The Range of FGCS

The umbrella term FGCS, also known as ‘vulvoplasty’, encompasses a range of cosmetic procedures aimed at surgically modifying the external and/or internal female genitalia for non-medical reasons, which may be either functional or aesthetic [3]. The most common request is for labiaplasty, which involves the trimming of the inner lips or labia minora. Labiaplasty may be combined with trimming or removal of the clitoral hood to expose the clitoris and to create even labia minora that do not protrude beyond the line of the outer lips – the labia majora. The desirability of this genital appearance has increased among women partly as a result of sociocultural changes such as the accessibility of online images that have been airbrushed, online pornography, changes in fashion and the increasing trend for genital hair removal which exposes anatomy with which women and girls are unfamiliar [4].

The terms labiaplasty, vulvoplasty and FGCS are often used interchangeably, although most requests are for labiaplasty. Vulvoplasty can include labiaplasty, clitoral hood reduction or removal, mons pubis fat injections or liposuction. Hymenoplasty, colloquially referred to as ‘revirgination’, is sought by women of certain cultural backgrounds where virginity is valued or in existing relationships as a ‘gift’ to one’s partner. ‘G-shot’ involves autologous fat or collagen transfer via injection into a pre-determined ‘G-spot’ location. There is no existing scientific literature describing this procedure. ‘Orgasm-shot’ is described as a sexual and cosmetic rejuvenation procedure for the vagina using the preparation and injection of blood-derived growth factors into the G-spot, clitoris and labia [5]. ‘Vaginal rejuvenation’ can either be delivered through the use of a fractionated CO₂ laser, or surgically. Perineoplasty, which involves the reinforcement of the pelvic floor sometimes performed with vaginal tightening, or vaginoplasty, is also referred to as ‘surgical vaginal rejuvenation’. This has been performed for post-birth stress urinary incontinence (SUI) or pelvic organ prolapse (POP). Traditionally, however, in this context it is performed to allegedly enhance sexual pleasure for both partners by increasing friction with penile thrust during coitus.

Incidence of FGCS

The first labiaplasty procedure reported was in 1987 in the USA, and by 2014 labiaplasty was listed in the USA as the fourth most common aesthetic surgical procedure following liposuction, rhinoplasty and breast augmentation [6]. Between 2011 and 2015, the number of labiaplasty rates climbed from 2,141 to 8,745, indicating a fourfold increase [6]. Similar increases in procedures over the period from 2001 to 2016 are documented in the UK, Canada, Europe, Australia, India, Brazil and parts of Asia. Numbers of government-subsidised procedures can be accessed from government data in Australia and the UK; however, these represent the tip of the iceberg, as the majority are performed in the private sector. UK government-subsidised procedures indicate FGCS requests increased fivefold for the period 2001–2011, from 397 to 1,726 [7]. The threefold climb in Australia over the 10 years 2003–2013 prompted a review, with subsequent restriction criteria for labiaplasty in 2015. This resulted in a 28% decline in requests through the public sector within one year [8]. The average age range of women requesting labiaplasty is between 25 and 45 years; however, statistics in Australia and the UK indicate that girls and young women from 15 to 24 years of age are presenting with concerns about their genital appearance as frequently as the 25- to 45-year-old age group and that as many as one-third of requests received by GPs in Australia have been from girls under the age of 18 [9].

What Is Normal?

The question often posed to the GP is, “Am I normal down there?” The obvious answer is that ‘normal’, as with all other physical attributes, covers a wide spectrum and that it is ‘normal’ to have labia minora that protrude beyond the labia majora in as many as 30%–50% of women. The current classification systems used to measure labia minora classify the common occurrence of labia minora that extend beyond the labia majora along the spectrum of ‘labial hypertrophy’, thereby reclassifying normal as an abnormal variant warranting surgery. Genital changes can occur with age, parity, hormones, skin disease processes and weight fluctuations [3]. It is important that the doctor informs women and girls that labia minora grow during puberty until full adult maturation is achieved, which is around 18 years and that many may have asymmetrical labia minora. Following menopause, labia minora can atrophy and decrease in size.

Genital Anatomy Anxiety

A GP will deal with genital anatomy anxiety far more commonly than with requests for labiaplasty [9]. However, if genital normality concerns are not adequately addressed by the GP, women are more likely to explore labiaplasty as a ‘correction’ towards the ‘single slit’, due to the normalisation of this being embedded through societal reinforcement [10]. Women and girls who seek information online using the commonly known terms such as ‘Barbie-plasty’, ‘vaginal rejuvenation’, ‘labiaplasty’ and ‘designer vagina’ are directed to a plethora of commercial websites which promote specific practitioner expertise, many displaying before-and-after photographs. The medicalisation of non-medical conditions on these sites, using terminology which is mostly unknown to the rest of the medical profession, can mislead women and heighten ‘genital anxiety’. The marketing strategies can sway emotionally vulnerable women into believing that these ‘medical conditions’ can be ‘corrected’ easily, without providing the assurance that the wide variations in appearance are normal [11].

