Women's Knowledge, Attitudes, and Practice About Female Genital Cosmetic Surgery: A Cross-Sectional Study in Saudi Arabia

Introduction Vulvoplasty, or female genital cosmetic surgery (FGCS), refers to any surgical alteration of the vaginal or labial anatomy for aesthetic or medical reasons. It aims to restore or enhance the female genitals and can involve multiple procedures such as labiaplasty, clitoral unhooding, monsplasty, vaginoplasty, hymenoplasty, G-spot augmentation, frenuloplasty, perineoplasty, fat injections, or a combination of these. Labiaplasty is currently the most popular procedure among patients. Since the public is exploring FGCS benefits in the media, it can be foreseen that it will soon gain popularity among the population of Saudi Arabia. As a result, the purpose of this study is to assess women's attitudes and knowledge towards genital cosmetic surgeries in Saudi Arabia. Methods This correlational cross-sectional survey was conducted in Saudi Arabia among women aged 18 years and above, using an online self-structured questionnaire distributed from April 2023 to October 2023. The sample size of 594 respondents was determined based on a minimum requirement of 500 participants, with a confidence level of 95% and a study power of 95%. A convenient sampling method was employed to select participants, and data collection was carried out through a self-administered online questionnaire distributed via various social media platforms. The survey was self-structured, and Cronbach's alpha values for all sections were greater than 0.7. These sections include demographic characteristics, sexual life and obstetric history, and women's knowledge, practices, and attitudes toward FGCS. Descriptive analysis, chi-square test, and t-test were used for data analysis using SPSS software. Results A total of 589 eligible women were included in the study; 284 (48.2%) were from the central region, and ages ranged from 18 to 65 years, with a mean age of 33.5 years. A total of 401 (68.1%) were married, 366 (62.1%) had a bachelor degree. Two hundred and ninety-one (49.4%) participants heard about FGCS, 165 (28%) knew that it involves surgical procedures to change the appearance of the female genitalia, 144 (24.4%) said it is also known as vaginal rejuvenation or designer vagina surgery and 200 (34%) knew it can involve procedures such as labiaplasty, clitoral hood reduction, or vaginal tightening, while 190 (32.3%) reported it is sometimes done for aesthetic reasons but may also be done for medical reasons. Only 45 (7.6%) had undergone FGCS, but 112 (19%) confirmed they consider undergoing FGCS for themselves. Four hundred and ninety-eight (84.6%) participants thought that it's important to have access to support services, such as counseling or peer support, 471 (80%) expressed that it's important that healthcare providers in Saudi Arabia are knowledgeable about FGCS, 425 (72.2%) were concerned about the potential risks and complications of FGCS. Conclusion In conclusion, the current study revealed that nearly one out of five women were knowledgeable about FGCS, mainly about the nature and types of the procedure. Higher knowledge levels about FGCS were associated with younger age, higher educational levels, and women who were more likely to consider undergoing FGCS in the future.


Introduction
Some women choose to undergo non-medical cosmetic surgery to alter the appearance and structure of their external and internal genitalia.This is known as female genital cosmetic surgery (FGCS) and includes procedures such as vaginoplasty, labiaplasty, hymenoplasty, mons pubis liposuction, G-spot augmentation, vaginal rejuvenation or laser rejuvenation, and orgasm-shot [1,2].Labiaplasty is the most frequently performed procedure [3].For women concerned about the appearance of their genitalia, FGCS provides significant psychological advantages, and following FGCS, the majority of women with severe deformity reported less pain or discomfort during everyday activities and sexual activity [4].It has been reported by the American Society for Aesthetic Plastic Surgery that there is a growing demand for FGCS in the United States.Specifically, there has been a 23.2% increase in labiaplasty surgeries between 2015 and 2016.Similarly, Australia saw a threefold increase in labiaplasties between 2003 and 2013, while the UK experienced a fivefold increase [5].Social media certainly contributed the most to this rise in awareness; Crockett et al. conducted a study on the influence of plastic surgery, and they discovered that television shows influenced four out of five patients to seek cosmetic surgery [6].All the studies that were conducted in Saudi Arabia targeted the patients' satisfaction, the perspective of their experience after the operation, and their motives [7].However, several studies evaluated physicians' knowledge from different subspecialties, and the reported knowledge level was suboptimal, but their attitudes improved [8,9].Since FGCS benefits are being explored by the public, it can be foreseen that it will gain popularity in the near future among our population.The rise in popularity of cosmetic surgery is likely due to media influence.In a study conducted by Crockett et al. on the impact of plastic surgery, 80% of patients reported being influenced by television shows to pursue a cosmetic procedure [6].It's also worth noting the significant expectations that often follow such surgeries [10,11].The current study aimed to discover the knowledge and attitudes of Saudi women about female genital cosmetic surgery.

