A pilot study is investigating a sharp increase in the number of Australian girls, some as young as 11, seeking cosmetic surgery on their genitals.
Demand appears to be driven by social pressures, and a lack of awareness generally about the true range of diversity.
University of Melbourne researcher Emma Barnard has begun interviewing young women who sought medical advice about their genital appearance.
The median age of the 41 girls and young women referred to the Royal Children's Hospital between 2000 and 2012 concerned by how their labia looked, was 14.5, and in nearly a quarter of cases it was the mother who was concerned, RCH figures show.
Medicare claims for labiaplasty and vulvoplasty more than doubled from 707 in 2002-03 to 1584 in 2013-14. And the number of claims among 15 to 24-year-olds was similar to women aged 25-44. Medicare no longer covers such surgery, but Ms Barnard has interviewed women who had the surgery done privately.
Female genital cosmetic surgery most commonly involves "labiaplasty" to cut the edges of the labia minora so that it doesn't extend beyond the outer skin folds, the labia majora. It can also extend to procedures like vaginoplasty to tighten the vagina, or vulval lipoplasty to remove fat around the vulva.
One study participant, now 18, told Ms Barnard that when she was just 13, she started worrying about how her vagina looked after noticing textbook drawings looked different to her body.
The girl's mother then took her to a doctor to explore the option of surgery. The doctor referred her to the Royal Children's Hospital in Melbourne where she was reassured that she was perfectly normal, Ms Barnard said.
"Something has changed in the last 10-15 years to make women and girls more aware of the appearance of their genital anatomy," said Ms Barnard, of the School of Population and Global Health.
"For nearly all the women I spoke to, this experience of having concerns is happening from around 13 to 16. It is a very specific and fraught time when they are trying to figure out who they are and how their bodies work," Ms Barnard said.
Many of the study's participants said that as girls they had only seen vaginas in stylised or airbrushed images in textbooks, magazines, social media or on the internet. Fashion for Brazilian waxing, tight-fitting clothing and G-strings were also an influence, but perhaps surprisingly pornography appeared not to have played a major role.
"You don't have to be an adult to have these worries, yet the voices of young women aren't in any of the research literature, possibly because it is difficult thing to talk about. If we have a better idea of how girls experience genital appearance concerns, then we can potentially improve clinical practice, and reduce or eliminate unnecessary surgeries," Ms Barnard said.
Explore further: Images of 'designer vaginas' in the media can encourage consideration of genital surgery