Four weeks ago, Elena had one of her labia trimmed by a Sydney plastic surgeon while under local anaesthetic.
"I didn't have any problems. I put my legs up in the stirrups, put my headphones in and chilled on social media for 45 minutes. They applied numbing cream and I couldn't even feel the needle," Elena said. "My surgeon was super professional. He made me feel like he was looking at my hand."
The procedure cost her $4000 and she received some of that back from Medicare.
According to Medicare data from the past financial year, 502 Australian women claimed the $262.40 refund after undergoing labiaplasty or vulvaplasty.
This refund is only available when the procedure is performed to correct an "anomaly" and is unavailable for purely cosmetic procedures and patients must provide a "detailed clinical history outlining the functional impairment and the medical need" for surgery.
Elena says she returned to work the next day and her stitches soon dissolved.
"I'm super happy with the results. I just feel more confident. To me, this is just like having a breast augmentation. It's just another cosmetic surgery," she said.
RISK OF BOTCHED SURGERY
Australian Society of Plastic Surgeons spokesman Professor Mark Ashton says labiaplasties should be performed by a fully qualified plastic surgeon or gynaecological surgeon.
"People need to do their homework and make sure their surgeon is appropriately trained," Professor Ashton told news.com.au.
But currently in Australia anyone with a standard medical degree is legally allowed to perform cosmetic surgical procedures.
A lack of industry regulation and confusion about the term "cosmetic surgeon" means unqualified medical practitioners are performing botched labiaplasties on patients.
"People who are untrained or poorly trained are setting up clinics in unlicensed facilities and performing this procedure and that is resulting in a high number of people with botched surgeries," Prof Ashton said.
"This is a very dangerous practice. There is a very real risk of the surgery going wrong. They can cut away too much (skin) or the patient can contract an infection. They can have problems with irritation or rubbing. Repair and construction is particularly difficult," he said.
Prof Ashton said many patients don't have a clear conversation with their doctor about what they want their new labia to look like.
"I've seen patients where the decision about how much tissue has been removed was left in the hands of the surgeon and the patient had a different idea of the outcome," he said.
TEENS WITH "ANXIETY" OVER THEIR GENITALS
But while women like Elena are undergoing labiaplasty to remove physical discomfort, many health experts say they are concerned by increasing number of women, especially teenage girls, who have "genital anatomy anxiety" and are requesting labiaplasty to alter "totally normal" body parts.
GPs, plastic surgeons and gynaecologists say many women have a warped understanding of what is a "normal-looking" vagina, due to the popularity of online porn, photoshopped images of genitalia and because more women are removing their pubic hair.
"A lot of people have an idealised view of what is normal and that's not anatomically true," Prof Ashton said.
"It's unbelievably common for women to have full Brazilians. Previously, the labia were covered by pubic hair. Now attention is drawn to their size and there is a distortion of what people perceive as normal," he said.
An alarming 2016 survey of 443 Australian GPs found a third have seen patients aged below 18 wanting to trim or shape their genitalia.
Almost all the doctors surveyed said they had seen women of all ages express concerns about the appearance of their genitalia.
"The GPs surveyed said a large proportion of women have some degree of genital anatomy anxiety," head researcher Dr Magdalena Simonis, a fellow at The Royal College of General Practitioners told news.com.au at the time.
The reasons for this anxiety included a "perception of normality based on images seen online", particularly those in porn.
According to more than half the GPs surveyed, women who request genital surgery may have a range of mental health issues, including anxiety, body dysmorphic disorder, depression or eating disorders.
The US and UK report similar issues. The American Society for Aesthetic Plastic Surgery says that 400 girls 18 and younger had labiaplasty last year, an 80 per cent increase from the 222 girls who had cosmetic genital surgery in 2014.
A 2013 British report found the number of labial reductions on girls and women done by the UK National Health Service had increased fivefold over 10 years.
Last July, the Royal College of General Practitioners issued guidelines for doctors on treating patients who request genital surgery, including recommending that they be directed to images of female genitalia that have not been digitally altered.
The Medical Board of Australia has now introduced a three-month cooling off period for patients under 18 years old considering cosmetic surgery, as well as mandatory counselling by a psychologist, psychiatrist or GP.
For Elena, while she acknowledges the pressure on women to look good, she says there is still a stigma attached to women who choose to undergo cosmetic surgery
"We're in this body positive era which is great, but we're looked down upon if we want to change something," she said. "If you can do something that is going to make you happier, why wouldn't you do that?"
