Clinical characteristics of well women seeking labial reduction surgery: A prospective study.

Crouch NS, Deans R, Liao L-M M et al (2011) 1471-0528: 1507-1510

This study between 2007-2010 was aimed at assessing the clinical characteristics and expectations of well women attending an outpatient clinic in a general gynaecology clinic in a central London teaching hospital, UK, for elective labial reduction surgery. There is currently no evidence available on the safety and efficacy of labial reduction surgery.

There was ethical approval for the study. The presenting complaints of the clients varied from physical to psychological, and the reasons for current dissatisfaction, expectations of genital surgery and previous exposure to genital images were documented. The authors had a practice to offer labial reduction surgery to clients aged 18 years or above, with either a labial width of over 50mm, or marked labial asymmetry with over 30mm difference in the labia, and this formed the basis of the inclusion criteria.

There were 33 participants over a period of three years. The age range was 11 to 45 years (mean age 23). Majority of the clients, 84% (28 women), self-identified as white, six percent were black, and three percent were asian, from South East Asia.

The majority of the clients, 66% (22 women), self-identified as students, and 30% (10 women) were in paid employment. Eight participants (24%) were aged 16 years or under and all were in full-time education.

Most of the women, 87% (29 women), were referred by their general practitioner, which is to be expected, and 6% (two women) were referred by either the Obstetrics and Gynaecology Registrar or a Consultant Paediatric Endocrinologist.

The sources of information on female genital cosmetic surgery (FGCS), assessed by the women before presentation, included adverts on FGCS in 33% of the women, medical illustrations in 15%, and 12% reported having viewed pornography. Up to 15% of the women had sought psychological services in the past or had actually seen a psychiatrist.

The wishes of the women after the surgery were also varied, from wanting the labia to be smaller, improved appearance, reduced discomfort, and improved confidence, to improved experience of coitus. One woman was unsure and was seeking advice about whether she needed surgery.

In terms of referral outcome, only three patients merit the inclusion for surgery and were offered unilateral labial reduction to address a significant asymmetry.

Of the 30 patients that were refused surgery, 11 (one third) accepted referral to clinical psychologist, 12 of the women (40%) said they would opt for a second opinion or for surgery in the NHS or the private sector, and one was referred urgently to mental health due to potential for self harm.

This is the first report on labial dimensions of women seeking cosmetic labial reduction surgery. In up to 90% (30 of the women), the labial dimensions was found to be within the normal range and this raises concern that the women and their referring doctors have felt that surgery was an appropriate treatment.

The authors admit definition of ‘normal’ may be problematic and may be subject to variable interpretation. The definition of normalcy defined in this study may therefore be helpful in counseling for the time being, until more larger prospective studies are available.

There are, however, clinicians’ dilemmas, as legislation in the UK prohibits incision, excision and infibulations of the labia majora, labia minora or clitoris for cultural and non-therapeutic reasons, even if an adult woman were to give consent and even if it were carried out by medical practitioners. It is difficult to see how operations on normal sex organs in the absence of quality data could be therapeutic as it is difficult to see how FGCS could be anything other than cultural. This also led the RCOG to issue a statement in 2009 advocating that any decision for surgery be based on clinical grounds.

The study was also concerned about the young age of some of the referred women, some as young as 11. As the external genitalia continues to develop throughout adolescence and may be asymmetrical initially, the prohibition of surgery on normal children should therefore not require any debate.