Thesis Submitted in Fulfilment of the Requirements for the Degree of Doctor of Philosophy

Exploring Genital Image, Body Image and Genital Cosmetic Surgery in Sexually Active Australian Women

Frances C. D’Arcy-Tehan

A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy

Faculty of Health Sciences

University of Sydney

October 2018

For Hannah, Isabella, Julia, Beth, Lucia and Teresa, and in memory of Anne (Aunty Darce) Stevenson Gomathi Sitharthan, Jenny Serrano, Barbara and Eugene Darcy.

ii Candidate’s Declaration

This is to certify that, to the best of my knowledge, the content of this thesis is my own work. This thesis has not been submitted for any other degree or purposes.

I certify that the intellectual content of this thesis is the product of my own work and that all the assistance received in preparing this thesis and sources have been acknowledged.

Frances C. D’Arcy-Tehan October 15, 2018

iii Editorial Assistance

In accordance with the University of Sydney policy on thesis editing, editorial assistance was sought in the production of this thesis.

Editing was provided by Charlotte Scarf, Ph.D., M.A., B.Ec (Hons).

iv Acknowledgements

The process of writing a thesis was more challenging and more rewarding than I had imagined. I am fortunate to have had the support of many people. I would first like to acknowledge the willingness and time that women gave by sharing their experiences – without their support this research would not be possible.

I am grateful for the support of a number of colleagues and friends for their advice, guidance and patient encouragement over the course of this research. I would particularly like to acknowledge my supervisors, Dr Gomathi Sitharthan, Dr Michael Hough and Dr Robert Heard for their support. I learned a great deal from working with Rob Heard, with his never- ending patience and superior intellect he gently challenged me and guided me through the ups-and- downs of the research process.

I would also like to thank my colleagues, mentors, family and friends for accompanying me on this epic journey. In particular, I would like to thank Brett McCann and Kent Chuang who provided me with a home-away-from-home. Thank you both for your bottomless generosity, abundant hospitality and support. Also, a big thank you to Dr Joanne Sheedy and Dr Lindy McDougall for their collegiality and support throughout. I would also like to acknowledge the contributions of Dr Hyder, Dr Matthew Dunn and Dr Patricia Weerakoon. Thanks to Suzanne Sprague and Kylie Jones for your enduring support and friendship throughout. Thanks also to Charmaine Morse for your enthusiasm for the project. I would thank my friends Jane Whitmore, Dr Jo Phillips, Helen Nicholls-Stary and Lucinda Rodriguez. A special dedication to Jenny Serrano – who passed away in 2014 – Hasta la proxima – friend and enabler who showed courage throughout her illness – your spirit lives on. A special mention to my sister Kate and cousin Christina – now we will have the time to cruise the world together! Last, and by no means least, I cannot fail to mention the two biggest champions in this whole venture – my late Aunty Darce and Judith O’Neill, who encouraged me to pursue an academic path – I am forever grateful to you and without your influence this research would not have been possible.

Abstract

This research explores factors that influence women’s attitudes and experiences regarding female genital cosmetic surgery, including female genital image and related areas of body image, in the Australian context. The research identifies two dimensions of female genital image (i.e. genital satisfaction and genital self-image) and explores their relationships to related areas of body image (i.e. body satisfaction and body image during sexual activity) and women’s attitudes and experiences regarding eight types of female genital cosmetic surgery

The sample consisted of 592 sexually active Australian women (18 to 71 years).1 Participants completed an anonymous Internet-based survey and completed a series of questionnaires. This was a quantitative correlational study that used a cross-sectional survey design. Results indicate that, in general, sexually active Australian women have moderate levels of genital satisfaction, moderately high positive genital self-image, moderate levels of body satisfaction and most women did not feel self-conscious about their body in the sexual settings. Results further indicate that while many sexually active Australian women approve of other women undergoing genital cosmetic surgery, most would not consider undergoing genital cosmetic surgery themselves.

The study found a very small percentage of women in the research sample had undergone some type of cosmetic surgery on their genitalia. Bivariate analysis found that women who desire at least one type of female genital cosmetic surgery tend to have genital dissatisfaction and negative genital self-image. Multiple regressions analysis found that body image during sexual activity statistically predicts genital satisfaction; that body image during sexual activity and the sexual functioning domain of desire statistically predict genital self-image; and body image during sexual activity, the sexual functioning domains of lubrication and desire, and genital self-image statistically predict women’s attitudes towards female genital cosmetic surgery. The results of the study provide new information on sexually active Australian women’s attitudes

1 The phrase “sexually active Australian women” applies to the larger population of sexually active Australian women who have characteristics similar to those of the sample, as described in sections 3.5 and 4.1. It is not a representative sample.

toward and experiences of female genital cosmetic surgery and their relationships with female genital image, body image and sexual functioning.

Table of Contents

ABSTRACT 1 CHAPTER ONE: INTRODUCTION ...... 7 1.1 BACKGROUND ...... 8 1.2 FEMALE GENITAL COSMETIC SURGERY...... 10 1.3 TYPES OF FEMALE GENITAL COSMETIC SURGERY ...... 12 1.3.1 Labiaplasty ...... 13 1.3.2 Labia majora augmentation ...... 18 1.3.3 Reduction of the mons pubis and/or labia majora ...... 19 1.3.4 Vaginal tightening ...... 20 1.3.5 Clitoral hood reduction ...... 21 1.3.6 Clitoral repositioning ...... 22 1.3.7 G-spot amplification ...... 23 1.3.8 Hymen reconstruction ...... 24 1.4 PREVALENCE DATA ON FEMALE GENITAL COSMETIC SURGERY IN AUSTRALIA ...... 27 1.5 THE IDEALISED VULVA AND VAGINA, AND OTHER SOCIOCULTURAL REASONS FOR CHANGES IN FEMALE GENITAL AESTHETIC ...... 29 1.6 STRUCTURE OF THE THESIS ...... 31 CHAPTER TWO: LITERATURE REVIEW ...... 33 2.1 THEORETICAL ORIENTATION OF THE RESEARCH ...... 34 2.2 DEFINING FEMALE GENITAL IMAGE ...... 35 2.2.1 Defining genital satisfaction ...... 37 2.2.2 Defining genital self-image ...... 38 2.2.3 Other approaches ...... 40 2.3 MEASURING FEMALE GENITAL IMAGE ...... 40 2.3.1 Measuring female genital satisfaction ...... 40 2.3.2 Measuring female genital self-image ...... 48 2.4 FEMALE GENITAL IMAGE AND GENITAL COSMETIC SURGERY ...... 56 2.5 FEMALE GENITAL IMAGE AND SEXUAL PROBLEMS ...... 62 2.6 BODY IMAGE AND SEXUAL ACTIVITY ...... 65 2.6.1 Body satisfaction ...... 66 2.6.2 Body image during sexual activity ...... 69 2.6.3 Genital image during sexual activity ...... 71 CHAPTER THREE: RESEARCH DESIGN ...... 78 3.1 RESEARCH RATIONALE ...... 78 3.2 RESEARCH AIMS AND QUESTIONS ...... 80 3.3 METHODOLOGY ...... 82 3.4 SURVEY DESIGN ...... 83 3.4.1 Female Genital Image Scale ...... 84 3

3.4.2 Genital Self-Image Scale-Female ...... 85 3.4.3 Body Areas Satisfaction Scale ...... 86 3.4.4 Body Exposure during Sexual Activities Questionnaire ...... 87 3.4.