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Investigating The Influence Of External Vaginal Appearance On Female Sexual Health
Ava G. Chappell, MD1, Daniel C. Sasson, BA1, Alex J. Soriano, MD2, Sumanas W. Jordan, MD, PhD1, Ivona Percec, MD, PhD2.
1Northwestern University Feinberg School of Medicine, Chicago, IL, USA, 2University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

PURPOSE: Female sexual health is influenced by a complex interaction of biological, psychological and sociocultural factors. To date, the impact of external vaginal appearance on sexual health and function is unknown. The objective of this study is to determine the influence of vulvar appearance on sexual health in adult women. Our primary aim was to assess the relationship between a woman's self-evaluation of vulvar appearance and sexual function. Our secondary aim was to describe aspects of vulvar appearance that were most concerning to women.
METHODS: An observational study of adult women was conducted utilizing a deidentified online survey via the Amazon MTurk platform. Inclusion criteria was all women who identified as cis-female over 18 years old. Non cis-female gender patients and participants who did not complete the survey were excluded. The survey included questions regarding baseline demographic information, aesthetic vulvar appearance and the Female Sexual Function Index (FSFI) questionnaire. The FSFI served as a validated measure of female sexual dysfunction which addresses sub-categories of sexual desire, arousal, lubrication, orgasm and pain. Subjects were identified as having a concern of the vulvar appearance based on subjective patient response. The responses were analyzed using Stata v15 software with chi-square, Mann-Whitney U and univariate analysis as well as multivariate analysis to control for differences between groups.
RESULTS: A total of 467 women over the age of 18 completed the survey. After excluding for non cis-female gender, 398 met inclusion criteria. Of the 398 included, 148 (37.2%) reported concern with vulvar appearance. Women who were uncomfortable with their vulvar appearance were more likely to be between the ages of 21-39. Women who expressed concern with their vulvar appearance had greater sexual dysfunction with an average FSFI score 24.6 (22.5-26.8) compared to women who were satisfied with their vulvar appearance 27.0 (20.3-30.8), p=<0.001. Sub-scales of lubrication 3.9 (3.3-4.2) and orgasm 4.0 (3.6-4.4) were decreased in women who were uncomfortable with vulvar aesthetics compared to those who were not 4.8 (3.3-5.7) and 4.8 (3.6-5.6), respectively, p<0.001. On multivariate analysis, women with higher subjective vulvar appearance scores were more likely to have a higher a higher FSFI score (OR 1.87, 95% CI (0.97-2.78), p<0.001) (Table 1). The anatomic structures of greatest concern included: labia minora 87 (58.8%) and labia majora 65 (43.9%).
CONCLUSION: This observational study which included surveys from 398 adult women demonstrated that 37.2% were concerned with their external vaginal appearance. Women who were uncomfortable with their vulvar appearance were more likely to have lower FSFI scores as well as a decrease in lubrication and orgasm. The results suggest self-perceived vulvar appearance impacts female sexual health and function, and the role of cosmetic female genital surgery in care for patients with female sexual dysfunction warrants further investigation.
Table 1.
Linear Regression: External Vaginal Appearance Score to Female Sexual Dysfunction

ORp-valueAdjusted ORp-value
FSFI Total1.87 (0.97-2.78)<0.0011.69 (0.76-2.62)<0.001
Desire0.27 (0.14-0.39)<0.0010.17 (0.06-0.29)0.001
Arousal0.37 (0.18-0.56)<0.0010.30 (0.10-0.49)0.003
Lubrication0.28 (0.08-0.47)0.0060.25 (0.05-0.45)0.014
Orgasm0.34 (0.14-0.53)0.0010.31 (0.10-0.51)0.003
Satisfaction0.42 (0.28-0.56)<0.0010.38 (0.24-0.53)<0.001
Pain0.20 (-0.03-0.43)0.086----

*Adjusted for Age, Sexual Orientation, Race, Prior cosmetic female genital surgery

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