Jessica Pin: Clitoracy and Labiaplasty

Jessica Pin had a labiaplasty at 18. The surgeon went on to perform an extra part of the operation that she did not consent to…..and things went wrong. Rather than listen to what she was experiencing post-operatively and explore what might have gone wrong, he denied anything physically had occurred and suggested her symptoms were purely psychological.

This led Jessica to question many things; the information she had been given about our ideas around “normal” available to us all on the internet; the medical profession listening to patient real problems; a lack of validation that her symptoms were indeed physical; the medical education system in general and superficially how much does a specialist gynaecologist/obstetrician (even a female specialist) know about the female anatomy. The answers may shock you.

This is an important conversation that also addresses cosmetic surgery, the influence of the internet and social media, the scope of basic anatomy and its role in medical training and clitoracy, a subject every adult, male and female should know about.

In this episode, we discussed her personal experience with labiaplasty, how little to no information the internet and textbooks have about the female reproductive anatomy, and so much more.

Jessica Pin: Clitoracy and Labiaplasty Introduction

Well, cosmetic surgery is a huge and growing industry, and social media’s impact on people’s decision to proceed with cosmetic surgery is huge as well. It is a huge industry and today we are going to explore one such cosmetic surgery which went wrong, which had implications on a patient’s life. 

It’s a story about the education of individuals of us as we are growing up. It’s a story about medical education. It’s a story about validation and listening to our patients. And there are a few other interesting parts to this.

Podcast Transcript

Dr Ron Ehrlich: [00:00:00] I’d like to acknowledge the traditional custodians of the land on which I am recording this podcast, The Gadigal People of the Eora Nation, and pay my respects to their Elders – past, present, and emerging.

Hello and welcome to Unstress. My name is Dr Ron Ehrlich. Well, cosmetic surgery is a huge and growing industry, and social media’s impact on people’s decision to proceed with cosmetic surgery is huge as well. It is a huge industry and today we are going to explore one such cosmetic surgery which went wrong, which had implications on a patient’s life. 

It’s a story about the education of individuals of us as we are growing up. It’s a story about medical education. It’s a story about validation and listening to our patients. And there are a few other interesting parts to this. I won’t spoil it. I hope you enjoy this conversation I had with Jessica Pin.

Dr Ron Ehrlich: [00:01:15] Welcome to the show, Jessica.

Jessica Pin: [00:01:17] Thanks so much for having me.

Dr Ron Ehrlich: [00:01:19] Jessica. Cosmetic surgery is a huge and growing industry, actually. And when you were, I think at 18, you chose to have cosmetic surgery. I wonder if you might tell us what that was, how you came to decide you needed it and what happened.

Jessica Pin: [00:01:38] So I had a labiaplasty when I was barely 18. A labiaplasty is a surgery that reduces the size of the labia minora, which are the inner lips of the vulva. Right. So the right around the vagina. And the reason why I sought labiaplasty is because when I was 17, I ended up online trying to figure out where my clitoris was because I did not know how to find it, and I didn’t even really know what it was. I had not been taught in sex ed. 

So I got online to find out. I ended up on the Wikipedia page for a clitoris, and then I ended up on the Wikipedia page for the vulva. And I saw, you know, I saw this vulva on Wikipedia with all the parts labelled, and it didn’t look like mine. And so then I ended up sort of confused. And so I realised, oh, like those flappy things are labia minora. 

And so then I Googled, you know, “Are my labia minora normal?” And I did an image search for labia minora. And I was just trying to figure out if other women had labia minora like mine also. 

Jessica Pin: [00:02:44] And that’s how I stumbled upon labiaplasty advertisements and labiaplasty surgeon websites. So I saw the before and after photos from labiaplasties, and I looked like the before photos. And I read that protruding labia minora are considered unfeminine and embarrassing. I read that they are caused by ageing sexual activity, masturbation, and excess androgens. 

And you know, and then I had to Google androgens, and I read that those are basically male hormones. I also read that they caused pain during sex. And I remember at 17, and as a virgin, that was very alarming because I thought I had this problem that would cause me pain during sex. 

And, yeah, I just felt like I had this really shameful, embarrassing problem. I’ve read that most women want labia minora that are completely hidden by the labia majora. And mine were definitely not hidden. So I felt like I had this terribly embarrassing problem.

Jessica Pin: [00:03:51] And I think I was probably a bit influenced by the fact that my father is a plastic surgeon. So I grew up with cosmetic surgery very normalised. You know, I’ve been, I’ve known all about cosmetic surgery since I was like five years old. I had gone to the O.R. with my dad. You know, I was always like a daddy’s girl. So it just seemed like I wasn’t sceptical of cosmetic surgery because I had grown up around it.

Dr Ron Ehrlich: [00:04:21] Yeah.

Jessica Pin: [00:04:21] And I just thought, Oh, if you have some really embarrassing aesthetic issue, you should just get it fixed. You know, like if I had had like giant ears or like a big nose or something, like, I probably would have had that fixed, you know? Just because that’s sort of like the culture that I grew up in, I wasn’t raised to just, like, embrace myself the way that I was. 

