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The names of the patients interviewed for this story have been changed.

Kim is a 27-year-old woman with a shy face and perfectly shaped pink acrylic nails. She’s naked from the waist down, wrapped in a flimsy paper gown, perched on the edge of an examining table. Looking nervous and uncomfortable, she wraps her arms protectively around her stomach as she fidgets.

Kim has had three children, and no longer enjoys sex. Her husband doesn’t either, and the couple thinks Kim’s vagina has been stretched out by the births and her last episiotomy, an incision to enlarge the vaginal opening during delivery.

So today Kim is here to consult with Dr. Joseph Berenholz, an OB/GYN who recently founded the Laser Vaginal Institute of Michigan. If she qualifies for the outpatient surgery, Berenholz will use a ballpoint pen-sized laser to cut Kim’s vagina and suture it, restoring the tightness she experienced before the childbirth. And Kim is willing to pay out-of-pocket for the procedure — which isn’t covered by medical insurance, and has an average cost of $7,000.

Berenholz’s office offers several other elective female genital surgeries, the primary selling points being enhanced sexual gratification for the women and aesthetically pleasing results. Starting at $4,500, a woman can have a labioplasty, in which her inner labia are cut and reshaped if she thinks they’re too large or asymmetrical. Or a woman can become “revirginized” and have an approximation of her hymen restored. (This is particularly popular among Middle Eastern women who need to “fake” their virginity before marriage.) And if she wants to combine more than one surgery, she can end up paying more than $10,000 for newer, tighter, prettier genitals.

This is the latest facet of cosmetic surgery — designer vaginas. Women have already nipped, tucked, implanted and vacuumed every other part of their bodies, and are now turning their perfection-obsessed eyes to their own genitals. Elective surgeries that promise a better sex life or more aesthetically pleasing private parts are rapidly gaining popularity — but both the medical community and cultural observers are divided over whether these are valid, beneficial surgeries or just personal vanity gone too far.

Though relatively new, these elective surgeries have already drawn a torrent of publicity and controversy. The technique was born in the country’s capital of plastic surgery — Los Angeles — but has now arrived in metro Detroit with Berenholz’s new venture, established at the end of 2004.

Everyone from medical professionals to feminists has weighed in on the topic. Some say it’s simply a way for greedy doctors to capitalize on women’s insecurities; but some patients who’ve undergone the procedure say it has changed their lives for the better.

The term laser vaginal rejuvenation (LVR) was coined by Los Angeles OB/GYN and plastic surgeon Dr. David Matlock, who says he has performed the procedure for 10 years now. Both Matlock and his work have been extensively profiled in glossy magazines and national media since the late ’90s.

The surgeries straddle the line between traditional OB/GYN surgery and elective cosmetic procedures. LVR is based on a longtime established procedure for incontinence or weakened vaginal walls — called anterior and posterior repair. Several conditions can result from childbirth: stress incontinence (losing urine when laughing, coughing, sneezing, etc.), the wall between the vagina and bladder is weakened (cystocele) or the wall between the rectum and the vagina is weakened (rectocele) — which is what anterior (bladder) and posterior (rectum) repair addresses. While these repairs are intended for medical purposes, they also may — or may not — result in a vagina that feels “tighter.”

Matlock adapted the surgery to focus on tightening the vagina, and swapped the traditional scalpel for a laser, which he says accounts for less blood loss and faster healing. He repackaged and marketed the surgery as a cure for women who’ve given birth and no longer enjoy sex.

Unlike Matlock, Berenholz is not a plastic surgeon, but an OB/GYN with 20 years of experience. He also has a private OB/GYN practice in Southfield and says he’s delivered hundreds of healthy babies in his career. With a rounded face and salt-and-pepper hair, Berenholz has the tranquil voice and soothing demeanor of someone who’s accustomed to making nervous or frightened people feel at ease.

Berenholz says that over the years in his career, he’s had many patients complain they could no longer enjoy sex after childbirth.

“You’re trained in residency to reassure a woman, to let her know this is normal, and to simply go home and live with it,” he says.

Traditionally, women who complain of these symptoms are advised to do Kegel exercises, a simple muscle training regimen women can perform either with or without instruments.

