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Requests for cosmetic genitoplasty: How should health care providers respond?
- Jacqueline Doyle (28 May 2007)
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Cosmetic surgery could improve psychological burdens
- Jeffrey CY Chan (14 June 2007)
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This is female genital mutilation; it should be stopped or prosecuted
- Marge Berer (17 June 2007)
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Body Dysmorphic Disorder and cosmetic genitoplasty
- David M Veale (3 July 2007)
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Jacqueline Doyle, Clinical Psychologist Department of Clinical Psychology, Hillingdon Hospital, Pield Heath Road, Uxbridge, Middlesex, UB8 3
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I welcome the debate stimulated by Drs Liao and Creighton on cosmetic genitoplasty. The authors refer to idiosyncratic decisions about surgery in the absence of local and national guidelines for practitioners. Having worked as a clinical psychologist in women’s health for a number of years, I have also struggled to think about my role in this area. I have seen patients at various stages on the labial surgery pathway and the reasons for referral to me have been varied. Some are women who have had labial surgery and are requesting further interventions, thus causing concern to their surgeons. Satisfaction with surgery has been professed, however, it has not changed how they feel about their bodies. These women are either faced with the prospect of more surgery or the stark reality that such a solution may not offer everything they had hoped. Others referrals are to “cover all bases”, check that the patient is in “sound mind” and rarely can a serious psychiatric diagnosis be invoked. Unfortunately, some of these patients have already been given a date for their surgery and have been under the impression that it can proceed unless the psychologist says otherwise. It is unlikely that in these circumstances women will embrace a psychological rather than a surgical solution. It is my impression that my surgical colleagues are reticent to provide such interventions, but they respond to psychological distress (something psychologists want doctors to do) and can be disempowered by the general rhetoric of “patient choice”. It is of interest that in the same week in which this article is published, a well known tabloid newspaper reported on cosmetic surgery holidays. Women and their friends go abroad to experience the delights of a better, sunnier climate, whilst having cheaper liposuction, breast augmentation and face lifts. Surgical solutions for a variety of concerns about the body may indeed be what patients appear to want but increasing its availability can inhibit the visibility of other choices. Some clinicians may believe that the issue of labial surgery is on the fringes of obstetrics and gynaecology. This may be the case for now but history repeats itself. We have all seen the rise in caesarean section rates in the United Kingdom. It is widely reported that this has happened due to the concern about litigation. However, I would argue that another process is in operation, i.e. the sanitisation of a surgical solution to giving birth. I regularly encounter women who have lost confidence in their ability to have a non-surgical labour. Patients report an understanding of the risks of caesarean section but these tend to be the more benign difficulties (e.g. slower recovery) and can easily discuss how these limitations will be overcome. My experience, however, is that even with the grand authority of the National Institute of Clinical Excellence (NICE) behind me, “complications” such as the increased risk of maternal death, are not ones that women and their partners really believe. This, I would argue, comes from the widespread availability of a surgical solution. Do we not already have a snapshot of how things will develop if we do not debate this issue now? Dr Jacqueline Doyle, Clinical Psychologist, Hillingdon Hospital, Central and North West London Mental Health Trust, jacqueline.doyle@thh.nhs.uk Competing interests: None declared |
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Jeffrey CY Chan, Surgical Research Fellow Department of Plastic Surgery, University College Hospital, Galway, Ireland.