Materials And Methods
A correlational cross-sectional study was conducted based on an online structured questionnaire distributed to Saudi women aged 18 years or more.The study was conducted from April 2023 to October 2023.The inclusion criteria comprised adult women aged 18 years and above residing in any region of Saudi Arabia.On the other hand, women aged less than 18 years of age, females who refused to participate, and those with incomplete survey answers were excluded.The sample size was determined using the G-power analysis program, which recommended a minimum of 500 participants for a study with a 95% confidence level and a study power of 95%.For this study, a total of 594 respondents were included.
To select participants, a convenient sampling technique was employed.The data collection process involved the use of a self-structured survey.The validity of the questions was assessed, and Cronbach's alpha values for all sections were found to be satisfactory, being greater than 0.7.
The questionnaire was presented in Google Forms and distributed through various social media platforms.Multiple data collectors were involved until no further responses were received.
The consent was obtained from the participants first.After that, answering an online questionnaire was requested.The questionnaire was designed in Arabic and contained three sections.The first section collected the bio-demographic data.The second section covered the sexual, gynecological, and obstetrical information regarding the recent experience of pregnancy and delivery, history of infections, and genital examination performance and frequency.The third section contained women's knowledge about FGCS, their source of information, and their need for more information.In addition, the questionnaire collected data about women's practice of FGCS, types of undergone cosmetic surgeries (FGCS or other cosmetic surgeries), and their attitude toward FGCS and the physician's role.Data was collected, coded, and subjected to direct analysis with the aim of minimizing bias.

Data analysis
The data were collected, reviewed, and then entered in Statistical Package for Social Sciences version 21 (SPSS; IMB Inc., Armonk).All statistical methods used were two-tailed with an alpha level of 0.05, considering a p-value less than or equal to 0.05 to be significant.Overall knowledge level regarding FGCS was assessed by summing up discrete scores for different correct awareness items.The overall knowledge score was categorized as a poor level if the participants' score was less than 60% of the overall score and a good level of awareness if the participants' score was 60% or more of the overall score.Descriptive analysis was done by presenting frequency distribution and percentages for study variables, including participants' personal data, medical, sexual, and obstetric history.Also, the frequency distribution of the women's knowledge about FGCS, their practice, attitudes, and overall knowledge level were tabulated.Cross tabulation was applied to show factors associated with participants' knowledge about genital cosmetic surgery using the Pearson chi-square test and exact probability test if there were small frequency distributions.

Results
A total of 589 eligible women were included, 284 (48.2%) of them from the central region.Ages ranged from       Factors associated with participants' knowledge about genital cosmetic surgery are presented in Table 7.A notable finding indicated that 25.7% of young women had a good understanding of FGCS, compared to 12.5% of women aged 55 years or older, and this difference was statistically significant (p=0.049).Also, 26.9% of highly educated women had a good knowledge level versus 8.7% of other participants with lower education (p=0.046).Good knowledge about FGCS was indicated among 43.8% of women who have ever considered undergoing FGCS compared to 16.4% of those who have not (p=0.001),and among 44.4% of other participants who had any type of cosmetic surgery versus 19.9% of those who hadn't (p=0.001).Likewise, 36.7% of women who talked about FGCS with a healthcare provider had a good knowledge level about the surgery versus 18.3% of others who didn't (p=0.001).

