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Complications related to pubic hair removal

Published:February 03, 2014DOI:https://doi.org/10.1016/j.ajog.2014.01.036

      Objective

      We investigated the prevalence and correlates of complications related to pubic hair removal among a diverse clinical sample of women attending a public clinic.

      Study Design

      Women (aged 16-40 years) who received care from April to June 2012 at 2 publicly funded clinics completed an anonymous, self-administered questionnaire (n = 369). After excluding women with missing data, analyses were conducted on 333 women. Additional measures were retrieved through a medical chart review. A χ2 and a multivariable logistic regression were used to analyze participant characteristics, pubic hair removal behaviors, and complications related to pubic hair removal.

      Results

      Most women (87%) admitted to current removal of at least some pubic hair, whereas the remainder responded that they had removed pubic hair in the past. Under- or normal-weight women were more likely to report total pubic hair removal than overweight or obese women. The majority (60%) had experienced at least 1 health complication because of the removal, of which the most common were epidermal abrasion and ingrown hairs. Black and Hispanic women were less likely than white women to report complications. Overweight or obese women were almost twice as likely to report a complication and almost 3 times as likely if they also had total hair removal. Only 4% had seen a health care provider for a complication related to hair removal and only 4% discussed safe removal practices with their doctor.

      Conclusion

      Minor complications commonly occur as a result of pubic hair removal. Gynecological visits could provide a safe environment for women to discuss pubic hair removal practices.

      Key words

      More than 50% of young women (18-24 years old) in the United States have admitted to removing pubic hair recently.
      • Herbenick D.
      • Schick V.
      • Reece M.
      • Sanders S.
      • Fortenberry J.D.
      Pubic hair removal among women in the United States: prevalence, methods, and characteristics.
      Most women remove pubic hair for sexuality or aesthetic reasons.
      • DeMaria A.L.
      • Berenson A.B.
      Prevalence and correlates of pubic hair grooming among low-income Hispanic, black, and white women.
      • Herbenick D.
      • Hensel D.
      • Smith N.K.
      • et al.
      Pubic hair removal and sexual behavior: findings from a prospective daily diary study of sexually active women in the United States.
      This practice may result in adverse health consequences, including genital burns from waxing, severe skin irritation leading to post inflammatory hyperpigmentation, vulvar and vaginal irritation and infection, and the spread or transmission of sexually transmitted infections.
      • Glass A.S.
      • Bagga H.S.
      • Tasian E.T.
      • et al.
      Pubic hair grooming injuries presenting to US emergency departments.
      • Dendle C.
      • Mulvey S.
      • Pyrlis F.
      • et al.
      Severe complications of a “Brazilian” bikini wax.
      • Tiggemann M.
      • Hodgson S.
      The hairlessness norm extended: reasons for and predictors of women's body hair removal at different body sites.
      • Castronovo C.
      • Lebas E.
      • Nikkels-Tassoudji N.
      • Nikkels A.F.
      Viral infections of the pubis.
      Less serious complications that may be experienced as a result of pubic hair removal include epidermal abrasion, ingrown hairs, folliculitis, vulvitis, or contact dermatitis.
      Pubic hair removal is now a contemporary trend, with total hair removal increasing in popularity, especially among adolescents and young adults.
      • Herbenick D.
      • Schick V.
      • Reece M.
      • Sanders S.
      • Fortenberry J.D.
      Pubic hair removal among women in the United States: prevalence, methods, and characteristics.
      • Herbenick D.
      • Hensel D.
      • Smith N.K.
      • et al.
      Pubic hair removal and sexual behavior: findings from a prospective daily diary study of sexually active women in the United States.
      • Glass A.S.
      • Bagga H.S.
      • Tasian E.T.
      • et al.
      Pubic hair grooming injuries presenting to US emergency departments.
      This practice is associated with being partnered (rather than single or married), having looked closely at one's own genitals in the previous month, cunnilingus in the past month, and more positive genital self-image and sexual function.
      • Herbenick D.
      • Schick V.
      • Reece M.
      • Sanders S.
      • Fortenberry J.D.
      Pubic hair removal among women in the United States: prevalence, methods, and characteristics.
      • Herbenick D.
      • Hensel D.
      • Smith N.K.
      • et al.
      Pubic hair removal and sexual behavior: findings from a prospective daily diary study of sexually active women in the United States.
      Little information is available on the frequency of clinical complications associated with this behavior, especially among adolescents and women from diverse ethnic and racial backgrounds. The purpose of this study was to report on pubic hair removal practices, complications, and characteristics associated with complications among a clinical sample of low-income, racially diverse women.

