Mental illness

2015

Research

Female genital cosmetic surgery: Investigating the role of the general practitioner

Volume 44, No.11, 2015 Pages 822-825

Tristan Harding

Jenny Hayes

Magdalena Simonis

Meredith Temple-Smith

Background

Labiaplasty, the surgical reduction of the labia minora, has significantly increased in demand in Australia. Although general practice is one gatekeeper for patients requesting labiaplasty, as a referral is necessary to claim Medicare entitlements, there is little information available to assist general practitioners (GPs) in managing these requests for female genital cosmetic surgery.

Methods

Semi-structured interviews were conducted with health professionals, including GPs, gynaecologists and plastic surgeons. Participants were recruited through the Victorian Primary Care Practice-based Research Network (VicReN), clinical teaching hospitals and snowball sampling. All interviews were digitally recorded, transcribed, and analysed using content and thematic analysis.

Results

Twenty-seven interviews were conducted. All participants were aware of genital labiaplasty; many had patients who were concerned about genital appearance, for which information had often been sought opportunistically. All participants agreed on the need for resources to inform women of normal genital appearance.

Discussion

This novel study demonstrates a need for clinical resources for GPs managing requests for genital labiaplasty.

Female genital cosmetic surgery (FGCS) encompasses a range of procedures including hymenoplasty, G-spot rejuvenation, vaginal tightening and labiaplasty, which is the surgical reduction of the labia minora. The number of FGCS procedures has increased from 444 in 2000 to 1605 in 2013,1 a figure that is a likely underestimate given this procedure is predominately performed in the private sector. The portrayal of hairless, prepubescent external genitalia in the media2–4 has contributed to the increase in procedures, although this is not representative of society.5 General practice is one gatekeeper to this procedure, but there are few clinical resources available to assist general practitioners (GPs) in the management of patients requesting FGCS.

Most of the limited research into the role of the GP in relation to labiaplasty was conducted in the UK.4–12 Many of these studies acknowledged that there were still significant deficits in the literature, and despite labiaplasty being promoted as effective treatment options with high success rates, no data on clinical effectiveness exists.8 Additionally, there were only scant data on the risks of these procedures, which could include scarring, permanent disfigurement, infection, dyspareunia and altered sexual sensations.13

This study sought to add to the literature by investigating the role of the Australian GP in managing patients who present requesting FGCS. Interviews were conducted with relevant Australian healthcare professionals, including GPs, gynaecologists and plastic surgeons, to provide different professional perspectives on the issue.

Methods

As little is known on this topic, this study used a qualitative research design to explore the viewpoints of Australian health professionals. Semi-structured interviews were conducted with Australian GPs, gynaecologists, plastic surgeons and other relevant professionals. GPs were recruited from the Victorian Primary Care Practice-based Research Network (VicReN). Other health professionals were recruited from clinical teaching sites affiliated with the University of Melbourne, and from snowball sampling. Participants were excluded if they were not currently practising in their designated specialty. The study was approved by the Human Research Ethics Committee (HREC) at the University of Melbourne (project HREC 1341070.2).

Data collection

Semi-structured, individual interviews were conducted and audio-recorded with participants at a time and location convenient to them. The interviews sought information on patients who presented with perceived genital imperfections and how these consultations were managed.

Data analysis

Interviews were transcribed. Thematic analysis was applied to the data, initially by blocking, grouping and labelling, followed by secondary analysis to identify emerging themes. Consensus on themes was reached by the study team, most of whom had different disciplinary backgrounds.

Results

Twenty-seven interviews were conducted with 13 GPs, four gynaecologists, four nurses, three plastic surgeons, one midwife, one sexual health physician and one policymaker.

Demographics

The demographics of interviewees are shown in Table 1. Three of the 13 GPs had completed a Diploma of Obstetrics, one had completed a short course on sexual health, and the remainder had never received formal women’s or sexual health training. The attribution of quotes in the results indicates profession, sex and age.

