'Designer vagina' ops for kids on the NHS?

‘Girls as young as nine are asking for vaginal cosmetic surgery on the NHS – driven by a trend in “pornstar chic”’, the Metro has reported, with little in the way of hard evidence to back up the claim.

The lurid headlines (in the Metro and other news sources) are purportedly based on a study examining the quality of information provided in online advertisements by 10 private clinics offering female genital cosmetic surgery.

The media focused on a type of surgery known as labiaplasty, which involves removing a section of labia tissue (the labia makes up part of the external structure of the female genitalia).

While the study does accurately quote NHS statistics showing more than 300 labiaplasties were performed by the NHS on girls aged 14 or younger in the last six years, there is no evidence that these operations were performed for cosmetic reasons (to create ‘designer vaginas’).

There are clinical reasons why a labiaplasty may be performed, such as in order to remove a tumour.

This is a worthwhile study on a new and controversial cultural phenomenon. It found that the quality and quantity of medical information provided by such online clinics on labiaplasties (and similar cosmetic procedures) is poor, unscientific and at times incorrect. It found that none of the websites gave a lower age limit for cosmetic labiaplasty procedures.

However, the media has ‘spun’ the results of this study to suggest that unjustified female genital cosmetic surgery in children is somehow commonplace in the NHS.

The Department of Health has reportedly said that labiaplasties, or other types of genital surgery, would be carried out in the NHS only on patients “who have a clinical need.”

Where did the story come from?

The study was carried out by researchers from University College Hospital London. There was no external funding.

The study was published in the peer-reviewed, open-access medical journal, BMJ Open.

Of the reporting of the study, only The Independent provided a balanced view of the findings, reporting that cosmetic surgery websites provided poor quality information on female genital cosmetic surgery. All the other newspapers reporting on the story (Metro, The Sun and the Daily Mail) lead with the baseless accusation that labiaplasties on children for cosmetic reasons have been undertaken hundreds of times by the NHS over the last six years.

While the researchers argue that labial anomalies requiring surgical interventions are extremely rare in teenagers, they do not provide any evidence that the NHS is carrying out unnecessary surgeries.

The study raises valid concerns about the advertising of female genital cosmetic surgery (FGCS), but the majority of the news reporting has not focused on this.

What kind of research was this?

This was an analysis of the content of online advertisements from 10 private providers offering FGCS.

The researchers point out that a number of such operations in the absence of any medical reason are currently offered by the private sector.

As well as labiaplasties (which the media were focusing on as being performed in ‘hundreds of children’), the researchers also looked at other related cosmetic procedures:

• hymenoplasty - in which the hymen, the tissue lining the vaginal opening, is restored
• G-spot amplification – a type of surgery alleged to increase female sexual arousal (the G-spot is an area of the vagina related to sexual arousal, although its existence is uncertain)
• vaginal “rejuvenation” – in which the tissue of the vagina is strengthened

The researchers say such cosmetic surgery is a “new cultural phenomenon”, the ethics of which are causing rising levels of clinical debate.

They argue the phenomenon may reflect “negative stereotypes” of the natural appearance of the female genitalia, and direct marketing of this type of surgery to women and girls via the internet may be one reason for the phenomenon.

To date, little attention has been paid to the information contained in such advertisements and little medical scrutiny of the quantity and quality of clinical information on what is “elective surgery with known risks” (such as post-operative infection, nerve damage and scarring).

They also point out that to date; there have been no good quality long-term studies on the outcomes of FGCS procedures, so any claims relating to clinical effectiveness are unsubstantiated.

What did the research involve?

The researchers identified websites offering FGCS using Google (chosen because it is the most popular search engine) and entering the term “designer vagina”.

The first five UK and five US providers to appear in the search results were included in the study.

