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Most women who undergo labiaplasty have normal anatomy; we should not perform labiaplasty

      An increasing number of patients are seeking cosmetic procedures of the vulva. In 2007, the American College of Obstetricians and Gynecologists released a Committee Opinion (#378) advising against cosmetic vaginal procedures due to a lack of safety and efficacy data. A growing number of observational studies has suggested overall high satisfaction rates, and complication rates that are “acceptable,” although a paucity of comparative data and validated outcomes measures remains. The issue is further intensified and complicated by the proprietary or franchised techniques and devices that surgeons “sell” to each other, and by the fee-for-service model that circumnavigates some of the rigors of the physician-payor-patient relationship. This point/counterpoint article, based on a debate held at the Society of Gynecologic Surgeons’ 2014 Annual Scientific Meeting, addresses the issue of an individual seeking a cosmetic reduction labiaplasty from her gynecologist in the contexts of available literature and standard ethical frameworks. The specific question posed to the panelists was, “Should the gynecologist feel comfortable offering cosmetic labiaplasty procedures to his or her patients?”

      Key words

      The Issue

      Women are seeking cosmetic gynecologic procedures in increasing numbers. Position papers from societies often discourage the gynecologist’s participation in these procedures, while the surgical training and experience in the anatomic region would support that the gynecologist is the best-trained person to perform these procedures. Although efficacy and safety data are emerging, the majority of data are composed of noncomparative studies without validated outcomes measures. This debate addresses the topic of the gynecologist’s role in providing cosmetic labiaplasty.
      Contributed by Charles R. Rardin, MD, Department of Obstetrics and Gynecology, Women & Infant's Hospital, Brown University, Providence, RI.
      Modification of the external genitalia has become one of the top-20 most frequently performed cosmetic surgeries.

      Cosmetic Surgery National Data Bank Statistics. American Society for Aesthetic Plastic Surgery; 2012. Available at: http://www.surgery.org/media/statistics. Accessed June 30, 2014.

