Recommendations for management of patients requesting FGCS or expressing concern about their genitalia

GPs should deal with a patient’s concerns in a sensitive and appropriate manner, asking what influences have played a role in this desire for surgery. It is also important to address the issues, such as lack of knowledge of diversity, clothing, exposure to digital images, partner criticism, family or peer comments, or the result of pubic hair removal.

Discuss factors influencing patient’s concern:

• Clothing, including G-string underwear, tight jeans and body-hugging sportswear that outlines genital detail.
• Images found on the internet, especially pornography. These images are often required to be airbrushed due to classification rules which deem explicit depictions of female genitalia to be inappropriate.^4,35
• Physical symptoms may relate to concerns regarding maintaining hygiene, such as during menstruation and with toileting. Pain or discomfort either when wearing tight clothing or during sporting activities such as walking, horse riding, cycling may also be described. Other symptoms may be related to painful intercourse such as with invagination of the labia minora at the time of penetration. Some women may be concerned regarding vaginal laxity, especially following vaginal childbirth. Assess the degree to which these issues impact the woman’s life and wellbeing both physically and psychologically.
• Lack of knowledge of genital diversity due to limited education in genital appearance.
• Comments made by others, directed at them or otherwise, and why this path has been considered. Offer counselling where coercion from a partner, friend or relative is suspected. This is an opportunity for the GP to enquire about intimate partner abuse, a history of sexual abuse or other domestic or family violence. Appropriate counselling should be provided in these cases. Refer to section 3.3.
• Grooming habits, such as waxing, depilation, shaving and lasering of pubic hair expose more genital skin, while some women develop recurrent skin irritations from procedures such as folliculitis, ingrown hairs and chafing. Draw the distinction between the grooming practices and the complications that can result from them, emphasising the fact surgery will not diminish the likelihood of these complications.

Documentation of psychosexual history as a baseline, along with a full gynaecological and medical history, is very important when discussing FGCS with a patient. The psychosocial context of the patient’s request should be an integral part of the discussion, thereby ensuring the patient’s decisionmaking is as well informed as possible.

Key aspects of a psychosexual history that will assist the GP:

• Assess the degree of anxiety/concern.
• Ask the patient how her concern affects her.
• Ask if the patient’s concern is affecting her intimate relationships, self-esteem, confidence and ability to function happily.
• Ask the patient if there is physical discomfort with or without sex.
• Acknowledge how she feels about the issue.

Refer to Appendix 2 for more information about how to take a psychosexual history.

When a woman presents to her GP with dissatisfaction regarding the appearance of her genitalia, it is important to consider the fact that body image concerns could be linked with psychological or relationship issues that have not been identified or managed. If a mental health diagnosis is made or the request is related to a relationship issue, a referral for counselling should be given.

The spectrum of anxiety can range from women feeling embarrassed about the appearance of their genitalia to thinking they are abnormal. This level of concern can be resolved by provision of information that counters this belief through education in the consultation room and the display of images that depict the diverse range of appearances. At the other end of the spectrum there is a pervasive, unrelenting belief that they are ugly and abnormal to the degree that it affects their quality of life and relationships. For some, this can present as clinical depression, social anxiety, an eating disorder or body dysmorphic disorder.

A referral to a psychologist or psychiatrist, rather than a direct referral for surgery, would be recommended.^5,29 A referral for counselling should be offered when the patient already has a history of mental health issues.

In cases where the GP lacks specific skill in women’s health, or is not granted permission to conduct a physical examination, referral to a women’s health GP, sexual health clinic or a gynaecologist is recommended. Dutch guidelines recommend patients be offered a mirror to assist their understanding of the anatomy and what constitutes normal at the time of a physical examination.⁴⁰

If a referral to another medical practitioner is made, it should clearly state that it is for patient reassurance and examination, not for surgery.

