Education

This unpleasant non-infectious dermatological condition – of unknown origin, but probably due to autoimmune disease – results in gradually progressive, partial or complete loss of normal vulval architecture. The skin becomes white (lichenification) and thickened with reduced blood supply (sclerosed), causing the natural contours of the skin to flatten out. The skin becomes fragile with blistering, and women suffer severe itching and pain with sex as the introitus (vaginal opening) shrinks. The condition is often misdiagnosed as chronic thrush.

The labia minora reduce and eventually disappear completely, fusing with the labia majora. The original line of the inner lip is sometimes visible. In the most severe, advanced cases, the clitoris becomes buried beneath the remnants of the clitoral hood and is completely lost from view.

The process can be stopped – but not reversed – using powerful topical steroid creams, and this treatment can help restore the majority of women sufferers to almost normal sexual function, provided the skin loss is not too extensive. Long term surveillance by a specialised vulval dermatology unit is recommended, as the condition has a small (1.6%) risk of eventual vulval cancer.

This perfectly healthy, symmetrical vulva has all the normal fully mature characteristics seen in the majority of non-obese adult women. The labia minora (inner lips) protrude outside the labia majora (outer lips – which are, in fact, fat pads), and are continuous with a well-developed clitoral hood. They have two main functions – to act as a sort of one-way valve to prevent fluids entering the vagina, and to move with the penis to reduce friction during intercourse.

The two main labiaplasty procedures – simple edge excision and wedge resection – reduce the size of the inner labia but can lead to uncomfortable scarring and subsequent pain with intercourse. Some procedures expose the clitoris supposedly to improve sensitivity; but as the normal clitoral hood and nearby tissues retract naturally after menopause, this might lead to considerable irritation in later life.

The pressure which drives some women to seek this surgery is discussed frequently and this work is a major contribution to extending and better informing public debate on the topic. Although many women are happier with their altered form and function, a responsible medical approach should involve psychological assessment and counseling, rather than surgical intervention.

These casts look almost identical as the only visible difference is swelling of the vulva, which is normal in the later stages of pregnancy. This is caused by the increasing size of the womb and increased blood flow to the skin: As the baby’s head pushes against the pelvic veins, pressure in the veins increases and they become engorged, producing this swollen effect, which is most obvious when the woman is standing up. This same process (unfortunately) causes varicose veins & piles.

Most women are concerned about how they will look and feel after the birth and there is sometimes a significant change in the shape of the labia, fourchette (the vulval area between 5 and 7 o’clock) and perineum (the area between the vagina and the anus) which are stretched and may be torn during birth, but usually heal very well because of their good blood supply.

Some may be reassured by these casts – of a woman who has had a normal vaginal delivery and experienced no obvious changes to her genital appearance.

These women have had surgery for cancer or high grade pre-cancer of the vulva (VIN, Vulval Intraepithelial Neoplasia). The cancer is caused in the same way as cancer of the cervix – by infection with high risk strains of wart virus. Both cancers are exceptionally rare in non-smokers. It takes many years to develop, and usually affects the fourchette area, which is the part of the vulva which takes most friction during intercourse.

Warning signs of vulval cancer include irregular darker pigmentation of vulval skin, irritation, cutting and bleeding with intercourse.

In the past, complete vulvectomy – including removal of the clitoris – was the usual treatment, but if the disease is caught early enough a partial vulvectomy can be performed. This removes only the lower part of the inner labia, the fourchette and the perineum (the skin above the anus), leaving the upper labia and clitoris intact. The open area is covered by stretching the nearby skin or using a skin graft to close the gap.

The covering skin should be less sensitive to pain, hopefully enabling less painful sex after operation than might be expected. The majority of women, if diagnosed early enough, can go on to lead normal healthy lives.

Gender dysphoria (GD) – the strong feeling or certain knowledge of having been born into the wrong sex – requires a total commitment to go through the sex change process. Yet most people with GD will have realised their predicament since childhood, before reaching the age of puberty, and have suffered considerable distress from social pressure to conform to a sexual stereotype, before finally asserting their transgender or transsexual identity.

Unlike women opting for cosmetic labiaplasty, in the UK there is a stringent procedure to ensure that an appropriate medical and surgical approach is followed: Two years of living in the desired sexual role and a formal assessment by a psychiatrist are required before referral to the gender reassignment specialist centre at Charing Cross Hospital.

For male-to-female reassignment, oestrogen hormone treatment precedes the definitive surgery, which removes the testicles, reduces the glans (head) of the penis to form an artificial clitoris and creates an artificial vagina using scrotal and penile skin. The external appearance differs from that of the natal female as there are no inner labial folds, and the “clitoral” area may be poorly defined.

Transsexualism is not a mental illness: The human rights of transgender individuals are protected in law which recognises that ”Each person’s self-defined sexual orientation and gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity and freedom”. Thus a person’s sexual orientation and gender identity are not “medical conditions”, so cannot and should not be treated or “cured”, as attempted by some extreme religious cults.

For female-to-male reassignment (which are far less common than male-to-female) there are months of hormonal treatments with testosterone and other drugs to block the menstrual cycle, and minor surgical works to modify the genital skin, before definitive surgery can take place. Genitally, hormones have the effect of enlarging the clitoris as seen in these images showing various stages of treatment.

Not all female-to-male transsexuals opt for the full final operative reassignment: Some will retain the vagina having had some clitoral enlargement and preliminary surgery.

Genital piercings are a popular body modification. For women, various anatomical parts can be suitable for piercings. These include the mons pubis, the clitoral hood, the (inner and outer) labia and the vulval vestibule (which is the area surrounding the vaginal opening).