Female Genital Cosmetic Surgery: Investigating the Role of the General Practitioner

RESEARCH

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

Tristan Harding, Jenny Hayes, Magdalena Simonis, Meredith Temple-Smith

Background emale genital cosmetic surgery (FGCS) encompasses a range of procedures including hymenoplasty, G-spot rejuvenation, Labiaplasty, the surgical reduction of the labia minora, has F vaginal tightening and labiaplasty, which is the surgical significantly increased in demand in Australia. Although reduction of the labia minora. The number of FGCS procedures has general practice is one gatekeeper for patients requesting increased from 444 in 2000 to 1605 in 2013,1 a figure that is a likely labiaplasty, as a referral is necessary to claim Medicare underestimate given this procedure is predominately performed entitlements, there is little information available to assist in the private sector. The portrayal of hairless, prepubescent general practitioners (GPs) in managing these requests for external genitalia in the media2–4 has contributed to the increase in female genital cosmetic surgery. procedures, although this is not representative of society.5 General Methods practice is one gatekeeper to this procedure, but there are few clinical resources available to assist general practitioners (GPs) in Semi-structured interviews were conducted with health the management of patients requesting FGCS. professionals, including GPs, gynaecologists and plastic Most of the limited research into the role of the GP in relation surgeons. Participants were recruited through the Victorian to labiaplasty was conducted in the UK.4 –12 Many of these studies Primary Care Practice-based Research Network (VicReN), acknowledged that there were still significant deficits in the clinical teaching hospitals and snowball sampling. All literature, and despite labiaplasty being promoted as effective interviews were digitally recorded, transcribed, and analysed treatment options with high success rates, no data on clinical using content and thematic analysis. effectiveness exists.8 Additionally, there were only scant data on the risks of these procedures, which could include scarring, Results permanent disfigurement, infection, dyspareunia and altered sexual Twenty-seven interviews were conducted. All participants sensations.13 were aware of genital labiaplasty; many had patients who were This study sought to add to the literature by investigating the role concerned about genital appearance, for which information of the Australian GP in managing patients who present requesting had often been sought opportunistically. All participants agreed FGCS. Interviews were conducted with relevant Australian on the need for resources to inform women of normal genital healthcare professionals, including GPs, gynaecologists and plastic appearance. surgeons, to provide different professional perspectives on the issue. Discussion Methods This novel study demonstrates a need for clinical resources for GPs managing requests for genital labiaplasty. 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

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were recruited from clinical teaching sites few of these women had subsequently of patients asked opportunistic questions affiliated with the University of Melbourne, requested a referral for labiaplasty. Some regarding genital appearance during vaginal and from snowball sampling. Participants GPs commented that they were unaware of examinations and Pap tests. Of concern, were excluded if they were not currently how to best handle these consultations. some patients had delayed Pap tests or practising in their designated specialty. I’ve seen four … they all presented sensitive examinations because of the fear The study was approved by the Human complaining of a feeling that there of being perceived as abnormal. Research Ethics Committee (HREC) at the was something unusual about the I’ve had a few … probably not that University of Melbourne (project HREC appearance of their vaginal region, and on frequently, maybe once every three 1341070.2). examination, it all appeared normal to me months, they may have a concern. (GP, female, 31 years) It’s normally incidental, like with a Pap Data collection I’ve had a few patients say to me ‘Can smear or something … – GP, female, Semi-structured, individual interviews you do a labiaplasty?’ – Gynaecologist, 55 years of age were conducted and audio-recorded female, 37 years of age I would say four, that I have spoken to, with participants at a time and location I gave [a patient] a referral in February to who actually expressed concerns … I convenient to them. The interviews sought see a plastic surgeon … the next time was doing each of their Pap tests, and information on patients who presented with she spoke to me was July of that year, they had delayed their Pap tests because perceived genital imperfections and how and she was extremely unhappy with the it embarrassed them … it did affect their these consultations were managed. surgery … that was my experience at the whole body image and their perception time, and it wasn’t a great one … I would of themselves. They thought they were Data analysis probably handle it differently now. – GP, abnormal. – Nurse, female, 53 years Interviews were transcribed. Thematic female, 46 years of age of age analysis was applied to the data, initially by [A patient] wanted to know if … actually, Some just ask ‘I don’t know if I’m blocking, grouping and labelling, followed maybe, she just said ‘It’s not normal’ … normal, can you tell me?’, but that’s the by secondary analysis to identify emerging She may have asked for a referral, which minority. I’ve had a few people, while themes. Consensus on themes was I didn’t give her, because I didn’t know doing other things like a Pap smear, [who] reached by the study team, most of whom who to refer to, apart from anything else, have expressed a lot of relief when I’ve had different disciplinary backgrounds. and I wasn’t sure it was a Medicare-type reassured them that they are normal … thing. – GP, male, 39 years of age – GP, female, 33 years of age Results Twenty-seven interviews were conducted Many queries regarding normality Assumptions of age of patients with 13 GPs, four gynaecologists, four were opportunistic requesting labiaplasty did not nurses, three plastic surgeons, one GPs noted that some patients who always match experience midwife, one sexual health physician and presented were determined to receive a Many of the practitioners in this study one policymaker. referral for labiaplasty; however, the majority had assumed that younger patients would