The researchers developed 16 information categories or criteria for analysing the content of the websites, building on the Questions to ask a surgeon article on the NHS Choices website, adding questions about clinical effectiveness and adverse effects. The 16 criteria were:

• types of procedure offered
• description of procedure (information on surgical technique)
• use of medical terms (to suggest that treatment is for a medical condition)
• symptoms that surgery treats (such as physical discomfort or concerns about appearance)
• benefits of surgery (such as improving discomfort, appearance or hygiene)
• success rates (what percentage of women achieve the benefits listed)
• reference to psychological and social advantages (non-medical benefits such as confidence)
• reference to enhancement of sexual experience (any mention sex will be improved for patient or partner)
• risks of surgery (such as infection and bleeding)
• absence or presence of a caution section (whether consumers were advised to think carefully before proceeding to FGCS)
• aftercare (basic wound hygiene)
• immediate outcomes (short-term benefits and risks)
• long-term outcomes
• absence or presence of positive testimonials (for example personal stories)
• absence or presence of before and after images
• lowest age limit for surgery (any mention that 16 years is the age of legal consent for surgery)

Each website was evaluated to confirm suitability for inclusion and to collect the information relevant to each category. All websites were then assessed independently.

What were the basic results?

The researchers found that the 10 websites named 72 different procedures using non-standard terminology. The researchers say these probably refer to the most common surgeries. Names included “vulval reshaping”, “vulva and vaginal rejuvenation”, “revirgination” and “Mommy Makeover”.

Below are the main findings:

• all websites claimed that surgery would improve the appearance of the female genitalia and give discomfort relief
• 5 out of 10 sites claimed improved sexual relationships and pleasure
• 4 out of 10 sites claimed improved hygiene
• none of the sites mentioned the current absence of evidence for clinical effectiveness
• only three sites made reference to “appearance diversity” – the fact that the size and shape of external female genitalia (labia) varies widely, but they still recommended surgery
• all sites mentioned that surgery has risks, but these were not named on 4 out of 10 sites
• all sites gave general aftercare advice
• there was no information on short-term or long-term outcomes of surgery based on actual data
• there was no mention of alternative ways of managing appearance concerns
• none of the sites gave a lower age limit for surgery

How did the researchers interpret the results?

They conclude that the quality and quantity of clinical information on the websites is poor and in some circumstances contained errors.

“Impeccable professionalism and ethical integrity is crucial for this controversial practice,” they argue. Adding that clear and detailed guidelines on how to raise the standard of information to women on all aspects of FGCS are urgently needed. They also argue that the websites themselves may be contributing to cultural stereotypes of an “idealised vulva”.

The researchers conclude that the absence of a lower age limit for any of the procedures is the most disturbing finding. In their discussion, they state that 343 labiaplasties were performed in the UK NHS on girls aged 14 and under in the past six years, pointing out that “the indications for surgery in this group of children are unknown, but labial anomalies requiring surgical interventions are extremely rare”. While the papers have interpreted this to mean that the surgery is being done on the NHS for cosmetic reasons, it is perhaps more likely that the authors were saying that it is rarely medically necessary and that is why there have only been around 57 per year.

It also reports that significant numbers of labiaplasties on girls under 18 years of age are reported in the medical literature, with one observational study in which girls as young as nine years had presented with normal labia. Again, the reasons for presentation are unclear.

Conclusion

This study of the information on female genital cosmetic surgery by private providers raises concerns about its quality. As the researchers point out, they did not conduct a systematic search of such information, and used only one search term and one search engine (Google).

However, the study does offer a glimpse of what women and girls may come across when searching for this kind of information on the internet. 

It could be argued that guidelines on advertising should be developed in this area, in particular on the terminology used to describe the surgery performed.

On the issue of FGCS within the NHS, a Department of Health spokeswoman told the media that “there is no such thing a designer vagina on the NHS. Of course there is cosmetic surgery carried out on the NHS, but this is only for patients who have a clinical need for it (such as reconstructive surgery after an accident) and absolutely not for those who would simply like to have it done.”