Greater Manchester EUR Policy Statement Title/Topic: Labiaplasty Date: November 2014 Last Reviewed: November 2015 Reference: GM027

Greater Manchester EUR Policy Statement Title/Topic: Labiaplasty Date: November 2014 Last Reviewed: November 2015 Reference: GM027

VERSION CONTROL Version Date Details Page number 0.1 12/05/2014 First draft for consideration by GM EUR Steering Group N/A 0.2 29/05/2014 Amendments made by GM EUR Steering Group on 21/05/2014: Diagram of external female genitalia labeled and the colour removed. Draft policy approved for consultation following the above amendments. Policy published for consultation from 09/07/2014 to 03/09/2014. 6 N/A N/A 0.3 25/09/2014 Amendments made by the GM EUR Steering Group on 17/09/2014 following a review of the feedback from the consultation: 17/09/2014 Amendment to section 4, mandatory criteria removal of the bullet point relating to significant functional impairment and the bullet point relating to trauma, defined as significant anatomical distortion as a result of obstetric trauma, other trauma and vulval diseases. Inclusion of female genital mutilation in the policy exclusions section. Policy approved by the GM EUR Steering Group subject to the above amendments. 6 7 N/A 0.4 08/10/2014 Branding change following creation of North West CSU on 1/10/2014. 1.0 17/09/2014 Policy approved by GM EUR Steering Group - required amendments have been made. All N/A 2.0 18/11//2015 Annual review of policy by GM EUR Steering Group no material changes necessary to the current policy. Added that locally commissioned treatment as part of a pathway of care within a contract or service level and treatment as part of previously agreed and externally funding trial are excluded from this policy. The Evidence Review section of the policy has been updated following annual review of the policy 7 9-16 2

POLICY STATEMENT Title/Topic: Labiaplasty Issue Date: November 2014 Reviewed November 2015 Date of Review: One year from the date of approval by Greater Manchester Association Governing Group and annually thereafter. Prepared By: The Greater Manchester Commissioning Support Unit Effective Use of Resources Policy Team Approved By Date Approved Variance Greater Manchester Effective Use of Resources Steering Group 17/09/2014 N/A Greater Manchester Chief Finance Officers / Greater Manchester Heads of Commissioning 20/10/2014 N/A Greater Manchester Association Governing Group 04/11/2014 N/A Bury Clinical Commissioning Group 04/02/2015 N/A Bolton Clinical Commissioning Group 28/11/2014 N/A Heywood, Middleton & Rochdale Clinical Commissioning Group 21/11/2014 N/A Central Manchester Clinical Commissioning Group 15/01/2015 N/A North Manchester Clinical Commissioning Group 12/11/2014 N/A Oldham Clinical Commissioning Group 04/12/2014 N/A Salford Clinical Commissioning Group 04/11/2014 N/A South Manchester Clinical Commissioning Group 14/01/2015 N/A Stockport Clinical Commissioning Group 03/12/2014 N/A Tameside & Glossop Clinical Commissioning Group 05/11/2014 N/A Trafford Clinical Commissioning Group 18/11/2014 N/A Wigan Borough Clinical Commissioning Group 05/11/2014 N/A 3

CONTENTS Policy Statement... 5 Equality & Equity Statement... 5 Governance Arrangements... 5 1. Introduction... 5 2. Definition... 6 3. Aims and Objectives... 6 4. Criteria for Commissioning... 6 5. Description of Epidemiology and Need... 7 6. Evidence Summary... 7 7. Rationale behind the Policy Statement... 7 8. Adherence to NICE Guidance... 8 9. Mechanism for Funding... 8 10. Audit Requirements... 8 11. Documents which have informed this Policy... 8 12. Links to other Policies... 8 13. Date of Review... 8 14. Glossary... 8 References... 8 Appendix 1 Evidence Review... 9 4