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Dear Editor, I welcome the effort of Liao and Creighton[1] to develop research and evaluation tools for women seeking cosmetic surgery and I read their article with great interest. However, I am deeply concerned with the fact that their attempt at this task begin with such negative opinion on the issue of cosmetic genitoplasty. The data presented by the authors from interviewing patients after their surgery, in my opinion, was selective and biased. In deed, surgeries aimed at changing body form and size are becoming increasingly popular and increasingly acceptable. Proceduces such as breast augmentation, rhinoplasty, dental orthodontic treatment and corrective surgery for prominent ears are common. As with any surgery, the procedure should at least be potentially helpful, and most importantly, do not harm the patient. The subject of labial reduction surgery is a challenging one, as it is by its nature, a private subject matter and concerned with the private appearance of the woman. What reasons would motivate their decision to undergo surgery to alter the appearance of their genitalia? Unlike other cosmetic surgical procedure such as rhinoplasty or breast augmentation, the site of surgery in question is concealed under clothing most of the time. They would have to be quite troubled and distressed by their appearance that they choose surgery as their solution. It is unlikely that the increasing number of requests for this procedure is simply due to a ‘current trend’, ‘availability’ or the influence from the mass media such as women’s magazine. It is more likely that some women’s dissatisfaction with her appearance had existed for a long time but is now brought into discussion and surgical solution presented by these media. It is important to determine the factors that motivate their desire to change their appearance which led to the decision to undergo surgery. The authors argued that surgery does not connect women with their ability to solve problems.[1] In my opinion, the decision to undergo surgery is part of the process of coping and finding a solution for their distress. In deed, non-surgical solutions should be offered to clarify any misconceptions and perceived abnormality about body dimensions and perhaps, could discourage some women from undergoing surgery. Perhaps, psychological intervention to improve self-esteem and body image could play a role here and could be offered. It remains to be seen whether these possible solutions would change a woman’s attitude. Surgery on the other hand, could offer a physical solution on the issue of appearance, and could improve psychological burdens associated with appearance satisfaction such as those shown in breast augmentation,[2] breast reduction[3] and otoplasty.[4,5] 1. Liao LM, Creighton SM. Requests for cosmetic genitoplasty: how should healthcare providers respond? Bmj 2007;334(7603):1090-2. 2. Kilmann PR, Sattler JI, Taylor J. The impact of augmentation mammaplasty: a follow-up study. Plast Reconstr Surg 1987;80(3):374-8. 3. Faria FS, Guthrie E, Bradbury E, Brain AN. Psychosocial outcome and patient satisfaction following breast reduction surgery. Br J Plast Surg 1999;52(6):448-52. 4. Bradbury ET, Hewison J, Timmons MJ. Psychological and social outcome of prominent ear correction in children. Br J Plast Surg 1992;45(2):97-100. 5. Simis KJ, Hovius SE, de Beaufort ID, Verhulst FC, Koot HM. After plastic surgery: adolescent-reported appearance ratings and appearance- related burdens in patient and general population groups. Plast Reconstr Surg 2002;109(1):9-17. Competing interests: None declared |
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Marge Berer, Editor Reproductive Health Matters, 444 Highgate Studios, 53-79 Highgate Road, London NW5 1TL
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This article is shocking. The answer to the question of how health care providers should respond to requests for so-called genitoplasty should be unequivocal: this procedure is a criminal offence under the Female Genital Mutilation Act 2003,[1] and the Female Genital Mutilation (Scotland) Act 2005.[2] In fact, it has been a criminal offence since the Prohibition of Female Circumcision Act 1985 (c.38) was passed. Notwithstanding the terminology used in the BMJ article itself (“genitoplasty”, “labial reduction”),[3] as well as in the Department of Health’s policy and guidance for patients on cosmetic surgery and non- surgical cosmetic treatments (“female genital reshaping”, “labia reduction”, “labiaplasty”)[4] and on the BUPA Hospitals website on cosmetic surgery (“body re-shaping”, “labial reduction”, “vaginal tightening”),[5] the surgical procedures described are all female genital mutilation. The Department of Health’s policy and guidance for patients on cosmetic surgery describes “genital re-shaping” this way: “Purpose: To change the size and shape of the labia… Standard genital reshaping simply means reducing the size of the inner labia (the inner genital lips). To do this, the surgeon will cut away the unwanted labia tissue to make the desired shape. Alternatively, they can remove a wedge- shaped section of the labia, leaving the front intact and removing the tissue from behind. This means there is no change in the colour of the labia and makes the surgery less noticeable. Some surgeons use a laser instead of a scalpel to reduce bleeding.”