Abstract
Objective
To provide Canadian surgeons and other providers who offer female genital cosmetic
surgery (FGCS) and procedures, and their referring practitioners, with evidence-based
direction in response to increasing requests for, and availability of, vaginal and
vulvar surgeries and procedures that fall outside the traditional realm of medically
indicated reconstructions.
Target Population
Women of all ages seeking FGCS or procedures.
Benefits, Harms, and Costs
Health care providers play an important role in educating women about their anatomy
and helping them appreciate individual variations. Most women requesting FGCS and
procedures have normal genitalia, and up to 87% are reassured by counselling. At this
time, due to lack of rigorous clinical or scientific evidence of short- and long-term
efficacy and safety, FGCS and procedures for non-medical indications cannot be supported.
FGCS and procedures are typically provided in the private sector, where costs are
borne by the patient.
Evidence
Literature was retrieved through searches of MEDLINE, Scopus, and The Cochrane Library
using appropriate controlled vocabulary and keywords. The selected search terms represented
keywords for FGCS (labiaplasty, surgery, vaginal laser therapy, laser vaginal tightening,
vaginal laser, vaginal rejuvenation, vaginal relaxation syndrome, hymenoplasty, vaginal
cosmetic procedures) combined with female genital counselling, consent, satisfaction,
follow-up, adolescent, and body dysmorphic or body dysmorphia. The search was restricted
to publications after 2012 in order to update the literature since the previous guideline
on this topic. Results were restricted to systematic reviews, randomized controlled
trials, and observational studies. Studies were restricted to those involving humans,
and no language restrictions were applied. The search was completed on May 20, 2020,
and updated on November 10, 2020.
Validation Methods
The authors rated the quality of evidence and strength of recommendations using the
Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).
Intended Audience
Gynaecologists, primary care providers, surgeons performing FGCS and/or procedures.
RECOMMENDATIONS
- 1.Health providers should play an important role in educating women about their anatomy and helping them appreciate individual variations, including transitions through the reproductive life cycle (strong, low).
- 2.For women who present with requests for vaginal cosmetic procedures, a complete medical, sexual, and gynaecological history must be obtained, and the absence of any major sexual or psychological dysfunction, including body dysmorphic disorder, should be ascertained. Any possibility of coercion or exploitation must also be ruled out (strong, high).
- 3.There is insufficient evidence to support any female genital cosmetic surgery or procedure to improve sexual satisfaction and/or self-image. Physicians choosing to proceed with these cosmetic procedures should not promote these surgeries for the enhancement of sexual function or self-image (strong, low).
- 4.Hymenoplasty is a surgical procedure that is not medically indicated. Counselling of the woman is paramount to provide both reassurance and accurate information that the procedure does not reliably result in the desired outcome of bleeding at first marital intercourse (strong, moderate).
- 5.Laser is not recommended for genitourinary syndrome of menopause or cosmetic genital indications without further rigorous short- and long- term clinical research (strong, low).
- 6.Counselling should be a priority for women requesting female genital cosmetic surgery and procedures that are not medically indicated. Topics should include normal variation and physiological changes over the lifespan, as well as the possibility of unintended consequences of cosmetic surgery to the genital area. The lack of both high-quality evidence and data regarding outcomes should also be discussed and considered as part of the informed decision-making process (strong, high).
- 7.Caution should be used in advertising female genital cosmetic surgeries, to ensure such advertising is factual and not misleading (strong, high).
- 8.Physicians who see adolescents requesting female genital cosmetic surgery require additional expertise in counselling adolescents (strong, low).
- 9.Female genital cosmetic surgery must not be performed until genital maturity (strong, low).
- 10.Surgery is not considered cosmetic if there is documented functional impairment, which may include structural, psychological, and/or anatomical concerns (strong, moderate).
