Female genital cosmetic surgery: a social trend driving surgical practice

The quest for ‘genital beauty’ in recent decades, has given rise to a set of controversial, non-medically indicated surgical procedures referred to as female genital cosmetic surgery (FGCS) [1]. The commonest of these is labiaplasty or trimming of the labia minora but can include excision of the clitoral hood, tightening of the vagina, plumping or liposuction of the mons pubis and G-spot injections [2]. Socially constructed aesthetic ideals have popularised requests for these, fuelled by a lack of knowledge and misinformation around the diversity and function of female genital anatomy, the medicalisation of functional discomfort, genital hair removal, which exposes previously hidden labia, digitally modified pornographic images, tight fitting leisurewear and medical opportunism, which promises a return to a ‘youthful’, genital appearance [1]. The suite of procedures is mostly unregulated and can be performed by plastic surgeons, aesthetic doctors (GPs with a special interest), dermatologists, urogynaecologists, gynaecologists and urologists. Preference for surgical technique varies, as are levels of training and knowledge of genital anatomy and function, which increases the vulnerability of women seeking ‘enhancement’. Few women are aware that labial tissue is richly innervated with nerve fibres that arise from the clitoral bulbs [3]. It is not just excess skin, but tissue that responds to sexual arousal resulting in increased blood flow, lubrication and heightened genital-cutaneous sensation, which suggests that removal of such tissue could have negative implications for sexual function after surgery and with menopause-related genital atrophy [4]. In 2013, an analysis of requests for labiaplasty funded by Medicare, the Australian national publicly funded health system, demonstrated a three-fold increase for the period from 2001 to 2010 (Australian Government Department of Health, MBS Reviews. Vulvoplasty Report. April 2014), without evidence of increased incidence of labial pathology. This triggered a review of the item numbers in April of 2014 resulting in restrictions on nationally funded labiaplasty procedures to medically indicated diseases with specific item numbers for repair of congenital anomalies, female genital mutilation, and another for vulval hypertrophy. The item number for labiaplasty or vulvoplasty (35534) can only be claimed in a patient aged ≥18 years, for a structural abnormality that causes significant functional impairment or extends more than 8 cm below the vaginal introitus in a standing position. Girls under the age of 18 years, require a mandatory psychological assessment and a 3-month ‘cooling-off’ period, which is in contrast with the British Society of Paediatric and Adolescent Gynaecologists (BritsPAG), who state that genital cosmetic surgery be delayed until after the age of 18 years, which is when full genital maturity is achieved (BritsPAG October 2013). Following the Medicare review of 2014, a significant reduction of measurable rates of labiaplasty in Australia occurred. However, these figures do not capture the number of procedures performed in the private sector. Health information is sought mainly from on-line sources that until recently, directed concerned women to websites promoting ‘Barbiplasty’ also known as the desirable ‘designer vagina’, or to pornographic sites. To counter misinformation and educate the public around genital diversity, Women's Health Victoria (WHV) responded by developing the interactive on-line ‘labia library’ in 2013 (www.labialibrary.org.au), drawing upon insights gained through a series of focus groups. The ‘labia library’ recently updated its gallery depicting genital diversity across various ages, races and from different angles, in response to feedback received (see Fig. 1 for an example from the website of a frontal image taken). Despite >11 million people accessing the site, the rates of FGCS continue to climb [5]. When seeing women seeking surgical modification of their external genitals for non-medical reasons, it is the clinician's responsibility to assess her knowledge of genital anatomy and function, what it is she wishes to have altered using diagrams or by referring to the website, explore her reasons why, exclude intimate partner or parental coercion, conduct a psychosexual and gynaecological history, and provide her with information around the diversity of genital appearance. Where mental health conditions such as depression, anxiety, or body dysmorphic disorder are suspected, refer for psychological support. Address all her concerns around functional discomfort and offer to perform a sensitive examination. Provide reassurance where medical indications for surgery do not exist, discuss physiological changes over the lifespan, potential risks of surgery, the lack of evidence regarding outcomes and potential changes during pregnancy and menopause. Marketing terms such as ‘vaginal rejuvenation’, ‘clitoral resurfacing’, ‘G-spot enhancement’ are non-medical terms and lack the rigour of scientific evaluation [6]. Genital cosmetic surgery is not recommended in adolescents under the age of 18 years and they should be referred for psychological assessment first. If the woman desires surgery, warn her of the risks such as pain, altered sensation, scarring, adhesions, need for repeat surgery, nodularity, bleeding, dyspareunia, wound dehiscence and infection, ensuring consent is informed. As FGCS poses a significant risk to women and girls when approved patient selection is not followed. Clinicians are well positioned to provide reassurance or counselling where appropriate through the use of suitable resources, thereby safeguarding the future health and wellbeing of patients. Associate Professor Magdalena Simonis has no conflict of interest to declare. Professor Helen O'Connell is the President of the Urological Society of Australia and New Zealand, at the time of authorship.