ETHICS/EDUCATION

Cosmetic genital surgery

configuration have shown a wide natural variation. Increased

access to female body images may change womens perceptions
of what is normal and desirable. Surprisingly, labial measurements of women requesting labial reduction surgery are usually
within the published normal range. A comparison of labial
measurements between women seeking labiaplasty in an NHS
gynaecology clinic and those in a private cosmetic clinic has
shown that NHS patients appeared to have significantly greater
labia minora width than the private patients. The personal predisposition of physicians also influence clinical decision making,
with plastic surgeons more likely to consider large labia minora
as unnatural, compared to gynaecologists or general practitioners
and male physicians are more inclined to opt for surgical intervention than their female colleagues.

Ilias Giarenis
Linda Cardozo

Abstract
Female cosmetic genital surgery (FCGS) is a rapidly expanding field of
cosmetic surgery. The increased demand for FCGS has caused a number
of ethical and scientific controversies. The use of emotive terms and
the lack of standardised terminology make the assessment of these operations challenging. Women seek FCGS for aesthetic, functional, sexual
and cultural reasons despite the well-recognised lack of robust evidence
regarding their efficacy and safety. Considering the wide natural variation
of female genitalia, increased access to female body images and personal
predisposition of physicians may change perceptions of what is normal
and desirable. Women should be carefully counselled and screened preoperatively for underlying psychological problems and sexual dysfunction. FCGS should ideally be provided by a multidisciplinary team (MDT)
of healthcare professionals with relevant training, demonstrated competence and with the required clinical governance arrangements in place.

Female genital mutilation

The rising number of these operations has also fired a controversy about the difference between FCGS and female genital
mutilation (FGM). FGM comprises all procedures that involve
partial or total removal of the external female genitalia, or other
injury to the female genital organs for non-medical reasons and
it is recognised internationally as a violation of the human rights
of women. In the UK, the Female Genital Mutilation Act 2003
excludes surgical operations which are necessary for womans
physical or mental health. Operations necessary for mental
health could include cosmetic surgery resulting from the
distress caused by a perception of abnormality. However, as
this term is open to interpretation and there is limited evidence
regarding the benefit of FCGS for physical and mental health,
there is some ambiguity around the legal status of some procedures. In order to be able to demonstrate compliance with the
FGM Act, the Royal College of Obstetricians and Gynaecologists
recommends that all surgeons who undertake FCGS keep written
records of the physical and mental health reasons which, in their
view, necessitate such operations to be performed.

Keywords designer vagina; female cosmetic genital surgery; female

genital mutilation; hymenoplasty; labiaplasty; perineoplasty; vaginal
rejuvenation; vaginoplasty

Introduction
The interest and demand for female cosmetic genital surgery
(FCGS) have increased over the last decade. This field has been
described as the old Wild, Wild West: wide open and unregulated. Designer vagina, vaginal rejuvenation, laser vaginal
rejuvenation and G shot as well as other poorly defined
procedures are widely advertised in popular media and the
internet, despite the lack of scientific evidence of their efficacy
and safety.

Indications

Definition and types of FCGS

Women seek FCGS for aesthetic, functional, sexual and cultural

reasons. A number of physical complaints are described by these
women, such as pain, discomfort or irritation associated with
clothing, exercise, sexual intercourse as well as a sensation of
vaginal relaxation and lack of coital friction. Women referred to
an NHS gynaecology clinic by their general practitioner are more
likely to report functional reasons, compared to self-referred
women to a private cosmetic clinic. In a multicentre cohort of
258 women undergoing FCGS, 64% reported discomfort preoperatively, 48% cosmetic reasons, 33% wanted surgery for
self-esteem and 30% for sexual enhancement.
The request for hymenoplasty is usually made by a different
group of patients. They often come from specific ethnic/religious
groups, where bleeding during post-nuptial intercourse and
vaginal tightness are considered proofs of virginity.

FGCS refers to non-medically indicated cosmetic surgical procedures which change the structure and appearance of the
healthy female genitalia. There are a number of procedures
included under the umbrella term FCGS (Table 1). The terminology needs to be standardised in an effort to avoid ambiguity
and inconsistency. It is of paramount importance to use
descriptive and clearly defined terms such as those employed in
the field of pelvic reconstructive surgery.

Anatomy; patient and doctor perception

Our knowledge about normal anatomy of the female genitalia is
limited. Studies reporting their anatomical dimensions and

Ilias Giarenis MRCOG is a Subspecialty Trainee in Urogynaecology at

Kings College Hospital, London, UK. Conflicts of interest: none
declared.

Efficacy and safety

Despite the increasing interest in FCGS, only limited outcome
data have been published. The majority of the studies are
retrospective, single-centre case series with short-term follow-up,

Linda Cardozo MD FRCOG is Professor of Urogynaecology at Kings College

Hospital, London, UK. Conflicts of interest: none declared.

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ETHICS/EDUCATION

Procedure Screening Scale modified for labia (COPS-L), which

are both validated in women seeking labiaplasty.
Another challenging group are patients with sexual dysfunction. Validated instruments of sexual function or structured
screening questions should be used pre-operatively. Women with
significant sexual dysfunction should be referred to a qualified
psychosexual therapist before any planned surgical intervention.

