Female genital cosmetic surgery: a new dilemma for GPs

Professional concerns about female genital cosmetic surgery (FGCS) are evident in a number of recent publications. Critiques have come from diverse positions including:

• the provision of medically unrecognisable procedures;¹

• professional laissez-faire relating to audits of adverse events and clinical outcomes;²

• absence of scientific evidence;^1,2

• extension of medicalisation of sex and sexuality;³

• commercial exploitation of women and girls;^1,3

• operations being offered to children;⁴ and

• rebound of the cosmetic surgery industry in the private sector on NHS resources.⁴

In the UK, women and girls are most likely to first present concerns about their genitalia to their GP. Their complaints are likely to fall into two broad categories: physical and psychological. Physical complaints may include discomfort, pain, rubbing, and chaffing during activities such as cycling and horse riding. Psychological complaints may include embarrassment as a result of the labia minora protruding beyond the labia majora, and attendant restrictions on lifestyle choices (for example, concerns about not being able to wear tight clothes or take public showers or engage in certain sexual activities). Reduction of the labia minora is the most likely first line FGCS procedure.

TYPES OF PROCEDURES

Labia reduction procedures fall broadly into two categories. The labial ‘trim’, where a strip of the labia is cut off, is usually performed by gynaecologists. The ‘wedge resection’, which is a more complex procedure involving cutting away a section of each labia minora, is usually carried out by plastic surgeons. The procedures have not been evaluated comparatively, but it is generally assumed that the latter is more likely to result in superior cosmesis, though it may also carry a higher risk of complications.

Labia surgery was first mentioned in the medical literature in 1976. However, it is only since the late 2000s that the number of surgical publications on the topic has surged.² There is no reason to suppose that the size of the labia minora has increased in the past decade. There is also no suggestion that the labia minora have recently become more prone to diseases, as there is no suggestion that surgery is carried out to ameliorate identifiable diseases. Therefore, it can be assumed that the increasing demand for surgery⁴ has something to do with women and girls being more dissatisfied with their labia minora and/or being more aware of the existence of operative techniques.

THE INVISIBLE VULVA

As women and girls are not known to seek surgical enlargement of their labia, it can further be surmised that there is a contemporary cultural preference for small labia. Some women commonly seek a flattened genital surface with labia so small that they are completely hidden by the labia majora or, as has been suggested, a prepubescent aesthetic⁵ that denotes female sexual immaturity.⁶

Clearly women and girls are not the only people who have to accommodate genital discomfort during activities and/or in contact with certain garments. Most men have a far greater share of this inconvenience and, because they do not seek reduction of their genital mass as a solution, some women's intolerance of the physical sensations of their labia is at least partly informed by a psychological ‘discomfort’ about how their genitals present.

Although a simplistic illness model (symptom therefore treatment) is unhelpful for understanding women's help seeking behaviour, it does not mean that their physical and psychological concerns are any less real or do not require addressing. On the contrary, some women and girls present significant emotional distress and an overwhelming desire to alter their genitalia. So what is giving rise to their troubles?

Few people would argue that our society has become more sexualised. It is now normal for women and girls to reveal their bodies in tighter and/or smaller clothes. Thongs and g-strings can be uncomfortable to wear and are too small to hold in all of the normal genitalia. Furthermore, nowadays, many women, especially in the younger age groups, remove most if not all of their pubic hair via the use of waxing, shaving, and depilatory cream. These lifestyle changes render the vulva more visible than ever and contribute to genital appearance consciousness.

In our society, idealised representations of male genitals are large and prominent, and female genitals as ‘lack’,⁷ perhaps symbolising active and passive sexualities respectively. In other words, men have supposedly pendulous, external genitalia, and women a hidden, internal receptacle. These gendered narratives powerfully shape perceptions and desires.

It is no accident that the vulva is commonly, and erroneously, referred to as the vagina – the internal part of the genitalia (as in ‘designer vagina’ and Vagina Monologues, for example). Some girls and women are surprised by the very fact that they have, rather than lack, genitals. The main source for social comparison is the flattened vulva popularised in pornography and advertisement.

GENITAL HEALTH AND HARM, AND THE ROLE OF THE GP

When women report a strong desire for partial excision of their external genitalia, GPs face a dilemma. They feel compelled to alleviate distress, but they are also duty-bound to follow evidence-based practice and to do no harm. Women and girls who are concerned about any part of their genitals should have an examination. Where the genitalia are healthy and normal,⁸ this should be made unambiguously clear to the women and girls.

Some GPs may choose to refer for a gynaecological opinion but they need to make absolutely clear that the referral is for an opinion only and not a passport to surgery. GPs can also help women to understand that surgery is far from straightforward. The majority of operations are carried out in the private sector and providers are not obliged to audit procedures and complications. Even if some providers are willing to do so, dissatisfied consumers may simply shop for different services and never return. Thus there are real barriers for surgeons to learn from consumer feedback.

The known immediate risks of surgery include infection, bleeding, wound dehiscence, and scarring. Importantly, the external genitalia contribute significantly to erotic pleasure, and surgery may result in decreased genital sensitivity. The potential increased risks of perineal trauma during vaginal delivery are as yet unknown but remain a possibility. Anecdotes of success in the popular press should not be confused with the currently missing evidence on long-term clinical effectiveness on physical, psychological, and sexual parameters.²

Genital appearance concerns are quintessentially social and psychological, and surgery is a psychosocial intervention by proxy. Rather than referring on, GPs, practice nurses, psychologists, and other frontline clinicians have a real opportunity to educate and support women and girls who have been strongly taught to devalue their bodies including their genitalia (Box 1).

Box 1 Patient and GP considerations

• The female sexual organs comprise the internal and external genitalia and not just the vagina.

• The flattened vulva is only a recent trend (which could change).

• The majority of operations are carried out in the private sector which is unregulated.

• Risks of surgery include potential increased risks of perineal trauma during vaginal delivery and the possibility of decreased sexual pleasure.

• GPs and other front-line staff have an important role in educating and reassuring women and girls.

But, clinicians, like their patients, have been likewise subjected to prejudicial ideas about female genitalia. They may need to begin by exploring their own attitudes and beliefs, and to become much more familiar with the wide variations in normal genital configurations.^8,9 Recent resources on female genital appearance diversity^10,11 say something about the depth of societal concerns about FGCS.

THE NEED FOR REGULATION

FGCS cannot be discussed as an uncomplicated lifestyle choice based on user autonomy, without reference to gender, class, race, and other social contexts. In her paper ‘Choice as a risk to women's health’, Lippman¹² drew attention to the danger of discussing autonomy as if it were anything other than embedded in social–political structures. Regulation of all FGCS procedures, including their promotion, is a responsibility for our legislature, which is silent on the subject. Clinical governance of FGCS, in the mean time, is a medical responsibility, which is also not taken up. No wonder the FGCS industry has been likened to ‘the old Wild Wild West: wide open and unregulated.’¹³

Provenance

Commissioned, not externally peer reviewed.