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Her question soon evolved into anxiety. Not to other women. Not even to her doctors. She preferred to keep her shame private. There was also a practical side to her discomfort.

Her labia would chafe from friction when she jogged. Riding an exercise bike was out of the question. She was constantly adjusting herself. Sometimes her labia would get caught on her partner, leaving her to wonder if she was a freak. This was the center of my womanhood, and to bring negative attention to it, that was just too much to even consider.

It was so private, and the way that I felt about it was so intense. For the longest time, she didn't. But by age 40, her anxiety got the best of her. On a visit to a plastic surgeon to discuss breast reduction, the question came up. Is there anything else you're concerned about? Daniel Medalie about the physical discomfort, how embarrassing it was to wear tight pants. He asked if he could examine her. She was too self-conscious. Medalie brought out a book filled with pictures of vaginas and asked her to point out which one looked like hers.

She finally told her boyfriend. Is it something psychological? I'm just sort of a deer in the headlights. Labioplasty grew out of men wanting to be women. Other procedures were born to improve function, not form. Vaginoplasty, for example, was developed for women who gave birth. On occasion, the muscles of the vaginal walls wouldn't heal right, leaving them loose. Doctors figured out how to tighten them.

It's supposed to help women better enjoy sex. But both procedures remained obscure, while the plastic surgery industry expanded in the '70s and '80s. Then came the rise of VCRs and the internet. Suddenly, even good girls who would never grace porn shops had home access to them. What once could be observed only with a quick glance in a locker room could now be "paused" and stared at on a screen. Many women were seeing other vaginas for the first time. Anxiety became a native byproduct.

Is mine too big? Are my lips too long? Is my boyfriend OK with it? How come these porn stars don't look like me? So they started talking to their doctors. The popularity of both vaginal lip reduction and tightening began where such things usually do -- in L.

But like all trends, it's slowly worked its way to Flyover Country. In the past year, Medalie -- who works at MetroHealth Medical Center -- has been fielding mounting queries.

I have a little bit of a backlog. He doesn't do the procedure. Not many doctors do. But it's all part of the growing industry of vaginal restoration. The growth prompted Elyria's Dr. Kevin Wisler to fly to Beverly Hills to study laser vaginal rejuvenation under gynecologist David Matlock, who's been featured on the reality show Dr.

Now Wisler's opening up his own institute at Elyria Memorial Hospital. Of course, no such trend is without its critics. Getting a surgery because of physical discomfort is one thing, they'll say. Getting it because a woman on a sex tape has a vagina like a teenager is another. In a report by British Medical Journal last month, authors warned of unknown risks with labioplasty -- especially when doctors are cutting around nerve endings.

Beth Haiken, who wrote Venus Envy: A History of Cosmetic Surgery, says it's all part of our increasing pursuit of artificial enhancement. There's got to be a better place to spend your money. Warner says he considers himself something of a maverick, a caring physician willing to challenge medical orthodoxy in order to help women. That's why the year-old board-certified obstetrician-gynecologist recently opened the Laser Vaginal Rejuvenation Institute of Washington in a red brick townhouse off Washington Circle.

There, he is building a business as the first area physician to perform controversial procedures that use a laser to enhance sexual gratification by repairing tissue damaged by childbirth, to give women a "youthful aesthetic look" or to make those who are not appear to be virgins. Warner's fledgling rejuvenation practice, experts say, exemplifies physicians' entry into what some have termed the "last frontier" of plastic surgery -- a realm where medical ethics collide with culture, commerce and technology.

In response to this growing interest, the American Society of Plastic Surgeons began tracking vaginal rejuvenation in and recorded procedures that year.

That figure is widely regarded as low, because many doctors who perform these operations are gynecologists, whose primary professional association, the American College of Obstetricians and Gynecologists, does not keep such statistics.

While numbers are elusive, both critics and proponents of the procedures agree they are increasing. Matlock, the flamboyant California gynecologist who invented or popularized many of these surgeries, says he has performed more than 3, in the past 12 years and has trained doctors in a dozen states and 20 countries, including Argentina, Korea and Australia.

The proliferation of such surgeries, fueled in part by the growing popularity of cosmetic surgery and of reality television makeover shows such as the E! Some say the procedures foster -- or create -- insecurity while doing little to treat the underlying causes of female sexual dissatisfaction. Warner, a graduate of Georgetown University School of Medicine who started an ob-gyn practice in and also maintains an office in Southeast Washington, said his goal is to empower women.

Warner was trained by Matlock, who promotes the surgeries over the Internet, on television and through a public relations firm he owns. Warner says calls to his practice increase dramatically after each of Matlock's television appearances. Matlock is himself a controversial figure.

