The first cut is the deepest : a psychological, sexological and gynecological perspective on female genital cosmetic surgery

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1 A C TA Obstetricia et Gynecologica AOGS COMMENTARY The first cut is the deepest : a psychological, sexological and gynecological perspective on female genital cosmetic surgery GIUSSY BARBARA 1, FEDERICA FACCHIN 2, MICHELE MESCHIA 1 & PAOLO VERCELLINI 3 1 Department of Obstetrics and Gynecology, G. Fornaroli Hospital, Magenta, Milan, 2 Faculty of Psychology, Catholic University of Milan, Milan, and 3 Department of Obstetrics and Gynecology, IRCCS Ca Granda Foundation, Maggiore Policlinico Hospital and University of Milan, Milan, Italy Key words Female genital cosmetic surgery, female genitalia, labiaplasty, vulvovaginal standard, ethics Correspondence Giussy Barbara, Department of Obstetrics and Gynecology, G. Fornaroli Hospital, Via Al Donatore Di Sangue 50, Magenta, Milan 20013, Italy. giussy.barbara@gmail.com Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. Please cite this article as: Barbara G, Facchin F, Meschia M, Vercellini P. The first cut is the deepest : a psychological, sexological, and gynecological perspective on female genital cosmetic surgery. Acta Obstet Gynecol Scand 2015; 94: Abstract In recent years increased numbers of healthy women and girls have been seeking female genital cosmetic surgery for esthetic reasons and/or to enhance sexual functioning. This phenomenon is associated with the development of a new vulvovaginal standard due to Internet pornography and the increased exposure of female genitalia. This strict standard may negatively affect women s psychological health and cause increased insecurity, which may drive even teenagers to seek female genital cosmetic surgery. Psychological counseling is recommended to inform women that surgery is not a definitive solution to treat psychologically based pain or dysfunction. Moreover, there is no robust evidence supporting the effectiveness of female genital cosmetic surgery, especially regarding sexual enhancement, as underlined by major scientific societies. The importance of a definite regulation of female genital cosmetic surgery should be emphasized and be based on an ethically oriented, multidisciplinary model aimed at providing exhaustive information on all gynecological, sexological, and psychological concerns raised by this type of surgery. Abbreviations: BDD, body dysmorphic disorder; FGCS, female genital cosmetic surgery. Received: 18 February 2015 Accepted: 14 April 2015 DOI: /aogs Imperfection: the true essence of beauty? Female genital cosmetic surgery (FGCS) involves a range of procedures (such as labiaplasty, vaginal rejuvenation, esthetic vulvar liposculpturing, re-virgination with hymenoplasty, and G-spot amplification) aimed at reaching better female genital appearance and/or enhanced function (1). These interventions are performed for cosmetic reasons with no specific medical indication. However, some of these procedures, for example labiaplasty, can be medically indicated in the case of remarkable labial asymmetry and hypertrophy caused by congenital anomalies or excess androgen exposure (2,3). Other surgical techniques (anterior or posterior compartment vaginoplasty and perineoplasty) are routinely performed in urogynecological services in the case of genital prolapse, cystocele, rectocele, stress urinary incontinence, and sequelae of perineal tears at delivery. In recent years increased numbers of women have been seeking FGCS for esthetic or sexual reasons, or both. According to the British National Health Service, the num- ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

2 Female genital cosmetic surgery G. Barbara et al. ber of labiaplasty interventions performed in the UK increased five-fold in 9 years, from 2001 to 2010 (4). The American Society of Plastic Surgeons reported a 30% increase in the rate of vaginal rejuvenation procedures, from 793 in 2005 to 1030 in 2006 (5). Not only adult women, but also teenagers are increasingly seeking FGCS. According to the British Society for Paediatric and Adolescent Gynaecology, 266 labial reductions were performed in the UK between 2008 and 2012 on girls under the age of 14. These data raise ethical and medical concerns, given that the Royal College of Obstetricians and Gynaecologists ethics committee and the British Society for Paediatric and Adolescent Gynaecology recommend not to perform FGCS without clear medical indications on girls under the age of 18, who are exposed to higher risks because of incomplete genital development during puberty. None of these procedures has proven effectiveness, and the potential for harm should always be taken into account (1). Some of these practices involve partial removal of the vaginal mucosa and the modification of healthy external genitalia, and for this reason some authors have argued that anatomically there is little distinction