Female Genital Cosmetic Surgery Rate Increase Prompts Review

Becky McCall

November 15, 2013

A 5-fold rise in the number of labial reduction procedures (labiaplasty) in the United Kingdom's National Health Service (NHS) over the course of the last 10 years has triggered serious concerns and suggestions that clinicians should revise their management of patients requesting female genital cosmetic surgery (FGCS).

The Royal College of Obstetricians and Gynecologists (RCOG) and the British Society for Paediatric and Adolescent Gynecology (BritSPAG) make a series of recommendations published in 2 reports launched today.

The 5-fold rise in labiaplasty procedures in the NHS, totaling 2000 in 2010, are largely for cosmetic reasons and are not the result of a rise in labial disease. Indeed, misinformation and lack of correct information have a fundamental role to play in the rise in demand for FGCS, according to Dame Suzi Leather, DBE, chair of the RCOG's Ethics Committee that authored the RCOG report. She said adolescent girls have a distorted understanding of what normal female genitalia should look like.

"Doctors are faced with adolescents who feel somehow that they need surgery to be normal," she commented in an interview with Medscape Medical News. "But the overwhelming majority do not need surgery and fall well within the normal limits. So it is the case that we need to supply better information about what normal means."

Also representing the RCOG Ethics Committee, Sarah Creighton, MD, consultant gynecologist at University College London Hospitals, added that if young girls are concerned about the appearance of their genitals and search online for images then they find either advertisements for cosmetic surgery or pornography. "You do not, first line, come across pictures of what healthy vulva should look like, so this then frames how these girls think about themselves."

The RCOG report recommends that clinicians provide young women expressing concerns about their labia with information on normal variation in female genitalia, and in extreme cases, the girls should be referred for counselling and psychotherapy for body dysmorphic disorder. "Referral should help provide a fuller picture of the background and clinical context for the girls' concerns," said consultant clinical psychologist Lih-Mei Liao, PhD, also from University College London Hospitals, who was speaking for BritSPAG.

Dr. Liao also highlighted the need for better clinical education on the topic. "This is a point for education for girls and parents: Vulva appearance is diverse, all shapes sizes are compatible. Education and support is at heart of good clinical practice."

From the practicing clinician's perspective, difficulties are associated with the lack of accurate clinical data on FGCS. Dr. Liao pointed out that in the NHS, several hundred cases of FGCS had been performed in the past 4 years. "We don't know why, who, and we don't know what happened to these girls afterwards."

She added that the lack of data was not because of an absence of will but because people tend to be secretive about having had cosmetic surgery, and with FGCS in particular, people rarely want to return in a few years and report how they are managing. "The optimism that some surgeons have is founded on a lack of negative feedback because if a patient is not happy with a result, most people do not return to a doctor and ask for a repeat operation — they would seek a new provider."

Short- and long-term physical and psychological risks are largely unknown beyond short-term risk for bleeding and wound infection. Long-term damage may occur to sensitivity and sexual function because surgery disrupts nerve supply. Other long-term issues relate to expectations of surgery. Addressing underlying psychological issues is essential, according to Dr. Liao, who says patients often return after surgery feeling dissatisfied because underlying problems remain, leading the patient to seek further surgery.

Dr. Liao stressed that clinicians faced with young girls and their parents seeking FGCS need improved resources to aid decision-making and management of patients and their families. "Currently, there are very limited resources to aid clinicians in their judgement in these cases, so this [is] a priority for our society," she explained.

In their statement, BritSPAG suggests that rather than sending young girls seeking labiaplasty away, front-line clinicians should perform a sensitive and skillful genital examination, and that normality needs to be communicated unambiguously and authoritatively.

Under-18s at Particular Risk

A theme common to both the RCOG report and the BritSPAG statement is the enhanced concern for FGCS in girls younger than 18 years, because full genital development is incomplete during the majority of teenage years. Dr. Liao explained that the earlier a girl begins her journey into labiaplasty, the greater the risk for multiple lifetime operations and significant scarring and numbing.

Female Genital Mutilation vs FGCS

The committee also wanted to make clear the distinction between female genital mutilation (FGM) and FGCS. FGM is usually performed without consent on very young girls outside of the medical setting. "An issue for doctors is that there is a piece of legislation that makes it a criminal offence to perform certain sorts of surgery on women's genitalia. This means doctors have to be very careful in their record keeping," said Emily Jackson, PhD, head of the Department of Law, London School of Economics, who was also a member of the RCOG Ethics Committee.

She added that in the UK FGM Act, there was an exception for operations conducted by a registered medical practitioner for health reasons, including mental health reasons, but this highlighted the importance of physicians carefully documenting why they think surgery is indicated in women and young girls.

A 1996 federal law also bans FGM in the United States, but the US law is more unambiguous than the UK law. According to Nawal Nour, MD, an obstetrician-gynecologist with a special interest in female genital circumcision, from Massachusetts General Hospital in Boston, US federal law states that it is a federal crime to perform genital surgery on a girl who is younger than 18 years. "This means that cosmetic surgery (or [FGM] for that matter) would not be an issue. As you are aware, American adults are able to do pretty much anything they want to do with their bodies — no extra documentation is necessary."

The RCOG's recommendations include:

  • a genital examination should be offered and conducted sensitively,

  • information about normal variations should be offered,

  • surgical reduction before the completion of pubertal development may lead to long-term problems and should be communicated to the girl and her guardian where appropriate,

  • simple measures to relieve labial discomfort should be suggested, and

  • in case of significant psychological distress, the girl and her family should be offered a referral to a pediatric clinical psychologist.

The authors, Dr. Liao, Dr. Nour, and Dr. Jackson have disclosed no relevant financial relationships.

Ethical Opinion Paper: Ethical Considerations in Relation to Female Genital Cosmetic Surgery (FGCS). Published online October 2013. Full text

Position Statement: Labial Reduction Surgery (Labiaplasty) on Adolescents. Published online October 2013. Full text

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