Keywords
Abbreviations:
BDD (body dysmorphic disorder), FGCS (female genital cosmetic surgery), GSM (genitourinary syndrome of menopause)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Obstetrics and Gynaecology CanadaAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Aesthetic plastic surgery national databank statistics.(Available at:)https://www.surgery.org/sites/default/files/Aesthetic-Society_Stats2019Book_FINAL.pdfDate: 2019Date accessed: October 28, 2021
- ISAPS international survey on aesthetic/cosmetic procedures performed in 2018.(Available at:)https://www.isaps.org/wp-content/uploads/2020/10/ISAPS-Global-Survey-Results-2018-1.pdfDate accessed: October 28, 2021
- Psychological characteristics and motivation of women seeking labiaplasty.Psychol Med. 2014; 44: 555-566
- Guideline no. 395-female genital cutting.J Obstet Gynaecol Can. 2020; 42: 204-217.e2
- Self-assessment of anatomy, sexual sensitivity, and function of the labia and vagina.Clin Anat. 2015; 28: 355-362
- Position statement: Labial reduction surgery (labiaplasty) on adolescents.(Available at:)https://www.rcog.org.uk/globalassets/documents/news/britspag_labiaplastypositionstatement.pdfDate: 2013Date accessed: October 28, 2021
- The labia library.(Available at:)http://www.labialibrary.org.au/Date accessed: October 28, 2021
- “Ethical issues in women's healthcare practice and policy.”.in: d’Agincourt-Canning L. Ells C. Drivers and dilemmas of female genital cosmetic surgery. Oxford University Press, 2019
- Hypertrophy of labia minora: Experience with 163 reductions.Am J Obstet Gynecol. 2000; 182: 35-40
- Labial surgery for well women: A review of the literature.BJOG. 2010; 117: 20-25
- Cosmetic gynecology in the view of evidence-based medicine and ACOG recommendations: A review.Arch Gynecol Obstet. 2011; 284: 617-630
- “Female genital cosmetic surgery: Psychological aspects and approaches.”.in: Liao L.-M. Creighton S.M. Female genital cosmetic surgery: Solution to what problem? Cambridge University Press, Cambridge2019: 118-128
- What's normal? Influencing women's perceptions of normal genitalia: An experiment involving exposure to modified and nonmodified images.BJOG. 2014; 121: 761-766
- Audit of referrals for concern regarding labial appearance at the royal children's hospital: 2000-2012.J Paediatr Child Health. 2018; 54: 439-442
- Female genital appearance: “Normality” unfolds.BJOG. 2005; 112: 643-646
- Cosmetic genital surgery in children and adolescents.Best Pract Res Clin Obstet Gynaecol. 2018; 48: 137-146
- Motivations, expectations, and experiences of labiaplasty: A qualitative study.Aesthet Surg J. 2016; 36: 920-928
- Labiaplasty: A 24-month experience in 58 patients: Outcomes and statistical analysis.Ann Plast Surg. 2018; 80: 316-322
- Initial experience in a vulvovaginal aesthetic surgery unit within a general gynecology department.J Low Genit Tract Dis. 2010; 14: 295-300
- “I don't see that as a medical problem”: Clinicians' attitudes and responses to requests for cosmetic genital surgery by adolescents.J Bioeth Inq. 2018; 15: 535-548
- Female genital and vaginal plastic surgery: An overview.Plast Reconstr Surg. 2019; 144 (284e–97e)
- A new surgical technique for hymenoplasty: A solution, but for which problem?.Int J Gynaecol Obstet. 2015; 130: 1-2
- Backgrounds of women applying for hymen reconstruction, the effects of counselling on myths and misunderstandings about virginity, and the results of hymen reconstruction.Eur J Contracept Reprod Health Care. 2012; 17: 93-105
Food and Drug Administration. FDA warns against use of energy-based devices to perform vaginal ‘rejuvenation' or vaginal cosmetic procedures: FDA safety communication. July 30, 2018.
