Dr. Goodman authors article on VulvoVaginal Aesthetic Surgery
"Is Elective Vulvar Plastic Surgery Ever Warranted, and what Screening should be Conducted Preoperatively?"
Is Elective Vulvar Plastic Surgery Ever Warranted, and What
Screening Should Be Conducted Preoperatively?
Michael P. Goodman, MD,* Gloria Bachmann, MD,
† Crista Johnson, MD,‡Jean L. Fourcroy, MD, PhD, MPH,
§ Andrew Goldstein, MD,¶ Gail Goldstein, MD, MA,**††*Caring for Women, Davis, CA, USA;
†Department of Obstetrics and Gynecology, UMDNJ, New Brunswick, NJ, USA;‡
Department Obstetrics & Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA; §Uniformed Services¶Department of Gynecology and Obstetrics, The Johns Hopkins††Sklar Center forA B S T R A C T
Introduction.
Elective vulvar plastic surgery was the topic of a heated discussion on the list-serve of the InternationalMethods.
Six people with expertise and/or strong opinions in the area of vulvar health, several of whom had beenMain Outcome Measure.
To provide food for thought, discussion, and possible further research in a poorlyResults.
Goodman believes that patients should make their own decisions. Bachmann further states that, while thatConclusion.
Vulvar plastic surgery may be warranted only after counseling if it is still the patient’s preference,Goodman MP,A
n interesting flurry of e-mails among participantsControversies in Sexual Medicine
© 2007 International Society for Sexual Medicine
J Sex Med 2007;4:269–276 269
to stellate lacerations during the many years
that I practiced obstetrics and backed-up nurse
midwives.
Secondary to requests from my gynecologic
patients with redundant labia at or above the large
range of normality and/or with widened, relaxed,
or gaping perineum or vaginal vaults, I began performing
labial reduction (“labioplasty”), perineoplasty,
and vaginoplasty several years ago, and
presently do 1–3 per month. My experience,
working with many women requesting vulvovaginal
alterations, is this.
Cosmetic surgery is an opportunity for people
to make a physical change in their appearance
to correct a (sometimes self-perceived) defect,
change how they look, etc., to either correct a
physical problem, enhance their self-esteem, or
look better in their clothes, etc. [2–4]. THIS IS
THEIR DECISION TO MAKE, NOT MINE.
My responsibility is to make sure the person: is
psychologically stable; is doing it for the right
reasons (not to “keep her boyfriend,” etc.!); fully
understands the procedure, its risks, and recovery
time; understands that the outcome may not
be exactly up to her expectation; and has the
opportunity and time to make a truly informed
decision.
If a man decides to get Botox, if a person decides
upon a rhinoplasty to correct what he or she feels
is a “deformed” nose, and if a woman decides on a
breast augmentation to fit better in her clothes or
enhance her self-esteem, few would take issue. But
many cringe when vulvovaginal aesthetics are discussed.
I think a very paternalistic and chauvinistic
attitude is displayed when this work is rejected out
of hand.
Like noses and breasts, vulvae and vaginas come
in a wonderfully varied array of sizes, shapes, and
colors. There is a wide range of normality and I
make sure my patients understand this. Given that,
many patients reasonably decide that they want
surgery. My responsibility then is to provide the
best care possible and to take the time to objectively
assess the patient’s motives, understanding,
and emotional stability.
Many pejorative remarks have been made
about the propriety of the procedure of hymenal
reconstruction or “hymenoplasty.” Patients
exhibit many different reasons for their request,
many of them cultural. A good hymenoplasty can
be very difficult to do. The tissue is often thin
and friable; it is often difficult to get mucosal
surfaces to align exactly as wished, and fibrin
glue does not work well on mucosal surfaces.
Because the purpose frequently is “to be tight
and bleed,” an effective procedure is often the
opposite of the meticulous surgery we would
hope for: remove a wedge, retighten, and hope
for as much scar tissue as possible to produce
tearing and bleeding with next coitus. Egad! Not
the type of surgery I’d like—but maybe just what
the patient wants!
It is imperative that the surgeon takes the time
to get to know her or his patient and her reasons,
desires, and exact expectations; not “You want it
done? . . . Let’s book it for next week!” Proper
preoperative preparation includes: negotiating
exactly what your patient wishes and how close
you can come to accomplishing this, reasonably
expected outcomes, exact and clear recovery times
and instructions, and a clear understanding of risks
and the possibility that results may not be exactly
up to expectations.
When time is taken preoperatively and the procedure
is performed carefully, I have found my
patients uniformly happy with their decisions and
the outcome.
Michael P. Goodman, MD
Like it or not, cosmetic procedures conducted to
alter body shape and contour are a fact of life!
