The RCOG ethical opinion paper has been produced by the College’s Ethics Committee and focuses on women of all ages undergoing female genital cosmetic surgery (FGCS).
FGCS refers to non-medically indicated cosmetic surgical procedures which change the structure and appearance of the healthy external genitalia of women, or internally in the case of vaginal tightening. This definition includes the most common procedure, labiaplasty, as well as others, such as hymenoplasty and vaginoplasty, also known as vaginal reconstruction and vaginal rejuvenation.
According to Hospital Episode Statistics (HES), the number of labial reduction procedures has risen five-fold in the NHS over the past 10 years, with over 2000 operations having been performed in 2010.
The RCOG’s Ethics Committee paper explores the ethical aspects of FGCS. It looks at the reasons why women request these procedures and the issues around body dissatisfaction. Labiaplasty is a procedure undergone for problems relating to the size of the labia minora and concerns with hygiene, difficulties during sexual intercourse, and discomfort when wearing tight clothes. However, for some women, the main reason for requesting labiaplasty can be concern about genital appearance. In extreme cases this concern is an aspect of body dysmorphic disorder.
As with any surgical procedure, labiaplasty carries short-term risks of bleeding and wound infection. However, there are no data on the potential physical and psychological risks in the medium and long term. Long-term damage to sensitivity and sexual function may also occur after labiaplasty, as surgery will disrupt nerve supply with consequences for sensitivity and the paper calls for more data to inform women about these potential outcomes.
A number of recommendations are made in the paper including:
- Women should be provided with accurate information about the normal variations in female genitalia and offered counselling and other psychological treatments for problems such as body image distress
- Women must be informed about the risks of the procedure, the lack of reliable evidence concerning its positive effects
- As full genital development is not normally achieved before 18, FGCS should not normally be carried out on girls under 18 years
- Surgeons who undertake FGCS should keep written records of the physical and mental health reasons why the procedure was carried out
- Advertising of FGCS should not mislead people on what is deemed to be normal or what is possible with surgery
- In general, FGCS should not be undertaken within the National Health Service (NHS) unless it is medically indicated.
The BritSPAG position statement focuses specifically on adolescents undergoing labiaplasty. This was the result of growing concerns over such surgery being performed on girls under 18 years.
It explores the reasons why girls may be dissatisfied with vulval appearance including accessibility to unrealistic and narrow representations of vulval appearance in popular culture and intensive marketing of labiaplasty as an unproblematic lifestyle choice.
The paper offers clinicians recommendations for best practice including:
- A genital examination should be offered and conducted sensitively
- Information about normal variations should be offered
- Surgical reduction before the completion of pubertal development may lead to long term problems and this should be communicated to the girl and her guardian where appropriate
- Simple measures to relieve labial discomfort should be suggested
- In case of significant psychological distress, the girl and family should be offered a referral to a paediatric clinical psychologist
The two papers both state that women and girls need to be made aware of the wide variation of genital appearance. More importantly, full physical development of the external genitalia is not usually finished until girls reach 18 years of age. There is a lack of evidence around clinical effectiveness of these procedures and there may be risks arising from the procedure.
Dame Suzi Leather, Chair of the RCOG’s Ethics Committee, said:
“The Ethics Committee at the RCOG is concerned about the recent increase in labial reduction procedures, fuelled in part by the mass media and inaccurate advertising. Some women are requesting it solely for cosmetic reasons and these decisions are not always being made on informed understanding of the normal variations that exist but influenced by images from popular culture and the pornography industry. We need to inform women that everyone is unique and that variation in appearance is normal in the vast majority of cases.
“Healthcare professionals should have access to accurate and sensitive information on genital variation to give to women and be sympathetic to individual female body insecurities. Education, support and advice should be at the heart of clinical practice in this area.”
Mr Paul Wood, Consultant Obstetrician and Gynaecologist, and Chair of BritSPAG said:
“Labiaplasty is a form of FGCS and there is no scientific evidence to support its practice. For adolescents the risk of harm is even more serious.
“It is important that clinicians inform girls and where appropriate their guardians about labial anatomy, its development and how there is variation. In addition girls should be aware of distortions in popular culture, the unknown risks and efficacy of procedures and ways to manage labial discomfort. When significant distress is detected, these girls should receive a psychological assessment.”
For more information please contact Naomi Courtenay-Luck on firstname.lastname@example.org or 020 7772 6357.
The RCOG produces briefings and Q&As for the public based on topical scientific papers written for clinicians. To read our key messages on the RCOG Ethics Committee paper on female genital cosmetic surgery, please click here.
About the RCOG Ethics Committee
The RCOG Ethics Committee considers ethical aspects and legal implications of matters of concern affecting the practice of obstetrics and gynaecology.
The aims of the British Society for Paediatric and Adolescent Gynaecology are:
- To encourage the study and treatment of paediatric and adolescent gynaecology and provide a multidisciplinary forum for discussion, education and training.
- To bring together professionals with an interest in paediatric and adolescent gynaecology and provide a UK network of communication, collaboration and support.
- To encourage and promote research in the area of paediatric and adolescent gynaecology including the collection of data for both epidemiological and research purposes.