Female Genital Cosmetic Surgery: a cross sectional survey exploring knowledge, attitude and practice of General Practitioners. For peer review only

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1 Female Genital Cosmetic Surgery: a cross sectional survey exploring knowledge, attitude and practice of General Practitioners. Journal: Manuscript ID bmjopen Article Type: Research Date Submitted by the Author: -Jun-0 Complete List of Authors: Simonis, Magdalena; University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Department of General Practice; Royal Australian College of General Practitioners, Quality Care Manocha, Ramesh; University of Sydney, Department of Psychiatry Ong, Jason; Monash University, Faculty of Medicine, Nursing and Health Sciences; Melbourne Sexual Health Centre <b>primary Subject Heading</b>: Secondary Subject Heading: Keywords: General practice / Family practice Medical education and training, Mental health, Obstetrics and gynaecology, Sexual health, Surgery Female Genital Cosmetic Surgery Labiaplasty, Labiaplasty, General Practitioner, GP, genital anatomy, Women's health : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

2 Page of Female Genital Cosmetic Surgery: a cross sectional surveyexploring knowledge, attitude and practice of General Practitioners. M Simonis a,b, R Manocha c, JJ Ong d,e a. Department of General Practice, University of Melbourne, Carlton, Australia b. Royal Australian College of General Practitioners, Expert Committee Quality Care c. Sydney University, Medical School d. Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia e. Melbourne Sexual Health Centre, Carlton, Australia Correspondence: Magdalena Simonis, Department of General Practice, University of Melbourne. 00 Berkeley Street Carlton, Victoria 0, Australia. contact magdalena.simonis@mac.com or ABSTRACT Objective: To explore general practitioner s (GP) knowledge, attitudes and practice regarding Female Genital Cosmetic Surgery (FGCS) in Australia. Design: Cross-sectional survey Setting: Australia - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

3 Page of Sample: GPs who attended a women s health seminar and GPs who subscribed to a nongovernmental, national health professional organization database that provides education to primary care professionals. Method: A national online survey of GPs was conducted for the 0 week period, commencing one week prior and months after a Women s Health seminar was held in Perth on th August 0, spanning. Thirty-one questions prompted GPs knowledge, attitudes and practice in managing patients asking about FGCS. Results: The survey was fully completed by GPs; % had seen patients requesting FGCS. Overall, % (% CI:-) of GPs did not rate their knowledge of FGCS as adequate and of those who had seen patients requesting FGCS, nearly half (%, % CI: -) reported they had insufficient knowledge of risks of FGCS procedures and % (% CI: -) reported being consulted by females younger than years of age requesting FGCS. Just over half (%, % CI: -0) of the GPs felt that women should be counselled before making a referral for FGCS and % (% CI: -) felt that patients under years of age are not suitable for FGCS, unless it was for genuine medical reasons. More than half the GPs suspected psychological disturbances in their patients requesting FGCS such as depression, anxiety, relationship difficulties and body dysmorphic disorder. Conclusion: - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

4 Page of GPs see women of all ages presenting with genital anatomy concerns and in those who request FGCS, GPs often suspected a range of mental health difficulties. GPs require greater education to support their patients who request FGCS. Key Words: Female Genital Cosmetic Surgery, Labiaplasty, General Practitioner, female genital anatomy, psychosocial, FGCS, GP, Women s health, Mental health, psychology Tweetable Extract: GPs see women and teens with genital anatomy concerns and some requesting FGCS, are often suspected to have undiagnosed mental health issues. Strengths and Limitations: This is the first large survey of Australian GPs to explore FGCS Nearly all GPs surveyed have been asked about genital normality in women of all ages More than one third of all requests for FGCS are from under year olds The survey confirms the need for further education of GPs This is a skewed group of GPs with mainly women s health interest There is little other research to compare findings with INTRODUCTION The popularity of Female Genital Cosmetic Surgery is rapidly growing and genital modification for cosmetic reasons has many social and medical implications. Female Genital Cosmetic Surgery (FGCS), also known as vulvoplasty, refers to a group of non-medically indicated cosmetic surgical procedures that change the structure and appearance of the healthy external genitalia of women, or internally in the case of vaginal tightening(, ). - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