Statistics confirm its widespread appeal—in 2005,
more than 10.2 million cosmetic plastic procedures
were performed in the United States, with
1.8 million of them surgical cases and 8.5 million
of them minimally invasive cases such as Botox
injections and chemical peels [5]. Compared with
the number of procedures from the year before,
this was an increase of 11%. Unfortunately, these
procedures are often confused with reconstructive
plastic surgery procedures, which are conducted to
improve function and/or appearance of abnormal
body areas that result, either congenitally, from
tumor excision, lacerations, accidents, and other
morbid circumstances.
For women who wish to have cosmetic reconstruction
of the external genitalia, there is no valid
reason to deny them this right. Female genital
reshaping falls into the same category as liposuction,
nose reshaping, breast augmentation, eyelid
surgery, a tummy tuck, or any other cosmetic alteration
of the body.
However, vaginal cosmetic surgery, often
referred to as “rejuvenation” surgery, should be
Controversies in Sexual Medicine
270 J Sex Med 2007;4:269–276
performed only when the woman has been counseled
that she is opting for a purely cosmetic
surgery and not a reconstructive plastic surgery.
Therefore, I firmly believe that, preoperatively,
the woman should be clearly told that excessive
labial tissue or prominent labia minora are variations
of normal genital anatomy and do not impair
genital function. For example, it should not be
inferred that labia minora are abnormal if they
protrude through the labia majora, and that this
condition will lead to sexual dysfunction, future
problems, or pathology. Language should be
avoided that infers that the labia minora, labia
majora, clitoral hood, or the mons pubis are misshaped
or ugly and, through surgery, can be
“restored” to be more appealing in size and shape.
The woman should be clearly told that she is
having cosmetic surgery, to make the area more
pleasing to her and/or her partner, and that she is
not having vulvar reconstruction, which denotes
surgery for abnormal function.
Gloria Bachmann, MD
Cosmetic beautification, the quest for the perfect
body image, is not a new phenomenon;
however, the surgical utilization of this desire has
exploded. Is there a desperate quest for physical
transformation—transformation to the dream
world? [6,7] I cannot deny the right of a woman (or
perhaps the couple) to seek what is thought to be
in that culture a perfect body. After all, I have long
since given up what could be my normal hair color,
and make great efforts to make my teeth conform
to cultural standards but fixing my genitalia?
Clearly, we are in the botox era, where perfection
to fit someone’s norm and an opportunity to make
money set the standards. The prevalence of labia
measurably outside the norm is small. But there
are women with labial hypertrophy that results in
both hygienic and sexual problems [8]. It is also
clear that labial reduction is a safe, simple procedure
that can be performed under local anesthesia
and on an outpatient basis with minimal sedation
[8,9].
Most of the body beautification schemes are
built on cultural expectations. The best examples
are female genital cutting and hymnography
[10,11]. Both of these procedures are built on centuries
of misinformation. Hymnography is illegal
in most Arab countries, but it is performed unofficially;
specialists undertake five or six procedures
weekly. The trade in hymen repairs, justifiable in
certain circumstances, when the woman would
otherwise suffer disgrace or worse [12–14]. We
also have polysurgical addicts who may undergo
repeated surgical transformation from the top
(face) to the bottom. One should ask whether the
use of these techniques is truly justified. In other
words, are these procedures both safe and efficacious?
It is important to make sure our surgical
procedures are based on sound evidence. I suspect
most are opportunistic procedures developed to
make money, and none have looked at the longterm
health outcomes. It is important to make sure
the women undergoing these procedures understand
the risks and benefits associated with the
magic of perfection.
Jean L. Fourcroy, MD, PhD, MPH
There is a raging debate regarding the juxtaposition
of the traditional cultural practice of female
genital cutting with elective genital cosmetic
surgery performed commonly in western societies.
Female genital cutting has achieved global
attention due to the increasing influx of immigrants
and refugees from indigenous countries to
Europe and North America. The World Health
Organization (WHO) estimates that 140 million
women worldwide have undergone a form of
female genital cutting, and each year 3 million
girls are at risk for the procedure [15]. The WHO
defines female genital cutting as “all procedures
involving partial or total removal of the external
female genitalia or other injury to the female
genital organs whether for cultural, religious or
non-therapeutic reasons” [16]. This definition,
however, fails to distinguish the traditional practice
of female genital cutting (often performed
out of love and societal pressures to preserve a
woman’s family honor, respect, chastity, marriageability,
and beauty) from elective vulvar
plastic surgery (often performed for aesthetics, to
promote mental, physical, and sexual well-being)
[17]; wherein lies the controversy as to whether
such procedures are ever warranted.