Table 1. Demographics of participants in the study by specialty and sex

Specialty

Female

Male

Total

Age (range)

Years worked (range)

Exams per week*

GPs

11

2

13

28–57

5–35

0–10+

Nurses

4

4

32–50

7–31

0–14

Gynaecologists

1

3

4

37–66

15–35

1–30

Plastic surgeons

1

2

3

47–58

7–20

0–10

Midwives

1

1

51

30

2

Policymakers

1

1

34

Sexual health specialists

1

1

54

14

30

Total

20

7

27

*Includes genital exams and Pap smears performed per week, on average, by each practitioner

Experience with patients concerned about their genital anatomy

All participants in this study were aware of FGCS. All practitioners had consulted patients who had questioned whether their genital appearance was normal; a few of these women had subsequently requested a referral for labiaplasty. Some GPs commented that they were unaware of how to best handle these consultations.

I’ve seen four … they all presented complaining of a feeling that there was something unusual about the appearance of their vaginal region, and on examination, it all appeared normal to me (GP, female, 31 years)

I’ve had a few patients say to me ‘Can you do a labiaplasty?’ – Gynaecologist, female, 37 years of age

I gave [a patient] a referral in February to see a plastic surgeon … the next time she spoke to me was July of that year, and she was extremely unhappy with the surgery … that was my experience at the time, and it wasn’t a great one … I would probably handle it differently now. – GP, female, 46 years of age

[A patient] wanted to know if … actually, maybe, she just said ‘It’s not normal’ … She may have asked for a referral, which I didn’t give her, because I didn’t know who to refer to, apart from anything else, and I wasn’t sure it was a Medicare-type thing. – GP, male, 39 years of age

Many queries regarding normality were opportunistic

GPs noted that some patients who presented were determined to receive a referral for labiaplasty; however, the majority of patients asked opportunistic questions regarding genital appearance during vaginal examinations and Pap tests. Of concern, some patients had delayed Pap tests or sensitive examinations because of the fear of being perceived as abnormal.

I’ve had a few … probably not that frequently, maybe once every three months, they may have a concern. It’s normally incidental, like with a Pap smear or something … – GP, female, 55 years of age

I would say four, that I have spoken to, who actually expressed concerns … I was doing each of their Pap tests, and they had delayed their Pap tests because it embarrassed them … it did affect their whole body image and their perception of themselves. They thought they were abnormal. – Nurse, female, 53 years of age

Some just ask ‘I don’t know if I’m normal, can you tell me?’, but that’s the minority. I’ve had a few people, while doing other things like a Pap smear, [who] have expressed a lot of relief when I’ve reassured them that they are normal … – GP, female, 33 years of age

Assumptions of age of patients requesting labiaplasty did not always match experience

Many of the practitioners in this study had assumed that younger patients would be more likely to request cosmetic vulval surgery; however, their experience was with a range of women. Plastic surgeons reported performing cosmetic labiaplasties on women aged in their 60s.

… I would say women in their late teens and early 20s; it’s before you have the confidence in your own self, physically and emotionally … I think you care less and less about it as you get older. – GP, male, 39 years of age

I’m guessing the younger age groups; these are the ones who tend to do more waxing and shaving, and seem to be more concerned with their appearance. – GP, female, 31 years of age

They aren’t just in their twenties like everyone thinks ... I remember one patient I did an operation on was in her 60s … you get some who are in their 60s. – Plastic surgeon, male, 58 years 
of age

Some women have a poor understanding of normal genital appearance

Several health professionals in this study commented that many young women had a poor understanding of ‘normal’ genital anatomy. This had an impact on some consultations, with women unable to articulate their concerns. Some noted that because the vulva is hidden, many young women were unaware of what constitutes normal. Some had experiences of relief expressed by women when they were told their genital anatomy was normal.

[We are finding that we] need to increasingly educate especially younger women about their bodies, both function and what they are meant to look like. – Gynaecologist, male, 58 years of age

I’ve had some people who have come in with a non-specific complaint, like ‘I just feel like something is not right down there’, but they have been unable to articulate it. – GP, female, 33 years of age

So I’m sure many of them don’t even know what their own genitals look like, I’m sure there is a lack of knowledge in that area for younger women. – GP, female, 49 years of age

I think [a patient] was anxious about other things, and where she was in her life, and she implied that this was an issue for her. We talked about it, and she was quite reassured to be told she looked normal. – GP, female, 49 years of age

What do health professionals think is normal?

Health professionals were asked what they believed constitutes normal female genitalia. A wide variety of responses were received, with many acknowledging that there is much variation in normal genitalia.