He has been disciplined by the Medical Board of California for what he says is a "misunderstanding" with racial overtones and sued for malpractice 10 times in the past decade for what he characterizes as "nuisance cases. Stovall, a past president of the Society of Gynecologic Surgeons. These surgeries are also often performed with other cosmetic surgeries, such as liposuction. They are rarely covered by insurance. Berman said she has treated about 15 women who have undergone vaginal procedures to improve their sex lives and developed complications such as painful intercourse.

Louis plastic surgeon V. Leroy Young, former chairman of the emerging trends task force of the plastic surgeons' society, said the hype surrounding these procedures underscores a lack of regulatory oversight. There is, Young noted, no counterpart to the Food and Drug Administration when it comes to surgery.

Because of the Internet, he said, "much of this stuff can be developed and is almost immediately on the market. Some women undergo the surgery, he said, because a man has told them, "Honey, you don't look like the girl in the movie.

What Women Want "Every single one of these procedures was developed" at the request of women, Matlock said. Why are they coming to me? Women are telling us that it's working. In Berman's view, much of the demand is fueled by ignorance or desperation. Most women, she said, have no concept of what is normal when it comes to genital appearance or functioning. She added that many women do not realize that incontinence often can be successfully treated with far less invasive methods such as exercises, biofeedback and medication.

Matlock says the exercises don't work and that laser rejuvenation is a modification of standard operations called anterior and posterior repair to fix a sagging bladder or rectum. But, he added, laser rejuvenation "goes way beyond" these procedures. Gynecologists say that some women do report improved sexual satisfaction after standard repairs. But they note that this is incidental to the functional reasons for surgery, which carries inherent risks.

Warner and Matlock say that patients frequently request "a nice sleek look" similar to images seen in Playboy magazine and on some cable TV channels. David Sarwer, an associate professor of psychiatry at the University of Pennsylvania School of Medicine's Center for Human Appearance, said he believes some of these patients could have body dysmorphic disorder, a psychiatric condition that affects between 7 and 15 percent of plastic surgery patients.

The disorder is characterized by an obsessive focus on a minor or nonexistent physical flaw. Some women, including year-old Lisseth Figueroa, an office manager in Los Angeles, say rejuvenation surgery helped rescue a foundering marriage.

Figueroa said she suffered from stress incontinence after four pregnancies and felt she was being rejected sexually. Since the surgery that's changed. I'm very happy with it -- and so is my husband. Julie Barragan, a year-old single mother who lives outside Los Angeles, underwent vaginal surgery several months after one of her relatives.

Another family member followed suit. The surgery, Barragan said, has "definitely given me more confidence. I haven't had any regrets. There is little dispute that one procedure, known as hymenoplasty, is performed primarily for the impression it will make on men. The surgery, which takes about 30 minutes, restores the hymen, the membrane that typically covers the vagina prior to first intercourse.

Surgeons say there is a growing demand for the surgery, particularly among women of Middle Eastern and Hispanic descent -- cultures where female chastity can be a prerequisite for marriage.

In one recent case, a college student was scheduled to return to Egypt to be examined by a gynecologist as a condition of her arranged marriage. She has recommended Warner to several friends who have scheduled this surgery, he said. Sometimes the surgery is done for other reasons.

Pelosi estimates he has done about hymenoplasties in the past two years. Some of his patients, Pelosi said, are celebrating a new relationship or second honeymoon. Tennessee's Stovall said he thinks the procedure is ridiculous. And for most women, losing their virginity was not the most pleasant experience. The March of Progress In April, Los Angeles gynecologist David Matlock licensed his 2-year-old G-spot-enhancing technology to 35 other doctors around the country to help spread the benefits of collagen injections that swell the so-called Grafenburg Spot a supposedly pleasure-registering zone which is, at best, tiny and hidden, but according to some doctors, nonexistent.

Boodman Washington Post Staff Writer Tuesday, March 6, ; HE05 While some physicians pride themselves on their business acumen, few are as unabashedly entrepreneurial as David Louis Matlock, the board-certified obstetrician-gynecologist regarded as the driving force behind vaginal cosmetic surgery.

That figure is more than 45 times higher than that of the average obstetrican-gynecologist, according to a survey compiled by the American Medical Group Association. Matlock said he operates each week on about 10 patients who wait months for an appointment. Many are drawn by his regular appearances on the E! Matlock says most of his earnings are derived from patient fees and royalties.

According to SEC filings, he owns stock options in a company that makes the lasers that he requires trainees, whom he calls "associates," to buy. Recently Matlock formed a television production company that is trying to sell a reality show called "DocStars," featuring him. Why should I give it away?

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