As a health and human rights violation, female
genital cutting has been the subject of increasing
legislation worldwide [18]. In 1996, the U.S. Congress
enacted a federal law criminalizing the performance
of female genital cutting on minors
(less than age 18). However, the law does not
address re-infibulation (the re-approximation of
the raw edges of tissue opened during childbirth,
recreating the original “infibulation”—which is
Controversies in Sexual Medicine
J Sex Med 2007;4:269–276 271
the most severe form of female genital cutting
involving excision of the clitoris, labia majora,
and/or minora with re-approximation of the cut
edges producing a narrow neo-introitus). If a
woman requests re-infibulation after delivery, this
should only be performed after extensive counseling
and at the discretion of the healthcare provider
after a thorough discussion of the medical
risks and cultural relevance of this procedure to
the woman. Elective defibulation (opening of the
prior female genital cutting scar) is warranted in
women who desire this procedure performed
before either marriage or childbirth, and/or to
alleviate the long-term complications and sexual
morbidity associated with infibulation. If performed
during pregnancy, defibulation should be
performed in the second trimester or at least
4–6 weeks before delivery to facilitate intrapartum
fetal monitoring, pelvic exams and reduce obstetric
complications. Elective clitoral reconstruction
may also be warranted in women who have undergone
female genital cutting to improve sexual
function [19,20].
Preoperative screening guidelines for circumcised
women desiring elective vulvar plastic
surgery should include a detailed history and
physical examination, including appropriate documentation
of the type of female genital cutting
present and exploration of the cultural significance
to the woman and medical sequelae experienced.
An interpreter should be present, along
with the woman’s partner/spouse to aid in
medical decision making. Visual aids/diagrams
illustrating vulvar anatomy should also be incorporated,
and women should be counseled on the
risks, benefits, and expectations postoperatively
(i.e., change in urinary stream postprocedure).
Primary female genital cutting should be discouraged,
and a discussion of the legal ramifications of
performing female genital cutting in women/girls
under age 18 should also ensue. Future efforts
must aim to further classify and/or distinguish
traditional female genital cutting from genital
cosmetic surgery.
Crista Johnson, MD
Labiaplasty (labia minora reduction, nymphectomy)
has been discussed in the peer-reviewed
medical literature since 1971. However, early
reports of this procedure consisted of correction of
labial hypertrophy caused by congenital malformation,
exogenous hormones, myelodysplasia, and
manual stretching of the labia with weights (a
practice of the Khoikhoi tribe in south-western
Africa) [21]. In 1984, Hodgkinson and Hait were
the first to discuss this procedure performed for
purely aesthetic reasons [22]. More recently, while
there are no published statistics from either the
American Society of Plastic Surgeons or the
American College of Obstetricians and Gynecologists,
it has become apparent in the lay press that
“this surgery is one of the fastest growing” areas of
plastic surgery [23]. Unfortunately, there has been
no discussion in the peer-reviewed medical literature
that addresses the biomedical ethical issues
surrounding this procedure [11].
Therefore, the authors of this article (a gynecologist
specializing in the treatment of vulvar disorders
with experience performing this procedure
[A.G.], and a dermatologist with an advanced
degree in medical ethics, who performs aesthetic
procedures [G.G.]) thought it necessary to
examine this procedure through the lens of established
and accepted principles of biomedical ethics
to offer guidelines for physicians who might consider
performing this procedure.
The four medical ethical principles applicable
to this discussion are:
autonomy, nonmaleficence,and justice [24]. However, it is importantAutonomy: It is an established medical and legalControversies in Sexual Medicine
272 J Sex Med 2007;4:269–276
psychiatric disorder that must be addressed
prior to agreeing to perform the surgery.
Second, the patient must be free of any outside
coercive influences. The surgeon must be
certain that the prospective patient is not being
convinced to have this surgery by a sexual
partner, theatric agent, etc. Third, in order to
act autonomously, the patient must be completely
aware of the true risks of this surgery
(discussed in more detail below). Lastly, the
patient must be free of any coercive influences
by the surgeon. This type of coercion can begin
even before a patient’s first visit with a surgeon
if the surgeon advertises this type of procedure.
A recent Committee Opinion from the American
College of Obstetricians and Gynecologists
stated that terms such as “top,” “world-famous,”
and “pioneer” are usually misleading and are
designed to attract vulnerable patients [25]. In
addition, the same guidelines state that there
must be a complete disclosure of any restrictive
commercial agreements that allow a surgeon to
claim unique skills or unique treatments such as
Designer Laser Vaginoplasty
TM. Additionally,Nonmaleficence: The ethical principle primum(first do no harm) is prima faciebinding, and is therefore a greater ethical principle
than beneficence (to do good). Therefore,
any procedure that has a greater chance of
harming a patient than helping her is unethical.
The majority of reports of labiaplasty are small
case series or case reports and therefore the true
complication rate associated with this procedure
is unknown. The authors of a large case series of
163 patients reported “no significant complications”
with this procedure; however, they report
that 20% of the patients reported that the
surgeon did not adequately explain the procedure
and the results to expect, 17% found the
results to be unsatisfactory, and many patients
experience transient postoperative pain and dyspareunia
[26]. In addition, while not reported in
the literature, one of the authors of this article
(A.G.) has seen persistent vulvar pain (dysesthetic
vulvodynia) as a direct consequence of
labiaplasty that required treatment with amitriptyline
for almost 1 year to treat neuropathic
pain. Lastly, the principle of nonmaleficence
allows any surgeon to refuse to perform labiaplasty
if he or she feels that it is not in the best
interests of the patient.