      Materials and Methods

      Participants were recruited from 2 publicly funded reproductive health clinics at the University of Texas Medical Branch (UTMB) between April 2012 and June 2012. All women between 16 and 40 years old who presented for an appointment on a day that a research assistant was assigned to that clinic were eligible to participate. When approached, women were informed their participation was voluntary and that they would be answering questions related to pubic hair removal and sexual health. Those who agreed to participate were then handed an anonymous, self-administered, written survey in either Spanish or English, which took approximately 30 minutes to complete. Upon returning the form, they chose a small gift valued at $3 or less for their time and effort.
      To ensure women completed the survey only once during the data collection period, a cumulative database containing the names of those who participated and those who declined participation was maintained. Overall, 79 women who were approached to take the survey (17.6%) declined to participate. Women who refused did not significantly differ from those who participated in age (25.7 years vs 24.7 years; P = .16) or race/ethnicity.
      The UTMB Institutional Review Board approved all procedures and protocols for this study, including a waiver of written consent. Participants consented verbally to complete the survey.
      Participants were excluded if they had never removed their pubic hair (n = 8), did not indicate how much pubic hair they removed (n = 6), did not select a race/ethnicity (n = 7), or had missing body mass index (BMI) data (n = 15). Of the original 369 women who were surveyed, 333 were included in this study. The survey included questions about current or past hair removal, amount and method of removal, and health complications resulting from removal (Table 1). Women who responded that they typically remove all of their pubic hair were assessed as total removers whereas all others were assessed as partial removers.
      Table 1Characteristics of clinical sample of women who have removed pubic hair currently or in the past (n = 333)
      CharacteristicEntire sample, n (%)

      (n = 333)
      Total removers, n (%)

      (n = 207) (62.2%)
      Partial removers, n (%)