Policy Statement The Greater Manchester Commissioning Support Unit (GMCSU) has developed this policy on behalf of Clinical Commissioning Groups (CCGs) within Greater Manchester, who will commission labiaplasty (also known as labia minora reduction, and labial reduction) in accordance with the criteria outlined in this document. In creating this policy the GMCSU has reviewed this clinical condition and the options for its treatment. It has considered the place of this treatment in current clinical practice, whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources. This policy document outlines the arrangements for funding of this treatment for the population of Greater Manchester. Equality & Equity Statement The GMCSU/CCG has a duty to have regard to the need to reduce health inequalities in access to health services and health outcomes achieved, as enshrined in the Health and Social Care Act 2012. The GMCSU/CCG is committed to ensuring equality of access and non-discrimination, irrespective of age, gender, disability (including learning disability), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, gender or sexual orientation. In carrying out its functions, the GMCSU/CCG will have due regard to the different needs of protected characteristic groups, in line with the Equality Act 2010. This document is compliant with the NHS Constitution and the Human Rights Act 1998. This applies to all activities for which they are responsible, including policy development, review and implementation. In developing policy the GMCSU policy team will ensure that equity is considered as well as equality. Equity means providing greater resource for those groups of the population with greater needs without disadvantage to any vulnerable group. The Equality Act 2010 states that we must treat disabled people as more equal than any other protected characteristic group. This is because their starting point is considered to be further back than any other group. This will be reflected in GMCSU evidencing taking due regard for fair access to healthcare information, services and premises. An Equality Analysis has been carried out on 3 rd July 2014. For more information about the Equality Analysis, please contact policyfeedback.gmscu@nhs.net. Governance Arrangements Greater Manchester EUR policy statements will be ratified by the Greater Manchester Association Governing Group (AGG) prior to formal ratification through CCG Governing Bodies. Further details of the governance arrangements can be found in the Greater Manchester EUR Operational Policy. 1. Introduction This commissioning policy has been produced in order to provide and ensure equity, consistency and clarity in the commissioning of labiaplasty by Clinical Commissioning Groups in Greater Manchester. When this policy is reviewed all available additional data on outcomes will be included in the review and the policy updated accordingly. Labiaplasty is performed in hospital, usually under general anaesthetic and is done in one of two ways, either by reducing the edges of the labia, or by snipping out a 'V' shape wedge of tissue. The remaining 5

edges are then carefully sewn back together taking care to obtain as natural a result as possible. The demand for labiaplasty on the NHS is increasing; however, as this is essentially a cosmetic procedure carried out on healthy tissues it is not routinely commissioned. 2. Definition A labiaplasty is a surgical procedure that removes excess tissue from the labia, usually the labia minora, although both can be reduced. The idea is to make the labia smaller either for cosmetic or on rare occasions for functional reasons, such as: Where the labia are directly contributing to recurrent disease or infection. Where repair of the labia is required after trauma. Diagram showing external female genitalia 3. Aims and Objectives Aim This policy document aims to specify the conditions under which labiaplasty will be routinely commissioned by Clinical Commissioning Groups in Greater Manchester. Objectives To reduce the variation in access to labiaplasty To ensure that labiaplasty is commissioned where there is acceptable evidence of clinical benefit and cost-effectiveness. To reduce unacceptable variation in the commissioning of labiaplasty across Greater Manchester. To promote the cost-effective use of healthcare resources. 4. Criteria for Commissioning Mandatory Criteria Labiaplasty is not commissioned for aesthetic reasons. Funding may be considered where there is objective evidence of: Significant anatomical distortion as a result of obstetric trauma, other trauma and vulval diseases. 6