Demographics The demographics of interviewees are Table 1. Demographics of participants in the study by specialty and sex shown in Table 1. Three of the 13 GPs had Years Exams completed a Diploma of Obstetrics, one Age worked per had completed a short course on sexual Specialty Female Male Total (range) (range) week* health, and the remainder had never GPs 11 2 13 28–57 5–35 0–10+ received formal women’s or sexual health Nurses 4 – 4 32–50 7–31 0–14 training. The attribution of quotes in the Gynaecologists 1 3 4 37–66 15–35 1–30 results indicates profession, sex and age. Plastic surgeons 1 2 3 47–58 7–20 0–10 Experience with patients Midwives 1 – 1 51 30 2 concerned about their genital Policymakers 1 – 1 34 – – anatomy Sexual health 1 – 1 54 14 30 All participants in this study were aware specialists of FGCS. All practitioners had consulted Total 20 7 27 – – – patients who had questioned whether their genital appearance was normal; a *Includes genital exams and Pap smears performed per week, on average, by each practitioner

be more likely to request cosmetic vulval I think [a patient] was anxious about more reluctant to proceed to surgery surgery; however, their experience was other things, and where she was in her than a plastic surgeon. Many practitioners with a range of women. Plastic surgeons life, and she implied that this was an highlighted the need for education to raise reported performing cosmetic labiaplasties issue for her. We talked about it, and awareness of FGCS. on women aged in their 60s. she was quite reassured to be told she My biggest concern for health … I would say women in their late teens looked normal. – GP, female, 49 years practitioners is the lack of awareness of and early 20s; it’s before you have the of age the issue; their lack of understanding … confidence in your own self, physically can have devastating effects. – GP, male, and emotionally … I think you care less What do health professionals 57 years of age and less about it as you get older. – GP, think is normal? I think any kind of casual remark in male, 39 years of age Health professionals were asked what this circumstance risks having a very I’m guessing the younger age groups; they believed constitutes normal female disproportionate effect on someone’s these are the ones who tend to do more genitalia. A wide variety of responses were psyche … and particularly us blokes, who waxing and shaving, and seem to be received, with many acknowledging that are pretty dopey about this sort of thing… more concerned with their appearance. there is much variation in normal genitalia. ‘But this is all I’ve said’ … But to her, – GP, female, 31 years of age There is a lot of normal variation in the it may have an incredible impact. – GP, They aren’t just in their twenties like external genitalia. – Gynaecologist, male, male, 57 years of age everyone thinks ... I remember one 58 years of age I think I would encourage GPs to have patient I did an operation on was in her I go off my functional definition: as long a higher threshold, and to examine the 60s … you get some who are in their as there was nothing about the anatomy patient, and to have the wherewithal to 60s. – Plastic surgeon, male, 58 years that was preventing sexual function, or say, ‘I think it’s normal’. – Gynaecologist, of age childbirth, or everyday life, then I would male, 48 years of age probably say that it is normal. – GP, … maybe it would be safer to go to a Some women have a poor female, 33 years of age gynaecologist first, because I do feel understanding of normal genital … it’s because it’s an area that’s that referring to a plastic surgeon would appearance hidden, not like ears – you can see that run the risk of leading to them offering Several health professionals in this study ears are all very very different, but you surgery for something that is actually commented that many young women had can’t see labia. Despite variation, it’s within the realms of normal. – GP, female, a poor understanding of ‘normal’ genital all very normal. – Midwife, female, 51 33 years of age anatomy. This had an impact on some years of age I think that primary healthcare providers consultations, with women unable to … experience actually gives you the … [if] they have a good understanding articulate their concerns. Some noted that range of normal … – GP, female, 46 of normal, can short-circuit some because the vulva is hidden, many young years of age of these concerns at the outset … women were unaware of what constitutes – Gynaecologist, male, 58 years of age normal. Some had experiences of relief What is the role of the GP? expressed by women when they were told Participants in this study identified several Discussion their genital anatomy was normal. ways to improve their management of All participants in the study were aware [We are finding that we] need to women requesting FGCS. Importantly, of FGCS, a testimony to the increasing increasingly educate especially younger many believed that simply being more popularity of procedures such as labiaplasty women about their bodies, both function aware of the issue would change their and associated media coverage.7, 8 Many and what they are meant to look like. practice; the importance of sensitive GPs had patients who expressed concern – Gynaecologist, male, 58 years of age language was also highlighted. over their genital appearance, and many I’ve had some people who have come Gynaecologists in this study consistently were surprised at being asked about this by in with a non-specific complaint, like ‘I affirmed that GPs should examine women women; however, on reflection, GPs were just feel like something is not right down who present with concerns about genital aware that there are resources for women there’, but they have been unable to appearance, and reassure them of to use in order to gain a real understanding articulate it. – GP, female, 33 years of age normality. Most participants shared the of normal female anatomy. One such So I’m sure many of them don’t even belief that patients should still be offered resource is the Labia Library.14 Further know what their own genitals look like, a referral should they request one, with advice from participants in this study is I’m sure there is a lack of knowledge some expressing the perception that summarised in Table 2. in that area for younger women. – GP, a gynaecologist would be more likely Some of the health professionals in this female, 49 years of age to reassure a woman of normality and study were able to satisfactorily reassure

