As Teen Girls Seek Breast and Genital Surgery, Experts Emphasize Education

Nicola Parry

Disclosures

June 13, 2016

As more and more teen girls express an interest in cosmetic breast and genital surgery, how should the medical community respond?

That's exactly what members of the Adolescent Health Care Committee of the American Congress of Obstetricians and Gynecologists (ACOG) asked themselves recently when they put together a committee opinion, "Breast and Labial Surgery in Adolescents."[1] Published in April, the document encourages ob/gyns to educate teen patients about normal differences in anatomy, growth, and development of breasts and genitalia.

According to the American Society of Plastic Surgeons, in 2010, more than 4600 breast reduction surgeries were performed on girls aged 13-19 years. In 2013, more than 8200 breast augmentation surgeries were performed on those aged 18-19 years.[1,2]

The main reason why ACOG put out its committee opinion at this time is that members have voiced concern about the increasing number of young girls who, during their ob/gyn appointments, discuss an interest in cosmetic surgery to improve the appearance of their vulva and breasts, says Julie L. Strickland, MD, MPH, lead author of the Committee Opinion. Dr Strickland, a professor in the Department of Obstetrics/Gynecology at the University of Missouri-Kansas City School of Medicine, estimated that most clinicians in her practice encounter this type of consultation about once or twice a week.

Because this trend is likely to affect many specialties, Medscape asked experts in various disciplines to advise clinicians on what to do if a teen patient expresses an interest in vulvar or breast surgery. Here's what they had to say.

OBSTETRICS AND GYNECOLOGY

How do you educate adolescents who are concerned about the appearance of their breasts and genitalia?

Advice from: Julie L. Strickland, MD, MPH, Professor, Department of Obstetrics/Gynecology, University of Missouri-Kansas City School of Medicine; Chair, Adolescent Health Care Committee, ACOG

Dr Strickland identifies unrealistic expectations as one of the main reasons why young girls are worried about the appearance of their breasts and genitals. Many girls lack knowledge and understanding of growth and development, and of the wide variation in appearance of normal anatomy. Many people think puberty begins abruptly with the onset of menstruation, she says, whereas its sequence of events progresses more continually throughout adolescence. Compounding this problem, young girls have ready access to images of labiaplasty—on the Internet, in particular. Dr Strickland says this combination of factors leads young girls to have unrealistic expectations about normal anatomy.

Dr Strickland uses visual materials to educate young girls about the wide variation in anatomical appearance of normal female genitalia. These include the book Petals[3] by Nick Karras and the website The Great Wall of Vagina.[4] Clinicians should inform patients that, even in the infrequent cases when cosmetic surgery may be appropriate, adolescence is rarely the best time to perform it. Clinicians should also offer practical suggestions to relieve discomfort in girls who might be requesting cosmetic surgery because they are experiencing chafing and irritation due to large or misshapen labia, she says.
 

PEDIATRICS

At what point would you be concerned that a teen might have something like body dysmorphic disorder (BDD) and refer them to a therapist or psychiatrist?

Advice from: Cora C. Breuner, MD, MPH, Professor of Pediatrics, Division of Adolescent Medicine, Seattle Children's Hospital, University of Washington; Chair, Committee on Adolescence, American Academy of Pediatrics

During consultations with teenagers who request cosmetic surgery, clinicians should be ready to identify those with body image problems or comorbid mental health conditions such as BDD, Dr Breuner says. This will facilitate early and appropriate psychiatric or mental health counseling and treatment, and is especially critical if a patient is either psychologically traumatized by the appearance of her genitalia or expresses thoughts about self-harm. Even during other consultations, clinicians should initiate a discussion about whether young girls have concerns about the appearance of their genitalia, despite the fact that it may be a sensitive topic. According to Dr Breuner, pediatricians do not typically initiate enough of these conversations, possibly due to either their own discomfort or concerns about offending the patient or parent. However, this discussion should not be perceived as an outlier question, because it can be easily incorporated in the general review of systems during the consultation, she says.