Policy Exclusions This does not apply to procedures as part of gender realignment - please refer to the NHS England commissioning policy for details on gender realignment surgery. Where labiaplasty is clinically indicated as part of the treatment pathway for the correction of female genital mutilation, this is considered part of the treatment pathway and is excluded from this policy. Labiaplasty is not routinely commissioned for aesthetic reasons. Funding may be considered on an individual patient basis, if there is evidence of clinical exceptional circumstances. Locally commissioned treatment as part of a pathway of care within a contract or service level agreement is excluded from this policy. Treatment as part of previously agreed and externally funding trial is excluded from this policy. Clinicians can submit an Individual Funding Request (IFR) if they feel there is a good case for exceptionality. Exceptionality means a person to which the general rule is not applicable. Greater Manchester sets out the following guidance in terms of determining exceptionality; however the over-riding question which the IFR process must answer is whether each patient applying for exceptional funding has demonstrated that his/her circumstances are exceptional. A patient may be able to demonstrate exceptionality by showing that s/he is: Significantly different to the general population of patients with the condition in question. and as a result of that difference They are likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. 5. Description of Epidemiology and Need This is an aesthetic procedure so the exact incidence and prevalence is not known, as labiaplasty is requested mainly to address a perception of abnormality but demand for this treatment on the NHS is increasing. 6. Evidence Summary Most studies agree that this is an aesthetic procedure with very limited numbers of cases where surgical intervention is medically indicated. Expert opinion designates this as an aesthetic procedure and notes that alternative approaches to dealing with perceptions are not readily accessible. Increasing awareness of an idealised normal is also leading to increased demand. There are very few situations where this procedure is medically indicated, these are usually related to trauma. Full details of the Evidence Review are contained with Appendix 1. 7. Rationale behind the Policy Statement 7

Labiaplasty is an increasingly sought after aesthetic procedure and demand on NHS services to provide it is increasing. As this is a predominantly aesthetic procedure this policy has been developed to target a scarce resource at those cases where there is a clinical indication for surgery. 8. Adherence to NICE Guidance NICE have not currently issued guidance on this treatment. 9. Mechanism for Funding Funding will be made available on an individual patient basis. Individual Funding Requests may be made in line with the procedures described in the Greater Manchester EUR Operational Policy. 10. Audit Requirements There is currently no national database. Service providers will be expected to collect and provide audit data on request. 11. Documents which have informed this Policy Greater Manchester EUR Operational Policy. 12. Links to other Policies This policy follows the principles set out in the ethical framework that govern the commissioning of NHS healthcare and those policies dealing with the approach to experimental treatments and processes for the management of individual funding requests (IFR). 13. Date of Review One year from the date of approval by Greater Manchester Association Governing Group and annually thereafter. 14. Glossary Term Aesthetic Gender realignment (aka gender reassignment) Genital Labia Labiaplasty Meaning Concerned with beauty or the appreciation of beauty. The process whereby a person s physical sexual characteristics are changed by means of medical procedures such as surgery or hormone treatment. Relating to the reproductive organs. The inner and outer folds of the vulva, at either side of the vagina. A plastic surgery procedure for altering the labia minora and the labia majora. References N/A 8

Appendix 1 Evidence Review Title/Topic: Labiaplasty Ref: GM027 Search Strategy Database NICE NHS Evidence and NICE CKS SIGN Cochrane York BMJ Clinical Evidence BMJ Best Practice General Search (Google) Result Nil found Nil found Nil found Nil found Nil found Nil found Nil Found Provider websites (not cited) Medline / Open Athens A large multicenter outcome study of female genital plastic surgery Goodman MP, Placik OJ, Benson RH III, Miklos JR, Moore RD, Jason RA, Matlock DL, Simopoulos AF, Stern BH, Stanton RA, Kolb SE, and Gonzalez F J Sex Med 2010;7:1565 1577 What's normal? Influencing women's perceptions of normal genitalia: an experiment involving exposure to modified and nonmodified images C Moran,et al BJOG An International Journal of Obstetrics and Gynaecology Volume 121, Issue 6; May 2014 ;Pages 761 766 What motivates her : Motivations for considering labial reduction surgery as recounted on women s online communities and surgeons websites Zwier S Sex Med; 2014;2:16 23 Is elective vulvar plastic surgery ever warranted, and what screening should be done preoperatively? Goodman MP, Bachmann G, Johnson C, Fourcroy JL, Goldstein A, Goldstein G, and Sklar S. J Sex Med 2007;4:269 276. Royal College Website Aesthetic Genital Surgery: Female Genital Aesthetic Surgery (Aesthetic Genital Surgery, Designer Vaginas) British Association of Plastic and Aesthetic surgeons BJOG release: Expectations and experience of labial reduction Royal College of Obstetricians and Gynaecologists 9

