There has been an avalanche of publicity in women’s magazines, the popular press, talk shows and amongst doctors themselves about a procedure called labiaplasty or cosmetic labiaplasty, the cosmetic surgery to change the look of the labia. Some call it labia rejuvenation, or cosmetic plastic surgery, or vaginal rejuvenation. The argument touched a nerve in the medical community, triggering at least one group of doctors and academics to discuss it on their internet list serve. The issue isn’t about needed medical labia surgery, but surgery generally and mainly done for cosmetic reasons. Many doctors claim that woman get the idea of the perfect vulva from magazine such as Playboy, and that woman rarely see other women’s vulvas, much less their own.

Here are some comments gleaned from doctors and health care providers. We are not using their names, but their thoughts certainly help set the stage…

• • What on earth drives the demand for such surgery I find it hard to imagine that many women have ever encountered a potential lover, particularly a male, who said, “Sorry your labia are too long (or too asymmetrical) for me to fall in love with you. Where do women get the idea that this is of any importance.

• • Women who make informed choices about having their nose done or their breasts augmented have seen thousands — maybe hundreds of thousands — of real noses and breasts. True, they may be swayed in their cosmetic choices by cultural standards of attractiveness, but at least they have a vast reservoir of visual experience from which to draw when deciding whose conception of beauty they wish to emulate. Most women who choose cosmetic genital surgery have seen but a few dozen photos of airbrushed vulvas, and maybe a handful of real vulvas, too. But in our culture, “live” female genitalia is so hidden, so secret, that most women have not examined their own, let alone those of other women.

• • If young women were in a position to make the same kind of informed decision about their genitals as they make about their noses, they would first need to be exposed to an equal number of vulvas, preferably across cultures. Imagine if the only female noses we ever saw were those on the faces that appear in Vogue. We’d all have a different conception of what a “normal” nose looks like, let alone a pretty one.

• • I had a woman…ask me for a referral for “vaginal rejuvenation”. She was convinced that she did not have a g-spot, at least that is what her partner told her. He recommended the surgery. I was so hurt for her.

• Of course women should have a choice as to what they do or don’t do with their bodies, but I do think there is an irony.

In this article by Dr. Andrew T. Goldstein, a gynecologist, author and lecturer and the medical director of our www.ourgyn.com site and Dr. Gail Goldstein, a dermatologist, look at the ethical issues involved.

By Andrew T. Goldstein, MD,

Director, www.ourgyn.com

And Gail R. Goldstein, MD, MA

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).

In 1984, Hodgekinson and Hait were the first to discuss this procedure performed for purely aesthetic reasons. More recently, while there are no published statistics from either the American Society of Plastic Surgeons or the American College of Obstetricians and Gynecologist, it has become apparent in the lay press that this surgery is one of the fastest growing areas of plastic surgery. Unfortunately, there has been no discussion in the peer-reviewed medical literature that addresses the biomedical ethical issues surrounding this procedure.

Therefore, the authors of this paper, (a gynecologist specializing in the treatment of vulvar disorders with experience performing this procedure (AG), and a dermatologist with an advanced degree in medical ethics who performs aesthetic procedures (GG)) 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, non-maleficence, beneficence, and justice. However, it is important to recognize that each of these four principles are not given equal weight when making medical decisions.

• • Autonomy: It is an established medical and legal principle that an adult person without mental impairment has the final decision with regards to any medical procedure he or she receives. It is the principle of autonomy that is most commonly used to justify cosmetic surgical procedures (i.e. if a woman decides that she would feel better if a perceived physical deficiency is corrected, she should be allowed to have this procedure). While autonomy can be used to justify performing this surgery, several obstacles must be overcome to convince the surgeon that the patient is acting completely autonomously. Firstly, the patient must not have any mental impairment. While the authors feel that it is paternalistic to require every prospective patient to have a psychological evaluation, the surgeon must be convinced that she has no evidence of depression, anxiety, or body dysmorphic disorder. A history of prior cosmetic procedures will alert the physician of the possibility of a psychiatric disorder that must be addressed prior to agreeing to perform the surgery. Secondly, 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. Thirdly, 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 Gynecologist stated that terms such as top, world-famous, and pioneer are usually misleading and are designed to attract vulnerable patients. 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, claims of scarless, painless, or bloodless procedures are not justified as the surgeon cannot truthfully assure the patient of these results in every instance.

