Appendix 5

According to the joint Royal College of Obstetricians and Gynaecologists (RCOG)–BritSPAG release, Issues surrounding women and girls undergoing female genital cosmetic surgery explored, the RCOG ethical opinion paper, Ethical considerations in relation to female genital cosmetic surgery (FGCS), has been produced by the College’s Ethics Committee and focuses on women of all ages undergoing FGCS.

FGCS refers to non-medically indicated cosmetic surgical procedures which change the structure and appearance of the healthy external genitalia of women, or internally in the case of vaginal tightening. This definition includes the most common procedure, labiaplasty, as well as others, such as hymenoplasty and vaginoplasty, also known as vaginal reconstruction and vaginal rejuvenation.

A number of recommendations are made in the paper, including:

• Women should be provided with accurate information about the normal variations in female genitalia and offered counselling and other psychological treatments for problems such as body image distress.
• Women must be informed about the risks of the procedure and the lack of reliable evidence concerning its positive effects.
• As full genital development is not normally achieved before 18 years of age, FGCS should not normally be carried out on girls under this age.
• Surgeons who undertake FGCS should keep written records of the physical and mental health reasons why the procedure was carried out.
• Advertising of FGCS should not mislead people on what is deemed to be normal or what is possible with surgery.
• In general, FGCS should not be undertaken within the National Health Service (NHS) unless it is medically indicated.

The paper offers clinicians recommendations for best practice, including:

• 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 this should be communicated to the girl and her guardian where appropriate.
• Simple measures to relieve labial discomfort should be suggested.
• In case of significant psychological distress, the girl and family should be offered a referral to a paediatric clinical psychologist.

Reproduced with permission from the Royal College of Obstetricians and Gynaecologists. Female genital cosmetic surgery. Ethical opinion paper. London: RCOG; 2013.

According to the article ‘Female genital cosmetic surgery’, published in Journal of Obstetrics and Gynaecology Canada:⁵²

Recommendations

1. The obstetrician and gynaecologist should play an important role in helping women to understand their anatomy and to respect individual variations. (III-A)
2. For women who present with requests for vaginal cosmetic procedures, a complete medical, sexual, and gynaecologic history should be obtained and the absence of any major sexual or psychological dysfunction should be ascertained. Any possibility of coercion or exploitation should be ruled out. (III-B)
3. Counselling should be a priority for women requesting FGCS. Topics should include normal variation and physiological changes over the lifespan, as well as the possibility of unintended consequences of cosmetic surgery to the genital area. The lack of evidence regarding outcomes and the lack of data on the impact of subsequent changes during pregnancy or menopause should also be discussed and considered part of the informed consent process.(III-L)
4. There is little evidence to support any of the FGCSs in terms of improvement to sexual satisfaction or self-image. Physicians choosing to proceed with these cosmetic procedures should not promote these surgeries for the enhancement of sexual function and advertising of female genital cosmetic surgical procedures should be avoided. (III-L)
5. Physicians who see adolescents requesting FGCS require additional expertise in counselling adolescents. Such procedures should not be offered until complete maturity including genital maturity, and parental consent is not required at that time. (III-L)
6. Non-medical terms, including but not restricted to vaginal rejuvenation, clitoral resurfacing, and G-spot enhancement, should be recognized as marketing terms only, with no medical origin; therefore they cannot be scientifically evaluated. (III-L)

Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on Preventive Health Care.

Quality of evidence assessment

I: Evidence obtained from at least one properly randomized controlled trial.
II-1: Evidence from well-designed controlled trials without randomization.
II-2: Evidence from well-designed cohort (prospective or retrospective) or case–control studies, preferably from more than one centre or research group.
II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category.
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Classification of recommendations

1. There is good evidence to recommend the clinical preventive action.
2. There is fair evidence to recommend the clinical preventive action.
3. The existing evidence is conflicting and does not allow to make a recommendation for  or against use of the clinical preventive action; however, other factors may influence  decision-making.
4. There is fair evidence to recommend against the clinical preventive action.
5. There is good evidence to recommend against the clinical preventive action.
6. There is insufficient evidence (in quantity or quality) to make a recommendation; however,  other factors may influence decision-making.

Reproduced with permission from Shaw D, Lefebvre G, Bouchard C, et al. Female genital cosmetic surgery.  J Obstet Gynaecol Can 2013:35(12);1108–14.