However, I was just sort of, like, intuitively cautious about surgery on my genitals. And so, I did spend a lot of time trying to learn about the risks of labiaplasty. I did read the peer-reviewed literature published at the time. I read outcomes studies. You know, I looked at all these patient education sites, and everywhere I looked, they said that there were no risks to sexual function. 

This one website called actually put that the labia minora are not involved in sexual function in capital letters. Wow. And they said: “No risk to sexual function.” So I almost felt like stupid for even suspecting that.

And I did feel like, sort of, you know, I actually felt like my labia minora were involved in sexual function. But when I saw all these experts saying otherwise, I sort of doubted my own perception of my own body.

Dr Ron Ehrlich: [00:05:46] This was all going on prior to you having the surgery.

Jessica Pin: [00:05:50] Yes. Yes.

Dr Ron Ehrlich: [00:05:51] So you did quite a bit of research online.

Jessica Pin: [00:05:55] I did, yeah. And I also tried really hard to find statistics on labia minora size. So I just wanted to know where I stood compared to everyone else. And one thing that happened is my mom took me to her OB-GYN, and her OB-GYN told me I was normal. But the problem was I had done so much research before that that I had read that they recommend that OB-GYNs tell all patients they are normal no matter how unusual they are. 

And so I wanted to know how normal I was. You know, I wanted to know, like, what percentile I was in. And I couldn’t get that information. And I tried to ask her to estimate, and she wouldn’t. And I tried to ask her to tell me, you know, of her previous ten patients, how many had labia minora bigger than mine? And she wouldn’t tell me. 

So I thought she was hiding, you know, I thought she was keeping the information from me. In retrospect, she most likely just hadn’t been paying attention. Right. So I’ve learnt since then that OB-GYNs just don’t pay a lot of attention to vulvas.

Jessica Pin: [00:06:58] So I felt like I had this embarrassing problem. And I thought that these surgeries were very low risk. And so, you know, basically, I went to my dad and one thing that I did was I claimed that I had pain when I rode my bike. And I had never had any symptoms, but I claimed that I had pain when I rode my bike because I felt desperate to have surgery. 

And the fact that I have lied, I think, made it very, very difficult for me to stand up for myself later because I blame myself so much. And I was afraid of other people blaming me. And as soon as I did start talking about it, other people did blame me.

Jessica Pin: [00:07:36] So basically, yeah, I claimed that they hurt when I rode my bike. And so my dad went and like talked to his colleagues who were doing maybe labiaplasty. He talked to other doctors at the hospital where he worked, and people told him that people do this all the time and it’s no big deal. 

So he got this idea that it was no big deal, that it was just removing extra skin. Right. Because that’s how a lot of doctors approach it as just removing extra skin. They even call it extra skin in this OB-GYN surgery textbook that I tried. 

You know, I did change their coverage of anatomy, but I was not able to change that. So they still call it extra skin. But so basically, my dad asked for a recommendation from the head of the OB-GYN department recommended my doctor.

Dr Ron Ehrlich: [00:08:25] Hmm.

Jessica Pin: [00:08:27] And so what my doctor did is he completely removed my labia minora, and he performed a clitoral hood reduction without my consent.

Dr Ron Ehrlich: [00:08:38] Wow. Wow. And, well, what happened then? What was the consequence of that?

Jessica Pin: [00:08:45] So what happened was I lost a lot of sensation. Basically, I no longer felt like I had an external sensation after my surgery. But what’s really sad is I was just so ignorant about, you know, female sexual function before my surgery and after my surgery that I wasn’t able to understand the significance of what he had done. 

And so I thought, you know, oh, well, I will still be able to orgasm just fine with my vagina, you know. And I actually saw a 16-year-old on Reddit saying something very similar like that. She had lost clitoral sensation, but she assumed that it would be all right because she gets the orgasm from her vagina. So I think she…

Dr Ron Ehrlich: [00:09:31] And that happened from labiaplasty as well?

Jessica Pin: [00:09:33] Yeah.

Dr Ron Ehrlich: [00:09:34] So this wasn’t just a one-off thing, you know, one in a million, you know like this has happened.

Jessica Pin: [00:09:41] Yeah. I mean, what’s going on is that surgeons are doing these surgeries without training, and they don’t know the anatomy. So all of these surgeons who are operating on the clitoral hood do not even think about where nerves in the clitoris are because, typically, those nerves have been omitted from anatomy diagrams. Right. So they weren’t even in OB-GYN literature until 2019.

Dr Ron Ehrlich: [00:10:09] Wow. Oh, that’s unbelievable. Listen, I mean, I want to get on to medical education, but you’ve raised so many issues there. Firstly, the OB-GYN’s knowledge or the focus is not even on the vulva because that is not part of the reproductive, I guess, you know, talk about holistic. 

You know, we’re very focussed on a holistic approach to health, and here we have an OB-GYN who’s focussed on reproductive health but come a little bit out of that area, and that’s out of the speciality. I mean, what does that say about medical education?