      (n = 126) (37.8%)
      P value
      Race/ethnicity
       Hispanic151 (45.4)89 (58.9)62 (41.1).31
       Black84 (25.2)51 (60.7)33 (39.3)
       White98 (29.4)67 (68.4)31 (31.6)
      Age, y
       16-2085 (25.5)60 (70.6)25 (29.4).18
       21-30196 (58.9)116 (59.2)80 (40.8)
       31-4052 (15.6)31 (59.6)21 (40.4)
      BMI
      BMI values for underweight to normal weight are less than 25 kg/m2, and BMI values for overweight or obese are 25 kg/m2 or greater.
       Under- or normal weight96 (28.8)72 (75.0)24 (25.0).002
       Overweight or obese237 (71.2)135 (57.0)102 (43.0)
      Pubic hair removal practices
       Do you currently remove your pubic hair?
      Yes289 (86.8)192 (92.8)97 (77.0)< .001
      No but have in the past44 (13.2)15 (7.2)29 (23.0)
       What methods have you used to remove your pubic hair?
      Razor blade297 (89.5)191 (92.7)106 (84.1).01
      Depilatory cream/foam53 (16.0)31 (15.0)22 (17.5).56
      Electric razor50 (15.1)22 (10.7)28 (22.2).004
      Trim39 (11.8)14 (6.8)25 (19.8)< .001
      Wax24 (7.2)15 (7.3)9 (7.1).96
      Laser2 (0.6)1 (0.3)1 (0.3)
      Pluck3 (0.9)3 (1.46)0
      Sugar0
      Thread0
      Have you ever experienced any of the following health complications as a result of removing your pubic hair?
       Any complication194 (59.5)126 (62.1)68 (55.3).23
       Epidermal abrasion120 (36.7)77 (37.9)43 (34.7).55
       Ingrown hairs107 (32.7)68 (33.5)39 (31.4).70
       Severe itching69 (21.1)44 (21.7)25 (20.2).74
       Cuts60 (18.4)44 (21.7)16 (12.9).05
       Rash43 (13.2)28 (13.8)15 (12.1).66
       Bruise0
       Allergy7 (2.1)6 (3.0)1 (0.8)
      Burns4 (1.22)4 (2.0)0
       Infection16 (4.9)8 (3.9)8 (6.4).31
      BMI, body mass index.
      DeMaria. Complications of pubic hair removal. Am J Obstet Gynecol 2014.
      a BMI values for underweight to normal weight are less than 25 kg/m2, and BMI values for overweight or obese are 25 kg/m2 or greater.
      Women who removed their pubic hair in the past but were not currently removing it were asked why they discontinued. Possible responses included the following: “I am not sexually active; I developed an infection; I did not like the side effects (stubble, bumps, rashes, ingrown hairs); it was too expensive; it was too much of a hassle; it was too painful; my partner wanted me to stop; I like the look of pubic hair; or other.” Participants were asked whether they had ever experienced complications from pubic hair removal, whether they obtained health care for these complications, and whether they had ever been counseled by a provider on hair removal practices.
      BMI was calculated using self-reported height and clinical measurements of weight obtained at their clinic visit. Participants were classified into 1 of 2 categories: underweight or normal weight (BMI <25 kg/m2) vs overweight or obese (BMI ≥25 kg/m2).
      Descriptive statistics were analyzed using a χ2 analysis to determine significant differences by amount of pubic hair removal (total compared with partial). Multivariable logistic regression was used to calculate the odds of reporting any health complication related to pubic hair removal. To examine whether an interaction between BMI and amount of pubic hair removal was associated with a report of complications, a dummy variable was developed with 4 possible categories: partial removers who were under/normal weight, total removers who were under/normal weight, partial removers who were overweight/obese, and total removers who were overweight/obese. Logistic regression analysis compared the odds of complication of the first 3 categories with overweight/obese women who were total removers. All analyses were performed using SAS 9.3 software (SAS Institute, Cary, NC).

      Results

      The mean age of participants was 24.7 years (SD, 5.5; range, 16–40 years). A significantly higher proportion of women reported removing all, as compared with only some, of their pubic hair (P < .001; Table 1). Furthermore, most were current removers (86.8%). Current removers were more likely to remove all their pubic hair (P < .001). Almost 90% reported using a razor blade, at least sometimes, to remove pubic hair.
      Nearly one-third of participants were under/normal weight and the majority were classified as overweight/obese. One-way χ2 analysis showed that under/normal-weight women were more likely to be total removers compared with the overweight/obese women (P < .01).
      More than half of respondents indicated experiencing at least 1 health complication because of pubic hair removal. Of those who experienced any health complication, 90.7% reported shaving with a razor. Only 3.9% had ever seen a health care provider for a complication related to pubic hair removal, and only 3.7% reported discussing safe pubic hair removal practices with a health care provider.
      Among the 44 women who reported prior but not current hair removal, 42 gave reasons for stopping this practice. The most common reason cited by 40.9% was disliking the side effects (stubble, bumps, rashes, or ingrown hairs). Other reasons were too much of a hassle (25%), lack of sexual activity (11.4%), liking the look of pubic hair (7.1%), and their partner wanted them to stop (2.4%). Fourteen women also volunteered that they stopped upon becoming pregnant.
      Hispanic and black women were less likely to experience a complication from pubic hair removal than white women (Table 2). Women who were overweight/obese were almost twice as likely to report experiencing complications than those under/normal weight. The most common complication reported by overweight/obese participants was epidermal abrasion (39.1%) followed by ingrown hairs (34.3%). These frequencies were similar to those experienced by under/normal-weight women.
      Table 2Odds of reporting any clinical complication as a result of pubic hair removal
      VariableOR (95% CI)
      Hispanic0.47 (0.26–0.82)
      Black0.31 (0.16–0.58)
      WhiteReference
      16-20 y0.64 (0.29–1.38)
      21-30 y0.67 (0.34–1.33)
      31-40 yReference
      Partial removers0.71 (0.44–1.14)
      Total removersReference
      BMI overweight or obese1.96 (1.16–3.30)
      BMI under- or normal weightReference
      Hosmer Lemeshow goodness of fit estimate (P > .05).
      BMI, body mass index; CI, confidence interval; OR, odds ratio.
      DeMaria. Complications of pubic hair removal. Am J Obstet Gynecol 2014.
      Women who were overweight/obese total removers were more than 2.75 times more likely to report complications compared with under/normal-weight total removers after adjusting for race/ethnicity and age (analyses not shown). Under/normal-weight and overweight/obese partial removers had a similar likelihood of reporting any complication compared with under/normal weight total removers.