But Berenholz says the Kegel regimen doesn’t always work.

“The people we see have done millions of Kegel exercises,” he says. “There is no exercise that can help women recover from torn muscle and damage.”

Berenholz says he began performing a surgery to tighten and strengthen the vaginal muscles. Then, six months ago, he flew out to Los Angeles to take a training course with Matlock, and founded the Laser Vaginal Rejuvenation Institute of Michigan a month later. Business is already booming.

The institute is actually a small cosmetic surgery office in Southfield where Berenholz usually works two to three days a week. The rest of his time is spent in surgery at area hospitals, or at his private OB/GYN practice, also in Southfield.

The doctor says he performs an average of two to three surgeries a day at the LVRI office, and receives as many as 20 e-mail inquiries on any given day via his Web site, lvriofmich.com. He even has a PR rep, and has aggressively advertised his institute with press releases on the Internet and in local print (including Metro Times).

LVR is an outpatient procedure, usually finished in about an hour. Patients can expect discomfort for the first two to three days, which Berenholz says is on the same level as an episiotomy. Sex can be resumed within six weeks. Berenholz says pricing depends on the needs of the patient, but can range from $6,500 to $8,500.

Besides LVR, he also offers several forms of Designer Laser Vaginoplasty (DLV). These include labioplasty, hymenoplasty, augmentation labioplasty (removing fat from the patient and transferring it to the labia majora, providing an “aesthetically enhanced and youthful” look) and vulvar lipoplasty (removing unwanted fat from the mons pubis or labia majora, which can “alleviate unsightly fatty bulges of this area and produce an aesthetically pleasing contour”). Prices range from $3,800 to $6,000. Berenholz says the two major risks of the surgery are infection and bleeding.

Although he says he’s yet to personally receive criticism from his local colleagues, Berenholz recalls a departmental OB/GYN meeting he attended few weeks ago, when he got some ribbing from his fellow physicians.

“I was being teased by several of them, being called ‘The Revirginator,’” he says. “I silently laughed it off, but afterwards, two physicians came up to me and asked where they could learn the techniques.”

And he believes this interest will only grow.

“I think this will become the fastest growing area of elective surgery in the U.S. over the next five years.”

Many pundits and talk radio hosts who’ve discussed cosmetic vaginal surgeries rejoice in mocking it, pointing out that most men who encounter labia are simply happy to be there, and couldn’t care less about perceived size abnormalities or unevenness. After all, have you ever heard a man utter the phrase “Yeah, she’s really a great catch, but those labia? Man, that’s a deal-breaker.” Ironically, many LVR doctors claim they are empowering women, while their practice caters to perhaps the most sexist of all notions — that, to be desirable, women should have a youthful, pert, tight vagina.

Labioplasty is nothing new, an established medical procedure used to treat women with labia hypertrophy — enlarged inner labia that protrude beyond the outer labia and cause discomfort. Again, Matlock has swapped the traditional scalpel for a laser, and marketed the procedure for aesthetic reasons.

“It’s being driven primarily by what the woman wants,” Berenholz says of labioplasty reshaping, “but there has to be some anatomical problem to correct.”

But what entails a problem, or, for that matter, normality? The procedure has sparked a firestorm of criticism in some feminist camps, who say this is yet another manner in which women are being pressured to conform to a homogenized, physical ideal. After all, Berenholz’s site says many of his prospective labioplasty patients come in with a copy of Playboy in hand, with a fold-out centerfold serving as their aesthetic model.

“Nobody thought about that until someone said, ‘Hey, here’s a body part nobody’s hit with the lasers yet. Let’s make a little money here,’” says Detroiter-turned-New Yorker Ophira Edut, editor of Body Outlaws, an anthology examining women’s body image issues. “Like there’s a right way for a woman’s private parts to look? I believe the majority of men don’t expect women to go out and surgically alter their bodies to look like a Playboy centerfold.

“It’s a tricky subject,” Edut says. “I respect a woman’s choice, and she should be the ultimate authority on her body and what to do with it. But at the same time, if a labioplasty is what you really think it will take to make you happy, it might be time to re-examine your idea of happiness.”

Berenholz says the majority of his patients who choose labioplasty do so for physical comfort, not just aesthetics.