5 Page of More specifically, it encompasses labiaplasty (trimming of the labia minora and less commonly labia majora), hymenoplasty, vaginoplasty (also known as vaginal reconstruction), mons pubis liposuction and vaginal rejuvenation or laser rejuvenation (, ). Following liposuction, breast augmentation and rhinoplasty, labiaplasty was reported to be the fourth commonest cosmetic surgical procedure according to US statistics in 0, rising by % in the 0 alone(). Over the decade 00-0, Australia had a threefold increase in labiaplasties() and the UK a fivefold increase(). Australian government statistics indicate a 0% increase in requests for rebatable vulvoplasty from 0 in 00 to more than 00 in 0(), without a concomitant rise in genital disease diagnoses (). These figures do not reflect the true number of procedures performed, as an unknown number of procedures are performed in the private sector for which there are no accurate published figures. Much of the research published to date has emanated from the UK and USA. It has explored sociocultural reasons for the rise in FGCS procedures(, ), the ethical aspects regarding its heavy marketing by sectors of the medical profession(, -), and surgical discourse regarding techniques(,, -), with little published literature for the medical profession discussing risks and long term outcomes of FGCS(, ). The role of the general practitioner ( GP) regarding this emerging area of surgery has been identified as a new dilemma for the general practitioner (GP) (, 0, ). A recently published qualitative study from Australia revealed that although all of the GP participants were aware of FGCS, and all practitioners had consulted patients who had questioned whether their genital appearance was normal(), they were unaware of how to best handle these consultations. In response to the increasing demand for FGCS and advice sought from the GPs regarding FGCS, the Royal Australian College of General Practitioners - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

6 Page of launched the resource guide for health professionals titled, Female Genital Cosmetic Surgery: a resource for general practitioners and other health professionals on st July 0(). As the first point of contact with the health care system, informed GPs can play an important and central role in educating women and girls regarding the varied range of genital appearance and the risks of genital surgery(). They can also help to address modifiable psychosocial factors, thereby assisting women towards better health outcomes(, ). To date, limited quantitative research has explored the management of FGCS from the GP perspective. This study addresses a significant research gap by being the first to explore the knowledge, attitude and practice regarding FGCS in a large group of GPs. METHODS Study population In order to recruit GPs, the online survey invitation was sent via times at intervals of days each, to approximately,000 GPs, who voluntarily subscribe to a private educational organisation database to receive free seminar information, material, invitations and updates in matters pertaining to primary health care. This database has been in existence since the year 000. The same survey announcement was sent to a convenience sample of seminar attendees from the same database by one week prior to a women s health seminar. The survey ran for the ten week period starting th July to th October 0. It was closed when the response rate to the survey remained at, for consecutive weeks.. To attain a confidence level of % and margin error of % from the estimated, GPs in Australia, the largest sample size required is : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

7 Page of Data collection Survey Monkeywas used to create and administer the online survey (Appendix ), which was prepared by two GPs (MS, RM) and a Sexual Health physician(jo). The survey items contained questions about the GP s knowledge, attitudes and practice regarding FGCS. Two open-ended items on the GP s attitudes to FGCS, were included at the end of the survey, inviting free-text responses. The survey was pilot tested with 0 primary care health professionals before distribution. This was a voluntary opt in, anonymous survey and no incentives were offered to participants. Only the fully completed surveys were examined. Analysis Participant demographics and their knowledge, attitudes and practice variables were analysed descriptively. Ninety five percent confidence intervals were calculated for proportions using the modified Wald method. All analyses were performed using the statistical software, STATA (Statacorp. 0. Stata Statistical Software: Release ). The two open ended questions were manually analysed by three researchers independently and the main themes and subthemes were agreed upon. This research was approved by the Alfred Health Human Ethics Committee (Project /) RESULTS: There were fully completed GP survey responses out of a total of. Each incomplete response was manually examined and the decision to exclude the information was based upon the failure to progress beyond the first question. Demographics are summarized in Table where comparison is made to nationwide data. The majority (%) of GP participants were female (% CI: 0-) and the mean age of all participants was. - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

8 Page of years with a mean duration of practice being. years. The majority of respondents (%, % CI: -0) expressed a special interest in women s health. Analysis of GP knowledge of FGCS procedures (Table ) showed that % (% CI: -) of total GPs did not rate their knowledge about FGCS as adequate. The most common sources of information were conferences (%, % CI: -), other health professionals (%, % CI: -) and the media (%, % CI: -0). When participants were asked if they felt confident to give advice for each of the FGCS procedures, the responses ranged from % to %. About half of GPs (%, % CI: -0) felt that a woman should be counselled before proceeding to FGCS (Table ) and that FGCS should not be performed on women less than years, unless for genuine medical reasons (%, % CI: -). A third (%, % CI: - ) indicated they needed more information before developing an opinion about FGCS requests and some indicated that if a woman requested FGCS, it was a matter of freedom of choice regardless of whether or not the GP felt it was appropriate or in the patient s best interests (%, % CI: -). Few GPs considered FGCS acceptable when only for cosmetic reasons (0%, % CI: -). Table summarizes the responses of GPs who have managed patients specifically requesting FGCS. Overall, the number of requests for referrals from these GPs per annum were low in number with the commonest range given being -0 per year. The majority of these GPs (%, % CI: -%) had been asked for a referral for surgery but only a minority felt confident in discussing and advising about short term (%,% CI: -0) and long term risks (%,% CI: -) associated with FGCS procedures. Less than half of the GPs (%,% CI: -) always discussed risk with their patients and over half of these GPs (%,% CI: -) felt comfortable in discussing FGCS with their patients. The majority of - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