Self-report questionnaires can help clinicians evaluate their patients' mental health, she says. Patients or their parents can complete questionnaires in the waiting room before the consultation. These tools include the Patient Health Questionnaire (PHQ-9) screen for depression and the Screen for Child Anxiety-Related Disorders (SCARED), which comes in a child version and parent version.

Dr Breuner emphasizes that the onus is on the clinician to determine whether the patient's problem is real or perceived, and to identify any comorbid mental health disorder that would deem the patient an inappropriate candidate for surgery. She stresses that cosmetic surgery in patients with BDD may simply exacerbate the problem and increase the likelihood that the patient will seek more surgical procedures in the future.

BEHAVIORAL HEALTH/PSYCHIATRY

What kind of evaluation would you recommend prior to surgery?

Advice from: R. Scott Benson, MD, Child and adolescent psychiatrist, Pensacola, Florida; Member, American Psychiatric Association

Dr Benson stresses the need to identify the underlying reason for the teenager's request for cosmetic surgery. He recommends that pediatricians, ob/gyns, and plastic surgeons refer all such patients to a mental health professional for evaluation before proceeding to surgery. Dr Benson also insists on parental involvement in these consultations, because parents often provide more clarity on the problem than the teen would provide if she was alone. However, he added that these consultations typically also allow some time during which the psychiatrist or therapist can interview the patient alone. This enables the patient to speak more freely about her problems, particularly if she is being pressured by a parent to undergo surgery.

Occasionally, a procedure may be necessary for the patient's health and well-being—for example, the need for breast reduction surgery in some girls. However, in many cases, the teenager's request for surgery is not realistic, because the physical feature that she perceives as abnormal may actually merely reflect normal individual variability, he says.

It is important to investigate what psychological factors, such as self-esteem, are at the root of the patient's request. Does the teenager simply want the procedure in order to fit in with the crowd? To further examine this possibility, Dr Benson says it's important to explore how well the teenager is doing in other areas of her life, including with parents, friends, and studies. Clinicians should examine what, outside of focusing on body image, the teenager is doing to define her sense of self. It is also important to determine whether the patient really wants the surgery, or whether she is being pressured by a parent.

In addition, Dr Benson emphasizes the need to differentiate between a teenager who is unhappy with her appearance and one who has BDD. He also notes that other issues, such as childhood sexual abuse, may serve as emotional drivers for BDD and therefore underpin such requests for surgery. Patients with BDD pursue cosmetic surgery with overwhelming intensity to fix perceived flaws, but no amount of surgical intervention tends to resolve the patient's distress in these cases, Dr Benson says.

PLASTIC SURGERY

How do you determine whether surgery is appropriate for a particular patient?

Advice from: Daniel C. Mills, MD, Aesthetic Plastic Surgical Institute, Laguna Beach, California; President American Society for Aesthetic Plastic Surgery

Dr Mills says that although he would "never say never," he would be extremely cautious about performing cosmetic breast or genital surgery on any girl younger than 18 years because she is still undergoing hormonally driven physical changes. The only reason he might perform these types of surgeries in younger patients would be for reconstructive purposes (eg, in adolescents who have experienced genital trauma, or who have deformed breasts). These patients may be emotionally traumatized because of their lesions, and cosmetic surgery can substantially improve their quality of life. Dr Mills stresses, however, that these surgeries involve only reconstruction of normal anatomy, without enhancement. A reputable board-certified plastic surgeon typically will not perform augmentative cosmetic surgeries in young girls, he said. Young girls should reconsider their desire for cosmetic breast or genital surgery later in life, after developmental changes are complete (after approximately age 18-20 years), and these procedures should be performed only by a board-certified plastic surgeon who is knowledgeable about these types of surgeries, he says.

One particular concern about young patients undergoing genital surgery is the long-term outcomes, says Dr Strickland. Nevertheless, although increasing numbers of teen girls are initiating consultations about cosmetic surgery with clinicians, she says appropriate education and reassurance tend to leave most girls feeling relieved that they are not abnormal.

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