 

This statement has been developed and reviewed by the Women’s Health Committee and approved by the RANZCOG Board and Council.

A list of Women’s Health Committee Members can be found in Appendix A.

Disclosure statements have been received from all members of this committee. Disclaimer This information is intended to provide general advice to practitioners. This information should not be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of any patient. This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The document has been prepared having regard to general circumstances.

First endorsed by RANZCOG: July 2008

Current: March 2015

Review due: March 2018

---

Background: This statement was first developed by Women’s Health Committee in July 2008 and most recently reviewed in March 2015.

Funding: The development and review of this statement was funded by RANZCOG.

Surgical or laser  techniques available which claim to improve the appearance of the female genitial tract and enhance sexual function such as  “vaginal rejuvenation”, “revirgination”, “designer vaginoplasty”, “G spot amplification” are poorly understood and what is involved in these procedures is often unclear since recognised clinical nomenclature is not being used. 

The American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice and the Society of Obstetricians and Gynaecologists of Canada have produced documents discouraging the practice of female genital cosmetic surgeries which do not include medically-indicated reconstructions. ^{1, 2}   Gynaecological conditions that merit surgery include genital prolapse, reconstructive surgery following female genital mutilation and labioplasties with clinical indications. Medical practitioners performing any vaginal surgery should be appropriately trained.

Recommendations by these bodies include that the obstetrician and gynaecologist should have a role in educating women that there is a large number of variations in the appearance of normal female external genitalia and that there are normal physiological changes over time, especially following childbirth and menopause. Patients requesting procedures other than for gynaecological conditions should be assessed thoroughly and the reasons for such a request assessed carefully. Sexual counselling is also recommended for patients requesting surgery that is purported to enhance gratification. The College is particularly concerned that such surgery may exploit vulnerable women. Doctors who perform these procedures should not promote or advertise that these surgeries enhance sexual function.

The College strongly discourages the performance of any surgical or laser procedure that lacks current peer reviewed scientific evidence other than in the context of an appropriately constructed clinical trial. At present, there is little high quality evidence, that these procedures are effective, enhance sexual function or improve self-image. The risks of potential complications such as scarring, adhesions, permanent disfigurement, infection, dyspareunia and altered sexual sensations should be discussed in detail with women seeking such treatments.³

References

1. Vaginal “rejuvenation” and cosmetic vaginal procedures, ACOG Committee Opinion No. 376. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110: 737-738. 
2. Shaw D, Lefebvre G, Bouchard C etal.  Female genital cosmetic surgery. J Obstet Gynaecol Can. 2013;35:1108-14
3. Singh A, Swift S, Khullar V, Digesu A.  Laser vaginal rejuvenation: not ready for prime time. Int Urogynecol J. 2015;26:163-164.

Reproduced with permission from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists Vaginal ‘rejuvenation’ and cosmetic vaginal procedures C-Gyn 24. Melbourne: RANZCOG; 2008.

According to resolutions passed at the Medical Women’s International Association (MWIA) 29th International Congress in Seoul, 2013:

MWIA recognises the autonomy of women and upholds the right of adult women to choose to undergo lawful medical and surgical treatments. MWIA advocates for the provision of informed consent for all patients undergoing medical and surgical procedures.

MWIA opposes the advertising of regulated health services (eg those usually provided by a healthcare practitioner) in a way that directly or indirectly encourages their indiscriminate or unnecessary use.

MWIA opposes the promotion of and use of surgical products and techniques that make unproven claims of enhancing female sexual satisfaction and/or attractiveness. MWIA believes that promoting and performing such surgery carries significant risks of physical and psychological harm to women and girls.

MWIA supports the use of gynaecological and plastic surgical techniques where the primary aim is to repair or reconstruct normal female anatomy following trauma, harmful traditional practices, pathologic processes or congenital anomalies.

MWIA opposes media depictions that directly or indirectly promote a prepubescent appearance of female genitalia as sexually desirable. MWIA opposes media images that directly or indirectly promote abnormal perceptions of the appearance of normal female adult genitalia.

Refer to this PDF.

The American College of Obstetricians and Gynaecologists released a committee opinion in 2007 titled Vaginal ‘Rejuvenation’ and Cosmetic Vaginal Procedures.

The Royal Australasian College of Physicians have released a clinical practice guideline in 2009, titled Genital examinations in girls and young women: a clinical practice guideline.