9 Page of these GPs (%, % CI: -) were asked by patients interested in FGCS, for a genital examination and % of GPs (% CI: -0) always examined the genital area of women requesting FGCS. Virtually all the GPs who responded (%,% CI: -) reported having been asked by patients regarding genital normality. This may or may not be associated with a request for FGCS information or referral for FGCS. However, not all (%,% CI: -0) of the GPs expressed confidence in assessing female genital anatomy. The age range of patients seen by GPs requesting FGCS referral varied from as young as ten years to as old as. About a third (%,% CI: -%) of GPs had been asked about FGCS by girls under the age of. Modifiable psychosocial problems were identified by the majority of respondents as significantly affecting a woman s motivation to have FGCS and an overall % (% CI: - ) of the GPs reported, listed mental health as an area of practice interest also. More than half of all the GPs surveyed suspected the following conditions as often or sometimes contributing to their patients request to have FGCS: anxiety (%, % CI: 0-), relationship difficulties (%, % CI: ), and body dysmorphic disorder (%, % CI: - ). Of the social factors influencing the perceived need for FGCS listed in the survey, 00% (% CI:-00) of the GPs thought their patients were most commonly influenced by each of fashion (appearance in clothes), comfort in clothes, perception of beauty and pornography. Key themes revealed in the open ended questions are listed in Table. A typical comment from one GP suggests that GPs see many women with genital anatomy concerns and few for FGCS requests stated: I do not have many women asking me questions about FGCS, they sometimes ask for referral to surgeons they have heard of. But almost on a daily basis I have women ask me if their genitals look normal and often wish their labia were smaller, - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

10 Page of (female, aged years, urban practice, years, women s health interest, trained in Australia). The significance of the genital examination was encapsulated by one respondent: This is what happens in my rooms. I see people who worry that they may not look normal. They always look normal. I reassure them of such. They usually appear very relieved. I try to address reasons for their concern, and with this I guess I close the door by and large on some potential requests for surgery, (female, aged 0, urban practice, years, women s health interest, trained in Australia,). Interestingly, the following statement suggests that genital concerns are not always expressed by the patient and they might therefore not be addressed: At first pap smear or when examining a young woman for the first time I will always comment 'everything looks entirely normal' the response is always 'relief' even when I wasn't aware there was any anxiety beforehand, (female, aged, rural practice, years, women s health interest, trained in Australia). A free text response from a year old female GP (urban practice, years, trained in Australia) explains why genital examination is not always undertaken: Most of my patients have been so set on having it done that they were not open to counselling, an examination of the genitals etc. Others reported a lack of knowledge and need for further GP education, I think we should know more to be able to counsel our patients. Currently I just refer them as I cannot answer their questions. (female, aged, urban practice, years, women s health interest, trained in Australia). DISCUSSION - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

11 Page 0 of This study is the largest study to examine GP knowledge, attitudes and practice in a previously little explored area. The GPs who responded were mainly female and those primarily interested in women s health. The range of responses did not vary significantly according to gender, age, country of primary education, duration and location of practice. The findings suggest that % of GPs have seen women with genital normality concerns and in those who request FGCS, GPs often suspected or diagnosed a range of psychological problems. More than a third of the GPs have seen girls under requesting FGCS and the majority of the GPs felt in need of more information to support their patients. The findings regarding genital anatomy concerns amongst women are consistent with a large international survey, which explored women s knowledge and attitudes to their genital appearance(0) and found that only % stated that they knew their vaginal appearance exactly, % had a reasonable idea, and % had a partial idea, or no idea at all. Similarly, a small qualitative study of university students conducted in Australia, indicated that young women had little knowledge of genital appearance, anatomy and diversity(). Although % of the GPs in this study had been asked about genital normality, examination was performed in only % of consultations, which correlates with published research from the UK() which found that only % of referrers reported physically examining the patient. There are many complex issues that can unfold following an apparently simple remark such as am I normal down there?. GPs can reassure women, but only if they themselves are confident of normality. As depictions of genital anatomy are sparse in the medical literature(), it is not surprising that only % of GPs were confident in evaluating normality of female genital anatomy : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

