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Determinants of elongation of the labia minora in Tete Province, Central Mozambique: findings of a household survey.

Introduction

Labia minora elongation (LME) is the expansive modification of the inner lips of the female external genitalia, or labia minora, by a process of elongating with the help of a variety of herbs, oils, cremes, and other instruments (1). The anthropological literature documented this practice as common amongst the Venda and Lovedu of South Africa (2,3) in the central and northern part of Mozambique (4) in the south of Tanzania amongst the Makonde speaking people (5) in the central region of Uganda among the Baganda linguistic group (6) in Zambia among the Bemba (7) and in Zimbabwe amongst the Shona (8,9). A joint statement by WHO, UNICEF and UNFPA tagged LME as Female Genital Mutilation (FGM) Type IV in 199610. Although that categorization raised many concerns, the WHO revised the statement in 2008 and maintained that LME is FGM11,12,13. However, there is paucity of biomedical literature on the physical and psychosocial health implications of LME.

Anthropological literature indicates that LME is still practiced by some linguistic groups in Southern and East Africa (1,4,6). This practice has been studied mainly from an anthropological lens, highlighting the motivation of the practice for beauty, hygiene and femininity, in preparation for sex, or as a symbol of cultural identity. The population-level prevalence of LME in sub-Saharan Africa is largely unknown (1). An understanding of the determinants of the practice, the products used and its possible health implications have not previously been assessed in a population-based study. The present research thus represents the first account of this type.

This paper draws on quantitative data collected in a World Health Organization (WHO)led Gender, Sexuality and Vaginal Practices (GSVP) multi-country prevalence study conducted in 2007 in Tete Province (central Mozambique) (14,15,16,17,18,19,20). Although the data were collected nearly ten years ago, we believe that they can still provide useful insights to improve the understanding of the health implications of this widespread genital modification practice.

Data from the GSVP survey reporting the prevalence, motivations and timing of LME has previously been published (14,15). Those findings showed that LME was universal in the area (14,15). The practice starts during initiation rituals for about half the women (47.0%) and the same proportion reported practicing LME in preparation for sexual intercourse (4.0%) (15). The median age at first practice was 11 years (15). The motivations mentioned were that it was a symbol of female identity (72%), it contributed to keeping one's partner committed (38%) or enhanced male sexual pleasure (35%) (14,15). To have elongated labia was the intended direct outcome of the practice (96%), However, some women mentioned vaginal tightening (11%) and heating (5%) as expected effects (14,15).

More detailed statistical analysis investigating associations between practice of LME in the past 30 days and the participants' health-related variables is presented here. The objective of this paper is to analyze the determinants and possible health implication of LME amongst a randomly selected population of women aged between 18 and 60 living in the Province of Tete.

Methods

Study design

The GSVP consisted of a cross-sectional population-based household survey, which was conducted in 2007. A preliminary ethnographic component informed the development of the survey questionnaire (11,20). The questionnaire had 54 items about socio-demographics and reproductive health and 22 questions on each of the 8 vaginal practices that were described by the female participants in the ethnographic stage. Here we present only the findings pertaining to the practice of LME.

Study setting

Mozambique is a poor country -three-quarters of the population live on less than a dollar (USD) per day (21). The Tete province lies in the central part of Mozambique, and it borders Zambia to the north, Malawi and Zambezi province to the east, Zimbabwe to the west, and the provinces of Manica and Sofata to the south. Tete is inhabited by 1,807,485 people (22). The population is predominately rural (85%) (22). Poor access to primary education has a great impact on women: 71% of women are illiterate, compared to 39% of men (22). The predominant languages are Cinyanja (46.5%), Cinyungwe (27.5%) and Cisena (11.6%) and the official national language is Portuguese (22). The estimated HIV prevalence in Tete is 7% among people 15 to 49 years (8% among women) (23).

