An increasing number of patients are seeking cosmetic procedures of the vulva. In 2007, the American College of Obstetricians and Gynecologists released a Committee Opinion (#378) advising against cosmetic vaginal procedures due to a lack of safety and efficacy data. A growing number of observational studies has suggested overall high satisfaction rates, and complication rates that are “acceptable,” although a paucity of comparative data and validated outcomes measures remains. The issue is further intensified and complicated by the proprietary or franchised techniques and devices that surgeons “sell” to each other, and by the fee-for-service model that circumnavigates some of the rigors of the physician-payor-patient relationship. This point/counterpoint article, based on a debate held at the Society of Gynecologic Surgeons’ 2014 Annual Scientific Meeting, addresses the issue of an individual seeking a cosmetic reduction labiaplasty from her gynecologist in the contexts of available literature and standard ethical frameworks. The specific question posed to the panelists was, “Should the gynecologist feel comfortable offering cosmetic labiaplasty procedures to his or her patients?”
The Issue
Women are seeking cosmetic gynecologic procedures in increasing numbers. Position papers from societies often discourage the gynecologist’s participation in these procedures, while the surgical training and experience in the anatomic region would support that the gynecologist is the best-trained person to perform these procedures. Although efficacy and safety data are emerging, the majority of data are composed of noncomparative studies without validated outcomes measures. This debate addresses the topic of the gynecologist’s role in providing cosmetic labiaplasty.
Contributed by Charles R. Rardin, MD, Department of Obstetrics and Gynecology, Women & Infant’s Hospital, Brown University, Providence, RI.
Patient requests for labial reduction (labiaplasty) are on the rise. Cultural shifts in pubic hair grooming (80% of today’s women performing some or all pubic hair removal) and greater visibility of the vulva (widespread access to images through media and Internet), as well as increasing attention to sexual well-being, have fostered this demand. While the natural contours of the labia minora vary in symmetry, length, and width, in our society small, nonprotruding, symmetrical structures are described as “normal” by the majority of women.
Gynecologists care for women. We are their physicians from young adulthood through and beyond the menopausal transition. We are pelvic specialists, and the appropriate provider to address, but not promote, labiaplasty. Though we may not view ourselves as cosmetic surgeons, such requests may not be driven by appearance alone.
The principles of medical ethics dictate consideration of autonomy , nonmaleficence, beneficence, and justice when treating patients. Autonomy states that an adult person without mental impairment has the final decision with regard to medical procedures received, provided there is not external influence for their choice, such as coercion, and they are not experiencing body dysmorphic disorder. Thus, understanding the rationale behind the woman’s choice is critical. Nevertheless, the majority of these patients cite functional alone or a combination of functional and aesthetic motivators. Prominent reports include difficulty grooming, discomfort with sports and exercise, and problems with intercourse. Women who believe their labia are abnormal often avoid wearing certain clothing or bathing suits. Comments from these women include: “I am fed up of being embarrassed about my body. It prevents me having a sex life”; “I don’t feel confident in changing rooms…”; and ”the pain when I exercise and just walking can be awful.” Resultant low body image and feelings of self-consciousness may impact quality of life and mental well-being, as well as lead to sexual dysfunction.
The second principle of medical ethics is nonmaleficence , or “first do no harm.” Anatomic studies suggest the labia are innervated along their edge, and bear an erectile core. However, ability to achieve orgasm from stimulation of these areas is not robust, nor have these studies assessed the role of the labia minora in the sexual response of women seeking labiaplasty. Furthermore, satisfaction following these surgeries is overwhelmingly high, at 90-100%. Additionally reassuring is the low risk (2-6%) of complications, with most being minor. These rates are far lower than those reported after breast augmentation and other widely accepted procedures.
Beneficence dictates that medical providers act in the patients’ best interest and be familiar with appropriate techniques. As gynecologists, we understand the anatomy, and operate on the vulva and vagina, and we should be comfortable doing these repairs. Several methods of performing labiaplasty have been described, with none deemed superior. Central wedge, linear resection, Z-plasty, or de-epithelialization have all been employed with good outcomes.
Finally, justice states that these surgeries should not take resources from other medically necessary allocations, and patients should bear the costs of the procedure.
We are dedicated to caring for our female patients. We can best educate about the wide range of size and symmetry to the labia, and advise regarding risks. Yet we are also cognizant that despite reassurance and meticulous counseling women may experience “…psychological distress, loss of self-esteem …and diminished libido” if their condition is not appropriately attended to, and continue to seek repair. In such situations, we should feel secure healing these women. Given reassuring outcomes and low complications from labiaplasty, it is possible to respect autonomy, while upholding nonmaleficence.
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