Ethical opinion paper: Ethical considerations in relation to female genital cosmetic surgery (FGCS) Royal College of Obstetricians and Gynaecologists (added at review November 2015 Other Armed Forces Interim Clinical Commissioning Policy: Labiaplasty, Vaginoplasty and Hymenorrhaphy NHS England Summary of the evidence Most studies agree that this is an aesthetic procedure with very limited numbers of cases where surgical intervention is medically indicated. Expert opinion designates this as an aesthetic procedure and notes that alternative approaches to dealing with perceptions are not readily accessible. Increasing awareness of an idealised normal is also leading to increased demand. There are very few situations where this procedure is medically indicated, these are usually related to trauma. The evidence Levels of evidence Level 1 Level 2 Level 3 Level 4 Level 5 Meta-analyses, systematic reviews of randomised controlled trials Randomised controlled trials Case-control or cohort studies Non-analytic studies e.g. case reports, case series Expert opinion 1. LEVEL 3: CROSS SECTIONAL STUDY / REVIEW A large multicenter outcome study of female genital plastic surgery Goodman MP, Placik OJ, Benson RH III, Miklos JR, Moore RD, Jason RA, Matlock DL, Simopoulos AF, Stern BH, Stanton RA, Kolb SE, and Gonzalez F J Sex Med 2010;7:1565 1577 ABSTRACT Introduction: Female Genital Plastic Surgery, a relatively new entry in the field of Cosmetic and Plastic Surgery, has promised sexual enhancement and functional and cosmetic improvement for women. Are the vulvovaginal aesthetic procedures of Labiaplasty, Vaginoplasty/Perineoplasty ( Vaginal Rejuvenation ) and Clitoral Hood Reduction effective, and do they deliver on that promise? For what reason do women seek these procedures? What complications are evident, and what effects are noted regarding sexual function for women and their partners? Who should be performing these procedures, what training should they have, and what are the ethical considerations? Aim: This study was designed to produce objective, utilizable outcome data regarding FGPS. Main Outcome Measures: 1) Reasons for considering surgery from both patient's and physician's perspective; 2) Pre operative sexual functioning per procedure; 3) Overall patient satisfaction per 10