Sampling and recruitment

The survey aimed to enroll a representative sample of women of Tete province using a stratified multi-cluster sample design. The 2003 Demographic Health Survey was used to identify residential households grouped in clusters. From a list of 52 enumeration units in the province, 34 clusters were selected and, in each cluster, 30 households randomly selected.

Female interviewers, trained to conduct the questionnaire, identified the eligible women. For women to be considered eligible, they had to be 18-60 years old; to be resident in the identified household; and to be willing to provide consent to participate in the survey. At each randomly selected household, a woman aged 18-60 was selected using a Kish table and was invited to participate in the study. If the woman selected was not at the household at present, the interviewers made two further house calls. Sampling was done without replacement of either household or individual refusals. Overall, 1,025 households were approached in 34 clusters; 82 households had no eligible women, 24 women did not participate, and 919 women were interviewed (89.7% response rate; 919/1025).

Written informed consent was sought from all participants. To minimize non-response, interviewers were trained to ask questions in a sensitive and non-judgmental manner in a private location. The interviewers read questions to the consenting women and captured their responses onto paper-based forms that were double-entered electronically by separate data clerks using Epidata ([TM]Odense, Denmark). Women who required medical assistance were given a referral card to local health services.

Data analysis

The survey questionnaire -which was informed by the preliminary ethnographic component, developed collaboratively in a series of workshops, and was translated into local languages and pretested locally- specifically asked the participants if they were currently practicing LME (having had practiced LME in the past 30 days). Current practice of LME is the primary outcome in the analysis presented in this paper.

Descriptive univariate and bivariate inferential analysis was carried out. Cross tabulations and Pearson Chi-squared test (X2) or Fisher's exact test are used to explore whether demographics and sexual and reproductive health characteristics of women were associated with currently practicing LME. The non-parametric Krustal-Wallis test is used where appropriate.

Multiple logistic regression was used to estimate the presence and size of associations between current practice and demographic, and sexual and reproductive health characteristics, adjusting for potential confounders. Variables associated with the primary outcome (current practice of LME in the past 30 days) in bivariate analysis (p<0.05) were included into the initial model and retained if their removal markedly altered model fit. A correlation coefficient matrix was run to measure how strongly included independent variables were related to each other: it was found that variables did not correlate at >0.80 (24). Included interval (age) and nominal (partnership status) variables were dichotomized by a process of creating multiple categorical variables. The final model adjusted for age, partnership status, participants having more than one sexual partner, engagement in sex in the past month, condom use at last sex and contraception use. Statistical analysis was conducted using STATA v.12.0. ([TM]College Station, Texas).

Ethics

The Ethics Committee of the Mozambique Ministry of Health approved the protocol of the GSVP study. Ethical approval was also obtained from the UNDP/UNFPA/WHO/World Bank Special Programme on Research, Development, and Research Training in Human Reproduction's Scientific and Ethical Review Group (SERG) and the WHO Ethical Review Committee.

Results

Of the 919 women who participated, 907 (98.7%) had ever practiced LME. The 907 women who had ever elongated comprise the population on which the analysis reported in this article is done. Almost a quarter of the 907 women reported having practiced LME in the past 30 days (n=218, 24.0%; 95%CI=21.2-26.9). The remaining 689 women (75.9%, 95%CI=73.0-78.9) had previously practiced LME, but not in the past calendar month. In the past 30 days, 218 women (24.0%, 95%CI=21.2-22.6) had practiced LME a median 3 times (IQR 2-7; Table 1). With regards to timing of LME, most participants (28.4%) reported that this was done in preparation for sex.

These figures were similar for those currently practicing, or who had not practiced in the past 30 days. There was a two-fold increase in the percentage of women who currently practiced and reported to do so for no specific reason (62.8%) when compared with women who did not currently practice LME (31.9%, p<0.001).