“It’s, ‘Doc, I ride my bike five miles a day and it hurts,’ or, ‘I want to wear blue jeans. I can’t wear tight clothes.’ Not one of these patients has been vain,” he says.

But Susan Hendrix, professor of OB/GYN at Wayne State University and director of the Women’s Health Initiative, says the occurrence of pronounced labia hypertrophy is rare.

“Labioplasty is only done in very unusual or rare cases,” Hendrix says. “I’ve been in practice for over 16 years and I’ve maybe done two or three.” She says she only performs the procedure “when medically indicated” because possible complications include chronic pain, and, in a worst case scenario, the inability to have sex.

“It’s really somewhat repulsive to me,” Hendrix says of aesthetically driven labioplasty, “because it implies this is a cosmetic surgery somehow, and women should worry about how their vagina looks.

“There’s a right and wrong in what you practice in medicine, and patients really rely on their doctors. To go out and establish something just for money? That’s disgusting that a physician would do that.”

Despite the fact that the clitoris is the woman’s primary source of pleasure, doctors who perform LVR claim it will improve sex for both partners, not just the man. Matlock’s literature (titled, “As a sexual biological organism, women are superior to men”) states that LVR will result in increased friction, which will in turn increase pleasure for the woman.

Isabella is a trim, 44-year-old blonde from the Detroit area, mother to three children. Her last child weighed 9 pounds at birth, resulting in a pronounced episiotomy for the 105-pound, small-framed woman. Though her youngest is now 19, she says she began to experience problems within the last five years. “Over the years, what they tried to do (with the episiotomy) broke down,” she says. In addition to some stress incontinence, sex with her partner was no longer enjoyable. “I couldn’t feel anything. And I knew if I couldn’t, he couldn’t.”

Isabella was certain the problem was coming from her end, not her mate’s. Her gynecologist advised her to do Kegels, which she says didn’t work. Isabella then turned to the Internet to research alternatives. She learned of LVR and was convinced the procedure was right for her — so convinced that she was ready to fly to Los Angeles to undergo it. Then she found Berenholz’s Web site, just after it launched.

“He never made me feel like a freak of nature. He’s very compassionate,” she says.

After undergoing the procedure, Isabella was back to work within a few days, and says the pain and healing process was on par with her last episiotomy. She’s thrilled with the results.

“Any kind of surgery has risk, but I would do it again in a second,” she says. “It’s definitely been an incredible experience for me.” She’s even inspired some of her girlfriends to get the surgery. “This problem is more widespread than people think,” she says. “Honestly, I think if more women knew about this procedure, it would save marriages. Men are men. If a man’s going to stray from marriage it’s for sex.”

With her experience completely satisfactory, Isabella brushes off critics.

“I think criticism comes from people who don’t have this problem and don’t understand how it can affect you emotionally and physically,” she says.

Happy patients like Isabella serve as Berenholz’s response to criticism from other physicians. He offers the following response to those who object to the procedure:

“I’d pose this question: What have they offered their patients who come to the same complaints? To deny these women an alternative or choice is absurd.”

WHAT OPTIONS are available for women who feel the need for a tigher vagina? And at what cost?

The traditional surgery LVR is based on, anterior and posterior repair, is covered by most insurance when medically necessary to treat cystocele, rectocele, prolapse (the weakening of vaginal walls) or incontinence. But it may or may not result in a tighter vagina. And because LVR is elective surgery, it doesn’t qualify for insurance (which Berenholz doesn’t accept anyway).

Cost was an issue for Jane, 34, of Indianapolis, who has two kids and traveled to Michigan to see Berenholz for LVR.

“Price was an issue for me,” Jane says. “I financed part of this. My guess is a lot of women who do this have a lot of money. I would consider it a luxury. Not to say that I don’t think it should be covered by insurance, because I think it should be.”

Dr. Laura Berman is director of the Berman Center in Chicago, a clinic for women’s sexual issues. She says many women who complain that Kegels don’t work simply aren’t performing the excercise correctly, an error that can be monitored by an over-the-counter device.

“The other key muscles are the transverse abdominal muscles,” says Berman, who offers patients a course on how to train those muscles.