The GP who is aware of these issues has the opportunity to allay genital anatomy concerns, while exploring reasons for the patient’s motivation and expectation of outcomes. Recent research indicates that women who are considering labiaplasty and are given time to think about their decision after being shown images depicting the wide range of diversity preoperatively, choose to undergo surgery less frequently [12] (Table 12.1).

Psychosocial Factors Influencing Women

The range of factors influencing women’s perception of genital normality is wide and includes factors such as online pornography and ‘photo shopped’ images of genitals, which present the external appearance as a simple, hairless slit. Genital hair removal, which has become extremely popular, reveals soft, previously unexposed genital skin, increasing its vulnerability to trauma, skin infections, chafing and rubbing. Women should be made aware that vulval skin is delicate and prone to irritation and if the appearance of their external genital region creates concern for them, they should be provided adequate reassurance of the diversity that exists.

The lack of formal education around genital anatomy and function throughout life extends from school curricula all the way through to medical curricula. A consequence of this lack of education is that online images are then accepted as the norm, and an unrealistic perception is established. Opportunities that are open to the GP to educate women regarding genital anatomy arise at the time of cervical screening / PAP (Papanicolaou) test, consultations around sexually transmitted infection screening (STI screening), contraceptive advice, insertion of intrauterine contraceptive device (IUCD), postpartum (after childbirth) checks and during menopause discussions.

Rapid Increase in Requests Precedes Adequate Education of the Profession

In 1995 the GP population would have had little or no idea regarding the FGCS group of procedures. By 2015, almost all GPs surveyed in a large Australian study were aware of FGCS. Ninety-seven percent had been asked by their female patients about the normality of genital appearance and around 50% had been asked directly for a referral to have labiaplasty surgery [9]. In the UK, this has been referred to as the ‘new dilemma for GPs’ [1]. The Royal Australian College of General Practitioners (RACGP) responded to the need for professional guidance in dealing with the increase in requests, by developing a guide entitled, ‘Female genital cosmetic surgery: A resource for general practitioners and other health professionals’ [13]. This is a useful resource and can be downloaded from the RACGP website. Position statements from American College of Obstetricians and Gynaecologists (ACOG) [14], Royal College of Obstetricians and Gynaecologists (RCOG) [15], Society of Obstetricians and Gynaecologists Canada (SOGC) [16], Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)[17] and British Society of Paediatric and Adolescent Gynaecologists (BritSPAG) [18] have also issued guidelines for the health profession (see Resources in the appendix).

Helping a Woman Make an Informed Choice

Adopting the stance that FGCS represents a simple case of women choosing to do with their bodies as they wish neglects to address the background of genital anatomy ignorance endemic among the wider population including health professionals, upon which FGCS has flourished [19]. The doctor is in a unique position to determine whether the patient’s concern is due to functional, aesthetic, psychological or a combination of these reasons. The observations should then drive the consultation, including inquiries into any mental health history and any relationship difficulties and/or partner abuse. Although a referral for psychological counselling prior to surgery is often recommended [15], it is not for rubber stamping an intervention that the patient has already signed up to. The purpose of any psychological counselling must be clear. It usually involves a desire for a psychological outcome and the patient must be able to opt in. Although labiaplasty appears to positively elevate women’s genital appearance satisfaction, it has not been proven to improve the woman’s general psychological well-being or the quality of her intimate relationships or long-term sexual and aesthetic satisfaction outcomes [12].

Useful Open-ended Questions

Listen to the Patient

It is good practice to offer Casey the opportunity to be alone with you to talk more about her own concerns, and politely request that the mother wait in the waiting room. This gives Casey the opportunity to express herself without the mother/guardian present and assists in building trust with the GP, not only in this context but for future medical concerns she might have.

Educate the Mother and the Patient

The mother and Casey refer to the whole area as ‘the vagina’ but they are really referring to the labia minora. This is an opportunity for the GP to educate both the mother and daughter on the correct terminology and the anatomy of the vulva using a simple sketch diagram. This is also an opportune time to refer them to an online site such as the Labia Library (www.labialibrary.org.au) [20], or to show them images from a book titled Femalia [21], that will allow both mother and daughter to see that the range of diversity is vast and that Casey fits well within the spectrum (see Resources in the appendix). They should be informed that genital development in adolescence reaches completion at around the age of 18 years. It is important to emphasise to Casey and her mother that surgery prior to this time might not result in the outcome expected.

Explore Psychosocial Influences

Casey’s choice of language is very strong, as is her expression of repulsion, which should invite further questions regarding how this is affecting her. Is it affecting her ability to do things like swimming and other sports or to be with friends? Ask her how or why she derived this notion that she had a problem. How often does she think about this and how does she feel overall? Is it affecting her ability to sleep or eat and is she avoiding people because of this? Of particular interest is the observation that Casey rejected the offer to look at herself in a mirror during the examination and also refused to touch her genital region to show the GP what it is that she ‘hates’. This level of self-disgust should alert the GP to deeper psychosocial issues and warrants further exploration.

Peer pressure is at its most impactful during these years of change and adjustment and there is peer pressure to look, dress and even behave in particular ways. The need for social acceptance can underlie many insecurities surrounding physical appearance, as this is a period during which body image sensitivity, eating disorders, anxiety around acceptance and physical appearance can be heightened.