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Female Genital Cosmetic Surgery: a Cross- Sectional Survey Exploring Knowledge, Attitude and Practice of General Practitioners

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Female Genital Cosmetic Surgery: a Cross- Sectional Survey Exploring Knowledge, Attitude and Practice of General Practitioners Open Access Research BMJ Open: first published as 10.1136/bmjopen-2016-013010 on 26 September 2016. Downloaded from Female genital cosmetic surgery: a cross- sectional survey exploring knowledge, attitude and practice of general practitioners M Simonis,1,2 R Manocha,3,4 JJOng5,6 To cite: Simonis M, ABSTRACT Strengths and limitations of this study Manocha R, Ong JJ. Female Objective: To explore general practitioner’s (GP) genital cosmetic surgery: a knowledge, attitudes and practice regarding female ▪ cross-sectional survey This is the first large survey that explores general genital cosmetic surgery (FGCS) in Australia. exploring knowledge, attitude practitioner (GP) experience of female genital and practice of general Design: Cross-sectional survey. cosmetic surgery (FGCS). practitioners. BMJ Open Setting: Australia. ▪ Nearly, all GPs surveyed have been asked about 2016;6:e013010. Sample: GPs who attended a women’s health seminar genital normality in women of all ages. doi:10.1136/bmjopen-2016- and GPs who subscribed to a non-governmental, ▪ Thirty-five percent of GPs had been asked about 013010 national health professional organisation database that FGCS by girls under the age of 18. provides education to primary care professionals. ▪ The survey confirms the need for further educa- ▸ Prepublication history and Method: A national online survey of GPs was tion of GPs. additional material is conducted for the 10-week period, starting 1 week ▪ This is a skewed group of GPs with mainly available. To view please visit prior and 2 months after a Women’s Health seminar women’s health interest. the journal (http://dx.doi.org/ was held in Perth on 8 August 2015. 31 questions 10.1136/bmjopen-2016- prompted GPs’ knowledge, attitudes and practice in 013010). managing patients asking about FGCS. and medical implications. FGCS, also known Results: The survey was fully completed by 443 as vulvoplasty, refers to a group of non- Received 15 June 2016 GPs; 54% had seen patients requesting FGCS. Overall, medically indicated cosmetic surgical proce- Revised 11 August 2016 75% (95% CI 71% to 79%) of GPs rated their dures that change the structure and appear- http://bmjopen.bmj.com/ Accepted 1 September 2016 knowledge of FGCS as inadequate and 97% (95% CI 94% to 99%) had been asked by women of all ages ance of the healthy external genitalia of about genital normality. Of those who had seen women, or internally in the case of vaginal 12 fi patients requesting FGCS, nearly half (44%, 95% CI tightening. More speci cally, it encom- 38% to 51%) reported they had insufficient passes labiaplasty (trimming of the labia knowledge of risks of FGCS procedures and 35% minora and less commonly labia majora), (95% CI 29% to 41%) reported seeing females hymenoplasty, vaginoplasty (also known as younger than 18 years of age requesting FGCS. Just vaginal reconstruction), mons pubis liposuction, over half (56%, 95% CI 51% to 60%) of the GPs felt ‘ ’ ‘ ’ vaginal rejuvenation or laser rejuvenation , on September 24, 2021 by guest. Protected copyright. that women should be counselled before making a G-spot augmentation and Orgasm-shot.12 referral for FGCS. More than half the GPs suspected Following liposuction, breast augmentation psychological disturbances in their patients and rhinoplasty, labiaplasty was reported to requesting FGCS such as depression, anxiety, relationship difficulties and body dysmorphic be the fourth most common cosmetic surgi- disorder. cal procedure according to US statistics in 3 Conclusions: GPs see women of all ages presenting 2013, rising by 44% in the 2013 alone. Over – with genital anatomy concerns and in those who thedecade20032013, Australia had a three- 4 request FGCS, GPs often suspected a range of mental fold increase in labiaplasties and the UK a health difficulties. GPs require greater education to fivefold increase.5 Australian government statis- support their patients who request FGCS. tics indicate a 140% increase in requests for rebatable vulvoplasty from 640 in 2001 to more For numbered affiliations see 4 end of article. than 1500 in 2013, without a concomitant rise in genital disease diagnoses.6 These figures do INTRODUCTION not reflect the true number of procedures per- Correspondence to Dr M Simonis; The popularity of female genital cosmetic formed, as an unknown number of procedures magdalena.simonis@mac. surgery (FGCS) is growing and genital modi- are performed in the private sector for which com fication for cosmetic reasons has many social there are no accurate published figures. Simonis M, et al. BMJ Open 2016;6:e013010. doi:10.1136/bmjopen-2016-013010 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2016-013010 on 26 September 2016. Downloaded from Much of the research published to date has emanated consecutive weeks which also coincided with a GP from the UK and USA. It has explored sociocultural