procedure; 4) Effect of procedure on patient's sexual enjoyment, per procedure; 5) Patient's perception of effect on her partner's sexual enjoyment, per procedure; 6) Complications. Methods: This cross sectional study, including 258 women and encompassing 341 separate procedures, comes from a group of twelve gynecologists, gynecologic urologists and plastic surgeons from ten centers in eight states nationwide. 104 labiaplasties, 24 clitoral hood reductions, 49 combined labiaplasty/clitoral hood reductions, 47 vaginoplasties and/or perineoplasties, and 34 combined labiaplasty and/or reduction of the clitoral hood plus vaginoplasty/perineoplasty procedures were studied retrospectively, analyzing both patient's and physician's perception of surgical rationale, pre operative sexual function and several outcome criteria. Results: Combining the three groups, 91.6% of patients were satisfied with the results of their surgery after a 6 42 month follow up. Significant subjective enhancement in sexual functioning for both women and their sexual partners was noted (p = 0.0078), especially in patients undergoing vaginal tightening/perineal support procedures. Complications were acceptable and not of major consequence. Conclusions: While emphasizing that these female genital plastic procedures are not performed to correct abnormalities, as there is a wide range of normality in the external and internal female genitalia, both parous and nulliparous, many women chose to modify their vulvas and vaginas. From the results of this large study pooling data from a diverse group of experienced genital plastic surgeons, outcome in both general and sexual satisfaction appear excellent. 2. LEVEL N/A: PSYCHOLOGY STUDY What's normal? Influencing women's perceptions of normal genitalia: an experiment involving exposure to modified and nonmodified images C Moran,et al BJOG An International Journal of Obstetrics and Gynaecology Volume 121, Issue 6; May 2014 ;Pages 761 766 ABSTRACT Objective: Examine women's perceptions of what is normal and desirable in female genital appearance. Design: Experiment with random allocation across three conditions. Setting: Community Sample: A total of 97 women aged 18 30 years. Methods: Women were randomly assigned to view a series of images of (1) surgically modified vulvas or (2) nonmodified vulvas, or (3) no images. They then viewed and rated ten target images of surgically modified vulvas and ten of unmodified vulvas. Main outcome measures: Women used a four point Likert scale ( strongly agree to strongly disagree ), to rate each target image for looks normal and represents society's ideal. For each woman, we created two summary scores that represented the extent to which she rated the unmodified vulvas as more normal and more society's ideal than the modified vulvas. Results: For ratings of normality, there was a significant effect for condition (F 2,94 = 2.75 P = 0.007, = 0.082): women who had first viewed the modified images rated the modified target vulvas as more normal than the nonmodified vulvas, significantly different from the control group, who rated them as less 11

normal. For ratings of society's ideal, there was again a significant effect for condition (F 2,92 = 7.72, P < 0.001, = 0.125); all three groups rated modified target vulvas as more like society's ideal than the nonmodified target vulvas, with the effect significantly strongest for the women who had viewed the modified images. Conclusions: Exposure to images of modified vulvas may change women's perceptions of what is normal and desirable. This may explain why some healthy women seek labiaplasty. 3. LEVEL N/A: PSYCHOLOGY STUDY What motivates her : Motivations for considering labial reduction surgery as recounted on women s online communities and surgeons websites Zwier S Sex Med; 2014;2:16 23 ABSTRACT Introduction: Increasing numbers of women are seeking labial reduction surgery. We studied the motivations for considering labial reduction surgery as recounted on women s online communities and surgery provider s websites. Aims: The study analyzed motivations for considering labial reduction surgery expressed by women on online communities, looked at the role of the women s age and nationality, compared findings with motivations indicated on the websites of an international sample of surgery providers, and identified similarities to and differences from what is known from extant studies. Methods: Quantitative content analysis of the posts of 78 American, British, and Dutch women on online communities, and 40 international surgery providers websites about labial reduction surgery was conducted. Main Outcome Measures: Main outcome measures concerned the incidence and prominence of different motivational categories (functional/emotional and discomfort/enhancement related). Differences in motivations as a function of age, national background, and women s vs. surgeons stated motivations were tested. Results: Emotional discomfort regarding self-appearance and social and sexual relationships was found to be the most frequent and most prominent motivation for considering labial reduction surgery on women s online communities, regardless of age and national background. Functional discomfort and desired emotional enhancement ranked second. Very few age or national differences were found. The surgeons websites recognized functional discomfort more and elaborated upon emotional issues in sexual relationships less than members of the online communities. Conclusions: Feelings of emotional and psychosexual distress in addition to functional distress are a highly prevalent motivation among women considering labial reduction surgery. Emotional distress appears to be greater and more freely emphasized when women communicate on online communities, while functional issues appear to receive greater notice on surgery provider s websites. 12