“And it’s not just strengthening the muscles, it’s learning how to use them during sex,” she says. “A lot of times women have these surgeries because some jerk told them they were too loose, when in fact he may have been too small.”

Berman says that when a woman learns to strengthen and control her pelvic floor muscles, “she can squeeze around any size she wanted to, even the size of a pinky.”

Dr. Hope Haefner is director of U-M’s Center for Vulvar Diseases. “I see a lot of women who have vestibulodynia — they’re having pain because their vaginas are too tight. So there’s the issue of overcorrection.”

Haefner remains undecided on the value of these surgeries.

“I’d really like to see the studies that show this really makes a difference in the long-term outcome of relationships,” she says. “I’d like to see studies that prove this is beneficial.”

The marketing of the procedure is of concern to registered nurse and sex therapist Casey Wilhelm. “I think the public has the idea that this laser means it’s less invasive of a procedure, and it’s not,” says Wilhelm, who works with Haefner. “The laser cauterizes while it cuts, but it cuts nonetheless.”

On the other hand, Wilhelm says patients should have the right to choose whether or not to undergo such surgery. “I support the idea of a woman being able to do whatever she wants to with her body, and that goes along with cosmetic surgery or other body work,” she says. “While having something medically indicated is important for certain kinds of surgery, it shouldn’t be contraindicated because there isn’t a medical basis for it.

“There’s no one answer for everybody. There’s no absolute line, and that’s why this is controversial. A one-size-fits-all answer to the problem is highly unlikely.”

There’s no certification required to perform LVR, other than a medical license. Berenholz says after researching online, he’s found many plastic surgeons who offer the procedure but have no background in OB/GYN. “For this kind of surgery, I firmly believe it should only be done by a board-certified OB/GYN,” he says.

Plastic surgeons agree — for the most part.

Dr. V. Leroy Young chairs the committee for emerging trends for the American Society of Plastic Surgeons (ASPS). He says the trend of elective female genital surgery is growing rapidly, “but we don’t have any hard statistics.” He says lots of plastic surgeons perform labioplasty procedures, and have done so for some time — without the laser, which he describes as “a gimmick” — but that LVR is better left up to those in the OB/GYN field.

“Labial reduction is reasonably common among plastic surgeries,” he says. “This new interest seems to be affected by the mainstreaming of pornography, and the lack of understanding of what is normal versus what represents a perceived ideal. The thing that surprises me is how little understanding there is of what normal is.”

Young says the ASPS has seen an influx of inquiries about these elective surgeries. “We’ve been waiting to see, is this real, and is there enough demand for it that we need to collect stats? And that’s a decision I think we’ll have to make this year,” he says. “If the numbers are there, then we’ll develop guidelines and begin teaching courses.”

But just for labioplasty. “We’re not going to get into the vaginal department,” he says.

Young thinks that unless a woman has prolapse of the rectum or bladder, “it’s meddlesome surgery. It also poses the risk that you can end up with loss of sensation or a painful scar. But if you’ve got a real problem, then, sure, there’s nothing wrong with the procedures, but they ought to be performed for a legitimate reason.” When told of Isabella’s scenario, Young says he feels the surgery was justified in her case.

Berman, on the other hand, thinks LVR is never a useful or necessary procedure, and can actually cause damage.

“Over the years I’ve treated many women who’ve had these surgeries because their partner told them to, and they end up with some sexual dysfunction,” Berman says. “Our genitals and pelvic region in general is rich in nerves and vascular bundles, so any kind of vaginal surgery runs the risk of effecting sexual response because of nerve damage.”

Dr. Stanley Zinberg of the American College of Obstetricians and Gynecologists issued a letter in June of 2004 expressing concern over the surgeries. The following is an excerpt:

“The Committees on Gynecologic Practice and Ethics are continuing to monitor this issue and expressed several concerns. First, it is difficult to determine exactly what procedures are being performed, as the nomenclature used for procedures such as ‘vaginal rejuvenation’ and ‘revirginification’ does not describe standard gynecologic surgical procedures.

“Of concern to the Committee on Ethics is the way in which these procedures are being marketed and promoted. The use of a business model that aims to control the dissemination of scientific knowledge is troubling. For physicians who perform these procedures, obtaining a patient’s informed consent will be challenging, given the absence of medical literature about these procedures.”