12 Page of More than half of the participant responses suggested that women seeking advice for FGCS may be in an emotionally vulnerable state, as GPs suspected or diagnosed a range of psychological difficulties. There is evidence that GPs deal with multiple issues per consultation and are identifying mental health issues such as depression more frequently than ten years ago(). These findings correlate with a study that explored online forums for reasons women were enquiring about labiaplasty and compared them to the reasons they gave the surgeons for wanting the modification(). The study suggested that contrary to reasons patients gave their surgeon such as their ability to exercise due to rubbing or chafing of genital tissue, the online forums disclosed deeper emotional distress due to anxiety regarding normality, aesthetics, embarrassment or even sexual anxiety related to this(0, -). This adds a different light to the study of Miklos et al(), which found that % sought FGCS for aesthetic reasons only, % for functional impairment, % for both functional and aesthetic reasons. Many studies report size of the labia minora as the most common concern, and that most women seeking genital cosmetic surgery believe that their labia minora are too visible(,,,, ) however, the psychological and emotional drivers for wanting surgery are as yet, less well researched. Adolescents see GPs for genital anatomy concerns also and the Australian Medicare statistics so far indicate that FGCS incidence in the group aged -, has matched the group aged -(). Australian findings are similar to findings in the UK() and USA() and our study confirmed that % of the GPs have seen girls under the age of requesting FGCS. More than half the GPs surveyed also believed that it should not be performed on women less than years, unless for genuine medical reasons, which complies with the recommendations from the joint Royal College of Obstetricians and Gynaecologists and British Society of Paediatric and Adolescent Gynaecology position statement(0). - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

13 Page of GPs in this survey desired more information regarding this surgical trend to support their patients with confidence. The RACGP resource guide was launched one week before the survey was distributed and only % of respondents knew about it and had accessed it. Although GPs have to date received little formal training or education on the topic, the survey findings suggest that % of GPs do make the effort to discuss the possible risks of surgery. Some significant issues for the GP arise, since the Medical Board of Australia announcement that patients under the age of be referred to a GP, or psychologist, or psychiatrist for psychological evaluation, with a mandatory three month cooling off period prior to any major cosmetic procedure, such as FGCS(). Strengths and limitations: Strengths include this being the largest study of GPs to date. Although the GP demographic is not representative of all Australian GPs which may indicate bias, it does however comprise mostly of female GPs with an interest in women s health, half of whom have experience in managing patients who have requested FGCS and this may in turn increase the validity of these findings. This GP demographic would by extension see more female patients who have genital anatomy concerns or are inquisitive regarding FGCS procedures than other GPs and as such provides insight into knowledge gaps, concerns and recommendations of experienced GPs. Many genital anatomy concerns are dealt with in the GP setting, however some women may have significant underlying mental health, sexual and domestic abuse issues, that have as yet not been diagnosed and it is important that the GP be mindful of this when giving advice and consider appropriate referral. Limitations of the study pertain to the use of terms such as counselling and sexual dysfunction which were not specified in detail in order to simplify the survey and increase participation. Likewise, sociocultural influences in relation to patient age group were not - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

14 Page of differentiated and as such we could not distinguish differences between adolescents who might be responding to peer comments, the pressures of the fashion industry and exposure to pornography, compared with the older woman following childbirth or upon entering a new relationship after divorce who might seek FGCS wanting the new look and the new me (). The terms low, medium or high were used as a measure of levels of confidence rather than a numerical scale, thereby increasing the variability of the response according to personal interpretation. The aim of any doctor patient interaction should be to provide the patient with the best and most appropriate care for the presenting complaint and ultimately to do no harm, whether that be short term or long term. The surge in requests for FGCS has implications for the clinician and the RACGP guide can provide GPs with information sufficient to enable them to assist women to make better informed choices(). There is need to explore reasons influencing the rise in surgery requests for adolescents under the age of and to conduct objective research of long term and short term risks of FGCS that evaluate sexual satisfaction and aesthetic appearance satisfaction. Further research that explores the degree and range of psychological disturbances that motivate the FGCS requests, would be welcomed. CONCLUSION: GPs see females of all ages regarding genital anatomy concerns and for FGCS requests. Most of the GPs who had managed patient requests for FGCS felt underprepared to provide advice and requested professional education. Females of all ages, some with complex psychosocial and mental health issues requested FGCS information of the GPs which - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

