LOW PRIORITY PROCEDURE: Policy T33 Labiaplasty Author: Ipswich and East and West Suffolk Clinical Commissioning Group First published: July 2011 First revision: April 2014 Second revision: August 2015 Reviewed: July 2016 Review date: July 2018 Policy Summary As with all cosmetic procedures, surgery to alter the appearance of the female genitalia will not be routinely funded by the NHS unless there is a clear clinical need. Patients with a clear clinical indication for labiaplasty will meet one of the criteria detailed in this policy and will be offered surgery. Individual Funding Request* panel will consider requests from clinicians if a patient does not meet the criteria but the clinician feels there is a strong clinical need. *An Individual Funding Request will only be accepted if it is supported by an Obstetrics and Gynaecology Consultant who has performed and documented a clinical examination and confirms that there is a defined clinical need. Eligibility Criteria Patients will be considered for labiaplasty if one or more of the criteria below are met: 1. The presence of another medical condition (such as cancer or congenital malformation) has caused labial hypertrophy and there is clinical indication for labiaplasty. 2. Repair to the labia is required following trauma, including traumatic birth injury. Background to the condition and treatment The term ‘labial hypertrophy’ refers to a state in which the inner labia minora are disproportionately large compared with the outer labia majora. There is no universal definition or measurement for what is ‘normal’ and what is disproportionate and women vary considerably both in the shape and size of their genitalia, and in their perception of normality1. Assessment therefore tends to focus on functionality, for example if a patient finds her labia chafe uncomfortably against her clothes, limit her participation in activities like horse riding or cycling, or interfere with her sexual function2. Labiaplasty is the process of surgically resecting the labia minora in order to reduce their size. The number of labial reduction procedures undertaken by the NHS has increased five-fold over the last decade, and true incidence is probably much higher as no activity data are available for labiaplasties undertaken in the private sector. According to Hospital Evidence Statistics data, 2,000 labiaplasties were undertaken in 2010, however it unknown how many of these were for clinical indications and how many for cosmetic reasons3. Rationale behind the policy The Royal College of Obstetricians and Gynaecologists is of the opinion that there is a lack of high quality evidence supporting the use of labiaplasty and the College reports no data exist on the efficacy of labiaplasty for the treatment of functional problems. Labiaplasty carries the risks of bleeding and wound infection, with wound dehiscence (rupture or splitting open) reported in up to 30% of cases. This can require a second operation to correct. The College also warn of the risk of damage to sensitivity and sexual function following labiaplasty, as surgery can disrupt the nerve supply to the vagina and vulva. The labia minora are thought to play a role in sexual arousal – the area is densely innervated and contains oestrogen receptors and erectile tissue. Removal of this tissue could therefore result in decreased sensation and altered sexual experience. The surgery also carries the risk of scarring, and scar tissue has the potential to disrupt sexual function as the tissues become less contractile3. This stance is mirrored by that of the American College of Obstetrics and gynaecology4. A review of policies by other Clinical Commissioning Groups found eligibility criteria tended to extend only to cancer and congenital malformation and severe trauma, with some CCGs excluding birthing trauma. Media coverage has raised the profile of labiaplasty and increasing numbers of women who are dissatisfied with the appearance of their genitalia are seeking surgery for aesthetic reasons. Issues surrounding gender politics, body dysmorphia and the increasing influence of the porn industry reflect society’s general inclination towards the pursuit of an often distorted view of perfection5-7. The potential explosion of referrals for labiaplasty carries considerable financial implications for the NHS. In order to ensure resources are available to those with real clinical need, Ipswich and East and West Suffolk Clinical Commissioning Group has devised the above criteria which excludes patients seeking labiaplasty for cosmetic reasons. References 1. http://reference.medscape.com/article/1372175-overview#a0102 2. Goodman MP. Female genital cosmetic and plastic surgery: a review. J Sex Med. 2011 Jun;8(6):1813-25 3. http://www.rcog.org.uk/files/rcog-orp/RCOG%20FGCS%20Ethical%20opinion%20paper.pdf 4. ACOG Committee Opinion ‘Vaginal “Rejuvenation” and Cosmetic Vaginal Procedures’, 378, (September 2007). 5. http://www.bbc.co.uk/news/health-18947106 6. http://www.theguardian.com/lifeandstyle/2009/nov/20/cosmetic-vulva-surgery 7. http://blog.wellcome.ac.uk/2012/07/20/new-short-film-centrefold-tackles-the-ethics-of- labiaplasty/ Policies by other CCGs 1. Hull: http://www.hullccg.nhs.uk/data/uploads/clinical-commissioning-policies-from-1-4- 13/new-updated-policies/labiaplasty-and-vaginoplasty-hull-ccg-2014.pdf 2. West Essex: http://www.westessexccg.nhs.uk/Downloads/Your%20NHS/Service%20Restriction%20Polici es/Updated/Labiaplasty%20policy.pdf 3. Warwickshire North: Partially excluded policy. “Labiaplasty of the labia minora for cosmetic or functional reasons is not funded. This policy does not relate to reversal of female genital mutilation which is routinely funded.” 4. Kernow: IFR only. https://www.kernowccg.nhs.uk/media/96960/patient_information__cosmetic_procedures.pdf 5. South Gloucestershire, Bristol, North Somerset: http://www.swcsu.nhs.uk/media/12246/Labiaplasty-Vaginoplasty-and-Hymenorrhaphy- Policy.pdf .