Jessica Pin: [00:10:47] Yeah. So the vulva, in general, has not been considered relevant to reproduction because it’s not directly involved in reproduction. And so that’s why anatomy for the clitoris and vulva, in general, has been so neglected.

Dr Ron Ehrlich: [00:11:02] And the surgery was done by an OB-GYN, an obstetrician gynaecologist, not by a plastic surgeon.

Jessica Pin: [00:11:08] Yeah, it was done by an OB-GYN. In retrospect, I would have been much safer in the hands of a plastic surgeon. However, because my father was a plastic surgeon, he knew that plastic surgeons were not getting trained to do this, and he knew that plastic surgeons didn’t have a lot of education on vulva anatomy. And he got the impression that his colleagues who were doing them didn’t really know what they were doing.

Dr Ron Ehrlich: [00:11:32] This raises so many issues also about education, because not just medical education. I’m talking about education for us as we’re growing up because here you were at the age of 17 or 18 and weren’t even sure where your clitoris was or very familiar with the anatomy, your own anatomy?

Jessica Pin: [00:11:51] Mm hmm. Yeah, so. I had…

Dr Ron Ehrlich: [00:11:52] I mean, what would you say? I mean, what should we obviously be teaching girls and boys about the anatomy of each other’s genitals because we do interact with them throughout our lives?

Jessica Pin: [00:12:05] Well, they teach about boys’ genitals. So they typically don’t teach much about the vulva in sex ed because the vulva is not seen as reproductive anatomy. So once again, the problem with sex ed is the same as with medical education. And I’ve talked to, you know, teachers who teach sex ed, and they say they get told to not teach about the clitoris and to not teach about female orgasms. Which is really sad.

Dr Ron Ehrlich: [00:12:33] It’s a very… I mean, talk about a patriarchal society just taking it to, well, I guess completely on another level, but the Internet, there’s a few things here about medical education, but there’s also about an issue about validating your own experience when you presented post-surgery with these issues, how was that dealt with?

Jessica Pin: [00:12:56] So the doctors that I told, told me that I just needed to relax, that my surgery could not have caused my lack of sensation. One, OBYGN told me I just needed to fall in love. Well, so she actually said she was horrified by how my doctor had removed my labia minora, and she was concerned about me having discomfort. But she told me that my surgery could not have affected my sexual function. 

What’s crazy is she told me, she told me about it. She told me my loss of sexual function could not have been caused by my surgery. But then later, when I explained to her how it did, you know, when I explained the anatomy to her, and I asked her to please, you know, be more helpful to future patients if she encountered anybody else like me, she said that I should have known. So, on one hand, she said that was impossible. And then later, she said, I should have known that it could happen. Hmm. A little crazy.

Dr Ron Ehrlich: [00:13:54] I mean, it’s one thing to have a 17 or 18-year-old unfamiliar with the anatomy. The female anatomy. Well, the obvious anatomy. But one thing to be not even familiar with the neuroanatomy, you wouldn’t expect a 17-year-old but a female obstetrician gynaecologist to not have that knowledge as well. It’s extraordinary. It’s almost breathtaking.

So what did you learn about the medical education of obstetricians and gynaecologists in this journey? I’m sure I know you’ve written in the Journal of Aesthetic Surgery with your father. But tell us a bit about what you’ve learnt about the existing pre-2009 teen medical education in this area.

Jessica Pin: [00:14:44] Well, so I learnt that OB-GYNs were not learning about the nerves in the clitoris.

Dr Ron Ehrlich: [00:14:48] That’s an extraordinary statement.

Jessica Pin: [00:14:51] Yeah. I mean, that anatomy was missing from their textbooks. It was missing from the journals. There is one exception. There was one O’Brien Journal article published in the Low Impact Factor Journal in 2016, but I don’t tend to count that. Some of the descriptions of the clitoris is incorrect. And it’s, you know, it’s not anywhere where many OB-GYNs would have read it. So I don’t count that. So just in general, the anatomy was missing.

Dr Ron Ehrlich: [00:15:17] But we’re talking about the training of the specialist. I mean, the specialist goes through four or five years of post-graduate training, and yet even within that training, the correct description of the anatomy.

Jessica Pin: [00:15:32] Yeah. So what’s interesting is that it was actually in Netter, and it was in Grey’s Anatomy for students, and I’m not actually sure when they added it to those textbooks. That’s one of those things where I might need to go back and check because I know that I checked Netter when I was in college, and I couldn’t find it. 

And then later, I did find it. So I was sort of I remember being confused and wondering, was I not careful, you know? So I can’t really say. But I know that by 2018 it was definitely in Netter, and it was definitely in Grey’s Anatomy for students. And previously, when I had analysed all the OB-GYN literature in 2011, which is when I really dug in, I assumed that OB-GYN speciality literature would have more detail for the vulva, and so I didn’t really dig into anatomy textbooks back then. 

However, in 2012, I remember I visited an ex-boyfriend in medical school, and I bet him that he would not be able to find the nerves in the clitoris. And he said, “No way.” He said, “I’m sure they’re in my textbook somewhere.” And they weren’t.