• • Non-maleficence: The ethical principle primum non nocere (first do no harm) is prima facie binding and is, therefore, a greater ethical principle than beneficence (to do good). Therefore, any procedure which 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 expected, 17% found the results to be unsatisfactory, and many patients experience transient post operative pain and dyspareunia.

• • In addition, while not reported in the literature, one of the authors of this paper (AG) has seen persistent vulvar pain (dysesthetic vulvodynia) as a direct consequence of labiaplasty that required treatment with amitriptyline for almost one year to treat neuropathic pain. Lastly, the principle of non-maleficence allows any surgeon to refuse to perform labiaplasty if he/she feels that it is not in the best interests of the patient.

• • Beneficence: The majority of peer-reviewed literature regarding labiaplasty suggests that most women undergo the procedure purely for cosmetic results. However, additional motives for requesting surgery include discomfort in clothing, discomfort when taking part in sports, and dyspareunia from invagination of the excess labial tissue during penetration. Therefore, in order for a surgeon to benefit the patient by performing labiaplasty, the patient must get the functional and cosmetic results that she expects. Thus, the surgeon must know the proper surgical techniques and have enough experience with the procedure to adequately reassure a prospective patient that her results will meet with her expectation. A review of the available literature suggests that simple excision of the excess labial tissue and oversewing the edges give an inadequate cosmetic and functional result. Several authors have suggested that wedge resection gives good cosmetic results. However, other authors have suggested that the suture lines on wedge resection are under tension which may lead to wound dehiscence or narrowing of the introitus. Giraldo and colleagues have suggested that a 90-degree Z-plasty gives better functional and aesthetic results. Regardless of technique utilized, it is essential that the surgeon have adequate experience performing this procedure. As most gynecologists have not been taught this procedure in their residency training, it is imperative that the surgeon have adequate hands-on training under direct supervision before performing the surgery on his or her own. The authors want to emphatically state that the old axiom ‘see one, do one, teach one does not represent adequate training for this procedure. Clearly, if a surgeon has not had sufficient training in this procedure, he or she would be acting in a non-beneficent (unethical) manner by performing the procedure.

• Justice: The ethical principle of justice implies that the resources of society are utilized for the greater good of society. In medical ethics, the principle of justice suggests that everyone is entitled to a decent-minimum of health care. When labiaplasty is performed for aesthetic reasons, and the costs of the operation is born solely by the patient, the issue of justice is not especially applicable (though one might argue that the doctor, having used society’s resources when getting medical training, should use his 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 paper 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.

Sources:

1.Alter GJ. A new technique for aesthetic labia minora reduction. Ann Plast Surg 1998;40(3):287-90.

2.Hodgkinson DJ, Hait G. Aesthetic vaginal labiaplasty. Plast Reconstr Surg 1984;74(3):414-6.

3.Kobrin S. More Women seek Vaginal Plastic Surgery. Women’s Enews 2004:http://www.womensenews.org/article.cfm/dyn/aid/2067/context/archive.

4.Beauchamp T, Childress, JF. Principles of Biomedical Ethics. 3rd ed. New York: Oxford University Press; 1989.

5.Ethics ACoOaGCo. Ethical Ways for Physicians to Market a Practice. Obstet Gynecol 2006;108(1):239-42.

6.Rouzier R, Louis-Sylvestre C, Paniel BJ, Haddad B. Hypertrophy of labia minora: experience with 163 reductions. Am J Obstet Gynecol 2000;182(1 Pt 1):35-40.

7.Giraldo F, Gonzalez C, de Haro F. Central wedge nymphectomy with a 90-degree Z-plasty for aesthetic reduction of the labia minora. Plast Reconstr Surg 2004;113(6):1820-5; discussion 6-7.

8.Maas SM, Hage JJ. Functional and aesthetic labia minora reduction. Plast Reconstr Surg 2000;105(4):1453-6.

Additional resources on female sexuality are available at MayoClinic.com