15 Page of suggests that the GP is seen as an important information source, who in turn can play a pivotal role in patient education and care in this emerging area. CONTRIBUTIONS: This paper was written by Magdalena Simonis(MS), supervised by Jason Ong(JO) and Ramesh Manocha (RM). Together they designed the survey, analysed data and discussed the findings. MS was solely responsible for the literature review and RM arranged the survey distribution by to the database of consenting GPs. Acknowledgment should go to my supervisors, as well as to Susan Bewley, Lih-Mei Liao, Sarah Creighton, Naomi Crouch for their preliminary research, which inspired me examine the GP role more closely. COMPETING INTERESTS: Magdalena Simonis is on the RACGP Expert Committee of Quality Care and in 0 she authored the RACGP guide on FGCS titled, Female genital cosmetic surgery: a resource for general practitioners and other health professionals ; she has also participated in the development of FGCS guidelines for GPs. FUNDING: No funds, grants, payments or incentives were received for this research. DATA SHARING: Survey results, statistical code and dataset are available upon request from the corresponding author at magdalena.simonis@mac.com. REFERENCES:. Bramwell R, Morland C. Genital appearance satisfaction in women: the development of a questionnaire and exploration of correlates. Journal of Reproductive and Infant Psychology 00;(): : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

16 Page of Pardo J, Ricci P, Sola V. Comment on Pauls: "Nip, tuck and rejuvenate: the latest frontier for the gynecologic surgeon". Int Urogynecol J Pelvic Floor Dysfunct. 00;():-0; author reply.. The American Society of Aesthetic Plastic Surgery. Cosmetic surgery national data bank statistics. [Available from: Australian Government Department of Human Services. Medicare Item Reports. [Available from: British Association of Aesthetic Plastic Surgeons. Aesthetic genital surgery: female genital aesthetic surgery (aesthetic genital surgery, designer vaginas). London. [Available from: Australian Government Department of Health. MBS Reviews: Vulvoplasty Report [Available from: Braun V. Female genital cosmetic surgery: a critical review of current knowledge and contemporary debates. Journal of women's health. 00;():-0.. Deans R, Liao LM, Crouch NS, Creighton SM. Why are women referred for female genital cosmetic surgery? The Medical journal of Australia. 0;():.. Michala L, Liao L-M, Creighton S. Female genital cosmetic surgery: how can clinicians act in women's best interests?. The Obsterician and Gynaecologist. 0;: Liao LM, Creighton SM. Requests for cosmetic genitoplasty: how should healthcare providers respond? BMJ. 00;(0):00-.. Liao LM, Taghinejadi N, Creighton SM. An analysis of the content and clinical implications of online advertisements for female genital cosmetic surgery.. 0;(). - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

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18 Page of Howarth C, Hayes J, Simonis M, Temple-Smith M. Everything s neatly tucked away : young women s views on desirable vulval anatomy. Journal of Culture, Health & Sexuality, 0 Andrikopoulou M, Michala L, Creighton SM, Liao LM. The normal vulva in medical textbooks. J Obstet Gynaecol. 0;():-0.. Britt H, Miller G, Charles J, Henderson J, Valenti L, Harrison C. A decade of Australian general practice activity 00 0 to 0. General Practice Series no.. Sydney: Sydney University Press, 0 [Available from: Zwier S. "What Motivates Her": Motivations for Considering Labial Reduction Surgery as Recounted on Women's Online Communities and Surgeons' Websites. Sex Med. 0;():-.. Lloyd J, Crouch NS, Minto CL, Liao LM, Creighton SM. Female genital appearance: "normality" unfolds. BJOG : an international journal of obstetrics and gynaecology. 00;():-.. Michala L, Koliantzaki S, Antsaklis A. Protruding labia minora: abnormal or just uncool? J Psychosom Obstet Gynaecol. 0;():-.. Liao LM, Michala L, Creighton SM. Labial surgery for well women: a review of the literature. BJOG : an international journal of obstetrics and gynaecology. 00;():0-.. Berman L, Berman J, Miles M, Pollets D, Powell JA. Genital self-image as a component of sexual health: relationship between genital self-image, female sexual function, and quality of life measures. Journal of sex & marital therapy. 00; Suppl : : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

19 Page of Mowat H, McDonald K, Dobson AS, Fisher J, Kirkman M. The contribution of online content to the promotion and normalisation of female genital cosmetic surgery: a systematic review of the literature. BMC Womens Health. 0;:0. 0. Royal College of Obstetricians and Gynaecologists joint British Society of Paediatric and Adolescent Gynaecologists. Joint RCOG/BritSPAG release: Issues surrounding women and girls undergoing female genital cosmetic surgery explored [Available from: Medical Board of Australia - Medical Board issues guidelines on cosmetic medical and surgical procedures. [Available from: 0-media-statement.aspx - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