Some physicians charge that these surgeries are simply a way for doctors to cash in on women’s insecurities. For his part, Matlock does little to counter that notion.

About five years ago, Matlock decided to expand his ventures. He trademarked the term “LVRI” and “vaginal rejuvenation,” and actually patented some of the procedures. Then he started a franchise operation.

“We don’t want to term it franchise,” Matlock objects hastily by phone, in between surgery and international phone calls. “The doctors are associates of LVRI. We taught and trained them in all techniques, and offered them a business model. We also offer support to these associates.”

And for that support, those associates pay Matlock a monthly fee. Doctors who wish to enroll in his four-day course pay an initial fee of $8,900, followed by a program participation fee: $2,500 per month over the next 24 months. That’s a total of nearly $70,000. Matlock says he has about a dozen such associates in this country (Berenholz is one of them), and about 30 internationally, including doctors in Canada, Sweden, France, Indonesia and Australia. That all adds up to nearly to $3 million.

He’s already sent cease-and-desist letters to other doctors who are using any variant on “vaginal rejuvenation” in their advertising, citing trademark infringement. Although others in the medical community have expressed chagrin over Matlock’s attempts to corner the market, Matlock, who also has a master’s degree in business administration, sees it differently.

“If this is intellectual property, why should I give it away?” he asks. “Medicine is a business too. Doctors want in because it’s a cash business. Insurance, you might get paid nine months, six months, three months at best. But here, they’re coming in and they’re paying cash.”

One breath later, he offers the following pledge:

“Our whole mission is to empower women with knowledge, choice and alternatives.”

“I think that’s wrong,” Jane says after learning of Matlock’s trademark and patent. “That troubles me. It makes it seem like it’s just a cosmetic procedure. It’s going to make it expensive and unavailable. They’re covering Viagra with Medicare; I don’t get it.”

In contrast to Matlock’s bluntness, Berenholz says he’s providing women with a choice, when, in the past, they were told they simply had to live with vaginal looseness or aesthetically displeasing labia. “This is being driven by women, not doctors,” he says.

And he isn’t afraid to turn patients away. He tells of a woman in her 20s who came in complaining of long labia. “But there was virtually no hypertrophy. We saw nothing wrong,” he says. They sent her on her way.

Another woman flew all the way from California for an LVR consultation, because her husband said he could no longer feel her. But after examining her, Berenholz found no relaxation in her vagina, and, as it turns out, the woman’s husband had erectile dysfunction. She got on the next plane back to California.

“She told us she didn’t know if she should laugh or cry,” Berenholz says.

During Kim’s consultation, Berenholz asks her a number of frank questions about her ability to orgasm, before and after childbirth. “I’m just really loose down there,” she says with a shrug. Having finished with his questions, Berenholz begins conducting his exam, speaking gently and telling Kim exactly what he’s doing as he probes her vagina with a speculum and conducts a rectal exam. A flash of surprise shows up on his face.

Berenholz finishes the exam, and tells Kim that if he had to classify her on a scale from normal to slightly relaxed to very relaxed, he would classify her as normal.

Kim looks shocked. “You think so?” she asks, unconvinced. “I know so,” Berenholz assures her.

He then gently suggests that the problem may lie with her husband. He refers Kim to urodynamic testing, to treat her issue of stress incontinence, but says she has no need for LVR.

“You really don’t think so?” she asks again, looking perplexed and rather disappointed. After a moment, she wonders, “Well, maybe he’s got a problem.”

Despite the fact that she’s just learned she’s normal, and won’t have to pay nearly $7,000 to have her vagina surgically altered, Kim looks almost crestfallen.

“It happens a lot,” Berenholz’s assistant assures her. “Because we’re women, we’ll see a doctor when we think something is wrong, but men are very prideful …”

“There are many women who’ve had more than three or four children who have a very fine sex life,” Wilhelm says. “It doesn’t mean because your sex life is no longer enjoyable it’s because you’ve had three kids and your vagina is stretching. That’s a lot easier to fix than looking to yourself or your relationships.”

# posted by Unknown : 6:35 PM