between FGCS and female genital mutilation (6). According to the UK Female Genital Mutilation Act 2003, the complete or partial excision, infibulation, and mutilation of women s (and girls ) labia majora, labia minora or clitoris, must be considered an offence and be punished accordingly. Thus, the doubt arises as to whether non-medically indicated FGCS is a fully legitimate surgical activity (7). As suggested by Kelly and Foster, the pressures that cause women to undergo FGCS are pressures which society should disapprove, and that legislation may have a place in resisting (6, p. 391). Much of this pressure comes from the Internet, for different types of reasons. First, many women who are worried about the appearance of their genitals or are seeking FGCS, search for information on the web. The quality of the information provided online, very frequently by surgery providers sites, has been investigated by Liao et al. (8). The authors found that these websites used confounding labels to describe different FGCS procedures, with little or no information about the absence of evidence for clinical effectiveness of these procedures, while at the same time there was minimization of risks and exaggeration of psychological and physical benefits. Secondly, Internet pornography has contributed to the development of a new vulvovaginal standard of attractiveness, in which the labia minora do not protrude beyond the labia majora (1,4). The increased exhibition of female external genitalia is also facilitated by Brazilian waxes (1) and more women regularly self-examining their vulva, as they think its appearance is important (1,9). The dictatorship of beauty ideals: psychological insights on FGCS Several studies have shown the extent to which the exposure to images of the perfect vagina (1) (for instance pornographic altered images) may lead to the development of unrealistic concepts of normal genitalia based on the uniform morphology described above (4). The standards of beauty are cultural products and change over time under the influence of gendered narratives. When these standards become too narrow, negative psychological effects should be taken into account, as any deviation from the norm may be considered unattractive, or even pathological. The new vulvovaginal standard is incredibly strict if we consider that female external genitalia have a wide range of normality (1). As a consequence, some women may experience significant emotional distress, such as feeling freakish or being ashamed (10). Although not based on legitimate and diagnosed medical conditions, women s concerns about their genitalia should be taken very seriously, as they may be epiphenomena of a more profound insecurity, lack of selfesteem, or even a specific mental disorder such as body dysmorphic disorder (BDD). According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edn (DSM-5) (11), BDD is characterized by extreme preoccupation with minor or nonexistent defects or flaws in physical appearance associated with intrusive thoughts, persistent distress, significant impairment in social and occupational functioning, and repetitive behaviors, such as mirror checking, seeking reassurance from others, and even requesting unnecessary cosmetic surgery (12 14). In this regard, Veale et al. (15) have shown that of 55 women who were seeking labiaplasty, 10 met diagnostic criteria for BDD. The onset of BDD typically occurs during early adolescence, with constant delusional obsessions focused on physical appearance (16). In general, youth moving from childhood to adulthood has to cope with multiple developmental challenges in identity and selfconcept (17), which comprises body image. These clinical and developmental issues should be considered to understand the reasons why a teenager might seek cosmetic surgery, regardless of the type of surgery (breast augmentation or FGCS). Thus, the assessment of the psychological health of women seeking FGCS is even more important when the request comes from young adolescents. Overall, we hypothesize that the increased numbers of healthy women and girls who undergo FGCS (and cosmetic surgery in general) represent the expression of a contemporary drama, which is the impossibility of dealing with diversity. Under the dictatorship of the beauty gold standard, individual differences are not acceptable. 916 ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

