[4] Unlike public hospitals, cosmetic surgeons in private practice are not required to follow these rules, and critics say that "unscrupulous" providers are charging to perform the procedure on women who would not want it if they had more information.

[4] Images of vulvae are absent from the popular media[5][6] and advertising[7][8]: 19  and do not appear in some anatomy textbooks,[9] while community opposition to sex education[10][11] limits the access that young women have to information about natural variation in labias.

[13]: 6  [14][15][16] At the same time, many pornographic images of women's genitals are digitally manipulated, changing the size and shape of the labia to fit with the censorship standards in different countries.

[20] Although it is also suggested that evidence for this is lacking,[20] the National Health Service stated that some women bring along advert or pornographic images to illustrate their desired genital appearance.

[25] In sexual reassignment surgery, in the case of the male-to-female transgender patient, labiaplasty is usually the second stage of a two-stage vaginoplasty/vulvoplasty operation, where labiaplastic techniques are applied to create labia minora and a clitoral hood.

The technical disadvantages of the labial-edge resection technique are the loss of the natural rugosity (wrinkles) of the labia minora free edges, thus, aesthetically, it produces an unnatural appearance to the vulva, and also presents a greater risk of damaging the pertinent nerve endings.

Moreover, there also exists the possibility of everting (turning outwards) the inner lining of the labia, which then makes visible the normally hidden internal, pink labial tissues.

Some women complain of a "small penis" when the trim procedure is performed, owing to the un-addressed clitoral hood tissue and completely removed (amputated) labia minor.

[35] Labial reduction by means of a central wedge-resection involves cutting and removing a partial-thickness wedge of tissue from the thickest portion of the labium minus.

Labial reduction by means of the de-epithelialization of the tissues involves cutting the epithelium of a central area on the medial and lateral aspects of each labium minus (small lip), either with a scalpel or with a medical laser.

[37] Labial reduction occasionally includes the resection of the clitoral hood when the thickness of its skin interferes with the woman's sexual response or is aesthetically displeasing.

The physician informs the woman that the reduced labia are often very swollen during the early post-operative period, because of the edema caused by the anaesthetic solution injected to swell the tissues.

She is also instructed on the proper cleansing of the surgical wound site, and the application of a topical antibiotic ointment to the reduced labia, a regimen observed two to three times daily for several days after surgery.

Critics argue that a woman's decision to undergo the procedure stems from an unhealthy self-image induced by their comparison of themselves to the prepubescent-like images of women they see in commercials or pornography.

[4] Unlike public hospitals, cosmetic surgeons in private practise are not required to follow these rules, and critics say that "unscrupulous" providers are charging to perform the procedure on women who would not undergo it if they had more information.

[4] Increasing numbers of women in Western countries are also using Brazilian waxing to remove pubic hair, and choosing to wear tight-fitting swimwear and clothing.

[12] Linda Cardozo, a gynaecologist at King's College Hospital, London, told the newspaper that women were placing themselves at risk in an industry that is largely unregulated.

[47] The American College of Obstetricians and Gynecologists (ACOG) published an opinion in the September 2007 issue of Obstetrics & Gynecology that several "vaginal rejuvenation" procedures were not medically indicated, and that there was no documentation of their safety and effectiveness.

[48] In the UK, Lih Mei Liao and Sarah M. Creighton of the University College London Institute for Women's Health wrote in the British Medical Journal in 2007 that "the few reports that exist on patients' satisfaction with labial reductions are generally positive, but assessments are short-term and lack methodological rigour."

The authors noted that "the patients consistently wanted their vulvas to be flat, with no protrusion beyond the labia majora ... some women brought along images to illustrate the desired appearance, usually from adverts or pornography that may have been digitally altered.