Discussion
FGCS involves changing the appearance of the labia or vulva [12].Some individuals select this surgery because they are dissatisfied with the appearance of their genitalia.This type of surgery is also referred to as "aesthetic genital surgery" [13].Female genital reshaping, or labiaplasty, specifically focuses on changing the size and shape of the inner labia or the inner lips of the vulva.It is important to note that labiaplasty and phalloplasty are not the same as gender reassignment surgeries [14,15].
The current study aimed to assess females' attitudes and knowledge towards genital cosmetic surgeries in Saudi Arabia.Regarding knowledge level, the current study showed that about one-fifth of the women who participated in the study had good knowledge about the surgeries.Approximately half of the study participants were familiar with the term FGCS.The most common definition provided was as follows: "It can involve procedures such as labiaplasty, clitoral hood reduction, or vaginal tightening".Less than one-fifth of the study women think that there is enough information available about FGCS in Saudi Arabia, and about one-fifth indicated that information or taboos influence their decision toward FGCS, making them more likely to consider FGCS, but most of them noted that information does not influence their decision to consider FGCS.The most reported source of information included social media, which played the main role in providing participants with needed information about FGCS, which was similar to other studies' conclusions [16,10].Other less frequent sources, including online searches, friends, or family, were reported.Similar findings were reported among medical students in Saudi Arabia by Iqbal et al. [17], where about 68.7% of the participants did not have much knowledge about vulvovaginal aesthetics procedures.Also, in India, Gowardhan and Bagade [18] documented that 26.2% of females had satisfactory knowledge about FGCS.Social media (56.5%) was the most common source of information for these participants.A much lower awareness level was reported by Bello and Lawal [19], as only 27.7% heard about FGCS.In contrast to the current study, medical personnel were the main source of information in their study.Regarding factors associated with women's knowledge, young age, high education, considering FGCS, undergoing cosmetic surgery, and talking about FGCS with a healthcare provider were significant predictors.
Regarding women's attitudes, the current study showed that most of them think that it's important to have access to support services, such as counseling or peer support, and it is important that healthcare providers in Saudi Arabia are knowledgeable about FGCS.About three-fourths were concerned about the potential risks and complications of FGCS, and about two-thirds agreed that it's important to have the procedure performed in Saudi Arabia when considering FGCS.Less than half think that it's important that the husband/partner supports the decision to undergo FGCS, and one-third think that discussing FGCS with the husband/partner is comfortable.All these indicate a nearly positive attitude towards the procedure with the need for support and availability of surgeries in Saudi Arabia.
Limitations that were faced while conducting this study were the difficulty of reaching participants from other regions as most of our team were from the central region; therefore, it affected the regional composition of participants who were reached.Another limitation is the unwillingness of the participants to take part in the survey due to the stigmatized views around the topic among the Saudi population.Finally, another obstacle was translating medical and technical terms related to our research into the Arabic language to make sure that our participants were able to fully understand the context and the scope of our research.

Conclusions
In conclusion, the current study revealed that nearly one out of five women were knowledgeable about FGCS, mainly about the nature and types of the procedure.Higher knowledge was associated with young age, high education, and future consideration of undergoing the surgeries.Social media was the main player in gaining information, with no role for healthcare staff.Also, the females who participated in the study had a positive attitude towards FGCS, mainly if supported by partners and their healthcare staff with the availability of surgeries in Saudi Arabia.Saudi women should be informed mainly by healthcare staff in detail about the merits and hazards of the FGCS procedures to make a precise, informed decision about the FGCS procedures.