3 G. Barbara et al. Female genital cosmetic surgery Some women may experience their uniqueness as a limit and not as a value. FGCS interventions performed on perfectly normal women may confirm and even strengthen this idea. Patients are not likely to disclose their deepest feelings of insecurity in the clinical encounter with practitioners, who should consider that the fear not to be accepted for the surgery and/or not to have health insurance coverage may drive the women to emphasize more functional reasons for considering FGCS, such as interference with physical exercise, sexual intercourse, and tight-fitting clothes (10). Another source of pressure may be represented by sexual partners, whose attitudes and expectations may influence women s decision to seek cosmetic surgery. A study of 258 women undergoing FGCS (18) has shown that 32% of the vaginoplasties were conducted for enhancement of the partners sexual pleasure. Psychological counseling should be strongly recommended to all healthy women who are considering FGCS because it may offer them a chance to express undisclosed thoughts and feelings. This may help women to understand that the nature of the problem is not physical but psychosocial. Clinical assessment should be conducted to evaluate the presence of specific mental disorders such as BDD. Several studies have demonstrated that cosmetic surgery typically leads to no change or even worsening in BDD symptoms (19,20). This particular disorder has a complex etiology characterized by the co-occurrence of multiple biological, psychological, and sociological factors, and involves a deep sufferance that cannot be eliminated by esthetic medical treatments. A psychotherapeutic intervention should be indicated to all women seeking FGCS who are diagnosed with any psychological disorder; as regards BDD, there is evidence of the effectiveness of cognitive behavioral therapy (21). Talking takes time and effort, whereas cutting may seem a quick fix, but women should be informed that this is not a definitive way out. Is FGCS the way to sexual satisfaction? The development of a new vulvovaginal standard is not the unique consequence of the increased exposure to Internet pornography. Another important effect is the propagation of a distorted representation of sexuality as a standardized, mechanical performance ; in this case, the gold standard is a perfect anatomically and physiologically functioning mechanism. This ideal of perfection is associated with the over-medicalization of sex and disease-mongering (22), which may enhance women s perceptions of their own sexual dysfunction or inadequacy, and drive them to seek FGCS to meet the gold standard of sexual performance. The biomechanical thinking about sex and life in general may also be promoted by the global pharmaceutical industry and some private health services, as the promise of sex enhancement increases financial opportunities (22). Given this background, the question arises as to whether FGCS keeps its promise. To answer this question, two main issues should be considered: (i) how many women seek surgery for sexual reasons, which may help determine the extent of the phenomenon, and (ii) whether FGCS is effective in enhancing sexual satisfaction. Only a few studies have investigated women s motivation for seeking FGCS, reporting that the proportion of participants who indicated sexual motivations as primary reasons for surgery ranged from one-third to 74% of the sample (18,23 25). In some of these studies (18,24,25) increased sexual satisfaction was reported by the women after FGCS. However, the quality of the evidence was limited. Sexual satisfaction was evaluated in terms of improvement without using any validated questionnaire and without testing the impact of FGCS on the specific components of sexual functioning; no comparisons of sexual function before and after surgery were conducted, and information on long-term effects was missing. Although vaginoplasty and perineoplasty performed to decrease the sensation of wide vagina may improve sexual satisfaction of women and their partners (26), there is limited scientific evidence on the effectiveness of other procedures aimed at enhancing female sexual pleasure (such as laser vaginal rogation, or G-spot amplification). Female sexuality is a complex function that involves the interaction of anatomical and psychosocial factors. Overall, FGCS is not indicated in the case of sexual dysfunction as it is not effective in increasing libido and reducing arousal and orgasm difficulties unless these problems are related to anatomical distortion, such as labia hypertrophy or genital prolapse (26). Recommendations from gynecological scientific societies In recent years several gynecological societies (Table 1) have released documents expressing concerns about FGCS and discouraging the performance of any surgical intervention in the absence of peer-reviewed scientific evidence (3,27 29). These societies pointed out the importance of obtaining a fully informed consent, after sexual and psychological counseling, when offering FGCS. All women considering surgery should be informed about the risks associated with these procedures (i.e. bladder or bowel injuries, delayed bleeding, infections, wound dehiscence, scarring, alteration in sensation, pain, dyspareunia, ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

