GPs caught out by rise in requests for genital cosmetic surgery: study

The RACGP has published guidelines
for GPs to consult on FGCS

by Anne Crawford

A ground-breaking study of Australian general practitioners has found that of those who saw patients requesting female genital cosmetic surgery (FGCS), around a third reported seeing patients younger than 18 years.

The large online survey, the first of its kind, was conducted jointly by University of Melbourne and Monash University researchers. The survey quizzed 443 GPs about their knowledge, attitudes and practice in managing patients who asked about the surgery and found many were ill-equipped to advise on it.

The study was led by Dr Magdalena Simonis, a general practitioner with many years' experience in women’s health, who is a researcher with the Department of General Practice, University of Melbourne, and fellow of the Royal Australian College of General Practitioners. It was supervised by the Central Clinical School’s Dr Jason Ong, from the Faculty of Medicine, Nursing and Health Sciences at Monash University, who works at the Melbourne Sexual Health Centre. 

The survey found that 97% of GPs had been asked about genital ‘normality’, reflecting anxiety about this, and that more than half had seen patients requesting FGCS ranging in age from as young as 10 years to 65 years.

Significantly, nearly half the GPs surveyed reported that they had insufficient knowledge of the risks of FGCS procedures, suggesting they required greater education to support patients. The RACGP has responded by producing the RACGP female genital cosmetic surgery guide for general practitioners and health professionals, free to download from the RACGP guidelines website. 

“They all felt it was a new phenomenon,” Dr Simonis said. “They felt unprepared for it.”

FGCS, or vulvoplasty, refers to a range of surgical procedures that change the structure and appearance of the healthy external genitalia of women, or internally, e.g. vaginal tightening. 

Dr Simonis said the findings showed that women were comparing themselves to a “certain genital appearance” shown online and in pornography – possibly digitally enhanced –without realising there was a range of appearances.  

“There are people building a business around labiaplasty, advertising images online of women with prepubertal genitalia, depicting it as the desirable norm and a lifestyle choice,” Dr Simonis said. Labiaplasty involves removing folds of tissue around the vulva.

Dr Ong, also a GP and sexual health physician, said advertisements and social media were calling the procedures “vaginal rejuvenation”, “designer vaginas” and “Barbie-plasty”.

He said it was important that GPs, as first point of contact for many Australian women, were able to advise and reassure women about their genitalia.

“The thing that concerns me as a doctor is that a lot of these procedures are not proven as to their benefits and there are no studies about the long-term effects of having them,” Dr Ong said.

The industry was unregulated and no formal specialist surgical training beyond a medical degree was needed to perform the procedures, he said.

The GPs surveyed thought their patients were influenced by fashion (appearance in clothes), comfort in clothes, perceptions of beauty and pornography, and peer group pressure. ‘Brazilians’ – women removing their pubic hair – had meant that genitalia were more visible to women and their partners.

However, more than half the GPs suspected mental health difficulties such as depression, anxiety, relationship difficulties, partner abuse and body dysmorphic disorder, in women seeking advice for FGCS.

“I think that what this alerts us to is the need to actively engage women in discussion about their relationships and their mental health – surgery is not an answer to mental health issues,” Dr Simonis said.

The popularity of FGCS is growing, mirroring trends in Britain and the US. Australian Government statistics indicate a 140% increase in requests for rebatable vulvoplasty from 640 in 2001 to more than 1500 in 2013, without a concomitant rise in genital disease diagnoses. Medicare has since reviewed the rebate for FGCS and now requires proof of a medical reason for it.

“The figures are only the tip of the iceberg – they only capture the procedures surgeons charge to Medicare,” Dr Ong said.

Dr Simonis, who became interested in FGCS in 2012 after a patient and her teenage daughter asked about it, has led two smaller qualitative studies and contributed to the guidelines produced by the RACGP.

The researchers caution that the sample of GPs in the study was skewed as the majority who responded were female and primarily interested in women’s health.

Reference: Simonis M, Manocha R, Ong JJ. Female genital cosmetic surgery: a cross-sectional survey exploring knowledge, attitude and practice of general practitioners. BMJ Open. 2016 Sep 26;6(9):e013010. doi: 10.1136/bmjopen-2016-013010.