Dr Ron Ehrlich: [00:16:44] Wow.

Jessica Pin: [00:16:44] And his textbook was Rowan’s Colour Atlas of Anatomy.

Dr Ron Ehrlich: [00:16:49] Wow. Well, so what should… I know you’ve become an advocate for the clitoris. And what should we all know about the clitoris? Because, I mean, I think I mentioned to you before we came on that there was an article recently in a major paper in Australia about a year ago that did a whole feature on the clitoris, and both my wife and I were surprised at how big the clitoris actually is. Tell us about the clitoris.

Jessica Pin: [00:17:15] Well, I guess you’re talking about how the clitoris has crura and bulbs that are basically inside the body. And there has been a lot of focus on that. However, I tend to think that it’s the external part of the clitoris that is the most important for female sexual function. And so that’s what I focus on mainly. 

However. Yeah. I mean, I haven’t actually observed that the internal parts were missing, you know, because actually the bulbs and crura and the clitoris were shown in my father’s 1981 anatomy textbook that he had when he was at Duke Medical School. 

So that’s why I kind of question all the hype around the bulbs and crura because they haven’t exactly been missing. However, I do realise the lay population often does not know about them. So the clitoris is, you know, I guess it’s quite a lot bigger than most people realise because so much of it is internal, and it surrounds the vagina basically. 

It’s actually quite a clever design because, you know basically that the bulbs at least definitely do play a role in stimulation. I tend to think that crura are a little too lateral. But you know, yeah… 

Dr Ron Ehrlich: [00:18:37] You’ve got a model of the clitoris there. I know. It’d be very interesting to hold that up because I think for most people, it’s… Yes, you see, for most people, it’s seen as just this little sort of micro penis at the top of the vagina, the opening of the vagina. And that’s it. But there’s so much more to it than that.

Jessica Pin: [00:18:59] Yeah. So I guess most people are aware of the glans, which is the part that you can expose, and you pull back the hood. But there’s also the external part of the clitoral body, which even a lot of doctors don’t seem to recognise. And that is so bizarre to me because you can feel it. 

So anyone can feel that there is basically like a little shaft under a little hood. And that’s where I think a lot of surgeons are not paying any attention because when they operate on the clitoral hood, they’re fundamentally operating on the skin of the clitoris, and the nerves of the clitoris are just beneath the skin. So that’s how they can get damaged. 

And the American College of OB-GYNs still does not recognise that risk in their committee opinion on female genital cosmetic surgery, which is very frustrating because I got them to redo their committee opinion. So they, you know, the previous committee opinion had misinformation, and so I got them to redo it, and now it just has more misinformation.

Jessica Pin: [00:19:56] So basically, I focus on the anatomy of the clitoral body because that’s what’s getting put at risk and clitoral hood reductions and biopsies and, you know, any repair that has to be done in that area, you know, like sometimes vulvas do get injured and they have to repair them. And one thing that we figured out in my study is that the nerves are actually big enough to be repaired. 

So right now, I’m trying to help a woman who just recently was harmed in a critical head reduction. So she lost clitoral sensation in a clitoral hood reduction only eight months ago. And so we’re trying to find her a surgeon who can help her. And she happens to be in Dallas. 

I’m trying to, you know, I’m trying to get my father to help. So my dad is a plastic surgeon in Dallas. He trains residents at UT Southwestern. And there are some really good plastic surgeons at UT Southwestern. So we’re trying to find her someone. But so that’s the main thing that I focus on. I focus on the dorsal nerves that are in the clitoral body. I don’t know as much about the crura and bulbs, honestly.

Dr Ron Ehrlich: [00:21:04] Yeah, yeah. No, that’s good. But I mean, I was genuinely I mean, even that, even the shaft and the hood, I was genuinely surprised at the size of it all. But I’m also genuinely surprised that this isn’t just standard. I mean, you know, this would be just standardizing Obstetrician Gynaecology 101. At least. 

Jessica Pin: [00:21:32] Yes. The one thing I’ve been focussed on lately is how all mid-sagittal plane illustrations of the female pelvis show the clitoris is severely minimised and a lot of them actually look like female genital mutilation. The clitoris actually looks amputated in these medical illustrations.

 And it’s very bizarre because, you know, you can see and feel that women don’t typically look like this illustration. And it’s funny how people have just accepted this misrepresentation of the female anatomy. And I think it just has to do with a lot of people being uncomfortable with how phallic the clitoris is.

Dr Ron Ehrlich: [00:22:08] Mm-hmm. Mm-hmm. I mean, the whole story culturally, there are many cultures that actually perform female genital mutilation, or they call it female circumcision, but it’s essentially female genital mutilation. I mean, one can only I mean, that’s it. And if the obstetrician gynes in the US and in the world are unfamiliar with the dorsal nerve and its implications, then I’m fairly sure people performing genital; female circumcision would have no idea.

Jessica Pin: [00:22:41] Well, they do generally know that they are taking sensation away, and they do that on purpose because they’re trying to keep women from being too sexual because they believe that women shouldn’t be too sexual, that they should just be maternal and that they’re trying to control female sexuality. That’s where this practise comes from.