      Comment

      Although prior reports have focused on the frequency of pubic hair removal among primarily white, college-aged women,
      • Herbenick D.
      • Schick V.
      • Reece M.
      • Sanders S.
      • Fortenberry J.D.
      Pubic hair removal among women in the United States: prevalence, methods, and characteristics.
      • Tiggemann M.
      • Hodgson S.
      The hairlessness norm extended: reasons for and predictors of women's body hair removal at different body sites.
      we focused on women from underrepresented minorities and found this practice has been adopted by women from diverse backgrounds. In fact, more than half of the women we surveyed reported removing all pubic hair. This practice was especially common among women who were underweight or of normal weight. Hairlessness has been described as a culturally constructed model of femininity, particularly among white women. In modern Western culture, body hair has been viewed with disgust as unclean.
      • Toerien M.
      • Wilkinson S.
      Gender and body hair: constructing the feminine woman.
      However, this study indicates that pubic hair removal is not practiced solely by white women as has been commonly believed but rather is a widespread practice among diverse racial and ethnic groups. Thus, these practices are a source of health complications among women from these groups as well as among white women.
      Smolak and Murnen
      • Smolak L.
      • Murnen S.K.
      Gender, self-objectification and pubic hair removal.
      found that the most common reported reason for pubic hair removal among women is that it makes them feel sexy and clean. The media has reinforced this cultural model in recent years through its depictions of highly desirable women. A review of centerfold models that appeared in Playboy magazine between 1953 and 2007 showed that among those in which the mons pubis was visible, pubic hair became less visible as years increased. Between 2007 and 2008, no pubic hair was visible in 61.2% of the pictures.
      • Schick V.R.
      • Rima B.N.
      • Calabrese S.K.
      Evulvalution: the portrayal of women's external genitalia and physique across time and the current Barbie doll ideals.
      In fact, more than half of the women we surveyed reported removing all pubic hair. Thus, pubic hair removal is now considered by many to be necessary to meet modern society's definition of attractiveness, femininity, and cleanliness among females.
      • DeMaria A.L.
      • Berenson A.B.
      Prevalence and correlates of pubic hair grooming among low-income Hispanic, black, and white women.
      • Tiggemann M.
      • Hodgson S.
      The hairlessness norm extended: reasons for and predictors of women's body hair removal at different body sites.
      • Toerien M.
      • Wilkinson S.
      Gender and body hair: constructing the feminine woman.
      • Smolak L.
      • Murnen S.K.
      Gender, self-objectification and pubic hair removal.
      • Schick V.R.
      • Rima B.N.
      • Calabrese S.K.
      Evulvalution: the portrayal of women's external genitalia and physique across time and the current Barbie doll ideals.
      Similar to past studies, we found that shaving with a razor was the most frequently used method of pubic hair removal.
      • Herbenick D.
      • Schick V.
      • Reece M.
      • Sanders S.
      • Fortenberry J.D.
      Pubic hair removal among women in the United States: prevalence, methods, and characteristics.
      • DeMaria A.L.
      • Berenson A.B.
      Prevalence and correlates of pubic hair grooming among low-income Hispanic, black, and white women.
      • Herbenick D.
      • Hensel D.
      • Smith N.K.
      • et al.
      Pubic hair removal and sexual behavior: findings from a prospective daily diary study of sexually active women in the United States.
      • Tiggemann M.
      • Hodgson S.
      The hairlessness norm extended: reasons for and predictors of women's body hair removal at different body sites.
      The popularity of this method is probably related to the fact that shaving is a low-cost, easy-to-access method that can be done in the privacy of one's home. Although we did not determine the method being used when injuries occurred, we found a large majority of complications related to pubic hair removal occurred among women who had shaved with a razor. This could have been due to the frequency of using the razors or because shaving all areas of the pubic region is more difficult and exposes more sensitive vulvar regions to trauma.