Socio-demographics of women currently practicing LME (in past 30 days)

Most women (62.8%, p=0.009) lived in rural areas and belonged to the Nyungwe linguistic group (54.4%). Only 8.4% had completed secondary level education (p<0.001; Table 1). Being young, a resident in rural areas, a Nyungwe woman, and not having had completed primary studies were associated with current practice of LME (Table 1). The women who currently practiced were a median 27 years (IQR 21-33), six years younger than those who did not practice in the past 30 days. After adjusting for potential confounding variables, women had twice the odds of currently practicing LME if they were younger than 25years (OR 2.05, 95%CI=1.47-2.87) compared with women older than 25 years (Table 5).

Sexual and reproductive health characteristics

Among the women who had a male partner (n=773), 91.4% were cohabiting with him, and 31.1% reported that their partner had concurrent relationships with other women (Table 2). Current LME practice was particularly common among unmarried women in a stable sexual relationship. On average, the primary partners of the women who had practiced LME in the past 30 days were younger (median 33, IQR 27-40) than the partners of the women who had stopped the practice (median 38, IQR 30-49). Eighty-five women currently practicing LME (6.9%) had more than one sexual partner, more than double that of women who had discontinued the practice (2.9%, p=0.008). Having had sex in the past four weeks was associated with current practice of LME (67.6% of women, p<0.001; Table 2). Condom uptake was very low among all women, with 84.2% of the women reporting that they never used them.

In multi-variate analysis (Table 5), women who were in a relationship (OR 1.81, 95% CI: 1.01-3.2) and women who had more than one partner (OR 2.44, 95% CI: 1.17-5.06) had greater odds of practicing LME in the past 30 days. However, after controlling for all other variables in the model, sex in the past 30 days (OR 1.38, 95% CI: 0.96-1.98) and condom use at last sex (OR 1.65, 95% CI: 0.90-3.40) were not associated with practice of LME in the past 30 days.

Almost all women (96.9%) had been pregnant at least once (Table 3). Of these, approximately one tenth were pregnant at the time of the survey. Women who currently practiced LME had fewer children (median=3, IQR 2-6) than women who had discontinued the practice (median=5, IQR 3-8).

Almost one third of the women who had practiced LME in the past 30 days (30.1%) were using contraception, whilst only 15.1% of the women who had stopped LME were doing so (Table 3) after adjusting for all variables, women who used contraception other than condoms, had almost twice the odds of practicing LME in the past 30 days (OR 1.65, 95%CI: 1.10-2.46) (Table 5).

Self reported ill health and adverse effects associated with LME

One third of women (32.6%) reported that they had ever had vaginal discharge, which was most commonly a white color (83.1%) (Table 3). Similarly, about one third of women had experienced menstrual problems. Menstrual symptoms of spotting and lower abdominal pain were less common in women who currently practice than in those who had stopped. Also, discomforting itchiness of the genitalia was less frequent among women who currently practice LME than among women who had stopped (Table 3).

The women mentioned few symptoms or adverse health effects that they associated with LME (Table 4). Notably, ten (4.7%) and five (2.4%) women respectively reported having suffered pain or irritation and swelling in the past 30 days. Only one woman, who had not practiced LME in the past month, mentioned dyspareunia. All the women who reported genital pain or irritation and swelling were also using other vaginal practices, at least concurrently using external washing with LME (Table 4). The self-reported adverse events of LME in the past 30 days were compared with contemporaneous practice of other vaginal practices. Compared with women not practicing LME, current users were more likely to also currently practice external washing (p=0.005) and oral ingestion and intravaginal insertion of substances (p<0.001) (Table 4).

Discussion

The study identified key determinants of current LME, both demographic characteristics and sexual behaviors. Recent use of LME was associated with being younger than 25 years, a resident in rural areas; not having completed primary level education; and a member of the Nyungwe ethno-linguistic group. Moreover, LME was more common among women in a relationship; having more than one male partner; and those reporting recent sexual activity. The analysis corroborated that, as LME is practiced in preparation for sexual intercourse, the women concurrently engaged in other practices, such as external washing, that aim to alter the tightness, temperature and lubrication of the vagina (20). Some of these associations relate to the main motivators reported for LME in Mozambique in the literature (1,4,20,30). Namely: to feel feminine, to keep a partner committed and to enhance pleasure for both men and women (1,4,20,30).

