Female genital cosmetic surgery.

Sir,

The World Health Organisation's (WHO) definition of female genital mutilation is, all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs, whether for cultural, religious, or other non-therapeutic reasons.[1] Women's concerns about their appearance, fuelled by commercial pressure for surgical fixes, now include the genitalia. A lot more women are stated to be troubled by the shape, size, or proportions of their vulvas, hence, elective genitoplasty is apparently a demanding cosmetic procedure. The latest survey by the British Association of Aesthetic Plastic Surgeons reported that the staggering 31% increase in the uptake of cosmetic surgery in UK women accounted for 92% of this uptake.[2] The increased demand for cosmetic genitoplasty may reflect a narrow social definition of normal, or a confusion of what is normal and what is idealised. The provision of genitoplasty could narrow acceptable ranges further and increase the demand for surgery even more. Research involving women with atypical genitalia has shown that clitoral surgery is associated with the inability to reach an orgasm and has emphasised the role of the vulvar epithelium in sensuality and arousability.[34] Women who seek cosmetic genital surgery fall into two main categories. First, women with congenital conditions such as intersex for which the current standard practice advises feminizing genitoplasty procedures, with the objective of reducing the clitoral size and opening the vaginal introitus.[56] Second, some women with no underlying condition affecting their genital development also seek surgery to alter the appearance of their genitals, for example, labial or clitoral reduction.[78] Patients (women) desired alteration of their vulvas and vaginas for reasons of cosmesis, increasing self-esteem, and improving sexual function. The patients must be assured that their surgeon is properly trained and should understand that few validated long-term safety or outcome data are presently available in this relatively new field. It is important that training guidelines for practitioners be established and that long-term outcome, psychosexual, and safety data be published. The genital plastic surgeon must have sufficient training in sexual medicine, to withhold these procedures from women with sexual dysfunction, mental impairment, or body dysmorphic disorder.[9] It is important for these physicians to be adequately trained in the vulvar and vaginal anatomy and the intended surgical procedure(s), and the patients should understand their surgeons’ professional training and background.[5] It is the obligation of the surgeon to inform the patient fully regarding the treatment options and the potential risks and benefits of these options. Once the physician is satisfied that the patient fully comprehends the options, the patient's autonomous decision should ordinarily be respected and supported.[9] It is necessary to examine these procedures through the lens of the established and accepted principles of biomedical ethics: respect for autonomy, beneficence, non-maleficence, justice, and veracity.[10] With striking accessibility of pornography in everyday life, women and their sexual partners are a lot more exposed to idealised, highly discriminating images of the female genital anatomy. Thus, in the future, more women may request genital surgery because a solution involving experts with minimal personal responsibility is more appealing than a personal commitment to problem solving. In the absence of measurable standards of care, lack of evidence-based outcome norms, and little standardisation, either in nomenclature or training requirements, concern has been raised by both ethicists and specialty organisations.