20 Page of Table : Demographics of general practitioners: Study participants (n=) n (%, % confidence interval) GP % Response rate to survey % % Australian General Practice National Workforce Statistics I 0-0 (n=,) n (%, % confidence interval) Mean age (SD) in years. (.) unavailable as mean age; NWS data shows age distribution as total: < years: age -: age -: 0 age -: age-: 0 age+: Duration of practice (SD) years. (.) unavailable Female (%, 0-), (%, -) Country of study: Australia/NZ Overseas Location of practice I (%, -0) (%, 0-) 0,0 (0%, 0-),0 (0%, -0) Australian Government Department of Health. Department of Health General Practice Statistics. e+statistics- (accessed March 0). - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

21 Page 0 of Urban - Outer Metropolitan - Rural +Remote - Missing (%, -) 0 (%, -) (%, -0) (%, 0-), (%, -), (%, -), (%, -) (%, -) GP Special interest in - Women s Health - Mental Health - Sexual Health - Obstetrics/Gynaecology - Cosmetic surgery 0 (%, -0) National data unavailable (%, -) (%, -0) (%, -) (%, -) : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

22 Page of Table : Knowledge of GPs regarding FGCS (n=) n (%, % CI) GP feels they did not have adequate knowledge of FGCS (%, -) GP feels confident in assessing - Female genitals (%, -0) - Male genitals (%, 0-) GP acquired information regarding FGCS from: - Media - Conferences - Medical training (%, -) - RACGP FGCS resource - Other health professionals - Consumer websites GP feels confident to give patient adequate advice for each of the following procedures: - Labiaplasty - Hymenoplasty - Perineoplasty - Vaginal rejuvenation - Clitoral hood reduction - Vulval liposuction - Orgasm shot (%, -0) (%, -) (%, -) (%, -) 0 (%, -0) 0 (%, -0) (%, -0) (%, -) (%, -0) (%, -) (%, 0-) 0 (%, -) - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

23 Page of G-spot augmentation (%, -) Table : Attitudes about FGCS for GPs (n=) n (%, % CI) I need more information before developing my opinion (%, -) If a woman wants this, it is her choice (%, -) It should not be performed on women less than years (%, -) unless for genuine medical reasons A woman should be counselled first before referral for FGCS (%, -0) FGCS is acceptable even when only for cosmetic reasons (0%, -) FGCS is unacceptable when only for cosmetic reasons (%, -) FGCS is not different to other types of cosmetic surgery, in my opinion (%, -) - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

24 Page of Table : Management practices of GPs who had seen a patient considering FGCS (n=) n (%, % CI) GPs who have seen patient aged < requesting FGCS (%, -) Patient requesting FGCS - youngest age reported in whole 0 years sample Patient requesting FGCS - oldest age reported in whole years sample Patient asked GP about opinion of genital normality (%, -) Patient asked GP opinion about FGCS (%, -) Patient asked GP for genital examination (%, -) Patient requested referral for FGCS from GP (%, -) GP discussed risk of FGCS procedures with patient - All the time - Sometimes - Only if they asked me - Not sufficiently aware of risks to discuss (%, -) (0%, -) (%, -) 0 (%, -) GP felt confident in discussing short term risks of FGCS (%, -0) GP felt confident in discussing long term risks of FGCS (%, -) GP felt comfortable in discussing FGCS upon request from (%, -) patient - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

25 Page of GP examined genitalia - All the time (%, -0) - Sometimes (%, 0-) Resources used with patient - Labia Library ( website, (%, -) - Diagrams (%, -) - Anatomy books (%, -) - Consumer websites (%, -) - RACGP FCGS resource (%, -) GP reported influences of why patient asked about FGCS - Fashion (comfort in clothes) (00%, -00) - Perception of beauty (00%, -00) - Pornography - Perception of normal - Spouse/partner comments - Physical discomfort - Consumer websites - Fashion (appearance in clothes) - Peer comments (00%, -00) 0 (%, 0-) (%, -) 0 (%, -) (%, -) (%, -) (%, -) - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