•
Beneficence: The majority of peer-reviewed literatureJustice: The ethical principle of justice impliesControversies in Sexual Medicine
J Sex Med 2007;4:269–276 273
solely by the patient, the issue of justice is not
especially applicable (although one might argue
that the doctor, having used society’s resources
when getting medical training, should use his
or her skills in a more “useful” manner). However,
in countries where medical resources are
rationed, the principle of justice does apply. The
authors would suggest that, in this situation,
only the most extreme cases of labial hypertrophy
would warrant labiaplasty. More importantly,
the principle of justice should prevent
any physician from suggesting to a third-party
payer (i.e., insurance company or government)
that there is a medical indication for the procedure
to obtain monetary coverage in situations
where aesthetic concerns are the main motivation
of the patient.
In conclusion, we have attempted to examine
the labiaplasty within the construct of established
medical ethical principles. After applying these
principles to this procedure, it is apparent that
performance of this procedure is not always
ethical, nor it is always unethical. Therefore, it is
the surgeon’s burden to be aware of the ethical
principals involved and to practice well within the
boundaries of ethical conduct. Lastly, while this
article has only examined the medical ethical
issues surrounding labiaplasty, the same principles
can be applied to other vulvovaginal cosmetic
procedures, such as “vaginal rejuvenation” and
“hymenoplasty.”
Andrew T. Goldstein, MD and
Gail R. Goldstein, MD, MA
To answer the question of whether elective vulvar
plastic surgery is ever warranted, it is important
to put aside emotional reactions and go back
to look at basic ethic issues. Beauchamp and
Childress [24] outline four basic groups of
principles—respect for autonomy, beneficence,
nonmaleficence, and justice (which is too broad a
topic to cover here).
One of the bases for autonomy of patient choice
is the freedom of the patient from controlling
influences [24]. Although the choice of genital
alteration is presented as empowering for women
by the media, such a decision must be viewed in
the context of relationships and socialization
which are in many ways limiting for women. The
influence of the media and societal ideals impose
pressure on women to alter their appearances.
At the current time, there is no definition of
what constitutes normal labium minora length.
Freidrich [28] stated that a maximum horizontal
length of 5 cm or less from medial to lateral border
was the normal length. In some of the plastic
surgery literature, 3 cm is now considered the
upper limit of normal length [29]. To distinguish
between the two aspects of plastic
surgery—cosmetic and reconstructive [30], the
American Medical Association states: “Cosmetic
surgery is performed to reshape normal structures
of the body in order to improve the patient’s
appearance and self-esteem. Whereas reconstructive
surgery is performed on abnormal structures
. . .” [30,31]. This lack of consensus in the
professional world translates into confusion for
patients whose ideals for vulvar appearance are
imagined or based on images seen in the pornographic
literature. One physician even encourages
his patients to use Playboy magazine as a guide for
their desired vulvar appearance [17].
Beneficence refers to the contribution a physician
makes to a patient’s welfare [24]. This means
contributing to a patient’s health. Numerous
studies use the patient satisfaction ratings as a
gauge of benefit [32,33]. This, however, converts
the goal of medicine from healing to patient happiness.
While there have been cosmetic surgery
studies showing improvement in patient interpersonal
relationships and sexual function with a
decrease in depression [34], this still remains to be
shown for genital altering surgeries. The study by
Berman and colleagues on genital self-image,
although it shows increased desire correlating with
positive genital self-image, does not translate to
improved relationships or improved sexual function
[35].
Nonmaleficence is the obligation to “do no
harm” in the treatment of patients [24]. One study
of labial reconstruction on women with symptomatic
labial hypertrophy described a 23.8% complication
rate with complications such as flap necrosis
[29]. Is this an acceptable rate for a procedure
which is performed on normal structures?
At the heart of the physician–patient relationship
is the fiduciary nature of the relationship.
“Both law and medical tradition distinguish the
practice of medicine from business practices that
rest on contracts and marketplace relationships.
The patient-physician relationship is founded on
trust and confidence” [24]. “If the only indication
for a medical procedure were the wishes of the
Controversies in Sexual Medicine
274 J Sex Med 2007;4:269–276
patient, medical technology could be used to
gratify almost any whim” [32]. In this largely
market-driven part of cosmetic surgery, what will
be the limiting factor for physicians who perform
these surgeries?
Thus, patient autonomy and technological
advancement have been linked together in a business
proposition, where the patient is able to chose
a procedure and, if she has the money, obtain it if
there is a physician willing to provide the technology.