This study demonstrates that pain, irritation and swelling were uncommon effects of LME. These were reported when other vaginal practices -external washing, intravaginal insertion and oral ingestion- were practiced contemporaneously. No woman who was currently practicing LME alone reported any adverse effect. The few short-term effects described by our participants are consistent with previous reports of pain, irritation, and swelling reported by women in qualitative research in Malawi (25), South Africa (26), Rwanda (27), or Uganda (25). Only one woman among the 907 women from Tete province (who was not currently using LME) reported symptoms consistent with a WHO report claiming that dyspareunia may be an adverse effect of LME28.

Our study provides useful insights into arguments that LME may be linked with higher levels of risky sexual behavior or with genital ill health (1,25). Albeit the percentage of women with more than one partner was higher among the group of women who currently practiced LME; condom and contraception use were higher in these women. Additionally, there was no association between current practice and other genital symptoms such as menstrual complaints and vaginal discharge. Overall, there is little scientific evidence that LME increases risk of ill health beyond the potential adverse effects -pain, irritation and swelling- identified in our survey (1). There is paucity of documents measuring the role that LME plays in HIV/STI transmission or in altering vaginal pH or lactobacilli vaginal flora. A prospective cohort study that includes serial laboratory investigations of vaginal flora may assist in establishing an association between LME and sexual and reproductive ill health.

Participants in qualitative research in Mozambique (29), Rwanda (30), South Africa (26), or Uganda (31) noted that men may feel discouraged to use a female condom as it impedes foreplay with their partner's elongated labia. A research group from the University of Padova in Italy, The Padova Working Group in Female Genital Mutilation, described LME as a 'form of masturbation socially accepted ... a pretext for encouraging sexual promiscuity' (22), and then considered that LME had an influential role on women's higher vulnerability to HIV (25). This statement was shared by one of the authors of this paper with Zambian women and men that participated in another research conducted in South Africa in 2014 (26). The participants opposed such a statement and argued that the elderly instructors advise the young girls to keep their virginity until marriage and not to engage in early sex with other boys (26). It must be noted that practices such as intravaginal insertion or LME are not direct causes of the HIV infection, are not invariably associated with uptake of risky sexual attitudes, but are carried out in environments in which women are subjected to a myriad of gendered norms that may contribute to their vulnerability. Modern-day academia should ask the women what the motivations and health implications of traditional genital modification practices are. As reported by many participants in qualitative studies on LME, beyond the enhancement of sexual pleasure women want to be admired, considered, valued, integrated, and fit as members of their society and their culture (1,20,26). This is, ultimately, what most women want all around the world.

Future prospects

Understanding of the consequences of LME can help inform interventions that aim to improve women's health. These interventions might include discussion on traditional genital practices in groups of men and women, culturally-appropriate educational materials on LME, and assisting mothers to provide instructions on LME to their daughters, drawing on evidence-based recommendations (33). Furthermore, in the frame of continuing nursing education programs in Mozambique, nurses attending women who practice LME could be encouraged to explore their sexual and reproductive practices; assess their agency to use HIV/STI prevention technologies; and provide appropriate health education to help them improve their sexual health. As LME is a sensitive practice that is not discussed in public, it will be important to carefully design and field test any health promotion activities related to LME.

A longitudinal prospective study may help to understand causality; as the women from Tete province also linked pain, irritation and swelling to other vaginal practices (14,15,19). Such a study could also untangle linkages between any adverse effects of LME and whether these are related to the concurrent use of other vaginal practices involving vaginal drying. We encourage scholars, prevention product developers and sexual health programmers to investigate how concurrent engagement in LME and other vaginal practices may hinder or foster opportunities for women and men to use HIV/STI prevention technologies. Mixed-methods research is also required to understand how the practice of LME impacts women's psychosocial and sexual health and how engaging in this practice at an early age may reinforce gendered norms that raise the vulnerability of girls and women to HIV/STI.