26 Page of Table : Major themes from free text responses to Question 0: What is your opinion regarding the role of GPs for FGCS? Total responses (n ) Major theme: Subtheme GP is seen as an educator: Source of information regarding FGCS i)regarding FGCS Information regarding risks of FGCS ii)genital anatomy Provides access to information regarding FGCS Provider of normal anatomy advice Reassures women regarding their normality GP is seen as the GP should be able to assess women regarding need for surgery. gateway to referral GP should avoid providing referral when only for cosmetic or pathway aesthetic reasons. GP should refer to gynaecologist rather than to plastic surgeon GP seen as first port of call by patients GP should refer to psychologist psychiatrist for mental health GPs request information regarding FGCS GP examination of genital area is necessary GP screen for mental health issues is important GP role is very important GP performs multiple functions issues Need more information regarding risks of FGCS Need more information regarding FGCS practices Patients expect GP to know about FGCS and genital anatomy GP issued referral in past due to lack of information about FGCS Lack of information is a cause of low confidence giving advice Need more information in order to form opinion regarding FGCS Provider of reassurance Routine gynaecological examination is an opportunity to educate women regarding genital normality Examination upon expression of genital anatomy concern GP role is to provide or refer for counselling GP reassurance provides relief of minor anxiety symptoms Some serious mental health issues may present with genital anxiety concerns Relationship issues can cause genital anxiety concerns For patient education For patient reassurance regarding normality For appropriate referral GP is seen as a reliable source of information GP should listen, examine reassure, counsel, then if necessary refer This is a sociocultural trend, outside the realm of medicine - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

27 Page of AGE years FEMALE GENITAL COSMETIC SURGERY (FGCS) HEALTH PROFESSIONAL QUESTIONNAIRE:. GENDER (Please circle): Male Female. YEARS OF PRACTICE: years. HEALTHCARE PROFESSIONAL CATEGORY (tick all that apply) GP Obstetrician Gynaecologist Nurse Cosmetic Surgeon Plastic Surgeon Urologist Allied Health Professional describe: Other In which country did you complete your professional degree?. LOCATION OF PRACTICE (tick all that apply) Urban Outer Metropolitan Rural What state are you from?. SPECIAL INTEREST IN: (tick all that apply) Women s Health Obstetrics and Gynaecology Mental Health Sexual Health Cosmetic Medicine Other. FEMALE GENITAL COSMETIC SURGERY (FGCS): Knowledge and practice. (please circle) i) Have you heard about FGCS? Yes / No ii) Where have you acquired this knowledge from? (tick all that apply) Media - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

28 Page of Conferences Other health professionals Consumer websites Other ii) FORMS OF FGCS: do you know about labiaplasty? Yes / No do you know about clitoral hood reduction? Yes / No do you know about vaginoplasty? Yes / No do you know about hymenoplasty? Yes / No do you know about orgasm shot ( O-shot)? Yes / No do you know about vaginal rejuvenation? Yes / No do you know about mons pubis liposuction? Yes / No iii) How comfortable do you feel advising a woman who asks for FGCS? Not comfortable Comfortable Very comfortable iv) Have you seen patients who have asked you about any form of FGCS?Yes /No v) How many patients do you see requesting FGCS? per week per month per year vi) Have you had any patients less than years old asking you about FGCS? Yes / No What is the age range of women asking you about FGCS? Not applicable. I haven t had any patients asking me about FGCS. Youngest: years Oldest: years vii) FGCS and risks of surgery Do you know about the possible short term risks of FGCS? Not at all A little A lot Do you know about the possible long term risks of FGCS? Not at all A little A lot - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

29 Page of Do you talk about possible risks of FGCS for patients who request this? Not applicable. I haven t seen a patient asking for FGCS Only if they ask me Sometimes All the time viii) Have you been asked for (tick all that apply): an examination? your opinion? a referral? ix) Do you examine these women s genital area? Yes No Sometimes Not applicable (I haven t seen any patients asking about FGCS) x) Do you offer / refer for counselling? Yes No Sometimes Not applicable (I haven t seen any patients asking about FGCS) xi) Which specialist group have you referred women to for FGCS? (tick all that apply) Cosmetic Surgeon Plastic Surgeon Obstetrician Gynaecologist Urologist Psychologist / Psychiatrist Colleague for second opinion Women s health GP Not applicable (I haven t seen any patients asking about FGCS).. GENITAL APPEARANCE AND EDUCATION: i) Do you feel confident in assessing genital appearance? Female anatomy Not confident Confident Very confident Male anatomy Not Confident Confident Very confident ii) How much teaching regarding genital anatomy (both male and female) have you received in your medical training? Female- - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

30 Page of none a little some a lot Male none a little some a lot. INFORMATION TOOLS: Have you heard of the Labia Library(LL) website? Yes Have you used or referred patients to L.L? / No Yes / No Do you have other tools to assist you? Describe them 0. Please indicate what you think about Female Genital Cosmetic Surgery. (tick all that apply) I have no opinion If a woman wants this it is her choice It should not be performed on women less than years A woman should be counselled first It is acceptable for cosmetic reasons This surgery is unacceptable for cosmetic reasons It is no different to other types of cosmetic surgery. What is your opinion of the role of GPs for FGCS?. Any final comments? - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