      Increased demand for labiaplasty has been attributed to increased visibility of the vulva with shaving or waxing, access to pornographic images of the external genitalia, and advertising in the media. Of 482 women surveyed in a gynecologic practice, 78% found out about labial reduction through the media, and 14% believed that their vulva was abnormal in appearance. Increasingly, women are examining their external genitalia, with over half of women examining their vulva at least monthly. Thankfully, most women think that their vulva is normal and are satisfied with its appearance. Nonetheless, approximately 10% of women in one survey considered undergoing vulvar cosmetic surgery.
      • Yurteri-Kaplan L.A.
      • Antosh D.D.
      • Sokol A.I.
      • et al.
      Interest in cosmetic vulvar surgery and perception of vulvar appearance.
      The increased demand for vulvar surgery is spurred by the belief that the vulva is abnormal in appearance. What is normal in terms of labial anatomy? We know from limited studies as well as clinical experience that there are wide variations in labial size, symmetry, and coloration.
      • Lloyd J.
      • Crouch N.S.
      • Minto C.L.
      • Liao L.M.
      • Creighton S.M.
      Female genital appearance: “normality” unfolds.
      Proponents of labiaplasty aim to create labia that are symmetrical, small, and hidden by the labia majora; characteristics that are shared with prepubescent girls.
      • Griss S.
      Composite reduction labiaplasty.
      In fact, in adult women, complete labial symmetry is not common, and the labia minora commonly protrude outside the labia majora. Proponents of labiaplasty state that the procedure improves sexual function and body image, however, limited published data do not confirm improved sexual function in either the patient or her partner.
      • Ostrzenski A.
      Cosmetic gynecology in the view of evidence-based medicine and ACOG recommendations: a review.
      • Ostrzenski A.
      Selecting aesthetic gynecologic procedures for plastic surgeons: a review of target methodology.
      A review of labiaplasty Internet marketing found unsubstantiated claims for physical, psychological, and sexual benefits on most sites.
      • Liao L.M.
      • Taghinejadi N.
      • Creighton S.M.
      An analysis of the content and clinical implications of online advertisements for female genital cosmetic surgery.
      In reality, prospective comparative data using validated outcome measures are lacking regarding the safety and efficacy of labiaplasty.
      The World Health Organization defines female genital mutilation surgery as procedures that involve the partial or total removal of external female genitalia for nonmedical reasons. Of course, female genital mutilation surgery is largely performed on nonconsenting children, and female cosmetic surgery is performed on consenting adults. Nonetheless, labiaplasty does fit the definition of nonmedically indicated removal of part of the external female genitalia. One wonders if the marketing of “ideal” labial appearance purporting to improve the lives of women is just another form of furthering exploiting the social vulnerability of women.
      Proponents of labiaplasty most often quote the ethical principle of autonomy, stating that a woman has the right to choose or refuse treatment, including labiaplasty. Autonomy must be weighed against other important ethical principles including beneficence, nonmaleficence, and justice. “Beneficence” is defined as acting in the best interests of the patient; “nonmaleficence,” that the physician should “first, do not harm”; and “justice,” that we pay attention to the distribution of scarce resources. Our patients’ trust is based on the principle of beneficence; patients are confident that there is no incentive, financial or otherwise, for their physician to perform a particular procedure. The fathers of medical ethics, John Gregory (1724 through 1773) and Thomas Percival (1740 through 1804) wrote “…surgeons should protect and promote the patient’s health-related interests as their primary concern and keep their economic and other forms of self-interest systematically secondary.” In addition, they wrote “…surgeons should not [act] as a merchant guild that exists to protect the economic, political and social interests of its privileged members.”
      • McCullough L.B.
      • Jones J.W.
      The art of medicine; unraveling ethical challenges in surgery.
      Often accompanied by concurrent cosmetic surgeries such as labia major augmentation, G spot amplification, vaginal rejuvenation, hymenoplasty, or clitoral hood reductions, labiaplasty is nearly always performed on a fee-for-service basis that is costly for the patient and lucrative for those who offer these services.
      • Iglesia C.B.
      • Yurteri-Kaplan L.
      • Alinsod R.
      Female genital cosmetic surgery: a review of techniques and outcomes.
      In 2007, Dr Pauls wrote “What is unique to this area is the patented and secretive nature of some of the most marketed technologies and the large financial gain driving this industry.”
      • Pauls R.N.
      Nip, tuck and rejuvenate; the latest frontier for the gynecologic surgeon.
      Unfortunately, the widespread marketing of labiaplasty and other vulvar cosmetic surgeries undermines the principle of beneficence and calls into question the motivation underlying these practices.
      The principle of nonmaleficence has not been met with the performance of labiaplasty. While a relatively minor procedure, the majority of publications regarding labiaplasty are either case series or expert opinion written by proponents of the procedure. While the physical risks of labiaplasty are thought to be minor, until prospective comparative data with validated outcome measures are available, the safety and efficacy of labiaplasty will remain unknown. Finally, the principle of justice has not been met. In an environment of increasing health care costs and scarcity, diversion of resources to nonmedically indicated procedures with little to no safety or efficacy data is unjust.
      As gynecologists, we are often the primary provider of health services; women look to us to provide guidance and counsel on their health and well-being. I agree with Dr Pauls’ statement in 2007: “Our offices should be a safe haven for women to feel beautiful and accepted because we see them at their most vulnerable. Succumbing to a ‘boutique’ mentality of practicing medicine does not become us.”
      • Pauls R.N.
      Nip, tuck and rejuvenate; the latest frontier for the gynecologic surgeon.
      Exploitation of the social vulnerability of women as sex objects needs to end.
      • Cain J.M.
      • Iglesia C.B.
      • Dickens B.
      • Montgomery O.
      Body enhancement through female genital cosmetic surgery creates ethical and rights dilemmas.

      References

      1. Cosmetic Surgery National Data Bank Statistics. American Society for Aesthetic Plastic Surgery; 2012. Available at: http://www.surgery.org/media/statistics. Accessed June 30, 2014.

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        Female genital appearance: “normality” unfolds.
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        Composite reduction labiaplasty.
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        Selecting aesthetic gynecologic procedures for plastic surgeons: a review of target methodology.
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        An analysis of the content and clinical implications of online advertisements for female genital cosmetic surgery.
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        The art of medicine; unraveling ethical challenges in surgery.
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        Female genital cosmetic surgery: a review of techniques and outcomes.
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