Limitations

Because of its large sample size, a strength of this study is that it is powered to detect potential harms of LME. However, as this is a cross-sectional study, it was not possible to ascertain causality. Most especially, we could not assess the temporal order of the vaginal practices and adverse effects.

A further limitation of our study is that almost all women had ever practiced LME and we thus could not compare those who had and those who had not used the practice. The GSVP study was conducted in 2007; should such a survey be conducted today in the same setting, the percentage of women who have never practiced LME might have increased and different groups of women (ever versus never having practiced it) could be compared. A recent study in Maputo, Nampula and Zambezi provinces of Mozambique suggests that the proportion of women adopting the practice may be reducing (34). Interestingly, in that study, around forty percent of women had stopped LME, often citing 'disliking a painful experience' as a key motivator for this (34).

Conclusion

Socio-demographic determinants of current use of LME were: younger than 25 years; being a resident in rural areas; not having had completed primary level education; and belonging to the Nyungwe ethno-linguistic group. Other important variables associated with current practice of LME were: being in a relationship; having more than one partner; and recent sexual activity. Women practicing LME had higher levels of condom and contraception use than non-users. These factors together reflect the main motivators identified for LME in Mozambique: to feel feminine, to keep a partner committed and to enhance sexual pleasure. This study finds that according to the reports of most participants LME is not a major contributor to sexual and reproductive ill health among mature women. Pain, irritation and swelling were uncommon effects of LME, and may be due to other vaginal practices used concurrently. Importantly, overall, the study does not suggest that the practice of LME is linked with high-risk behaviors for HIV transmission.

Contribution of Authors

AMH conceived, designed and directed the study. BB, MH, EM, FM and TH contributed to study design, data collection and analysis. GMP contributed to data analysis and prepared this manuscript. All authors listed in this article approved the manuscript for publication.

References

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(18.) Martinez Perez G, Mariano E and Bagnol B. Perceptions of men on puxa-puxa, or labia minora elongation, in Tete, Mozambique. Journal of Sex Research 2015; 52(6): 700-709.

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Guillermo Martinez Perez [1] *, Brigitte Bagnol [2], Matthew Chersich [3], Esperanza Mariano [4], Francisco Mbofana [5], Terence Hull [6] and Adriane Martin Hilber [7]

Department of Psychiatry and Nursing, University of Zaragoza, Zaragoza, Spain [1]; Department of Anthropology, University of the Witwatersrand, Johannesburg, South Africa [2]; Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa [3]; Universidade Eduardo Mondlane, Faculty of Arts and Social Sciences--Department of Archaeology and Anthropology, Maputo, Mozambique [4]; Mozambique Sexual & Reproductive Health Unit, Instituto Nacional de Saude (INS), Maputo, Mozambique [5]; Australian Demographic and Social Research Institute, The Australian National University, Canberra, Australia [6]; Swiss Tropical and Public Health Institute, Basel, Switzerland [7]

* For Correspondence: Email: gmartinezgabas@gmail.com; Phone: 657066850
Table 1: Summary of Participants' Demographic Characteristics and
Practice of LME

Variable                                Women ever   Did not practice
                                        did LME      in past 30 days
                                        Number       Percentage
                                        (n = 907)    (n = 689)

Current Practice of LME:                n = 907
Yes (95%CI)                             907          75.9 (73.0-78.9)
Median frequency in past month (IQR)                 --
Median age first practiced (IQR)                     10 (10-12)

Timing of practice of LME: (C)          n = 907
Part of hygiene                         18           2.0
Before or during menstruation           123          14.1
In preparation for sex                  248          27.0
After sex                               5            0.4
No pattern                              357          31.9

