Evaluation of the interest of women assisted by the Centro de Atenção à Mulher (CAM) of Rio do Sul in intimate aesthetic surgeries

Introduction: The term female genital surgery encompasses several techniques to improve the female vulvar area, both aesthetically and functionally. Feelings of emotional distress are common in women who seek such surgeries, significantly impacting their self-esteem, sexuality, hygiene and vulvar functionality. The objective is to evaluate the interest of women assisted in a Women Care Center in intimate surgery. Methods: Observational study carried out at the Women Care Center (CAM) in Rio do Sul-SC. For data collection, a semi-structured questionnaire developed by the authors was used. Data were processed and grouped in Microsoft Excel, and descriptive data analysis was performed using the Statistical Package for Social Sciences (SPSS) program. Results: The findings indicated a great general interest in performing intimate aesthetic surgeries. Of the 100 women interviewed, 32 were interested in performing some intimate aesthetic surgery. Conclusion: Due to the importance given to intimate cosmetics in physical, psychosocial, sexual and everyday interference, with a major impact on the quality of life of these people, adequate resources must be allocated to a greater supply of such procedures in the Unified Health System for the population of Brazil. ABSTRACT


METHODS
This research is characterized by an observational study of quantitative, qualitative, field, and exploratory types. The research took place at the CAM in Rio do Sul-SC. The population of the present study were women aged between 18 and 54 years old, attended by the Gynecology services from February to March 2021. All patients who met the inclusion criteria were invited to participate in the research. As a sample estimate, an average of the consultations performed/day was used; thus, 150 patients were expected to be interviewed. At the end of the collection period, 100 women were interviewed, according to the sample calculation by Medronho 11 ; in this research, the sample had a CI of 91.5%.
In a pre-gynecological consultation approach, the questionnaires were applied to sexually active and inactive patients whom the CAM assists. Those who had previous surgeries and/or intimate aesthetic procedures or had cognitive deficits that made it difficult to apply the questionnaire were excluded (Figure 1).

INTRODUCTION
For a long time, plastic surgeons and gynecologists have been working on vulvar reconstructions related to episiotomies scars and functional muscle defects in urinary incontinence 1,2 . The term female genital surgery encompasses several techniques aimed at improving the female vulvar area, both aesthetically and functionally 3 .
The field of female vulvar and vaginal plastic surgery encompasses a set of very broad surgical and non-surgical interventions, including labia minora reduction surgery (called labiaplasty or nymphoplasty), genital rejuvenation procedures, surgery to reduce or increase labia majora, mons pubis liposuction, hymenoplasty, interventions on the G-spot and clitoris, and vulvar whitening procedures [4][5][6][7] .
The demand for these surgeries has been growing more and more. According to the American Society for Aesthetic Plastic Surgery, there was a 14% increase in demand for these surgeries from 2014 to 2015, corresponding to a growth of almost 220% in the last 5 years. Currently, it is practiced by more than 25% of plastic surgeons 8 .
The reverence for the body and its appearance is an important resource for obtaining self-esteem and female well-being. In this way, it influences not only aspects related to vanity but also those involved in health in all its aspects. In this context, female genital plastic surgery has been one of the most sought after in the last five years, especially by aesthetically dissatisfied women who seek a healthier and more pleasurable sexual and social life 2,4 .
Feelings of emotional distress are common in these women, significantly impacting their self-esteem, sexuality, hygiene and vulvar functionality. Various physical complaints involving the labia minora have been reported, including pain, infection, discomfort during various physical activities (including sexual intercourse) and difficulties with personal hygiene 4,9 . It was observed that the main reason for consulting women who want labiaplasty is emotional dissatisfaction with the genital appearance and sexual relations, referring to anxiety or inhibition 10 .
Thus, this research sought to quantify the interest of women assisted by the Centro de Atenção à Mulher (CAM) in Rio do Sul-SC in these procedures, understanding the reasons for dissatisfaction and showing how intimate aesthetics can interfere in the lives of patients. Therefore, the objective is to evaluate the interest of women assisted by the CAM of Rio do Sul in intimate aesthetic surgeries.  Data were processed and grouped according to study variables. The database was organized using a spreadsheet in Microsoft Excel and then transferred to the Statistical Package for the Social Sciences (SPSS), version 26.0 (IBM Corporation, Armonk, New York, USA). A descriptive analysis of the results was performed, representing the quantitative variables by mean and standard deviation and the qualitative ones by absolute number and percentage. Table 1, regarding the characterization of the sample, the mean age was 37.56±12.96 years. Of the 100 patients, the vast majority were married (54%), Catholic (61%) and had completed high school (34%). Furthermore, it can be observed that 86% reported being attracted to the opposite sex (heterosexuals), and, on average, the patients were overweight (Body Mass Index -BMI -26.65 kg/m 2 ).