Does this reflect the true nature of the practice
of medicine and of the physician–patient
relationship? I would argue no.
Susan Sklar, MD
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Michael P. Goodman, MD,* Gloria Bachmann, MD,
† Crista Johnson, MD,‡Jean L. Fourcroy, MD, PhD, MPH,
§ Andrew Goldstein, MD,¶ Gail Goldstein, MD, MA,**††*Caring for Women, Davis, CA, USA;
†Department of Obstetrics and Gynecology, UMDNJ, New Brunswick, NJ, USA;‡
Department Obstetrics & Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA; §Uniformed Services¶Department of Gynecology and Obstetrics, The Johns Hopkins††Sklar Center forA B S T R A C T
Introduction.
Elective vulvar plastic surgery was the topic of a heated discussion on the list-serve of the InternationalMethods.
Six people with expertise and/or strong opinions in the area of vulvar health, several of whom had beenMain Outcome Measure.
To provide food for thought, discussion, and possible further research in a poorlyResults.
Goodman believes that patients should make their own decisions. Bachmann further states that, while thatConclusion.
Vulvar plastic surgery may be warranted only after counseling if it is still the patient’s preference,Goodman MP,A
n interesting flurry of e-mails among participantsControversies in Sexual Medicine
© 2007 International Society for Sexual Medicine
J Sex Med 2007;4:269–276 269
to stellate lacerations during the many years
that I practiced obstetrics and backed-up nurse
midwives.
Secondary to requests from my gynecologic
patients with redundant labia at or above the large
range of normality and/or with widened, relaxed,
or gaping perineum or vaginal vaults, I began performing
labial reduction (“labioplasty”), perineoplasty,
and vaginoplasty several years ago, and
presently do 1–3 per month. My experience,
working with many women requesting vulvovaginal
alterations, is this.
Cosmetic surgery is an opportunity for people
to make a physical change in their appearance
to correct a (sometimes self-perceived) defect,
change how they look, etc., to either correct a
physical problem, enhance their self-esteem, or
look better in their clothes, etc. [2–4]. THIS IS
THEIR DECISION TO MAKE, NOT MINE.
My responsibility is to make sure the person: is
psychologically stable; is doing it for the right
reasons (not to “keep her boyfriend,” etc.!); fully
understands the procedure, its risks, and recovery
time; understands that the outcome may not
be exactly up to her expectation; and has the
opportunity and time to make a truly informed
decision.
If a man decides to get Botox, if a person decides
upon a rhinoplasty to correct what he or she feels
is a “deformed” nose, and if a woman decides on a
breast augmentation to fit better in her clothes or
enhance her self-esteem, few would take issue. But
many cringe when vulvovaginal aesthetics are discussed.
I think a very paternalistic and chauvinistic
attitude is displayed when this work is rejected out
of hand.
Like noses and breasts, vulvae and vaginas come
in a wonderfully varied array of sizes, shapes, and
colors. There is a wide range of normality and I
make sure my patients understand this. Given that,
many patients reasonably decide that they want
surgery. My responsibility then is to provide the
best care possible and to take the time to objectively
assess the patient’s motives, understanding,
and emotional stability.
Many pejorative remarks have been made
about the propriety of the procedure of hymenal
reconstruction or “hymenoplasty.” Patients
exhibit many different reasons for their request,
many of them cultural. A good hymenoplasty can
be very difficult to do. The tissue is often thin
and friable; it is often difficult to get mucosal
surfaces to align exactly as wished, and fibrin
glue does not work well on mucosal surfaces.
Because the purpose frequently is “to be tight
and bleed,” an effective procedure is often the
opposite of the meticulous surgery we would
hope for: remove a wedge, retighten, and hope
for as much scar tissue as possible to produce
tearing and bleeding with next coitus. Egad! Not
the type of surgery I’d like—but maybe just what
the patient wants!
It is imperative that the surgeon takes the time
to get to know her or his patient and her reasons,
desires, and exact expectations; not “You want it
done? . . . Let’s book it for next week!” Proper
preoperative preparation includes: negotiating
exactly what your patient wishes and how close
you can come to accomplishing this, reasonably
expected outcomes, exact and clear recovery times
and instructions, and a clear understanding of risks
and the possibility that results may not be exactly
up to expectations.
When time is taken preoperatively and the procedure
is performed carefully, I have found my
patients uniformly happy with their decisions and
the outcome.
Michael P. Goodman, MD
Like it or not, cosmetic procedures conducted to
alter body shape and contour are a fact of life!
Statistics confirm its widespread appeal—in 2005,
more than 10.2 million cosmetic plastic procedures
were performed in the United States, with
1.8 million of them surgical cases and 8.5 million
of them minimally invasive cases such as Botox
injections and chemical peels [5]. Compared with
the number of procedures from the year before,
this was an increase of 11%. Unfortunately, these
procedures are often confused with reconstructive
plastic surgery procedures, which are conducted to
improve function and/or appearance of abnormal
body areas that result, either congenitally, from
tumor excision, lacerations, accidents, and other
morbid circumstances.