There is a lot of normal variation in the external genitalia. – Gynaecologist, male, 58 years of age

I go off my functional definition: as long as there was nothing about the anatomy that was preventing sexual function, or childbirth, or everyday life, then I would probably say that it is normal. – GP, female, 33 years of age

… it’s because it’s an area that’s hidden, not like ears – you can see that ears are all very very different, but you can’t see labia. Despite variation, it’s all very normal. – Midwife, female, 51 years of age

… experience actually gives you the range of normal … – GP, female, 46 years of age

What is the role of the GP?

Participants in this study identified several ways to improve their management of women requesting FGCS. Importantly, many believed that simply being more aware of the issue would change their practice; the importance of sensitive language was also highlighted.

Gynaecologists in this study consistently affirmed that GPs should examine women who present with concerns about genital appearance, and reassure them of normality. Most participants shared the belief that patients should still be offered a referral should they request one, with some expressing the perception that a gynaecologist would be more likely to reassure a woman of normality and more reluctant to proceed to surgery than a plastic surgeon. Many practitioners highlighted the need for education to raise awareness of FGCS.

My biggest concern for health practitioners is the lack of awareness of the issue; their lack of understanding … can have devastating effects. – GP, male, 57 years of age

I think any kind of casual remark in this circumstance risks having a very disproportionate effect on someone’s psyche … and particularly us blokes, who are pretty dopey about this sort of thing… ‘But this is all I’ve said’ … But to her, it may have an incredible impact. – GP, male, 57 years of age

I think I would encourage GPs to have a higher threshold, and to examine the patient, and to have the wherewithal to say, ‘I think it’s normal’. – Gynaecologist, male, 48 years of age

… maybe it would be safer to go to a gynaecologist first, because I do feel that referring to a plastic surgeon would run the risk of leading to them offering surgery for something that is actually within the realms of normal. – GP, female, 33 years of age

I think that primary healthcare providers … [if] they have a good understanding of normal, can short-circuit some of these concerns at the outset … – Gynaecologist, male, 58 years of age

Discussion

All participants in the study were aware of FGCS, a testimony to the increasing popularity of procedures such as labiaplasty and associated media coverage.7,8 Many GPs had patients who expressed concern over their genital appearance, and many were surprised at being asked about this by women; however, on reflection, GPs were aware that there are resources for women to use in order to gain a real understanding of normal female anatomy. One such resource is the Labia Library.14 Further advice from participants in this study is summarised in Table 2.

Table 2. Advice for GPs when managing patients concerned about genital appearance, based on participants’ responses in this study
  • Be aware that this is an increasing issue and women may present with concerns regarding genital appearance.
  • If patients are comfortable with being examined, do so, and, if appropriate, reassure them that their genital appearance is within the normal range.
  • Use the Labia Library14 to inform young women about the range of genital appearance.
  • Carefully consider appropriate body language and choice of words while discussing this sensitive issue, as seemingly benign remarks may be misinterpreted.
  • Refer where appropriate, keeping in mind that some surgeons may operate on patients with normal genital anatomy.

Some of the health professionals in this study were able to satisfactorily reassure women of normality. Lack of immediate reassurance of normality from a healthcare provider, and referral to a specialist, may be interpreted by women as proof of the need for surgery.10 As part of their approach, the healthcare providers suggested that the normal range of female genitalia is defined and conveyed to patients,10 along with the notion of limited evidence for benefit of modification of genital morphology.12 It is therefore critical that healthcare providers are aware of the vast range of normal female genitalia. Participants in this study noted that their own view of normal was based on experience only, suggesting that in the absence of educational material, registrars and GPs with a limited female patient base may be less confident in reassuring women of normality.

The largest increase in FGCS in Australia is in the 15–24 age group,1 suggesting that young women need to be informed about normal genitalia, and to ensure that health professionals are in a position to inform and possibly reassure about the appearance to prevent potentially unnecessary surgery. External labia are likely to change during puberty,4 and this should be taken into consideration. The Labia Library,14 a new initiative from Women’s Health Victoria, is a website depicting the range of normal female genital anatomy. It can be used to inform practitioners and women, and is appropriate as a take-home resource to reduce discomfort in the clinical setting.

It is important to note that not all women presenting with concerns about their genitalia will be cosmetic in nature, nor are we suggesting that this surgery should be restricted. Each patient needs to have this issue explored on its merits. Some of the GPs in this study believed that reassuring women that their genitals were of normal appearance allayed their fears and did not result in a request for surgery.