Age group:                              n = 907
18-24                                   244          22.9
25-34                                   299          31.3
35-44                                   198          22.8
45-60                                   166          22.9
Median years (IQR)                                   33 (25-43)

Area of residence:                      n = 907
Urban                                   273          27.9
Rural                                   634          72.1

Highest education level:                n = 907
None                                    356          41.0
Primary incomplete                      400          45.8
Primary complete                        88           7.6
Secondary or tertiary                   58           5.7

Religion:                               n = 907
Islam                                   9            0.7
Catholic                                276          30.8
Protestant                              159          17.8
Zionist                                 7            6.2
Ancestor worship/African traditional    219          23.5
None                                    62           6.8

Ethno-linguistic affiliation:           n = 907
Portuguese                              7            0.7
Nyungwe                                 424          44.5
Nyanja                                  261          33.1
Other language in Tete                  173          17.8

Variable                                Practice in past   Pearson
                                        30 days            [X.sup.2]
                                        Percentage         P
                                        (n = 218)

Current Practice of LME:
Yes (95%CI)                             24.0 (21.2-22.6)   <0.001 (B)
Median frequency in past month (IQR)    3 (2-7)
Median age first practiced (IQR)        10 (10-12)         0.890 (B)

Timing of practice of LME: (C)
Part of hygiene                         1.8                0.856
Before or during menstruation           11.9               0.419
In preparation for sex                  28.4               0.677
After sex                               0.9                0.402
No pattern                              62.8               <0.001

Age group:
18-24                                   39.4
25-34                                   38.1
35-44                                   18.1
45-60                                   3.7                <0.001
Median years (IQR)                      27 (21-33)         <0.001 (B)

Area of residence:
Urban                                   37.1
Rural                                   62.8               0.009

Highest education level:
None                                    34.7
Primary incomplete                      38.8
Primary complete                        16.7
Secondary or tertiary                   8.4                <0.001

Religion:
Islam                                   1.8
Catholic                                29.5
Protestant                              18.9
Zionist                                 6.4
Ancestor worship/African traditional    26.2
None                                    6.9                0.503

Ethno-linguistic affiliation:
Portuguese                              0.9
Nyungwe                                 54.4
Nyanja                                  15.3
Other language in Tete                  23.2               <0.001

(B) Krustal-Wallis non-parametric test done to assess p value.

(C) Multi-response variable.

IQR: interquartile range

Table 2: Associations Between Sexual Health and Elongation of the
Labia Minora

Variable                           Women ever    Did not practice in
                                   did LME       the past 30 days
                                   Number        Percentage
                                   (n = 907)     (n = 689)

Marital status:                    n = 907
Married                            416           46.6
Unmarried, stable relationship     359           37.2
Single, never had partnership      14            0.9
Divorced                           48            5.8
Widowed                            70            9.6

Live with partner:                 n = 773 (E)
Yes                                716           93.1
No                                 57            6.9

Median age primary partner (IQR)   n = 773 (E)   38 (30-49)
Male partner has other partner:
Yes                                264           35.1
No                                 509           64.1

Woman has other partner:           n = 905 (D)
Yes                                85            2.9
No                                 870           97.1

Sex in the past four weeks:        n = 905 (D)
Yes                                508           52.5
No                                 397           47.5

Often use of condoms:              n = 905 (D)
Always                             19            1.8
Sometimes                          77            7.9
Rarely                             7             0.4
Never                              792           89.9

Condom use at last sex:            n = 905 (D)
Yes                                42            3.7
No                                 852           96.3

Variable                           Practice past    Pearson
                                   30 days          [X.sup.2]
                                   Percentage       P
                                   (n = 218)

Marital status:
Married                            43.6
Unmarried, stable relationship     47.2
Single, never had partnership      3.7
Divorced                           3.7
Widowed                            1.8              <0.001

Live with partner:
Yes                                91.4
No                                 8.6              0.435

Median age primary partner (IQR)   33 (27-40)       <0.001 (B)
Male partner has other partner:
Yes                                31.1
No                                 67.0             0.602

Woman has other partner:
Yes                                6.9
No                                 93.1             0.008

Sex in the past four weeks:
Yes                                67.6
No                                 32.4             <0.001

Often use of condoms:
Always                             3.3
Sometimes                          10.7
Rarely                             1.8
Never                              84.2             0.047

Condom use at last sex:
Yes                                7.9
No                                 92.1             0.011

(B) Krustal-Wallis non-parametric test done to assess p value.

