my genitals	2.95	0.53
3. I would feel comfortable letting a sexual partner look at my genitals	3.05	0.65
4. I think my genitals smell fine	2.72	0.59
5. I think my genitals work the way they are supposed to work	3.27	0.67
6. I feel comfortable letting a health care provider examine my genitals	2.81	0.88
7. I am not embarrassed about my genitals	2.95	0.58
FGSIS total score	20.79	2.79

Items range from 1 (strongly disagree) to 4 (strongly agree) with higher scores indicating a more positive genital self-image.

SD: standard deviation.

Sexual functioning was measured using the Female Sexual Functioning Index (FSFI) [34]. The questionnaire consists of 19 items with questions about sexual desire, arousal, lubrication, orgasm, satisfaction and pain, with a minimum score of 2 and a maximum score of 36, with lower scores indicating worse sexual function. The psychometric quality of the Dutch translation is excellent, with a Cronbach’s α = 0.97 [35].

With the Female Sexual Distress Scale-Revised (FSDS-R) [36] levels of sexual distress were measured. This questionnaire consists of 13 items measured on a 0–4 scale, with the total score ranging from 0 (no sexual distress) to 52 (high sexual distress). The psychometric quality of the Dutch translation is excellent, with a Cronbach’s α of 0.97 [35].

Self-esteem was measured using the Rosenberg Self-Esteem Scale (SES) [37]. This questionnaire consist of 10 items that are answered on a 4-point scale ranging from “strongly agree” to “strongly disagree”, with a total score ranging from 0 to 30. Earlier studies showed that the SES is a reliable scale with Cronbach α’s ranging from 0.77 to 0.88 [37,38].

The Self-Assessment Questionnaire [Zelf-Beoordelings Vragenlijst] [39] is an adaption of the Spielberger State Trait Anxiety Inventory (STAI) and measures both state anxiety and the general tendency to react with fear (trait anxiety). For this study, the 20 items of the trait anxiety scale were used. The items have 4-point scales ranging from “not at all” to “very much” or “almost never” to “almost always” (total score range 20–80), with high scores indicating high trait anxiety. Cronbach α’s were found to range from 0.73 to 0.95 [39].

The last questionnaire collected demographic information, information on sexual experiences, whether the participants had had cosmetic surgery of the vulva, or whether they had ever considered cosmetic surgery.

Procedure

Participants were randomly assigned with an allocation ratio of 2:1 such that for each subject assigned to the neutral pictures condition two subjects were assigned to the vulva pictures condition. Each participant was given an information leaflet explaining what the study entailed, after which written informed consent was obtained. The FGSIS was completed first. Then the PowerPoint presentation was started. Following this, the FGSIS was filled out again, followed by the other questionnaires. Two weeks after the survey, the participant was sent an email asking her to complete the FGSIS once more and to return the questionnaire by e-mail. The study ended with a debriefing which was sent by e-mail as well.

Statistical analysis

All questionnaire scores were normally distributed with Shapiro–Wilks W’s > 0.90. Relationships between FGSIS pretest scores and sexual, self-esteem and anxiety measures were investigated using Pearson correlation coefficients. The effect of vulva picture exposure on genital self-image was examined by a Condition (vulva pictures; neutral pictures)×Measurement (pretest, posttest, follow-up) repeated measures ANOVA. In case of interaction effects, follow up ANOVAs were calculated. To investigate whether the effect of exposure to vulva pictures on genital self-image was conditioned by sexual dysfunction, sexual distress, low self-esteem and high trait anxiety, 2 (Condition) × 3 (Measurement) repeated measures ANCOVAs were performed. Greenhouse–Geisser p values are reported to correct for possible correlations between repeated measures.

Results

Participants

Participants were 43 Dutch women, 9% of whom were non-Caucasian, with an average age of 23.28 (SD = 7.34, range 18–53). Of the participants, 29 were assigned to the vulva pictures condition, and 14 to the neutral pictures condition. The majority (90%) were students, of whom 77% were university students and 23% were college students. The participants were predominantly heterosexual (81%), and 80% was involved in a steady sexual relationship with an average duration of 3.5 years. Less than one-fifth of the women were living with a partner; 91% was nulliparous. All participants had experience with receiving oral sex and penile-vaginal intercourse, except for one lesbian woman who had never had intercourse. Nine participants (21%) had never seen explicit sexual images and 37% had never seen a real-life unaltered vulva of another woman prior to participation. All participants were accustomed to trim or shave their pubic hair. None of the participants had undergone genital surgery, and none of them had ever considered having such a surgical procedure. There were no significant differences between the vulva pictures condition and the neutral pictures condition with respect to the demographic data.