      Overall, minor complications resulting from pubic hair removal were common. This is consistent with a review of the National Electronic Injury Surveillance System, which found that the number of emergency room visits for genitourinary injuries related to grooming increased 5-fold in the United States between 2002 and 2010. One third of these injuries were recorded in 2009-2010, suggesting a substantial increase in recent years. Similar to our study, most of those injuries were minor, with 83% attributed to shaving with razors. However, 25% of female injuries in the National Electronic Injury Surveillance System report were diagnosed with a laceration, wax burn, or foreign body injury, demonstrating that pubic hair removal can lead to serious injuries.
      • Glass A.S.
      • Bagga H.S.
      • Tasian E.T.
      • et al.
      Pubic hair grooming injuries presenting to US emergency departments.
      Hispanic and black women in our sample were less likely to report complications than whites. However, this finding is limited by the fact that we did not ask how often women removed their pubic hair. If Hispanic and black women removed their pubic hair less frequently, this could have reduced their likelihood of sustaining an injury. In addition, it is difficult to speculate why total removers who were overweight/obese had a much greater risk of sustaining an injury than those who were normal/underweight. One possibility is that overweight/obese women may have a more difficult time adequately viewing the entire pubic region when removing pubic hair. These women may avoid complications when only partially removing their pubic hair because the insides of the thighs and outside of the vulvar region are easier to view and require less flexibility to remove hair in these areas.
      Future studies should examine why overweight/obese women who remove all of their pubic hair have significantly higher odds of a complication so that preventive measures may be taken so that additional information about safer hair removal practices in these women are available to health care providers.
      This study has several limitations. First, participants were limited to a clinical sample of women in the Texas Gulf Coast region and may not be generalizable to other populations. Additionally, it is difficult to determine the accuracy of the responses because this was a self-administered questionnaire. We also were not able to determine what method of hair removal respondents used when an injury occurred. Future studies should determine what methods of hair removal lead to complications.
      Overall, this study supports the need for women to receive health advice on pubic hair grooming from their physician, with an emphasis on teaching safe removal practices, particularly among overweight/obese women. Gynecological visits could provide safe contexts for women to talk with their providers about this issue.

      Acknowledgments

      We are grateful to Ophra Leyser-Whalen, PhD, Assistant Professor, Department of Sociology, University of Texas at El Paso, El Paso, TX, for her support and development of the measurement tool and for her feedback and assistance with the study protocol. Dr Leyser-Whalen was a National Research Service Award postdoctoral fellow at the University of Texas Medical Branch at Galveston, Galveston, TX, supported by an institutional training grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development during the development of this study.

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      Linked Article

      • Complications following “Brazilian” waxing for pubic hair removal
        American Journal of Obstetrics & GynecologyVol. 211Issue 6
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          We read with interest the article by Demaria et al1 as pubic hair removal has gained more popularity in recent years. Various methods of hair removal may also be associated with sexually transmitted diseases. Primary genital herpes from contamination from a waxing salon has been described in the literature.2 Cases of molluscum contagiosum outbreak and septic shock due to staphylococcal infection are yet other complications of pubic waxing.3 Contamination of waxing tools such as a spatula from a previously infected patient or the individual performing it rather than the waxing tub are more likely causes of transmission of herpetic infection, or even a shingles outbreak in a patient under significant stress.
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