4. LEVEL 5: EXPERT OPINION Is elective vulvar plastic surgery ever warranted, and what screening should be done preoperatively? Goodman MP, Bachmann G, Johnson C, Fourcroy JL, Goldstein A, Goldstein G, and Sklar S. J Sex Med 2007;4:269 276. ABSTRACT Introduction: Elective vulvar plastic surgery was the topic of a heated discussion on the list-serve of the International Society for the Study of Women's Sexual Medicine. At the suggestion of a board member, it was determined that this discussion might of interest to journal readers in the form of a published controversy. Methods: Six people with expertise and/or strong opinions in the area of vulvar health, several of whom had been involved in the earlier online discussion, were invited to submit evidence-based opinions on the topic. Main Outcome Measure: To provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine. Results: Goodman believes that patients should make their own decisions. Bachmann further states that, while that is a woman's right, she should be counselled first, because variations in looks of the vulvar region are normal. Johnson furthers this thought, discussing the requirement for counselling before performing reinfibulation surgery on victims of female genital cutting. Fourcroy emphasizes the need to base surgical procedures on safety and efficacy in the long term, and not merely opportunity at the moment. Goldstein and Goldstein state that, based on the four principles of ethical practice of medicine, vulvar plastic surgery is not always ethical, but not always unethical. Sklar pursues this thought further, pointing out specific examples in regard to the principles of ethics. Conclusion: Vulvar plastic surgery may be warranted only after counselling if it is still the patient's preference, provided that it is conducted in a safe manner and not solely for the purpose of performing surgery. 5. LEVEL 5: EXPERT OPINION Aesthetic Genital Surgery: Female Genital Aesthetic Surgery (Aesthetic Genital Surgery, Designer Vaginas) British Association of Plastic and Aesthetic surgeons Aesthetic surgery of the female genitalia, or 'designer vaginas', includes a number of surgical procedures designed to improve their appearance. It is claimed that, occasionally, sexual function may be enhanced. The availability of such surgery in the UK is limited. With a growing acceptance of surgery designed to alter appearance, and the increasing availability of explicit images of naked women, a number of women are requesting surgery to alter their intimate appearance feeling that they compare unfavourably. There are other women who claim that the size or shape of their vagina or external genitalia prevent them or their partner from achieving full sexual satisfaction. The most commonly requested procedures are labial reduction ('labiaplasty') and vaginal tightening ('vaginaplasty') operations. Other procedures include liposuction to the mons pubis; fat injections to the labia majora or mons in order to give a more youthful appearance to these areas; removal or reduction of skin around the clitoris ('hoodectomy'), to improve clitoral sensitivity; and reconstruction of the hymen 13

for cultural reasons. Laser therapy has been described for the removal of labial wrinkles; and hair transplantation for hypotrichosis of the mons pubis. Labial reduction includes a number of operations designed to decrease the size and degree of protruberance of the labia minora, or 'inner lips' of the vagina. The most common reason for women to request this operation is because the labia are perceived to be too large and aesthetically un-pleasing. A small number of women state that the large size of their labia make them noticeable in tight clothing, or make sports such as cycling uncomfortable. Others have problems with penetration. The procedure is relatively simple, excising an area of the labia minora using a variety of incisions; and can be performed under local anaesthetic. Careful placement of the scar is important, however, in order to prevent painful scar contracture along the rim of the labia. 6. LEVEL N/A: COMMISSIONING POLICY Armed Forces Interim Clinical Commissioning Policy: Labiaplasty, Vaginoplasty and Hymenorrhaphy NHS England Labiaplasty Labiaplasty is generally a cosmetic procedure to change appearance alone and is not routinely funded. Requests for Labiaplasty will be considered for the following indications: Where the labia are directly contributing to recurrent disease or infection. Where repair of the labia is required after trauma. 7. LEVEL N/A: PRESS RELEASE BJOG release: Expectations and experience of labial reduction Royal College of Obstetricians and Gynaecologists New research published in BJOG: An International Journal of Obstetrics and Gynaecology has found that women seeking labial reduction opt for the procedure because they feel stigmatised by social norms about how they should look and may have unrealistic expectations of the surgery. The incidence of labial reduction in the NHS has doubled in recent years and the study, from the University of Liverpool, looked at why women underwent the surgery, what they hoped to get out of the operation and their experiences afterwards. The study took place in an NHS hospital setting and identified women who had undergone labia reduction surgery over a two year period, 17 women were invited to take part and six accepted. The study found that the main reason the women requested surgery was because they viewed their presurgery appearance as defective and sought a normal genital look. The women tended to base their view of normal on social norms projected in the media that female genitalia should be invisible, with no protruding labia, and they requested the operation because they found their situation stigmatising. Clinicians may have a very different view of normality, based on healthiness and incorporating the natural variations that occur among women. However, the study highlighted that health professionals are delivering mixed messages about what is normal. The women s perception of being abnormal were inadvertently reinforced by being given reassurance of normality, alongside referral to a specialist for further investigation or surgical intervention. 14