response rate of around 1% of the national GP popula- reasons for the rise in FGCS procedures,78the ethical tion and 4% of the database GP population. The aspects regarding its heavy marketing by sectors of the Raosoft sample size calculator was used (http://www. – medical profession7911 and surgical discourse regard- raosoft.com/samplesize.html) to attain a confidence – ing techniques,121215 with little published literature for level of 95% and margin error of 5%. Accordingly, the the medical profession discussing risks and long-term largest sample size required from the estimated 33 275 outcomes of FGCS.15 16 The role of the general practi- GPs in Australia was 380. The number of survey tioner (GP) regarding this emerging area of surgery has responses preceding the seminar reached 379 and fol- been identified as a ‘new dilemma for the general practi- lowing the seminar, there were 64. Of the 64 respon- tioner (GP)’.91017 dents, it is not possible to differentiate between those A recently published qualitative study from Australia who attended the FGCS information session and those interviewed 27 health professionals of which 13 were who did not. GPs.18 This study revealed that although all of the GP participants were aware of FGCS and all practitioners Data collection had seen patients who had questioned whether their Survey Monkey was used to create and administer the genital appearance was normal, they were unaware of online survey (see online supplementary file 1), which how to best manage these consultations. In response to was prepared by two GPs (MS, RM) and a Sexual Health the increasing demand for FGCS and advice sought physician (JJO). The survey items contained questions from the GPs regarding FGCS, the Royal Australian about the GP’s knowledge, attitudes and practice regard- College of General Practitioners launched the resource ing FGCS. Two open-ended items on the GP’s attitudes guide for health professionals titled, ‘Female Genital to FGCS were included at the end of the survey, inviting Cosmetic Surgery: a resource for general practitioners free text responses. The survey was pilot tested with 20 19 and other health professionals’ on 31 July 2015. As the primary care health professionals before distribution. first point of contact with the healthcare system, This was a voluntary opt in, anonymous survey and no informed GPs can play an important and central role in incentives were offered to participants. Only the fully educating women and girls regarding the varied range completed surveys were examined. of genital appearance and the risks of genital surgery.17 fi They can also help to address modi able psychosocial Analysis factors, thereby assisting women towards better health 717 Participant demographics and their knowledge, attitudes outcomes. and practice variables were analysed descriptively. To date, limited quantitative research has explored the Ninety-five percent CIs were calculated for proportions management of FGCS from the GP perspective. This using the modified Wald method. All analyses were per- http://bmjopen.bmj.com/ fi study addresses a signi cant research gap by being the formed using the statistical software, STATA fi rst to explore the knowledge, attitude and practice (Statacorp. 2013. Stata Statistical Software: Release 13). The regarding FGCS in a large group of GPs. 2 open-ended questions were manually analysed by 3 researchers independently and the 6 main themes and 29 subthemes were agreed on. We used a qualitative METHODS descriptive research approach, a pragmatic approach Study population commonly used in health science research as it aims to In order to recruit GPs, the online survey (see online provide straight descriptions of events or topics in every- on September 24, 2021 by guest. Protected copyright. fi supplementary le 1) and Information Statement (see day language rather than an interpretive or theory-based fi online supplementary le 2) were sent via email three analysis.20 21 ∼ times at intervals of 3 days each, to 11 000 GPs. This This research was approved by the Alfred Health group of GPs voluntarily subscribes to a private educa- Human Ethics Committee (Project 348/15). tional organisation database to receive free seminar information, material, invitations and updates in matters pertaining to primary healthcare and this database has RESULTS been in existence since the year 2000. The RACGP guide- There were 443 fully completed GP survey responses out lines were published and launched on 31 July 2015. The of a total of 461. Each incomplete response was manu- survey was first sent out on 3 August 2015 and during ally examined and the decision to exclude the informa- the Women’s and Children’s seminar, at which an FGCS tion was based on the failure to progress beyond the first information session for GPs was held on 8 August 2015. question. Tables 1–3 give the overview of the 443 respon- It was considered important to send out the survey prior dents’ knowledge, practice and attitudes; tables 4–7 look to the seminar and as close to the launch of the RACGP closer at the 242 GPs who have seen women requesting guidelines, in order to assess a baseline of GP knowl- FGCS.
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