Genital self-image

In general, women reported a relatively positive view of their genitals with 60.5% of women reporting that they “agreed” to “strongly agreed” with each of the statements (M = 20.79, SD = 2.79). With a mean of 2.71 (SD = 0.59) the statement “I think my genitals smell fine” received the lowest mean score, with 65% of women reporting to “agree” or “strongly agree” with this statement. The statement “I think my genitals work the way they are supposed to work” received the highest mean score (M = 3.27, SD = 0.67), with 93% of women reporting to “agree” or “strongly agree”. Means and standard deviations for individual FGSIS items are presented in Table 1.

Relationship between pretest genital self-image and sexual, self-esteem and trait anxiety measures

Genital self-image was positively related to sexual function, but unrelated to sexual distress, self-esteem and trait anxiety (see Table 2).

Table 2. Intercorrelations between genital self-image (FGSIS) and sexual function (FSFI), sexual distress (FSDS-R), self-esteem (SES) and trait-anxiety. For correlations involving the FSFI, only scores of sexually active women (N = 34) were used.

Scale	FSFI	FSDS-R	SES	Trait-anxiety
FGSIS	0.32*	−0.27	0.27	−0.22
FSFI		−0.60**	0.44**	−0.46**
FSDS-R			−0.33*	0.26
SES				−0.74**

* p < .05.

** p < .01.

FGSIS: Female Genital Self Image Scale; FSFI: Female Sexual Function Index; FSDS-R: Female Sexual Distress Scale-Revised; SES: Rosenberg’s Self Esteem Scale.

Effects of exposure to pictures of natural vulvas on genital self-image

All participants returned their follow-up questionnaire. The follow-up data were returned on average three days after receipt. The 2 (Condition) × 3 (Measurement) ANOVA with the FGSIS total scores on the pretest, posttest and follow-up assessment as dependent variables showed a significant main effect of Condition (F (1, 41) = 4.51, p < .05, η_p² = 0.10) and a significant Condition × Measurement interaction effect (F (2, 82) = 4.76, p < .05, η_p² = 0.10). The follow-up ANOVAs revealed a significant effect of measurement in the vulva pictures condition (F (2, 56) = 10.39, p < .001, η_p² = 0.27) but not in the neutral pictures condition (p > .95, η_p² = 0.004). FGSIS scores of women in the vulva pictures condition at posttest (F (1, 28) = 21.96, p < .001, η_p² = 0.44) and follow-up (F (1, 28) = 11.81, p < .005, η_p² = 0.30) were significantly more positive than those at pretest. FGSIS scores of the women in the neutral pictures condition were similar for each measurement (all ps > 0.55, η_p² = 0.02 for the difference between pre- and posttest and η_p² = 0.00 for the difference between pretest and follow-up).

Univariate ANOVAs per measurement showed that genital self-image of women in the vulva pictures condition was similar to that of the neutral pictures condition at pretest (p > .35, η_p² = 0.02), but was significantly more positive than that of the neutral pictures condition at posttest (F (1, 41) = 7.06, p < .01, η_p² = 0.15) and follow-up (F (1, 41) = 5.37, p < .05, η_p² = 0.12). See Table 3 for FGSIS means and standard deviations of the two conditions.

Table 3. Means (and standard deviations) of pre-, post- and follow-up scores of the FGSIS total score for the vulva pictures condition and the neutral pictures condition.

	Pretest	Post-test	Follow-up	p’s for follow-up ANOVA
Vulva pictures  (N = 29)	21.07 (2.86)^a	22.66 (3.00)^b	22.44 (3.02)^b	<0.001
Neutral pictures  (N = 14)	20.21 (2.64)^a	20.14 (2.68)^a	20.21 (2.83)^a	>0.85

Note: Means with different superscripts are significantly different at p < 0.005.