Another common theme was that the women felt their appearance impacted negatively on their sex lives and relationships. Those in the group that were sexually active found that their dislike of the way they looked created anxiety about having sex with their partner or starting a new relationship. By having the operation the women expected to see an improvement in their sex lives and, for some, there was also the hope that it would improve or save a relationship. Although the operation did have the effect of making the women less self-conscious, expectations of improved sex-life and relationships were not met for all women. Dr Ros Bramwell, of the Liverpool University research team, said I think a key issue here is what is meant by 'normal'. Health professionals may understand 'normal' as meaning healthy or within the average range. But knowing that there are other women who look like you do doesn't help if you still feel that the way you look is somehow abnormal and wrong. The problem is that clinical time is usually limited and we are dealing here with what are probably longheld attitudes and issues of self-esteem which are quite difficult to change. Further research is needed into potential psycho-educational interventions to help change women s perception of their need for surgery. Professor Philip Steer, BJOG editor-in-chief, said There is an growing demand for labia reduction and it is increasingly important for clinicians to understand the reasons why women believe they need this surgery. Often these reasons go beyond the realm of the gynaecologist to wider social and cultural norms reflected in the popular media. Thus the suggestion that improved communication about normal genital appearance should begin at an earlier stage has merit as does the proposal that psychosocial elements be introduced to the referral process - both certainly warrant further investigation. Notes BJOG: An International Journal of Obstetrics and Gynaecology is owned by the Royal College of Obstetricians and Gynaecologists (RCOG) but is editorially independent and published monthly by Blackwell Publishing. The journal features original, peer-reviewed, high-quality medical research in all areas of obstetrics and gynaecology worldwide. Please quote BJOG' or BJOG: An International Journal of Obstetrics and Gynaecology' when referring to the journal. For more information, please contact the RCOG press office on 020 7772 6446 or 020 7772 6357. Reference Bramwell R, Morland C, Garden A. Expectations LEVEL N/A Ethical opinion paper: Ethical considerations in relation to female genital cosmetic surgery (FGCS) Royal College of Obstetricians and Gynaecologists 1. Executive summary General practitioners, gynaecologists and plastic surgeons are increasingly likely to be consulted by women and girls who are concerned about the structure and appearance of their genitalia. Clinicians have a duty of care to provide these women with accurate information on the diversity of morphology and appearance of the female genitalia and to suggest simple measures to relieve genital discomfort where no pathology can be identified. The importance of education, support and advice should be at the heart of clinical practice, with sympathetic appreciation of the female body insecurities that are rife in 15

western society. The presentation of female genital cosmetic surgery (FGCS) as an unproblematic lifestyle choice is undesirable because it misleads women as to the need for and the efficacy of such surgical techniques. Key points are as follows: Fully informed consent is fundamental when offering FGCS, as is the case for all medical treatment. Clinicians who perform FGCS must be aware that they are operating without a clear evidence base. Women should be advised accordingly. Owing to anatomical development during puberty, FGCS should not normally be offered to individuals below 18 years of age. In general, FGCS should not be undertaken within the National Health Service (NHS) unless it is medically indicated. 16