[4] The BUPA cosmetic surgery website says: “All women are different and labia come in different shapes and sizes. However, some women feel that their labia are too large and request surgery to reduce their size. Labial reduction is a term used to describe a range of surgical procedures that reduce the size and prominence of the inner lips of the vagina (known as the labia minora).”[5] BUPA is charging women from £1700 to £3900 to have their labia reduced and from £2600 to £4275 to have their vaginas tightened.[6] Yet an explanatory note to the 2005 Scottish Act defines female genital mutilation, in line with the the World Health Organization’s definition,[7] as follows: “Female genital mutilation (FGM) involves procedures which include the partial or total removal of the external female genital organs for cultural or other nontherapeutic reasons.”[2] The Female Genital Mutilation Act 2003 says: “A person is guilty of an offence if he excises, infibulates or otherwise mutilates the whole or any part of a girl's labia majora, labia minora or clitoris.”[1] and: “A person is guilty of an offence if he aids, abets, counsels or procures a girl to excise, infibulate or otherwise mutilate the whole or any part of her own labia majora, labia minora or clitoris.”[1] (Note: The Act defines “girl” as also including women.) Thus, removal is excision is mutilation. Unfortunately, the 2003 Act also says that no offence has been committed if the surgery “is necessary for [the girl’s/woman's] physical or mental health”, while the explanatory notes to the 2005 Scottish Act say: “An example of an operation necessary for physical health could be the removal of relevant cancerous areas. An example of an operation necessary for mental health could be gender reassignment surgery and this also could include, for example, cosmetic surgery resulting from the distress caused by a perception of abnormality... When assessing a person’s mental health, no account is to be taken of any belief that FGM is needed as a matter of custom or ritual. So an FGM operation could not be carried out legally on the grounds that a person’s mental health would suffer if they did not conform with their community’s prevailing custom... The Act does not make specific provision in relation to when a surgical operation will be considered to be necessary for a person’s mental or physical health. Ultimately, that will be a matter for the Scottish courts to determine on the facts of the case if a prosecution is brought.”[2] There are several blatant contradictions here. The first is a racist one. If a woman (probably African) asks for her own or her daughter’s genitals to be partially or fully excised for traditional or cultural reasons, it is considered a criminal offence in the UK, and women are hard put to find anyone to do it. Yet if a woman perceives her own genitals to be an abnormal shape or size, the surgery is being presumed to be legal. Secondly, what is the perception of genital abnormality actually about? The authors of the BMJ article describe the psychological condition of the women they interviewed who had had this surgery as “anxious” and “suffering” because they had been led to believe that their genitals were abnormal, that is, they perceived their labia to be too large, or longer on one side than the other, or not nicely shaped. In fact, and it should go without saying, there is no such thing as a normal shape or size for labia any more than for hands or eyes. Research is needed on the extent to which the perception of abnormality is being promoted in women’s magazines, advertisements for cosmetic surgery and visuals of women’s bodies in which the labia are very small or not visible at all, possibly because the pictures have been altered digitally. It is outrageous if perceptions of abnormality are being stirred up by commercially driven sources of information and then put forward as valid mental health grounds for female genital mutilation. It is therefore important to reiterate that in UK law, female genital mutilation for non-therapeutic reasons is a criminal offence. According to the qualitative interviews with the same anxious women, as reported in the BMJ article, they had the surgery to be able to “wear tight clothing, go to the beach, take communal showers, or ride a bicycle comfortably, or avoidance of some sexual practices”.