(D) Excluding 2 women who had never had sex (n = 905)

(E) The denominator is married and unmarried in a stable relationship
(n = 773)

Table 3. Associations Between Reproductive Health and Elongation
of the Labia Minora

Variable                      Women ever     Did not practice in
                              did LME        the last 30 days
                              Number         Percentage
                              (n = 907)      (n = 689)

Ever pregnant:                n = 905 (D)
Yes                           874            96.4
Currently pregnant            102            12.3
Median parity (IQR)                          5 (3-8)

Uses contraception:           n = 905  (D)
Yes                           169            15.1

Ever menstrual problems:      n = 907
None                          537            57.3
Spotting                      71             8.0
Lower abdominal pain          36             4.9
Both spotting and pain        64             7.3

Ever vaginal discharge?:      n = 907
Yes                           307            34.2

If Yes: What Type?: (C)       n = 307
          Excessive fluids    32             11.0
           White discharge    268            88.9
           Green discharge    4              1.3
          Yellow discharge    52             16.6
        Sticky consistency    30             10.6
                Foul odour    67             22.1

Other genital problems: (C)   907
Genital pain                  87             10.0
Genital ulcers and warts      23             3.0
Discomforting itchiness       251            30.1
Genital/vaginal burning       38             4.5
sensation                     89             10.0
Pain during sexual
intercourse

Variable                      Practice past 30   Pearson
                              days               [X.sup.2]
                              Percentage         P
                              (n = 218)

Ever pregnant:
Yes                           96.9               0.723
Currently pregnant            9.5                0.248
Median parity (IQR)           3 (2-6)            <0.001 (B)

Uses contraception:
Yes                           30.1               <0.001

Ever menstrual problems:                         0.048
None                          66.0
Spotting                      7.3
Lower abdominal pain          1.4
Both spotting and pain        6.2

Ever vaginal discharge?:
Yes                           32.6               0.647

If Yes: What Type?: (C)
          Excessive fluids    8.5                0.557
           White discharge    83.1               0.191
           Green discharge    1.4                0.922
          Yellow discharge    18.6               0.700
        Sticky consistency    7.1                0.389
                Foul odour    21.4               0.901

Other genital problems: (C)
Genital pain                  8.3                0.442
Genital ulcers and warts      0.9                0.081
Discomforting itchiness       20.2               0.004
Genital/vaginal burning       3.2                0.406
sensation                     9.2                0.707
Pain during sexual
intercourse

(B) Krustal-Wallis non-parametric test done to assess p value.

(C) Multi-response question

(D) Excluding 2 women who had never had sex (n = 905)

Table 4: Self-Reported Effects of Labia Minora Elongation, Compared
with other Vaginal Practices

Current Vaginal Practices (VP)    Adverse health effects (C)
                                  Women who have used labial
                                  elongation in past 30 days (n = 218)
(n = Women who have practiced
this VP in past 30 days) (F)      Women who concurrently practice
                                  labial elongation and other VP
                                  N (%) ([X.sup.2] p.005)

External washing:
(n = 895)                         211 (96.7%)
                                  [X.sup.2] 0.005
Douching/Cleansing:
(n = 800)                         195 (89.4%)
                                  [X.sup.2] 0.513
Intravaginal insertion:
(n = 276)                         103 (47.2%)
                                  [X.sup.2] < 0.001
Oral ingestion:
(n = 148)                         57 (26.1%)
                                  [X.sup.2] < 0.001
Cutting:
(n = 219)                         55 (25.2%)
                                  [X.sup.2] 0.668
                                  From the 907 women
Total (regardless of other
practices):                       218 (100%)