TABLE 1 : Bio-demographic data of study females in Saudi Arabia Sexual
and obstetric history of study participants are presented in Table2.As for sexual history, 276 (46.9%) of married women reported having sex for the first time at the age of 18-24 years.One hundred and eightyseven (41.9%) married women had sexual activity 1-2 times a week, and 131 (29.4%) had sexual activity less than once a week.Only 38 (6.5%) had sexually transmitted infections.Concerning obstetric history, most of the married women (80%) got pregnant, 240 (70%) had a normal vaginal delivery, of whom 81 (22.7%) did not experience any complications during pregnancy or delivery.Perineal tear/episiotomy during delivery was reported among 142 (41.4%) women who gave birth.Out of the total participants, 286 (48.6%) underwent a gynecological examination, primarily in response to specific concerns or issues, with the majority of 228 (79.7%) seeking such examinations only when faced with health concerns.Among the study participants, regular self-examinations of the genitalia area were reported by 168 women (28.5%), with the majority of them, 104 (62.3%), indicating that they performed such examinations only in response to specific concerns or health issues.Have you experienced any complications during pregnancy or delivery?Yes 81 22.7% 2023 Alrashed et al.Cureus 15(11): e49201.DOI 10.7759/cureus.4920177.3% Have you undergone perineal tear/episiotomy during the previous delivery?

TABLE 2 : Sexual, obstetrical and gynecological history of the participants
NVD -normal vaginal delivery; CS -Cesarean sectionWomen's knowledge about genital cosmetic surgery in Saudi Arabia is presented in Table3.Two hundred and ninety-one 291 (49.4%) participants heard of female genital cosmetic surgery (FGCS), 165 (28%) said it involves surgical procedures to change the appearance of the female genitalia, 144 (24.4%) told it also known as vaginal rejuvenation or designer vagina surgery and 200 (34%) knew it could involve procedures such as labiaplasty, clitoral hood reduction, or vaginal tightening, while 190 (32.3%) reported it is sometimes done for aesthetic reasons but may also be done for medical reasons.A total of 316 (53.7%) participants expressed a desire to acquire further knowledge about FGCS, while 105 (17.8%) believed that there is a sufficient amount of information available about FGCS in Saudi Arabia.Only 131 participants (22.2%) reported that information or societal taboos have an impact on their decision-making process regarding FGCS, making them more inclined to consider FGCS.However, most participants stated that this information does not influence their decision to undergo FGCS.The most reported source of information included social media (36.2%), online search (14.8%), friends or family (11.5%), while 30.4% had no information about FGSC.Generally, most of the participants (78.3%) had poor knowledge about FGCS.No %Have you heard of female genital cosmetic surgery (FGCS)?

TABLE 3 : Women's knowledge of genital cosmetic surgery in Saudi Arabia
Socio-demographics of women who responded to the question that FGCS involves procedures such as labiaplasty, clitoral hood reduction, or vaginal tightening are presented in Table4.The sample was composed of 41.4% of the participants aged between 18 and 24 years compared to 18.8% of participants aged 55 years or older (p=0.002).Additionally, 42% of them were single, while 30.7% were married participants (p=0.043).Likewise, 60% of women with cardiac disease indicated that FGCS can involve procedures such as labiaplasty, clitoral hood reduction, or vaginal tightening in comparison to 32.5% of those without chronic disease (p=0.001).Socio-

Table 6 .
Out of all participants, 84.6% think that it's important to have access to support services, such as counseling or peer support, 80% indicated that it is important that healthcare providers in Saudi Arabia are knowledgeable about FGCS, 72.2% were concerned about the potential risks and complications of FGCS, 62.8% agreed that it's important to have the procedure performed in Saudi Arabia when considering FGCS, 43.6% think that it's important that husband/partner supports the decision to undergo FGCS, and 30.2% think that discussing FGCS with husband partner is comfortable.