However, in one study of medical students in Alexandria, a lot of the medical students did not actually understand the impact that female genital mutilation has on sexual function. And so that was interesting to see. It wasn’t a majority by any means, but it was a large enough percentage that I do feel like educating people, especially doctors in countries that practise female genital mutilation, would help. 

I saw another article that said, you know, a lot of people in those countries, they go to their doctors for counsel, and a lot of the doctors are not comfortable talking about it or they’re not well informed. And so there is, you know, there is some potential for prevention there that’s not happening. But I am by no means an expert on this topic. 

And I have actually gotten in trouble on social media for discussing it because I tend to think that education would help a lot. And I tend to think that, you know, showing people the anatomy of the clitoris and showing them just how much it resembles a penis would actually help. Because I think that, you know, if people understood, if people truly understood, what they were doing to women, it might help prevent that.

Dr Ron Ehrlich: [00:24:18] Mm-hmm. I think part of the misconception may also be that male circumcision is actually a well. It’s been performed for thousands of years. And without those implications, then they probably think, “Oh, well, the clitoral hood is the same as doing, you know, a male circumcision. You know, it’s a little snip. And there we go.” It’s not quite the same, is it?

Jessica Pin: [00:24:40] Well, if they just removed the free end of the clitoral herb, that is actually the same thing as circumcision, basically. But I’m pretty sure female genital mutilation is rarely limited to that. I do, you know, I actually am against circumcision, but the anti-circumcision activists drive me crazy because they are always showing up. They’re always commenting in response to my tweets. 

And, you know, my TikToks and they ask me to advocate for men, too. And I’m just like, “No.” Well, actually, what I’ve told them is I will advocate for men when I have at least 50% male followers. Right. So when I have the audience, I will be advocating against circumcision. I have given them advice. Just you know, my issue with them is they tend to constantly compare circumcision to female genital mutilation, which I think is very damaging because they tend to minimise female genital mutilation. 

They tend to describe female anatomy incorrectly. They draw false equivalencies. Right. They’ll say that removing the foreskin is equivalent to removing the clitoris sometimes. Like they just say, you know, and statements like that are incredibly offensive to me. So they drive me crazy. And the funny thing is how they will always be asking women to help advocate for them. 

And I’ve asked them how often they tweet at men asking men to advocate, and they don’t seem to do that much. And so I find that very curious because there are tons of men with bigger platforms than I have who could be advocating against circumcision, but they’re not. You know, so I don’t know.

Jessica Pin: [00:26:32] I think the fundamental, fundamental problem with circumcision, from my perspective, is that it is a cosmetic surgery that they’re doing on infants who can’t consent. And I don’t feel the evidence of health benefits is compelling enough to justify that. Right. 

However, I have never, you know, when I’ve tried to ask these intactivists where they call themselves about outcomes, I haven’t actually heard of, you know, anyone with this sort of outcome that I have, you know, but I definitely have not encountered one in my personal life. TMI. So it is hard for me to take it as seriously, though I’m sure that there are some tragic outcomes sometimes.

Dr Ron Ehrlich: [00:27:18] Now, I know that you’ve been exploring and writing about stats on female orgasm, and I wondered whether you might share that with.

Jessica Pin: [00:27:26] Well, I guess you might be referring to how [Inaudible 00:27:31] has found that for 96% of women, direct external clitoral stimulation is the most reliable about orgasm. She has also found that about 85% of women require external clitoral stimulation to orgasm.

Dr Ron Ehrlich: [00:27:49] Yeah.

Jessica Pin: [00:27:50] And so a lot of women feel like they’re supposed to be able to orgasm from penetration alone, but that is not actually the norm. And so, if women can’t orgasm from penetration alone, that’s totally normal. There’s nothing wrong with them. One thing that I find alarming is that a lot of doctors are marketing procedures that are that supposedly help women orgasm from penetration alone. 

And I think that that is exploitive, right? I think that’s unethical because they’re taking advantage of these myths around female orgasm and around what is normal. And they’re sort of feeding this narrative that women are supposed to orgasm from penetration alone, and there is no supposed to, you know?

Dr Ron Ehrlich: [00:28:39] Mm hmm. I mean, this is another example kind of of of this sort of male-centric view, not just of the world but of sex itself. Penetrative sex is something that a male will reach orgasm on. And so, you know, of course, a woman would, too. But that’s actually not the case. Yeah, I mean, not necessarily.

Jessica Pin: [00:29:00] It is a little bit hard for me to speak on this because I was a virgin at the time of my surgery, so I’ve never had my normal equipment to have penetrative sex with. But I do tend to think that the external part of the clitoris, the glands and the clitoral body do get stimulated during penetration. 

And so this was actually how Masters and Johnson explained orgasms doing penetrative sex. What they said was that basically, pulling on the labia minora would pull on the clitoral hood and on the frenulum and that that would stimulate the clitoris indirectly. And I definitely think that there is that a mechanism going on there. It has not ever been studied.