[1] These are without exception non- therapeutic reasons for seeking this surgery, to say the least, and no medical practitioner with any ethical principles should have been willing to provide it for these reasons. That the Department of Health seems to be colluding in all this by lending legitimacy to female genital mutilation on a website for patients under the rubric of advice on cosmetic surgery is beyond outrageous. Are they unaware of the law? Ironically, the UK’s Department for International Development is supporting national and international efforts to combat female genital mutilation in other countries. Do they never talk to each other? This situation is partly a consequence of allowing private clinics to expand in this country, including those for whom cosmetic surgery is a major source of income and profit. However, according to the BMJ article, NHS facilities are also being used for this purpose, which is even more unacceptable, given the cuts in NHS services. The law could and should be invoked to stop anyone carrying out female genital mutilation in this country. Indeed, in my opinion, NHS surgeons should be stopped from using NHS facilities to provide any so-called cosmetic surgery for non- therapeutic reasons, let alone female genital mutilation. It seems a thorough investigation by the government is needed of all so-called cosmetic surgery, who is carrying it out, whether it is being promoted in an unethical manner by playing on the fears of vulnerable people, such as young women, and by whom, and policy should be developed for its stringent regulation. There is a gaping lack of evidence of any benefit of so-called cosmetic surgery for physical or mental health, but ample evidence of its potential and actual harm. Surgery is rarely an answer to psychological problems, and certainly not for the problems described in the BMJ article. Moreover, this is above all a gender issue. No one is offering to shorten or lengthen men's penises or change the shape or size of their testicles for cosmetic reasons. The vast majority of cosmetic surgery is promoted to and performed on women. The BMJ article shows just how much women’s lack of sexual and bodily self-esteem is being exploited, and increasingly successfully. This trend must be reversed. Female genital mutilation is not legitimised by being dressed up in the language of allaying anxiety about beauty or normality. The history of the surgical abuse of women’s bodies, e.g. in unnecessary hysterectomies, unnecessary episiotomies and unnecessary caesarean sections, is now being joined by unnecessary “cosmetic” surgery. There have always been surgeons who are ready to wield the knife on women’s bodies for dodgy reasons. One of these has certainly been to make money but the other, in my view, is a profound and often unchallenged misogyny. It is high time for the law against female genital mutilation to be enforced. Marge Berer Editor, Reproductive Health Matters London, UK References 1. The Female Genital Mutilation Act 2003. <www.opsi.gov.uk/acts/acts2003/20030031.htm#1>. Accessed 16 June 2007. 2. The Female Genital Mutilation (Scotland) Act 2005. <www.opsi.gov.uk/legislation/scotland/en2005/aspen_20050008_en.pdf>. Accessed 16 June 2007. 3. Lih Mei Liao, Creighton SM. Requests for cosmetic genitoplasty: how should healthcare providers respond? BMJ 2007;334(26 May):1090-92. 4. Department of Health. Advice for patients on cosmetic surgery and non-surgical cosmetic treatments. <www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/CosmeticSurgery/index.htm>. Posted 25 February 2006. Accessed 16 June 2007. 5. BUPA Hospitals. Cosmetic surgery. <www.bupahospitals.co.uk/asp/cosmetic/women/body_reshaping/labial_reduction.asp>. Accessed 16 June 2007. 6. BUPA Hospitals. Cosmetic surgery, guide prices. <www.bupahospitals.co.uk/asp/cosmetic/buyers_guide/guide_prices.asp>. Accessed 16 June 2007. 7. World Health Organization. Female Genital Mutilation. <www.who.int/topics/female_genital_mutilation/en/>. 2007. Accessed 16 June 2007. Competing interests: None declared |
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David M Veale, Consultant Psychiatrist in Cognitive Behaviour Therapy & Hon Senior Lecturer Institute of Psychiatry, Kings College London
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Liao and Creighton provide an excellent review of cosmetic genitoplasty highlighting the lack of an evidence base on psychosocial outcome. There is however very little data on the effect of cosmetic procedures in general on measures of body image such as self-consciousness, preoccupation, distress and handicap, not just in cosmetic genitoplasty. I suspect that some women requesting cosmetic genitoplasty are likely to have body dysmorphic disorder (BDD). A preoccupation with the shape and size of genitalia is sometimes disclosed in our BDD clinic but usually in the context of multiple concerns around the body. BDD should be identified as the diagnosis makes a cosmetic procedure unpredictable and more likely to lead to poorer outcome. In men, penile augmentation is increasingly popular procedure that has been recently audited with the identification of patients with BDD. Li et al (2006) reported on 42 men of whom 27 (64%) had “penile dysmorphic disorder”, who underwent division of the penile suspensory ligament. However the satisfaction rate in those with BDD was 27% and 54% requested further surgery. BDD can be effectively treated with cognitive behaviour therapy and/or SSRI anti-depressants and patients should be diverted to more appropriate settings (NICE, 2005). References: Li, C., Kayes, O., Kell, P.D., Christopher, N., Minhas, S., Ralph, D. (2006) Penile suspensory ligament division for penile augmentastion: indications and results. European Urology 49; 729-733 NICE, 2005: Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder http://www.nice.org.uk/CG031 Competing interests: None declared |
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