4 Female genital cosmetic surgery G. Barbara et al. Table 1. Recommendations of the major gynecological scientific societies on FGCS. RCOG (27) Provide fully informed consent. Inform women about normal genital variations. Suggest psychological intervention for problems such as body image distress. Be aware that surgeons are performing procedures that lack a clear evidence base. Do not perform FGCS on women and girls under 18 years, irrespective of consent. Advise women about the risks of FGCS and the lack of reliable evidence concerning its positive effects. FGCS should not be provided by the National Health Service. ACOG (3) FCGS is not medically indicated, nor is there documentation on its safety and effectiveness. Inform women about the lack of data supporting the effectiveness of FGCS, as well as about the potential complications. Evaluate for sexual dysfunction all women requesting FGCS to improve sexual functioning and consider other non-surgical interventions (e.g. counseling). Consider ethical issues associated with the marketing and franchising of FGCS. SOGC (28) Help women understand their anatomy and respect individual variations. Obtain complete medical, sexual, and gynecological history of women requesting FGCS and ascertain the absence of any major sexual or psychological dysfunction. Any possibility of coercion or exploitation should be ruled out. Prioritize counseling focused on normal genital variations, as well as the possibility of unintended consequences of FGCS. Discuss the lack of evidence regarding outcomes or subsequent changes in pregnancy or menopause. Clarify that there is little evidence to support FGCS in terms of improvement of sexual satisfaction or self-image. Do not promote FGCS for the enhancement of sexual function and avoid advertising of FGCS. Do not offer FGCS to adolescents. Recognize non-medical terms, including vaginal rejuvenation, clitoridal resurfacing, G-spot enhancement, as marketing terms only, with no medical origin; therefore they cannot be scientifically evaluated. RANZCOG (29) Thoroughly assess patients requesting FGCS and the reasons for such a request. Sexual counseling is also recommended. Discourage the performance of any surgical procedure that lacks peer-reviewed scientific evidence. Discuss in detail with women the risk of complications. FGCS, female genital cosmetic surgery; RCOG, Royal College of Obstetricians and Gynaecologists; ACOG, American College of Obstetricians and Gynecologists; SOGC, Society of Obstetricians and Gynaecologists of Canada; RANZCOG, Royal Australian and New Zealand College of Obstetricians and Gynaecologists. decreased sexual pleasure, and possible dissatisfaction with cosmetic results). What to do? This sensitive topic leads to more general considerations on contemporary society, which emphasizes the importance of meeting standards and discredits diversity. The idea that the mere conquest of the perfect vagina may lead to sexual satisfaction is a dismal and alarming human perspective. What is the destiny of passion, energy, romantic love, and relational happiness if the cult of the standard becomes predominant? The extent to which this type of discourse disseminated by the media might affect young adolescents should be considered as the primary ethical concern. However, the contemporary FGCS special market and women s requests for this type of surgery are not likely to be stopped. Therefore development of a clear regulation, which has been partly proposed by several scientific societies, is pivotal. The offer of these procedures should be based on an ethically oriented model aimed at providing transparent and complete information based on robust scientific evidence. If reliable data are not available, this should be clearly stated. Major gynecological and plastic surgery scientific societies should develop a common informed consent form for women considering FGCS, making it clear that: non-medically indicated FGCS is not accepted by major international scientific societies, is not a routine practice, and surgeons performing FGCS may have personal financial incentives deriving from it; there is ample individual variability in female genital anatomy and the expected impact of age and parity is normal; FGCS may involve short- and long-term complications, which must be extensively described; there is poor scientific evidence for the effectiveness of FGCS in enhancing sexual satisfaction. Thus, this type of surgery must not be offered for this purpose and women should opt for non-surgical interventions to treat sexual dysfunction; low self-esteem and sexual dysfunction depend on the interaction of multiple psychosocial factors and surgery is not a definitive solution; 918 ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