Jessica Pin: [00:29:45] So there was this one really ridiculous study that was done where they like tried to separate out different types of stimulation. But it was, it was not a good study. So no one has ever really examined this theory that indirect stimulation does occur during penetration because, basically, the biomechanics of the vulva. 

The biomechanics of the vulva have never been studied. So when I was first trying to figure out what had happened to me, this is actually a little bit embarrassing. But one of the first things I Googled was biomechanics of the vulva.

Dr Ron Ehrlich: [00:30:25] Mm hmm.

Jessica Pin: [00:30:26] You know, and I did like a PubMed search, and I didn’t find anything. And I did that because I was a biomedical engineering student. So I was taking biomechanics, and I was trying to draw a free body diagram of the vulva. A free body diagram is basically a diagram that you draw where you draw all the forces acting on different structures. And I was trying to analyse, like all of the forces that would be, you know, acting on different parts of the vulva during penetration. And I mean, I swear someone needs to model this somehow. 

Dr Ron Ehrlich: [00:31:02] Sounds like a fascinating study. I mean, the bioengineering of sex would be an amazing study to undertake. And, you know, you’ve still got time to do that, Jessica.

Jessica Pin: [00:31:12] I guess. I don’t know. I kind of just want to move on from this. But yeah, I would suggest that somebody else do it. Yeah.

Dr Ron Ehrlich: [00:31:20] Okay. Listen. I’m also interested in evolution, and I think one of the things that is interesting about humans is that it’s not just sex for reproduction, but it’s sex for pleasure. But are they.. do you think that’s different? Are they one or of the same? 

Jessica Pin: [00:31:36] Pleasure is not really an endpoint. Like, you know, sexual selection doesn’t care if you enjoy what you’re doing. Like the whole point of enjoying things is to motivate you to do those things. Hmm. So anytime there’s something that humans enjoy, it’s supposed to get us to do something that helps with our survival, generally speaking, or at best, is just neutral. 

Dr Ron Ehrlich: [00:32:01] Hmm.

Jessica Pin: [00:32:02] I actually went to this lecture recently on, like, the evolution of our response to alcohol, and he was arguing that our response to alcohol has had evolutionary benefits, and that is why we haven’t developed any resistance against that. Right. So there’s this thing called Asian Flushing Syndrome. But that is still restricted to very small populations. You know, it hasn’t really spread. 

And so, for the most part, you know, we all still get drunk. We all have a good time. And so he was asking, “How can this continue when there is such a cost?” Right. Because like so many of us do really stupid things when we’re drunk like we die or like we’re just very unproductive, you know?

Dr Ron Ehrlich: [00:32:41] Mm hmm.

Jessica Pin: [00:32:42] So he has asked, how can something with such a big cost continue? And so basically, he went through all these arguments that it has helped with, like social bonding and trust and innovation and all these different things. And he emphasised how evolution doesn’t care if we’re having a good time. Right. So like, we don’t get drunk because it’s fun. We get drunk because it has these other effects that have these evolutionary benefits. Right. 

So the same goes for sexual pleasure. The whole reason why orgasm is so much fun is because it’s supposed to motivate us to reproduce, and reproducing is so important for us.

Dr Ron Ehrlich: [00:33:31] Hmm.

Jessica Pin: [00:33:31] So that’s why it’s the greatest thing. And people take it for granted that male sexual pleasure has been evolutionarily important. But they tend to think that female sexual pleasure is just some kind of random accident with no purpose. 

And I think that that is wrong. What’s disturbing is there is actually a woman who wrote a whole book arguing that the clitoris or she wrote a whole book arguing that the female orgasm is just basically a by-product of the male orgasm. And I strongly disagree with that.

Dr Ron Ehrlich: [00:34:08] Yeah. Go on.

Jessica Pin: [00:34:08] So there is one paper that showed that sexual selection acts on female orgasm separately. And I forget, you know, and it has been disputed. But I think, you know, it’s pretty convincing. And yeah, I mean, like, for one, it facilitates pair bonding. And it also seems relatively intuitive that it motivates reproductive activity. Right. And we know that women who have orgasms have more sexual satisfaction, and women who are more sexually satisfied have more desire. 

And it’s a feedback system. And we want to do the thing that is enjoyable for us. People always want to separate female sexual pleasure from the desire to reproduce, but that’s just not reasonable because we know that the reason why female humans have sex is actually basically the same as it is for men. Right?

Jessica Pin: [00:35:07] So there’s this one study of why humans have sex. And the top three reasons are: (1) I was attracted to the person, you know, (2) to experience the pleasure, (3) and one other item basically about because it feels good. And the top three reasons are the same for males as for females. And it’s just, you know, it’s fundamentally because it’s fun. It feels good, right? And that’s not different for women. 

So it’s just weird that we have this idea that it’s different for women. And I think that that comes from the way that women don’t necessarily orgasm from penetration alone. However, we still do get pleasure and the clitoris, I would argue, is the main organ responsible for that pleasure. 

And I actually am not sure that the way that we don’t necessarily orgasm that easily from penetration alone is a defect and maybe a feature. It may keep us from pair bonding with the wrong guy, you know.