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women of normality. Lack of immediate restricted. Each patient needs to have this Meredith Temple-Smith BSc, Dip App Child Psych, Dip reassurance of normality from a healthcare issue explored on its merits. Some of the Movt Dance, MPH, DHSc, Associate Professor and Director, Research Training, Department of General provider, and referral to a specialist, may be GPs in this study believed that reassuring Practice, University of Melbourne, Carlton, VIC interpreted by women as proof of the need women that their genitals were of normal Competing interests: Tristan Harding has had a for surgery.10 As part of their approach, the appearance allayed their fears and did not scholarship paid from the Sexual Health Society of Victoria towards flights to present this study at a healthcare providers suggested that the result in a request for surgery. conference in 2014. normal range of female genitalia is defined From the participants in this study, a Provenance and peer review: Not commissioned, externally peer reviewed. and conveyed to patients,10 along with the number of suggestions can be made notion of limited evidence for benefit of to benefit GPs in their management of References 12 modification of genital morphology. It is these presentations. This novel study, 1. Department of Health and Ageing. Medicare therefore critical that healthcare providers which explored the role of the GP in Benefits Schedule item statistics report: Item 35533 [Requested Medicare items processed are aware of the vast range of normal managing FGCS, has demonstrated that from June 2000 to June 2013]. Canberra: DoHA, female genitalia. Participants in this study the education of GPs on FGCS may enable 2014. Available at www.medicareaustralia.gov. noted that their own view of normal was better outcomes for women with concerns au/statistics/mbs_item.shtml [Accessed 28 September 2014]. based on experience only, suggesting that regarding their genital appearance. Access 2. Bramwell R. Invisible labia: The representation of in the absence of educational material, to visual resources, such as the Labia female external genitals in women’s magazines. Sex Relation Ther 2002;17:187–90. registrars and GPs with a limited female 14 Library, and the development of guidelines 3. Braun V. Female genital cosmetic surgery: A critical patient base may be less confident in for GPs on FGCS, would go some way to review of current knowledge and contemporary reassuring women of normality. addressing this. debates. J Womens Health (Larchmt) 2010;19:1393–407. The largest increase in FGCS in Australia 4. Michala L, Koliantzaki S, Antsaklis A. Protruding is in the 15–24 age group,1 suggesting that Implications for general labia minora: Abnormal or just uncool? J young women need to be informed about practice Psychosom Obstet Gynaecol 2011;32:154–56. 