All covariates – sexual dysfunction, sexual distress, self-esteem and trait anxiety – were unrelated to FGSIS scores at posttest and follow-up. Therefore, the prerequisites for ANCOVA were met. None of the four 2 (Condition) × 3 (Measurement) ANCOVAs with FGSIS total scores on pretest, posttest and follow-up as dependent variables, and sexual dysfunction, sexual distress, self-esteem and trait anxiety, respectively, as a covariate, indicated a significant contribution of the covariate to the Condition main effect and the Condition × Measurement interaction.

Discussion

A majority of the participants felt generally positively about their genitals. With a mean genital self-image score of 21.31 (SD = 4.31), genital self-image of a US nationally representative large sample of 3800 women aged 18–60 [3] was comparable to genital self-image of the present Dutch sample (see Table 3).

Results showed that even in these women with a relatively positive genital self-image, exposure to pictures of a large variety of natural vulvas positively affected genital self-image. Exposure to photographs depicting a variety of natural vulvas had an immediate effect on women’s genital self-image, and this effect was still present two weeks later. It is likely that this effect was due to the content of the pictures, given that exposure to a similar number of photographs, depicting neutral objects, had no effect on genital self-image whatsoever. This effect on genital self-image of vulva picture exposure happened regardless of the degree of sexual dysfunction, sexual distress, self-esteem and trait anxiety. More than one-third of participants had never seen a real-life unaltered vulva of another woman prior to participation. Taken together, these findings suggest that availability of accurate information about the unrepresentativeness of vulvas in the media, as well as accurate knowledge about the great variety in the appearance of natural, unmanipulated vulvas, is very important for a positive genital self-image.

Even though the study was sufficiently powered for the main- and interaction effects that were investigated, the main limitation of this study was the limited number of participants. We cannot rule out that the lack of effect of the covariates on the experimental manipulation is due to a lack of power. The relatively small number of participants may also influence representativeness of the sample. Perhaps, women with a positive genital self-image were more likely to participate in the study. Exposure to vulva pictures may be even more effective in women with a more negative genital self-image.

On the other hand, this sample of women was predominantly young and highly educated, and a majority of them studied clinical psychology. Although Herbenick and colleagues found genital self-image not to be associated with education levels [3], clinical psychology students are known to be more anxious than other students [40] and thus may have a more negative image of their body than other women of similar age and education level [33]. On the other hand, the psychology students received course credit for participation. This may have helped those with a more negative genital self-image to participate in a study they would otherwise not have participated in.

Recruitment of participants appeared to be difficult, underscoring the likely presence of selection-bias. This subject may be taboo for many women, or indicative of embarrassment women may feel about the appearance of their genitals. If dissatisfaction with one’s genitals was indeed a reason for not wanting to participate in a study on this subject, this may indicate that a negative genital self-image is actually common.

Even though it is gratifying that the two-week follow-up data indicated that the positive effect on genital self-image was maintained, two weeks is a very brief period of time. Unfortunately, not much is known about the stability of women’s genital self-image. Herbenick and colleagues found a correlation of 0.78 between first measurement and a 2-week follow-up using the same measure [3], and they found genital self-image not to vary with age. The temporal stability of change in genital self-image following an experimental manipulation such as the one in this study is, however, quite unknown. Further research is needed to determine whether effects last beyond this period of two weeks.

The results of this study may indicate that even in young women with a relatively positive genital self-image, exposure to pictures of a large variety of natural vulvas positively affects genital self-image. However, the findings of this study need to be replicated in a more representative sample, as well as in women who do consider labiaplasty.

Current knowledge on the subject

• Many women have doubts about the normality of the physical appearance of their vulva.

• Genital self-image is found to be associated with sexual function and gynaecogical health seeking behavior.

• Women’s embarrassment about their genitals may be related to the increase in the number of women undergoing elective genital surgeries.

What this study adds

• We investigated whether exposure to pictures of natural vulvas affects genital self-image in young college-educated women.

• We demonstrated that even in women with a relatively positive genital self-image, exposure to pictures of a large variety of natural vulvas positively influences genital self-image.

• This effect on genital image of vulva picture exposure happened regardless of the degree of sexual dysfunction, sexual distress, self-esteem and trait anxiety.

• Our findings suggest that availability of accurate information about the unrepresentativeness of vulvas in the media, as well as accurate knowledge about the great variety in the appearance of natural, unmanipulated vulvas, is very important for a positive genital self-image.

Disclosure statement

The authors report no conflict of interest.