Dr Ron Ehrlich: [00:36:11] Yeah. I mean, I think this is very much about social bonding and finding a partner that is willing to help nurture a family, you know, who helps you in your journey. You know, it’s a kind of an expression of intent beyond the sexual act.

Jessica Pin: [00:36:28] Yeah. I would also imagine that giving a woman pleasure would have been, you know, unnecessary, like stage in the courting process. You know, like if you think about ancient humans and what we would have been doing before penetration, you know, I think it’s useful that like the parts that give us pleasure are on the outside because men would have had to stimulate us first to get us to willingly have sex with them. You know, and some people seem to have this idea that ancient humans would have just been raping all the time. And I don’t think that that’s reasonable.

Dr Ron Ehrlich: [00:37:06] No, no, no. I mean, I think we’ve gone way beyond that. And actually, I’ve been reading this book here, which has been a Human Evolution by Robin Dunbar and also another one called Recapture the Rapture. I don’t know whether you’ve been following that, but it’s an interesting book re-examining sex and its role in our human journey. It’s been more than just rape and pillage along the way.

Well, tell me. Thanks, Jessica. I really appreciate you coming on today and sharing with us this story, which got so many elements to it about education, not just for a young girl and boy but also the medical profession.

Dr Ron Ehrlich: [00:37:45] What advice would you give to anybody contemplating, you know, cosmetic surgery in general? But in this particular case, you know, genital surgery, cosmetic surgery.

Jessica Pin: [00:37:56] I think it’s important to recognise that the standard of care for female genital cosmetic surgery is lower than for other cosmetic surgery. And I don’t think many people understand that. So if you go to a board-certified plastic surgeon for a breast reduction, you know that your surgeon has been formally trained to do breast reductions and residency. 

You know that they’ve learnt detailed anatomy of the breast. You know that they have been taught to consider like functional issues, right? Like if you look at the literature on techniques, they’re very careful to mention, like, you know, try to avoid this nerve or that nerve, right? They don’t do that with vulva cosmetic surgery generally.

They’re only just now starting to there’s just a totally different approach. And pretty much all other major cosmetic surgeries are much more standardised. You know that your surgeon has been trained. There are no training standards for labiaplasty and for clitoral hood reduction. 

Jessica Pin: [00:38:56] So one thing that I’ve done is I’ve gotten consent forms changed, and I have tried to get the American College of OB-GYN to offer continuing medical education. I am not actually sure if the American Society of Plastic Surgery does. I know that they are still not covering labiaplasty in plastic surgery residency generally. It’s not in there like ACGME Curriculum. 

ACGME is the Accreditation Council on Graduate Medical Education. So they come up with minimum procedure numbers for all major procedures that each speciality performs. So in plastic surgery, they have a minimum number for rhinoplasties, breast reductions, for breast augmentation. 

So you know that your surgeon, if they have gone through a plastic surgery residency, they have done a minimum number of those, like under supervision in a formal setting. Right. And there are no such protections when it comes to female genital cosmetic surgery. And so that’s the fundamental thing.

Jessica Pin: [00:40:03] Personally, I think that it is actually unethical to pursue female genital cosmetic surgery as long as the standard of care is this low. Because even if you can manage to keep yourself safe, what you’re doing is you’re fundamentally funding an industry that misinformed women, that advertises surgery with fraud, which is fundamentally coercion, right? 

So, in my opinion, misinformed consent is not consent, it’s coercion. And so what they’re doing is they are marketing these procedures with misinformation. They’re misinforming about the causes of what they call hypertrophy.

Jessica Pin: [00:40:42] Hypertrophy means excessive growth, right? And so they say about half the female population has excessive labia minora. That’s just totally unreasonable because they’re making it sound like half the female population has some pathology, right? So I think that’s totally unethical. 

And I think, you know, the way capitalism works is this industry survives because we throw money at it. And I think that if women stop throwing money at it, they will change their tune. Right now, some people don’t like when I say this because they say don’t blame the victim. Well, that’s why I’m sharing this information so that people are not victims. They make informed choices.

Jessica Pin: [00:41:28] When it comes to women who really need these surgeries for medical reasons, you know, I would just tell them to be very careful. I would tell them to go to a plastic surgeon, not to an OB-GYN. And so yeah, I mean, just be very careful that they know the anatomy. Make sure that they only operate on the labia minora. I can’t see any reason to operate on the clitoral hood. Right. So that’s my opinion. 

And I also question how often there really are medical reasons for labiaplasty. You know, I see a lot of women talking about physical symptoms. However, according to one recent study in the Journal of Sexual Medicine, physical complaints were not correlated with objective labia minora size. 

They were correlated with the subject of labia minora size. So that makes me wonder, is it really a function of size? Is size really the problem? When women have pain from their labia minora, is it possible that it’s something else? Like could they have like I mean, I don’t know the answers, but I just question if it could be something else.

Jessica Pin: [00:42:34] One thing that they found was the most common physical complaint was sexual complaints. Right. So if women are primarily having sexual complaints about their labia minora pulling during sex, what does that really mean? Because to me, that sort of, you know, raises some alarm bells for me. 