Current Vaginal Practices (VP)    Adverse health effects (C)
                                  Women who have used labial
                                  elongation in past 30 days (n = 218)
(n = Women who have practiced
this VP in past 30 days) (F)      Swelling   Dyspareunia   Irritation
                                                           /Pain

                                  Number Women (%) (Fisher's Exact
                                  test p 0.05)
External washing:
(n = 895)                         5 (2.4)    --            10 (4.7)
                                  1.000                    1.000
Douching/Cleansing:
(n = 800)                         3 (1.5)    --            8 (4.1)
                                  0.088                    0.285
Intravaginal insertion:
(n = 276)                         2 (1.9)    --            6 (5.8)
                                  1.000                    0.522
Oral ingestion:
(n = 148)                         1 (1.7)    --            2 (3.5)
                                  1.000                    1.000
Cutting:
(n = 219)                         2 (2.3)    --            3 (5.4)
                                  0.602                    0.715
                                  8 (0.8)    1 (0.1)       6 (0.7)
Total (regardless of other
practices):                       5 (2.3)    --            10 (4.6)

(C) Multi-response question.

(F) See Francois et al 2012 for definition of vaginal practices

Table 5: Association Between Practice of Labial Elongation in the Past
30 days and Demographic/Health Factors

Variable              Percent practiced   Crude OR
                      in past 30 days     (95% CI)
                      (n = 218)

Age

Older than 25years    132 (60.5%)         Ref.
Younger than          86 (39.4%)          2.18 (1.58- 3.02)

25years

Partnership status

Not in relationship   20 (9.2%)           Ref.
In relationship       198 (90.1%)         1.92 (1.16-3.17)

Woman has other
Partners              202 (93.1%)         Ref.

No                    15 (6.9%)           2.48 (1.24-4.93)
Yes

Sex in past 30 days

No                    70 (32.4%)          Ref.
Yes                   146 (67.6%)         1.88 (1.36-2.59)

Condom at last sex

No                    199 (92.1%)         Ref.
Yes                   17 (7.9%)           2.23 (1.18-4.21)

Contraception
(excl. condoms)       165 (75.7%)         Ref.

No                    53 (24.3%)          2.00 (1.37-2.93)
Yes

Variable              P value for    Adjusted OR        P value for
                      bivariate OR   (95% CI)           multivariate
                                                        OR

Age

Older than 25years                   Ref.
Younger than                         2.05 (1.47-2.87)   <0.001

25years               <0.001

Partnership status
Not in relationship                  Ref.               0.045
In relationship       0.010          1.81 (1.01-3.2)

Woman has other
Partners                             Ref.

No                                   2.44 (1.17-5.06)   0.016
Yes                   0.008

Sex in past 30 days

No                                   Ref.
Yes                   <0.001         1.38 (0.96-1.98)   0.078

Condom at last sex

No                                   Ref.
Yes                   0.011          1.75 (0.90-3.40)   0.097

Contraception
(excl. condoms)                      Ref.

No                                   1.65 (1.10-2.46)   0.015
Yes                   <0.001

In this model, current practice of labial elongation (past 30 days)
was adjusted for variables with a significant association in bivariate
analysis (age, partnership status, women has other partners, sex in
past 30 days, use of condom at last sex, and use of contraception,
excluding condoms). OR = odds ratio.
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Article Details
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Title Annotation:ORIGINAL RESEARCH ARTICLE
Author:Perez, Guillermo Martinez; Bagnol, Brigitte; Chersich, Matthew; Mariano, Esperanza; Mbofana, Francis
Publication:African Journal of Reproductive Health
Article Type:Clinical report
Geographic Code:6MOZA
Date:Jun 1, 2016
Words:6199
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