For women who wish to have cosmetic reconstruction
of the external genitalia, there is no valid
reason to deny them this right. Female genital
reshaping falls into the same category as liposuction,
nose reshaping, breast augmentation, eyelid
surgery, a tummy tuck, or any other cosmetic alteration
of the body.
However, vaginal cosmetic surgery, often
referred to as “rejuvenation” surgery, should be
Controversies in Sexual Medicine
270 J Sex Med 2007;4:269–276
performed only when the woman has been counseled
that she is opting for a purely cosmetic
surgery and not a reconstructive plastic surgery.
Therefore, I firmly believe that, preoperatively,
the woman should be clearly told that excessive
labial tissue or prominent labia minora are variations
of normal genital anatomy and do not impair
genital function. For example, it should not be
inferred that labia minora are abnormal if they
protrude through the labia majora, and that this
condition will lead to sexual dysfunction, future
problems, or pathology. Language should be
avoided that infers that the labia minora, labia
majora, clitoral hood, or the mons pubis are misshaped
or ugly and, through surgery, can be
“restored” to be more appealing in size and shape.
The woman should be clearly told that she is
having cosmetic surgery, to make the area more
pleasing to her and/or her partner, and that she is
not having vulvar reconstruction, which denotes
surgery for abnormal function.
Gloria Bachmann, MD
Cosmetic beautification, the quest for the perfect
body image, is not a new phenomenon;
however, the surgical utilization of this desire has
exploded. Is there a desperate quest for physical
transformation—transformation to the dream
world? [6,7] I cannot deny the right of a woman (or
perhaps the couple) to seek what is thought to be
in that culture a perfect body. After all, I have long
since given up what could be my normal hair color,
and make great efforts to make my teeth conform
to cultural standards but fixing my genitalia?
Clearly, we are in the botox era, where perfection
to fit someone’s norm and an opportunity to make
money set the standards. The prevalence of labia
measurably outside the norm is small. But there
are women with labial hypertrophy that results in
both hygienic and sexual problems [8]. It is also
clear that labial reduction is a safe, simple procedure
that can be performed under local anesthesia
and on an outpatient basis with minimal sedation
[8,9].
Most of the body beautification schemes are
built on cultural expectations. The best examples
are female genital cutting and hymnography
[10,11]. Both of these procedures are built on centuries
of misinformation. Hymnography is illegal
in most Arab countries, but it is performed unofficially;
specialists undertake five or six procedures
weekly. The trade in hymen repairs, justifiable in
certain circumstances, when the woman would
otherwise suffer disgrace or worse [12–14]. We
also have polysurgical addicts who may undergo
repeated surgical transformation from the top
(face) to the bottom. One should ask whether the
use of these techniques is truly justified. In other
words, are these procedures both safe and efficacious?
It is important to make sure our surgical
procedures are based on sound evidence. I suspect
most are opportunistic procedures developed to
make money, and none have looked at the longterm
health outcomes. It is important to make sure
the women undergoing these procedures understand
the risks and benefits associated with the
magic of perfection.
Jean L. Fourcroy, MD, PhD, MPH
There is a raging debate regarding the juxtaposition
of the traditional cultural practice of female
genital cutting with elective genital cosmetic
surgery performed commonly in western societies.
Female genital cutting has achieved global
attention due to the increasing influx of immigrants
and refugees from indigenous countries to
Europe and North America. The World Health
Organization (WHO) estimates that 140 million
women worldwide have undergone a form of
female genital cutting, and each year 3 million
girls are at risk for the procedure [15]. The WHO
defines female genital cutting as “all procedures
involving partial or total removal of the external
female genitalia or other injury to the female
genital organs whether for cultural, religious or
non-therapeutic reasons” [16]. This definition,
however, fails to distinguish the traditional practice
of female genital cutting (often performed
out of love and societal pressures to preserve a
woman’s family honor, respect, chastity, marriageability,
and beauty) from elective vulvar
plastic surgery (often performed for aesthetics, to
promote mental, physical, and sexual well-being)
[17]; wherein lies the controversy as to whether
such procedures are ever warranted.