Some patients do not outwardly state that they wish to modify their genital anatomy. However, the GP may take the opportunity to explore any such concerns at the time of a routine Pap smear or gynaecological check-up if and when a woman expresses embarrassment or even apologises for her appearance. Look for dermatological conditions that require appropriate management.

Refer to Appendix 3 for more information on how to examine the patient.⁴¹

Refer patients to appropriate online resources, such as the Labia Library⁴² or other publications, including 101 vagina⁴³ and Femalia⁴⁴, in which there has been no digital enhancement.

When discussing female anatomy, it is important to focus on the sensorineural and functional aspects, and to clarify the differences in terminology.

Figure 1

Anatomy of female genitalia
Reproduced with permission from Women’s Health Victoria.

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Upon examining the genital region, use non-judgemental language to reassure the patient of their normality (provided there is no medical basis for the concern).

Care should be taken not to ‘medicalise’ cosmetic concerns and minor physical symptoms, such as chafing and discomfort from grooming procedures and clothing.

Physical symptoms, if any, need to be discussed with the patient. Identify whether these symptoms are related to the dimensions of her anatomy or due to other factors, such as recurrent infections, tight or poorly-fitted clothing, and skin irritations that are a result of chemical irritants or over-washing.

The medical conditions that constitute reasonable cause for the surgery to be performed have been changed as of November 2014, following the Australian Attorney–General’s investigation into reasons why labiaplasty and other forms of FGCS were being performed and claimed under Medicare. Currently, Medicare item 35533 is intended for the surgical repair of female genital mutilation/cutting (FGM/C) and major congenital anomalies of the uro-gynaecological tract not covered by existing item numbers. It is valid only for inpatient services and will not be paid for outpatient procedures. 

A new Medicare item number, 35534, is for ‘localised gigantism which causes significant functional impairment and where non-surgical treatments have failed’. This item number now requires a specific application to the Department of Human Services, which will then be reviewed by the Medicare Claims Review Panel, to determine if there is enough evidence to qualify for the item number. Medicare benefits can no longer be claimed for non-therapeutic cosmetic genital surgery.

In summary, the clinically relevant indications for vulvoplasty include non-inflammatory disorders of the vulva and perineum, congenital disorders and to repair or reconstruct normal female anatomy following trauma, harmful traditional practices or pathologic processes⁴ (refer to Appendix 4 and Appendix 5.3 for more information).

Refer the patient for a second opinion. A gynaecologist is likely to provide education and resources regarding the range of normal diversity of the anatomy.³³ It is important to clearly state that the referral is for opinion and not surgery, unless it is medically indicated.

Referral of adolescents (younger than 18 years of age) for genital cosmetic surgery is not advised unless it is to a specialist adolescent gynaecologist. Full genital development is not normally achieved before 18 years of age, therefore FGCS should not be carried out on adolescent girls^27,46 (refer to section 5 for further information).

If the patient is still considering undergoing FGCS, encourage them to describe exactly what they wish to have removed. Discuss the lack of long-term data on outcomes and satisfaction, as the potential for injury or complications.

Patients should be warned that the benefits of FGCS are not proven and they are not approved medical procedures. Genital cutaneous sensitivity, erotic sensitivity and orgasmic capacity, which can all be effected by FGCS, have important implications for women’s quality of life.^19,24

Providing the patient with a list of current, publicly-available position statements and recommendations from peak bodies around the world may be helpful (refer to Appendix 5).

Where appropriate, referral to appropriate colleagues (gynaecologists, women’s health GPs, plastic surgeons, etc) can be made. The Medical Board of Australia’s Good medical practice: A code of conduct for doctors in Australia should also be considered (refer to Appendix 6).

Given FGCS is classified as a set of procedures conducted for cosmetic reasons that have no set guidelines and can be performed by a range of practitioners as diverse as GPs, urologists, cosmetic doctors, gynaecologists and plastic surgeons, patients should be aware that outcomes might not be as expected. When a patient presents with postoperative complaints, it may be helpful to refer them to the psychosexual or gynaecological service at the women’s and children’s hospital in their state or territory.