Female genital cosmetic surgery

Female genital cosmetic surgery (FGCS) is a relatively new and highly controversial surgical field where sociocultural influences and medicine collide. Procedures under this umbrella term include vaginoplasty, hymenoplasty and labiaplasty. Labiaplasty is the most common of these and typically involves procedures to reduce or reshape the labia minora or less frequently the labia majora. A commonly desired outcome is ‘The Barbie’ vulva where the labia minora are trimmed to the extent of invisibility, with no visible protuberance beyond the labia majora.1 The procedure can be performed by gynaecologists, cosmetic surgeons, plastic surgeons and urologists with various surgical techniques described including wedge resection and labial trimming.2 FGCS is to be distinguished from vulvoplasty which may be medically indicated in the management of a range of congenital disorders, vulvovaginal malignancy, inflammatory conditions and following genital trauma including vaginal delivery and female circumcision. There are also cases of pronounced elongation of the labia minora where significant protrusion beyond the labia majora can result in discomfort in performing daily activities. First documented in the 1970s, FGCS is now advertised on clinician websites, featured in lifestyle magazines and a topic raised both in clinical and social contexts.3,4 In particular, the notion of the ‘perfect labia’ has entered public consciousness in the last few decades. Numbers of labiaplasty procedures have been growing over the same period in Australia, along with parallel rises in Europe and the United States.5 While accurate data from the Australian private sector is difficult to obtain as no Medicare item number is claimed, the number of women undergoing Medicarebilled vulvoplasty or labiaplasty in Australia increased from 640 in 2001 to more than 1500 in 2013 on a background of relatively stable numbers of procedures performed for medical indications.6 No publicly available New Zealand data could be found. Part of the issue is poor understanding of the wide variation in female external genital appearance within the community. This is coupled with no welldefined transition between ‘normal’ and ‘abnormal’ labial size in the medical literature.7,8 Indeed there is no such demarcation, with the systematic review by Hayes and TempleSmith which is contained in this issue highlighting the wide range of normal anatomical variation and that asymmetry between left and right side is common as is protrusion of the labia minora.1 The crura of the clitoris is contiguous with the labia minora and a major concern with labiaplasty also discussed in this systematic review is the removal of highly sensitive and well vascularised labial tissue with a potential adverse impact on sexual function and pleasure. As discussed in the recent Australian and New Zealand Journal of Obstetrics and Gynaecology (ANZJOG) editorial, ‘Moving from critical clitoridectomy’, the female organs involved in sexual pleasure have a long history of being poorly understood and underresearched.9 In 2014 an Australian Department of Health review of vulval surgery led to increased scrutiny over the indications for Medicare funded vulval procedures.10 There is now a discrete item number for repair of anomalies/female genital mutilation and another for vulval hypertrophy. The Medical Benefits Scheme item number 35534 (vulvoplasty or labiaplasty) can only be claimed ‘in a patient aged 18 years or more for a structural abnormality that is causing significant functional impairment, if the patient's labium extends more than 8 cm below the vaginal introitus while the patient is in a standing resting position’. There are requirements stipulated that a detailed clinical history outlining the structural abnormality and the medical need for surgery of the vulva need to be included in the patient notes.11 In the 2018/19 and 2019/20 financial years numbers dropped to 96 and 129 Medicarebilled procedures for this code respectively, suggesting there has potentially been movement of cases into the private sector with the inherent complexities in accurate auditing and quality assurance.6 The increased demand for FGCS is likely multifactorial, with broader population exposure to pornography and Australian laws requiring censorship of digital images from showing the labia minora, trends in pubic hair removal and increasing societal acceptability of cosmetic procedures all being touted as potential contributory factors.12 Women seeking labiaplasty are more likely to have prior experience with cosmetic procedures than the general population, and are often motivated to improve the appearance of the external genitals (toward their perception of ‘normal’) as they feel it will impact positively on their sexual function and selfconfidence.13,14 Many women considering the procedure seek information from online sources including provider websites where the quality of information is often poor, along with reinforcement that a desirable vulva is narrowly defined.15 Data demonstrate that Australian primary care providers also commonly encounter questions from women on their genital normality. Most general practitioners have been asked about FGCS with many reporting they are Aust N Z J Obstet Gynaecol 2021; 61: 325–327