Proposed classification of female cosmetic genital

surgical (FCGS) procedures
FCGS procedures
C
Labiaplasty
 Labia minora reduction
- linear resection
- wedge resection (V-wedge, Z-plasty)
- de-epithelised reduction
 Labia majora augmentation
 Labia majora reduction
C
Vaginoplasty
 Posterior colporraphy
- with levator ani plication
- without levator ani plication
 Anterior colporraphy
 Lateral colporraphy
 Vaginal bulking procedures
C
Perineoplasty
 Perineorrhaphy
 Fentons procedure
C
Clitoral hood reduction
C
Hymenoplasty (hymenorrhaphy)
C
G-spot bulking (amplification)

Training and service provision

In the current unregulated environment of FCGS, gynaecologists,
urogynaecologists, plastic surgeons and urologists perform these
operations, despite the absence of structured training programs.
In view of the increasing demand for these operations the relevant surgical professional bodies should provide some guidance
on training and practice requirements.
FCGS should ideally be provided by a multidisciplinary
team (MDT) of healthcare professionals, including surgeons,
psychologists, psychosexual therapists and physiotherapists.
Having representation from professionals with different experience would allow a wider choice for women and better patient selection for surgery. Furthermore, the MDT would also
be able to make special clinical governance arrangements,
audit interventions and continuously monitor and review
outcomes.

Table 1

Conclusions
FCGS is a rapidly expanding and poorly regulated field of
cosmetic surgery. Despite the controversies, the relevant professional bodies should attempt to regulate training and standardise terminology. Emotive terms such as designer vagina,
laser vaginal rejuvenation or G shot should be abandoned in an effort to avoid confusion and develop realistic patient expectations. Well-designed prospective studies with longterm follow-up, which use validated tools and patient reported
outcomes, are needed. Patients should be carefully counselled
and selected pre-operatively ideally by a multidisciplinary team.
The request for FCGS may be reasonable and whilst we respect
an individuals right to choose, there needs to be increased
regulation in this controversial area of medicine.
A

which report subjective, non-validated outcome measures. Every

published study shows success or satisfaction rates greater than
80%.
The incidence of reported complications varies in the literature from 3% to 30%. A wide range of post-operative complications have been reported such as infection, haematoma,
dyspareunia, localised pain, altered sensation, poor wound
healing, scarring, wound separation and even bowel and bladder
injury with fistula formation. Long-term damage to sexual
function and sensation may occur after FCGS, as surgery disrupts
the dense nerve supply of the female genitalia.

Informed consent
Women should be educated about the normal variations of
normal female genital appearance and be reassured about their
anatomy. Special attention should be paid to younger girls and
FCGS should not normally be carried out on women under 18
years of age, because full genital development may not be achieved before the age of 18. Those seeking FCGS should be made
aware of the lack of robust scientific evidence about the safety
and efficacy of these operations.
The increased prevalence of underlying psychopathology in
patients requesting cosmetic surgery has been well recognised in
the literature. Women seeking labiaplasty do not differ from
controls on measures of depression or anxiety, but they have a
worse body image and quality of life and are more likely to suffer
from body dysmorphic disorder (BDD). Consequently, preoperative screening for psychological problems and referral to
a suitable trained professional, such as psychologist or psychiatrist, should be considered. We recommend the routine use of the
Genital Appearance Satisfaction (GAS) scale and the Cosmetic

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 24:9

FURTHER READING
British Society for Paediatric and Adolescent Gynaecology. Position
Statement. Labial reduction surgery (labiaplasty) on adolescents.
October 2013, http://www.rcog.org.uk.
Crough NS, Deans R, Michala L, et al. Clinical characteristics of well
women seeking labial reduction surgery: a prospective study. BJOG
2011; 118: 1507e10.
Goodman MP, Placik OJ, Benson RH, et al. A large multicentre outcome
study of female genital plastic surgery. J Sex Med 2010; 7: 1565e77.
Goodman MP. Female cosmetic genital surgery. Obstet Gynecol 2009; 113:
154e9.
Iglesia CB, Yurteri-Kaplan L, Alinsod R. Female genital cosmetic surgery:
a review of techniques and outcomes. Int Urogynecol J 2013; 24:
1197e2009.
Moran C, Lee C. Whats normal? Influencing womens perceptions of
normal genitalia: an experiment involving exposure to modified and
nonmodified images. BJOG 2014; 121: 761e6.

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Reitsma W, Mourits MJ, Koning M, et al. No (wo)man is an islandethe

influence of physicians personal predisposition to labia minora
appearance on their clinical decision making: a cross-sectional survey.
J Sex Med 2011; 8: 2377e85.
Royal College of Obstetricians and Gynaecologists Ethics Committee.
Ethical considerations in relation to female genital cosmetic surgery.
October 2013, http://www.rcog.org.uk.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 24:9

Veale D, Eshkevari E, Ellison N, et al. Validation of genital appearance

satisfaction scale and the cosmetic procedure screening scale for
women seeking labiaplasty. J Psychosom Obstet Gynaecol 2013; 34:
46e52.
Veale D, Eshkevari E, Ellison N, et al. Psychological characteristics
and motivation of women seeking labiaplasty. Psychol Med 2014; 44:
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2014 Elsevier Ltd. All rights reserved.