From the participants in this study, a number of suggestions can be made to benefit GPs in their management of these presentations. This novel study, which explored the role of the GP in managing FGCS, has demonstrated that the education of GPs on FGCS may enable better outcomes for women with concerns regarding their genital appearance. Access to visual resources, such as the Labia Library,14 and the development of guidelines for GPs on FGCS, would go some way to addressing this.

Implications for general practice

This study has:

  • been the first to explore views of Australian health professionals around FGCS
  • taken a multidisciplinary approach to determine how GPs might manage patients requesting FGCS.

Authors

Tristan Harding MD, MSc, BSc, Intern, Western Health, Department of General Practice. tristan.harding@wh.org.au

Jenny Hayes MBBS, Associate Professor, Department of Anatomy and Neuroscience, University of Melbourne, Parkville, VIC

Magdalena Simonis MBBS, FRACGP, DipObst (RANZCOG), Member, Victorian Primary Care Research Network; Clinical Tutor, Department of General Practice, University of Melbourne, Carlton, VIC

Meredith Temple-Smith BSc, Dip App Child Psych, Dip Movt Dance, MPH, DHSc, Associate Professor and Director, Research Training, Department of General Practice, University of Melbourne, Carlton, VIC

Competing interests: Tristan Harding has had a scholarship paid from the Sexual Health Society of Victoria towards flights to present this study at a conference in 2014.
Provenance and peer review: Not commissioned, externally peer reviewed.

References

  1. Department of Health and Ageing. Medicare Benefits Schedule item statistics report: Item 35533 [Requested Medicare items processed from June 2000 to June 2013]. Canberra: DoHA, 2014. Available at www.medicareaustralia.gov.au/statistics/mbs_item.shtml [Accessed 28 September 2014].
  2. Bramwell R. Invisible labia: The representation of female external genitals in women’s magazines. Sex Relation Ther 2002;17:187–90.
  3. Braun V. Female genital cosmetic surgery: A critical review of current knowledge and contemporary debates. J Womens Health (Larchmt) 2010;19:1393–407.
  4. Michala L, Koliantzaki S, Antsaklis A. Protruding labia minora: Abnormal or just uncool? J Psychosom Obstet Gynaecol 2011;32:154–56.
  5. Lloyd J, Crouch N, Minto CL, Liao LM, Creighton SM. Female genital appearance: ‘Normality’ unfolds. BJOG 2005;112:643–46.
  6. Deans R, Liao LM, Crouch NS, Creighton SM. Why are women referred for female genital cosmetic surgery? Med J Aust 2011;195:99.
  7. Liao LM, Creighton SM. Female genital cosmetic surgery: A new dilemma for GPs. Br J Gen Pract 2011;61:7–8.
  8. Liao LM, Michala L, Creighton SM. Labial surgery for well women: A review of the literature. BJOG 2009;117:20–25.
  9. Liao LM, Taghinejadi N, Creighton SM. An analysis of the content and clinical implications of online advertisements for female genital cosmetic surgery. BMJ Open 2012;2:pii:e001908.
  10. Liao LM, Creighton SM. Requests for cosmetic genitoplasty: How should healthcare providers respond? BMJ 2007;334:1090–92.
  11. Andrikopoulou M, Michala L, Creightin SM, Liao LM. The normal vulva in medical textbooks. J Obstet Gynaecol 2013;33:648–50.
  12. Michala L, Liao LM, Creighton SM. Female genital cosmetic surgery: How can clinicians act in women’s best interests? The Obstetrician & Gynaecologist 2012;14:203–06.
  13. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. RANZCOG College Statement: Vaginal ‘rejuvination’ and cosmetic vaginal procedures [press release]. Melbourne: RANZCOG, 2011.
  14. Women’s Health Victoria. Labia Library. Melbourne: Women’s Health Victoria, 2013. Available at www.labialibrary.org.au [Accessed 10 February 2015].

Correspondence afp@racgp.org.au

Yes     No

Declaration of competing interests *

Yes No

Additional Author (remove)

Yes No

    

 

 

 

 

Competing Interests: 

Your comment is being submitted, please wait

 

Download citation in RIS format (EndNote, Zotero, RefMan, RefWorks)

Download citation in BIBTEX format (RefMan)

Download citation in REFER format (EndNote, Zotero, RefMan, RefWorks)

For more information see Wikipedia: Comparison of reference management software
Advertisement loading...

Advertisement

Type

Research

2015