31 Page 0 of Thank you for your contribution - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

32 Page of FEMALE GENITAL COSMETIC SURGERY (FGCS) HEALTH PROFESSIONAL QUESTIONNAIRE INFORMATION STATEMENT: The aim: The aim of this survey is to explore the knowledge of Health Professionals with respect to Female Genital Cosmetic Surgery in Australia and how they manage these requests. What does the research involve? The questionnaire will take about minutes to complete. Your completion of this questionnaire will contribute to this goal. This research has been initiated by Dr. Magdalena Simonis (University of Melbourne) with other researchers including Dr. Jason Ong (Melbourne Sexual Health Centre) and Dr. Ramesh Manocha (University of Sydney). Source of funding: No direct funding but we wish to acknowledge HealthEd for its provision of survey distribution and printing. Consenting to participate in the survey and withdrawing from the research By signing up to complete the questionnaire, you will be indicating that you have read this explanatory statement and consent to participating in the survey. You have the right not to finish the survey, to skip any questions you prefer not to answer, or not submit the finished survey. However, once you submit the survey it will not be possible to withdraw your data because your answers are anonymous and the researchers will have no way of knowing what data are yours. Possible benefits and risks to participants The results of this survey will be used to improve the management of requests for Female Genital Cosmetic Surgery by health professionals, by improving health professionals education guidelines and to thereby improve the health and wellbeing of women and girls in Australia. There are no reasonably foreseeable risks of harm from participation in this research. If you think that you will be upset or disturbed by questions about Female Genital Cosmetic Surgery you can choose not to participate. If you choose to proceed and find that the questions raise difficult topics for you, there is a list of services at the end of the survey that might assist you. Confidentiality and storage of data All information you give us will be completely anonymous. The name and address of anyone who answers these questions is not required. All data will be stored on a secure password-protected file on the Monash University system, accessible only to the researchers. All research data will be destroyed years from the time results are published. Results A summary of the results will be made available in the form of a publication or a presentation as well as the websites of our research partners. Complaints If you have any complaints about any aspect of the project, the way it is being conducted or any questions about being a research participant in general, then you may contact: Emily Bingle, Office of Ethics and Research Governance, Alfred Hospital (+ 0 ) Results from this study will be made available upon request from the researchers. You can the researchers directly at magdalena.simonis@mac.com and request to be sent the results via when they are available. If you have any questions about the research project you can contact the researchers: - : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

33 Page of Name: Dr Magdalena Simonis Name: Dr Jason Ong Role: Researcher and Doctor Role: Researcher and Doctor University of Melbourne Melbourne Sexual Health Centre/Alfred Health Telephone: Telephone: + Name: Dr Ramesh Manocha Role: Researcher and Doctor University of Sydney Telelphone: + 00 If you are troubled by topics raised in the questionnaire, you could contact: Your General Practitioner (GP) Women s Health Victoria Telephone: Lifeline Telephone: Mensline Telephone: 00 Jean Hailes for Women s Health Telephone; : first published as 0./bmjopen on September 0. Downloaded from on June 0 by guest. Protected by copyright.

34 Page of STROBE 00 (v) checklist of items to be included in reports of observational studies in epidemiology* Checklist for cohort, case-control, and cross-sectional studies (combined) Section/Topic Item Recommendation Reported on page # # Title and abstract (a) Indicate the study s design with a commonly used term in the title or the abstract (b) Provide in the abstract an informative and balanced summary of what was done and what was found,, Introduction Background/rationale Explain the scientific background and rationale for the investigation being reported, Objectives State specific objectives, including any pre-specified hypotheses Methods Study design Present key elements of study design early in the paper,, Setting Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection,, Participants (a) Cohort study Give the eligibility criteria, and the sources and methods of selection of participants. Describe methods of follow-up,, Case-control study Give the eligibility criteria, and the sources and methods of case ascertainment and control selection. Give the rationale for the choice of cases and controls Cross-sectional study Give the eligibility criteria, and the sources and methods of selection of participants (b) Cohort study For matched studies, give matching criteria and number of exposed and unexposed Case-control study For matched studies, give matching criteria and the number of controls per case Variables Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable Data sources/ * For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe,, measurement comparability of assessment methods if there is more than one group Bias Describe any efforts to address potential sources of bias, Study size 0 Explain how the study size was arrived at,, Quantitative variables Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why Statistical methods (a) Describe all statistical methods, including those used to control for confounding on June 0 by guest. Protected by copyright. (b) Describe any methods used to examine subgroups and interactions,, (c) Explain how missing data were addressed,, (d) Cohort study If applicable, explain how loss to follow-up was addressed - : first published as 0./bmjopen on September 0. Downloaded from