5. Lloyd J, Crouch N, Minto CL, Liao LM, Creighton normal genitalia, and to ensure that health This study has: SM. Female genital appearance: ‘Normality’ professionals are in a position to inform and • been the first to explore views of unfolds. BJOG 2005;112:643–46. possibly reassure about the appearance to 6. Deans R, Liao LM, Crouch NS, Creighton SM. Why Australian health professionals around are women referred for female genital cosmetic prevent potentially unnecessary surgery. FGCS surgery? Med J Aust 2011;195:99. External labia are likely to change during • taken a multidisciplinary approach to 7. Liao LM, Creighton SM. Female genital cosmetic 4 surgery: A new dilemma for GPs. Br J Gen Pract puberty, and this should be taken into determine how GPs might manage 2011;61:7–8. consideration. The Labia Library,14 a new patients requesting FGCS. 8. Liao LM, Michala L, Creighton SM. Labial surgery initiative from Women’s Health Victoria, is for well women: A review of the literature. BJOG Authors 2009;117:20–25. a website depicting the range of normal 9. Liao LM, Taghinejadi N, Creighton SM. An analysis Tristan Harding MD, MSc, BSc, Intern, Western of the content and clinical implications of online female genital anatomy. It can be used to Health, Department of General Practice. tristan. advertisements for female genital cosmetic inform practitioners and women, and is [email protected] surgery. BMJ Open 2012;2:pii:e001908. appropriate as a take-home resource to Jenny Hayes MBBS, Associate Professor, 10. Liao LM, Creighton SM. Requests for cosmetic Department of Anatomy and Neuroscience, reduce discomfort in the clinical setting. genitoplasty: How should healthcare providers University of Melbourne, Parkville, VIC respond? BMJ 2007;334:1090–92. It is important to note that not all women Magdalena Simonis MBBS, FRACGP, DipObst 11. Andrikopoulou M, Michala L, Creightin SM, Liao presenting with concerns about their (RANZCOG), Member, Victorian Primary Care LM. The normal vulva in medical textbooks. J Research Network; Clinical Tutor, Department of genitalia will be cosmetic in nature, nor are Obstet Gynaecol 2013;33:648–50. General Practice, University of Melbourne, Carlton, 12. Michala L, Liao LM, Creighton SM. Female we suggesting that this surgery should be VIC 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 Table 2. Advice for GPs when managing patients concerned about genital of Obstetricians and Gynaecologists. RANZCOG appearance, based on participants’ responses in this study College Statement: Vaginal ‘rejuvination’ and cosmetic vaginal procedures [press release]. • Be aware that this is an increasing issue and women may present with concerns regarding Melbourne: RANZCOG, 2011. genital appearance. 14. Women’s Health Victoria. Labia Library. Melbourne: Women’s Health Victoria, 2013. Available at www. • If patients are comfortable with being examined, do so, and, if appropriate, reassure them that labialibrary.org.au [Accessed 10 February 2015]. 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.