5 G. Barbara et al. Female genital cosmetic surgery emotional distress may dramatically increase in the case of unsatisfying esthetic and functional outcomes. We propose this common informed consent form to be submitted for formal approval to international and national health authorities and health care policy decision makers, thus entailing medico-legal implications as well. Such an initiative might moderate the enthusiasm of both surgeons and women towards these low-value procedures, characterized by undefined potential benefits, demonstrated potential harms, and high costs. Acknowledgments The title caption, The first cut is the deepest, is a quote from Cat Stevens. In: New Masters. U.K., Decca Records, References 1. Iglesia CB. Cosmetic gynecology and the elusive quest for the perfect vagina. Obstet Gynecol. 2012;119: Cain J, Iglesia CB, Dickens B, Montgomery O. Body enhancement through female genital cosmetic surgery creates ethical and rights dilemmas. Int J Gynaecol Obstet. 2013;122: Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 378: vaginal rejuvenation and cosmetic vaginal procedures. Obstet Gynecol. 2007;110: Moran C, Lee C. What s normal? Influencing women s perceptions of normal genitalia: an experiment involving exposure to modified and nonmodified images. BJOG. 2014;121: Lowenstein L, Salonia A, Shechter A, Porst H, Burri A, Reisman Y. Physicians attitude toward female genital plastic surgery: a multinational survey. J Sex Med. 2014;11: Kelly B, Foster C. Should female genital cosmetic surgery and genital piercing be regarded ethically and legally as female genital mutilation? BJOG. 2012;119: Bewley S. Should a psychiatrist give legal advice on cosmetic genital surgery? Arch Sex Behav. 2013;42: Liao LM, Taghinejadi N, Creighton SM. An analysis of the content and clinical implications of online advertisements for female genital cosmetic surgery. BMJ Open. 2012;2: e Koning M, Zeijlmans IA, Bouman TK, van der Lei B. Female attitudes regarding labia minora appearance and reduction with consideration of media influence. Aesthet Surg J. 2009;29: Zwier S. What motivates her : motivations for considering labial reduction surgery as recounted on women s online communities and surgeons websites. Sex Med. 2014;2: American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edn. Washington, DC: American Psychiatric Association, Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg. 2006;118:167e 80e. 13. Veale D, Boocock A, Gournay K, Dryden W, Shah F, Willson R, et al. Body dysmorphic disorder. A survey of fifty cases. Br J Psychiat. 1996;169: Veale D. Outcome of cosmetic surgery and DIY surgery in patients with body dysmorphic disorder. Psychiatr Bull. 2000;24: Veale D, Eshkevari E, Ellison N, Costa A, Robinson D, Kavouni A, et al. Psychological characteristics and motivation of women seeking labiaplasty. Psychol Med. 2014;44: Phillips KA. Body dysmorphic disorder: recognizing and treating imagined ugliness. World Psychiatry. 2003;3: Facchin F, Margola D, Molgora S, Revenson TA. Effects of benefit-focused versus standard expressive writing on adolescents self-concept during the high school transition. J Res Adolesc. 2014;24: Goodman MP, Placik OJ, Benson RH 3rd, Miklos JR, Moore RD, Jason RA, et al. A large multicenter study of female genital plastic surgery. J Sex Med. 2010;7: Sarwer DB, Spitzer JC. Body image dysmorphic disorder in persons who undergo aesthetic medical treatments. Aesthet Surg J. 2012;32: Crerand CE, Menard W, Phillips KA. Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder. Ann Plast Surg. 2010;65: Veale D, Anson M, Miles S, Pieta M, Costa A, Ellison N. Efficacy of cognitive behaviour therapy versus anxiety management for body dysmorphic disorder: a randomised controlled trial. Psychother Psychosom. 2014;83: Tiefer L. Activism on the medicalization of sex and female genital cosmetic surgery by the New View Campaign in the United States. Reprod Health Matter. 2010;18: Miklos JR, Moore RD. Labiaplasty of the labia minora: patients indications for pursuing surgery. J Sex Med. 2008;5: Rouzier R, Louis-Sylvestre C, Paniel BJ, Hadded B. Hypertrophy of the labia minora; experience with 163 reductions. Am J Obstet Gynecol. 2000;182: Alter GJ. Aesthetic labia minora and clitoral hood reduction using extended central wedge resection. Plast Reconstr Surg. 2008;122: Pardo J, Sola VD, Ricci PA, Guiloff EF, Freudnlich OK. Colpoperineoplasty in women with a sensation of wide vagina. Acta Obstet Gyn Scand. 2006;85: Royal College of Obstetricians and Gynaecologist. Ethical considerations in relation to female genital cosmetic ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

6 Female genital cosmetic surgery G. Barbara et al. surgery (FGCS). RCOG Ethics Commettee, Available online at: guidelines/ethics-issues-and-resources/rcog-fgcs-ethicalopinion-paper.pdf (accessed 25 April 2015). 28. Committee Clinical Practice Gynaecology, Ethics Committee, and Executive Council of the Society of Obstetricians and Gynaecologists of Canada. Female genital cosmetic surgery. J Obstet Gynaecol Can. 2013;35: e The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. RANZCOG College Statement: C-Gyn 24. Vaginal Rejuvenation and Cosmetic Vaginal Procedures ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)