As a health and human rights violation, female
genital cutting has been the subject of increasing
legislation worldwide [18]. In 1996, the U.S. Congress
enacted a federal law criminalizing the performance
of female genital cutting on minors
(less than age 18). However, the law does not
address re-infibulation (the re-approximation of
the raw edges of tissue opened during childbirth,
recreating the original “infibulation”—which is
Controversies in Sexual Medicine
J Sex Med 2007;4:269–276 271
the most severe form of female genital cutting
involving excision of the clitoris, labia majora,
and/or minora with re-approximation of the cut
edges producing a narrow neo-introitus). If a
woman requests re-infibulation after delivery, this
should only be performed after extensive counseling
and at the discretion of the healthcare provider
after a thorough discussion of the medical
risks and cultural relevance of this procedure to
the woman. Elective defibulation (opening of the
prior female genital cutting scar) is warranted in
women who desire this procedure performed
before either marriage or childbirth, and/or to
alleviate the long-term complications and sexual
morbidity associated with infibulation. If performed
during pregnancy, defibulation should be
performed in the second trimester or at least
4–6 weeks before delivery to facilitate intrapartum
fetal monitoring, pelvic exams and reduce obstetric
complications. Elective clitoral reconstruction
may also be warranted in women who have undergone
female genital cutting to improve sexual
function [19,20].
Preoperative screening guidelines for circumcised
women desiring elective vulvar plastic
surgery should include a detailed history and
physical examination, including appropriate documentation
of the type of female genital cutting
present and exploration of the cultural significance
to the woman and medical sequelae experienced.
An interpreter should be present, along
with the woman’s partner/spouse to aid in
medical decision making. Visual aids/diagrams
illustrating vulvar anatomy should also be incorporated,
and women should be counseled on the
risks, benefits, and expectations postoperatively
(i.e., change in urinary stream postprocedure).
Primary female genital cutting should be discouraged,
and a discussion of the legal ramifications of
performing female genital cutting in women/girls
under age 18 should also ensue. Future efforts
must aim to further classify and/or distinguish
traditional female genital cutting from genital
cosmetic surgery.
Crista Johnson, MD
Labiaplasty (labia minora reduction, nymphectomy)
has been discussed in the peer-reviewed
medical literature since 1971. However, early
reports of this procedure consisted of correction of
labial hypertrophy caused by congenital malformation,
exogenous hormones, myelodysplasia, and
manual stretching of the labia with weights (a
practice of the Khoikhoi tribe in south-western
Africa) [21]. In 1984, Hodgkinson and Hait were
the first to discuss this procedure performed for
purely aesthetic reasons [22]. More recently, while
there are no published statistics from either the
American Society of Plastic Surgeons or the
American College of Obstetricians and Gynecologists,
it has become apparent in the lay press that
“this surgery is one of the fastest growing” areas of
plastic surgery [23]. Unfortunately, there has been
no discussion in the peer-reviewed medical literature
that addresses the biomedical ethical issues
surrounding this procedure [11].
Therefore, the authors of this article (a gynecologist
specializing in the treatment of vulvar disorders
with experience performing this procedure
[A.G.], and a dermatologist with an advanced
degree in medical ethics, who performs aesthetic
procedures [G.G.]) thought it necessary to
examine this procedure through the lens of established
and accepted principles of biomedical ethics
to offer guidelines for physicians who might consider
performing this procedure.
The four medical ethical principles applicable
to this discussion are:
autonomy, nonmaleficence,and justice [24]. However, it is importantAutonomy: It is an established medical and legalControversies in Sexual Medicine
272 J Sex Med 2007;4:269–276
psychiatric disorder that must be addressed
prior to agreeing to perform the surgery.
Second, the patient must be free of any outside
coercive influences. The surgeon must be
certain that the prospective patient is not being
convinced to have this surgery by a sexual
partner, theatric agent, etc. Third, in order to
act autonomously, the patient must be completely
aware of the true risks of this surgery
(discussed in more detail below). Lastly, the
patient must be free of any coercive influences
by the surgeon. This type of coercion can begin
even before a patient’s first visit with a surgeon
if the surgeon advertises this type of procedure.
A recent Committee Opinion from the American
College of Obstetricians and Gynecologists
stated that terms such as “top,” “world-famous,”
and “pioneer” are usually misleading and are
designed to attract vulnerable patients [25]. In
addition, the same guidelines state that there
must be a complete disclosure of any restrictive
commercial agreements that allow a surgeon to
claim unique skills or unique treatments such as
Designer Laser Vaginoplasty
TM. Additionally,Nonmaleficence: The ethical principle primum(first do no harm) is prima faciebinding, and is therefore a greater ethical principle
than beneficence (to do good). Therefore,
any procedure that has a greater chance of
harming a patient than helping her is unethical.
The majority of reports of labiaplasty are small
case series or case reports and therefore the true
complication rate associated with this procedure
is unknown. The authors of a large case series of
163 patients reported “no significant complications”
with this procedure; however, they report
that 20% of the patients reported that the
surgeon did not adequately explain the procedure
and the results to expect, 17% found the
results to be unsatisfactory, and many patients
experience transient postoperative pain and dyspareunia
[26]. In addition, while not reported in
the literature, one of the authors of this article
(A.G.) has seen persistent vulvar pain (dysesthetic
vulvodynia) as a direct consequence of
labiaplasty that required treatment with amitriptyline
for almost 1 year to treat neuropathic
pain. Lastly, the principle of nonmaleficence
allows any surgeon to refuse to perform labiaplasty
if he or she feels that it is not in the best
interests of the patient.