As seen in
Regarding the patients' relationship with their intimate aesthetics, it can be noted that most patients considered intimate aesthetics very important (61%) and most were satisfied (62%). At some point, a good portion of the patients felt embarrassed by their intimate aesthetics (47% sometimes, 5% always), which was sometimes related to the use of clothes such as bikinis, panties and leggings (36% sometimes, 13% always).
Most patients had no discomfort or pain with clothing (59%) and were satisfied with the staining and lubrication of their genitals (75% and 48%, respectively). Regarding interference in everyday life, 65% of the women indicated that they always had interference and 20% sometimes. Interference with sexual and psychosocial life was not present in most cases (68% and 52%, respectively), as shown in Table 2.
In Table 3, it can be seen that, of the 100 patients, the vast majority had no knowledge about intimate aesthetic surgeries, and, in addition, a significant portion (32%) were interested in performing some intimate aesthetic surgery.
When analyzing Table 4, it is noted that most patients do not have any degree of hypertrophy of the labia minora (Figure 1) but that a relevant number of  patients (9%) have higher degrees (3 -labia minora greater than 5 cm and 4 -labia minora larger than 6 cm).

DISCUSSION
The findings obtained from the research indicated that there was a general interest in performing intimate aesthetic surgeries. Of the 100 women interviewed, 32 were interested in having some type of intimate aesthetic surgery.
The results, which indicated an interest in approximately 32% of the women interviewed,    Degree of hyperplasia of the labia minora mean ± SD or n (%) n=100 Degrees of hyperplasia (Colaneri) 12 Grade Currently, more and more intimate aesthetics are gaining ground, as women feel more empowered and encouraged to talk about their sexuality. In addition, the media and globalization brought the idealization of the perfect body 10 . Women desire intimate cosmetic procedures, mostly labiaplasty, for aesthetic reasons -for example, to reduce self-consciousness in public situations and feelings of ugliness and abnormality.
Functional reasons are, for example, to reduce discomfort, irritation or pain during activities (nonsexual, for example, irritation in clothing or sports activities). Sexual reasons are to lessen dyspareunia or fear of negative evaluation by a sexual partner or self-consciousness during intimacy. Sometimes they had a bad experience with negative comments or were teased about their genital appearance.
The factors influencing the decision to undergo labiaplasty are the media, relationships and psychological well-being 15 . Sharp et al. characterized women's motivations as "appearance", "functional", "sexual" and "psychological" motivations, as commonly reported 8,15,16 . Furthermore, Pardo et al. 17 reported that among the indications for labiaplasty, there were aesthetic causes in 95.4%, functional in 37.2% and psychological causes in 17.4%.
When analyzing the interest in the procedure according to age group, it is observed that 28% of the patients were under 30 years old, 34% were between 35-40 years old, and 37.5% were over 40 years old. Compared with the literature, these data agree with the study by Müllerová & Weiss, which shows that the prevalence of these procedures is higher in patients aged 25-35 years, with the second wave of demand between 40-50 years 16 . It is believed that these procedures' greatest interest and prevalence are in this age group due to the effects of puberty and menopause.
In addition to the high interest in the procedures, dissatisfaction with intimate aesthetics was an alarming point of the study. Of the patients studied, 16% were dissatisfied with their intimate aesthetics, which is in line with several studies carried out in Brazil, such as Lima 13 , which showed 15.3% of dissatisfaction, a statistic that is repeated in international studies such as Sharp et al. 9 , who reported that approximately 17% of women were dissatisfied.
Of the dissatisfied patients, 68.75% were interested in performing some intimate aesthetic procedure. Likewise, in the group formed by patients who responded that they felt embarrassed (always and sometimes), 48.97% were interested in performing some intimate intervention. These data show that aesthetic and psychological aspects are the main motivators for procedures 1,8,16,18,19 .
When resorting to physical/structural characteristics, observing the questionnaire of degrees of hypertrophy of labia minora (HPL), the patients who presented more severe degrees of hypertrophy, grades 3 and 4 in the Colaneri's Classification 12 were, on average, more interested in performing surgery of intimate aesthetics (100%). Compared with the literature, no data associating the prevalence of procedures with HPL degrees exists. This fact shows that, in addition to the mental component of how women relate to their intimate aesthetics, the physical component is directly linked to the greater demand for such types of surgeries. Also, this study observed that patients with HPL grades 3 and 4 suffer more from embarrassment and discomfort. Therefore, these assessments must be carried out and systematized in health systems.
When observing the women's knowledge about the types of intimate aesthetic surgery, the vast majority (87%) of the patients did not know about any intimate aesthetic surgery. When evaluating the women who responded knowing the procedures, 50% were interested in performing an intimate aesthetic procedure. This corroborates the hypothesis that perhaps the interest in performing these procedures is not greater due to a lack of knowledge about this type of surgery.
Finally, according to data from the Sociedade Brasileira de Cirurgia Plástica Estética, in 2017, Brazil performed approximately 21,000 labiaplasties per year, ranking first in the world a number lower than the interest shown by the study population. In addition, studies such as those by Sharp et al. 15 and Veale et al. 19 report that most patients undergo surgeries through private systems.

CONCLUSIONS
The results obtained indicated considerable interest in performing intimate aesthetic procedures. Such interest may be related to the growing female empowerment, which opens space for greater sexual expression and, thus, greater freedom to search for intimate beautification procedures. Furthermore, it may be closely linked to the growing search for the ideal body proposed by the media.
Due to the importance given to intimate aesthetics in the physical, psychosocial, sexual and daily interference, in addition to the discomfort and embarrassment that lead patients to seek specialized medical care, with an important impact on the quality of life of these people 8,15,16 , adequate resources must be allocated to greater provision of such procedures in the Unified Health System for the population of Brazil.