- Elective female genital cosmetic surgery: ACOG committee opinion summary, number 795.Obstet Gynecol. 2020; 135: 249-250
- Vaginal ‘rejuvenation’ and cosmetic vaginal procedures.(Available at:)
- International society for the study of vulvovaginal disease recommendations regarding female cosmetic genital surgery.J Low Genit Tract Dis. 2018; 22: 415-434
- The use of laser in urogynaecology.Int Urogynecol J. 2019; 30: 683-692
- The clinical role of laser for vulvar and vaginal treatments in gynecology and female urology: An ics/issvd best practice consensus document.J Low Genit Tract Dis. 2019; 23: 151-160
- Lasers in the era of evidence-based medicine.Climacteric. 2020; 23: S6-S10
- Cosmetic gynecology-a systematic review and call for standardized outcome measures.Int Urogynecol J. 2020; 31: 1979-1995
- Laser therapy for urinary incontinence and pelvic organ prolapse: A systematic review.BJOG. 2020; 127: 1338-1346
- New gynaecological technologies - proper evaluation needed before implementation into clinical practice.BJOG. 2020; 127: 1311
- The efficacy of vaginal laser and other energy-based treatments on genital symptoms in postmenopausal women: A systematic review and meta-analysis.J Minim Invasive Gynecol. 2021; 28: 668-683
- Bioethics for clinicians: 1. Consent.CMAJ. 1996; 155: 177-180
- Labiaplasty: Indications and predictors of postoperative sequelae in 451 consecutive cases.Aesthet Surg J. 2018; 38: 644-653
- Teen labiaplasty: A response to the may 2016 american college of obstetricians and gynecologists (ACOG) recommendations on labiaplasty in adolescents.Aesthet Surg J. 2016; 36: 807-809
Ministère du Travail, de l'Emploi et de la Solidarité sociale. Preliminary provision. In: Civil Code of Québec, Chapter CCQ-1991. Available at: http://legisquebec.gouv.qc.ca/en/showdoc/cs/ccq-1991. Accessed on October 28, 2021.
- Practice standard: Advertising and communication with the public (version 6.2). February 22, 2021.(Available at:)https://www.cpsbc.ca/files/pdf/PSG-Advertising.pdfDate accessed: October 28, 2021
- ACOG committee opinion no. 378: Vaginal “rejuvenation” and cosmetic vaginal procedures.Obstet Gynecol. 2007; 110: 737-738
The American College of Obstetricians and Gynecologists. The role of the obstetrician-gynecologist in cosmetic procedures. Statement of policy. 2018 (Reaffirmed). Available at: https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2018/role-of-the-obstetrician-gynecologist-in-cosmetic-procedures. Accessed on October 28, 2021.
- 686: Breast and labial surgery in adolescents.Obstet Gynecol. 2017; 129: e17-e19
- Ethical opinion paper: Ethical considerations in relation to female genital cosmetic surgery (FGCS).(Available at:)https://www.rcog.org.uk/globalassets/documents/guidelines/ethics-issues-and-resources/rcog-fgcs-ethical-opinion-paper.pdfDate: 2013Date accessed: October 28, 2021
- Vaginal ‘rejuvenation' and cosmetic vaginal procedures.Aust N Z J Obstet Gynaecol. 2019 Jul 25;
- Why women request labiaplasty.Plast Reconstr Surg. 2017; 139: 856-863
Article info
Publication history
No. 423, February 2022 (Replaces No. 300, December 2013)
Footnotes
This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not meant to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however, that they adequately document any such amendments.
Informed consent: Everyone has the right and responsibility to make informed decisions about their care together with their health care providers. In order to facilitate this, the SOGC recommends that health care providers provide patients with information and support that is evidence-based, culturally appropriate, and personalized.
Language and inclusivity: The SOGC recognizes the importance to be fully inclusive and when context is appropriate, gender-neutral language will be used. In other circumstances, we continue to use gendered language because of our mission to advance women’s health. The SOGC recognizes and respects the rights of all people for whom the information in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages health care providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to apply these guidelines in a way that is sensitive to each person’s needs.
Identification
Copyright
© 2021 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