•
Beneficence: The majority of peer-reviewed literatureJustice: The ethical principle of justice impliesControversies in Sexual Medicine
J Sex Med 2007;4:269–276 273
solely by the patient, the issue of justice is not
especially applicable (although one might argue
that the doctor, having used society’s resources
when getting medical training, should use his
or her skills in a more “useful” manner). However,
in countries where medical resources are
rationed, the principle of justice does apply. The
authors would suggest that, in this situation,
only the most extreme cases of labial hypertrophy
would warrant labiaplasty. More importantly,
the principle of justice should prevent
any physician from suggesting to a third-party
payer (i.e., insurance company or government)
that there is a medical indication for the procedure
to obtain monetary coverage in situations
where aesthetic concerns are the main motivation
of the patient.
In conclusion, we have attempted to examine
the labiaplasty within the construct of established
medical ethical principles. After applying these
principles to this procedure, it is apparent that
performance of this procedure is not always
ethical, nor it is always unethical. Therefore, it is
the surgeon’s burden to be aware of the ethical
principals involved and to practice well within the
boundaries of ethical conduct. Lastly, while this
article has only examined the medical ethical
issues surrounding labiaplasty, the same principles
can be applied to other vulvovaginal cosmetic
procedures, such as “vaginal rejuvenation” and
“hymenoplasty.”
Andrew T. Goldstein, MD and
Gail R. Goldstein, MD, MA
To answer the question of whether elective vulvar
plastic surgery is ever warranted, it is important
to put aside emotional reactions and go back
to look at basic ethic issues. Beauchamp and
Childress [24] outline four basic groups of
principles—respect for autonomy, beneficence,
nonmaleficence, and justice (which is too broad a
topic to cover here).
One of the bases for autonomy of patient choice
is the freedom of the patient from controlling
influences [24]. Although the choice of genital
alteration is presented as empowering for women
by the media, such a decision must be viewed in
the context of relationships and socialization
which are in many ways limiting for women. The
influence of the media and societal ideals impose
pressure on women to alter their appearances.
At the current time, there is no definition of
what constitutes normal labium minora length.
Freidrich [28] stated that a maximum horizontal
length of 5 cm or less from medial to lateral border
was the normal length. In some of the plastic
surgery literature, 3 cm is now considered the
upper limit of normal length [29]. To distinguish
between the two aspects of plastic
surgery—cosmetic and reconstructive [30], the
American Medical Association states: “Cosmetic
surgery is performed to reshape normal structures
of the body in order to improve the patient’s
appearance and self-esteem. Whereas reconstructive
surgery is performed on abnormal structures
. . .” [30,31]. This lack of consensus in the
professional world translates into confusion for
patients whose ideals for vulvar appearance are
imagined or based on images seen in the pornographic
literature. One physician even encourages
his patients to use Playboy magazine as a guide for
their desired vulvar appearance [17].
Beneficence refers to the contribution a physician
makes to a patient’s welfare [24]. This means
contributing to a patient’s health. Numerous
studies use the patient satisfaction ratings as a
gauge of benefit [32,33]. This, however, converts
the goal of medicine from healing to patient happiness.
While there have been cosmetic surgery
studies showing improvement in patient interpersonal
relationships and sexual function with a
decrease in depression [34], this still remains to be
shown for genital altering surgeries. The study by
Berman and colleagues on genital self-image,
although it shows increased desire correlating with
positive genital self-image, does not translate to
improved relationships or improved sexual function
[35].
Nonmaleficence is the obligation to “do no
harm” in the treatment of patients [24]. One study
of labial reconstruction on women with symptomatic
labial hypertrophy described a 23.8% complication
rate with complications such as flap necrosis
[29]. Is this an acceptable rate for a procedure
which is performed on normal structures?
At the heart of the physician–patient relationship
is the fiduciary nature of the relationship.
“Both law and medical tradition distinguish the
practice of medicine from business practices that
rest on contracts and marketplace relationships.
The patient-physician relationship is founded on
trust and confidence” [24]. “If the only indication
for a medical procedure were the wishes of the
Controversies in Sexual Medicine
274 J Sex Med 2007;4:269–276
patient, medical technology could be used to
gratify almost any whim” [32]. In this largely
market-driven part of cosmetic surgery, what will
be the limiting factor for physicians who perform
these surgeries?
Thus, patient autonomy and technological
advancement have been linked together in a business
proposition, where the patient is able to chose
a procedure and, if she has the money, obtain it if
there is a physician willing to provide the technology.
Does this reflect the true nature of the practice
of medicine and of the physician–patient
relationship? I would argue no.
Susan Sklar, MD
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