I guess, like, in my opinion, there may not be enough lubrication in some of these situations. However, I do know that some women’s labia minora are extremely large it can get in the way. I just I am sceptical because my doctor acted like I had such extreme hypertrophy, and I never had any symptoms at all. I never had any problems. I didn’t even have problems with underwear. 

Like I see some women talking about their labia minora like falling out of their underwear. And I have no idea what they’re talking about. Why? Because, you know, before my surgery, like I didn’t have any issues like that. They didn’t show like, bike shorts or anything like that. They just, you know… 

If I was standing naked, then they hung down. And I thought once I saw all the negative messaging by labiaplasty surgeons, I thought that was mortifying. But it’s actually normal, and it’s fine. There’s nothing wrong with it.

Jessica Pin: [00:43:53] Actually, about half of women have labia minora that protrudes, so it’s no big deal. And I also tend to think that a lot of thinner women have labia minora that protrude. Right. Because whether or not your labia minora stick out is not just a function of how big your labia minora are. It’s also a function of how big your labia majora are. 

So I think for some women who don’t have a lot of fat, you know, they might have labia minora sticking out. And I think that that may have been how I got the result that I got because I’ve always been very thin. I told my doctor that I didn’t want my labia minora to stick out, and I think that was an unreasonable goal for me based on my anatomy. 

And that may have been part of how he ended up removing so much. I’m not excusing what he did. I’m just saying I think this is an important thing for surgeons to consider and for women to consider. You know that having everything tucked in may not be a reasonable goal for everybody because some women just have smaller labia majora.

Jessica Pin: [00:44:57] I have noticed that some surgeons offer procedures to make the labia majora bigger, and I definitely think that those are safer. But I also think that they are pointless. However, I think that maybe if women have issues from their labia minora being exposed, that may be a more reasonable route because the labia minora are actually involved in female sexual response or sexually sensitive tissue. So I would say, you know, keep them if you can. Right.

Dr Ron Ehrlich: [00:45:31] Well. Jessica, thank you so much for joining us today and sharing that story and that information, which is clearly of such importance to actually everybody, to be honest, and the medical profession in particular. So thank you so much for joining us today. 

Jessica Pin: [00:45:47] Thank you. 


Dr Ron Ehrlich: [00:45:51] Well, this is a topic that obviously I haven’t covered before on my podcast, Unstress, but in a way, I have. It’s about the influence of media on decision-making. It’s about a very male-centric view of sex, which permeates right across sexes. Actually, 65% of obstetricians and gynecologists are female now. 

But as Jessica has observed, many of those are not that interested in what’s going on on the outside of the vagina. They’re more about the reproductive aspect of obstetrician gynaecology. And it’s also a story about how specialised the body has become, how compartmentalised. Is this the purvey of an obstetrician, a gynaecologist? Well, it should be.

Dr Ron Ehrlich: [00:46:40] You would think if anyone was to know about foetuses and vulvas and labia minora, that your gynaecologist and obstetricians would be that speciality. Well, apparently not. Perhaps you would think urologists would be aware of it, but no. You know, the urethra is the opening, and they’re interested in everything back inside the body. 

But that’s not really their speciality. There’s just a little more definite than that. What about plastic surgeons? Well, you know, plastic surgeons may or may not be familiar with that anatomy, but it’s a story about how compartmentalised the body is. It’s a story about the influence of what is normal and the whole preoccupation with image and social media and the influence of the Internet, Dr Google. 

I mean Dr Google I think there is tremendous information out there on the Internet, and you just have to look at PubMed, and you can access literally tens, hundreds of thousands, if not millions of articles written in journals.

Dr Ron Ehrlich: [00:47:44] It’s worth noting, and this goes back to Trust the Science??? (question mark), The Elephant in the Room, which two episodes explored this. And a lot of the episodes we’ve done in the past on the pandemic are, Can You Trust the Science? So we need to keep up. There’s lots of great information on Google, but we need to keep an open mind to it. 

And at the end of the day, I come back to the three things that, if I had a choice about what I would go back and study. I’ve said this often, it would be anatomy, biochemistry, and physiology. And here was a story about why the study of basic anatomy is so important. And it’s also a story about validating a person’s experience.

Dr Ron Ehrlich: [00:48:30] Now, when she went to see many practitioners, her concerns were dismissed. And we did a great episode recently with Dr. Sandeep Gupta, where we talked about how important it was to validate a patient’s experience that very rarely, in reality, very rarely, is this just a psychiatric problem of delusional experience. 

What we have to do as help practitioners is listen to our patients, understand anatomy, physiology, and biochemistry, understand how connected the body is, and listen to our patients. 

Anyway, I will have links to Jessica’s social media sites which are MediClit. She’s on Twitter on MediClit and jessica_ann_pin on TikTok and Instagram. I hope this finds you well. Until next time. This is Dr Ron Ehrlich. Be well.



This podcast provides general information and discussion about medicine, health, and related subjects. The content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences, and conclusions.