International Journal of Gynecology and Obstetrics 128 (2015) 85–86

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FIGO COMMITTEE REPORT

Ethical considerations regarding requests and offering of cosmetic genital surgery FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health

The FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health considers the ethical aspects of issues that impact the discipline of obstetrics, gynecology, and women’s health. The following document represents the result of that carefully researched and considered discussion. This material is intended to provide material for consideration and debate about these ethical aspects of our discipline for member organizations and their constituent membership. B. Dickens, Chair FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health E-mail: figo@figo.org Website: www.figo.org Bernard Dickens University of Toronto Faculty of Law 84 Queen’s Park Toronto M5S 2C5, Canada Tel.: +1 416 978 4849 Fax: +1 416 978 7899 E-mail: [email protected]

Background 1. Female genital cosmetic surgery is surgery performed on women who are physically healthy and whose genitalia are within the normal range of variation of human anatomy. Female genital cosmetic surgery does not have a medical indication, but rather is sought out to meet an individual cosmetic goal. By contrast, surgery for known medical indications, such as to address physical dysfunction and discomfort that limits normal function, is therapeutic (such as repair of fistula, surgical scarring, infections from scarring). 2. Surgery that intervenes to change appearance or to impact function on physically healthy women is considered nontherapeutic and is the focus of cosmetic genital surgery. This is generally differentiated from female genital cutting, circumcision, or mutilation, which also alters normative anatomy, by the active and voluntary surgical consent of women undergoing cosmetic procedures. 3. There is a wide variation of normal vulvar and vaginal anatomy. Education about normative anatomy particularly for sexual and reproductive functions is lacking worldwide. Women, their partners, and health professionals may be influenced by an increasing media focus on only small areas of the normal range, particularly adolescent or prepubertal genital appearance, into thinking this narrow range is ideal anatomy. 4. Ethical concerns have been raised regarding the performance of medically unnecessary surgery (elective surgery) on healthy women, particularly when women falsely believe that their genitalia are abnormal, that only a small range of anatomy is normal, and that “normality” or “normal function” can be achieved by surgical means. 5. Ethical concerns further arise if promotional advertising by members of the profession induces an unjustified belief that normal women’s genital appearance or function is abnormal. There is a direct conflict of interest if the promotional materials induce a belief that there is an abnormality that would then be addressed by the gynecologist advertising the procedures. 6. Cosmetic surgery in general and cosmetic genital surgery have the inherent risk of attracting patients who have body dysmorphic disorders and other psychological disorders and so perceive their anatomy as abnormal even if normal. Failure to recognize this underlying psychological disorder creates long term harm to patients, both by exposing them to risks of surgery and by failing to recognize and treat an underlying psychological medical condition. 7. Beyond the standard surgical risks of infection, bleeding, and scarring that disrupt normal function, the unique risks of these surgeries are yet to be well described with long-term and robust studies discovering, describing, and validating short-term and long-term benefits and harms. Additionally, the expectations of patients for cosmetic, sexual, social, and/or other advantages may not be achieved. All of these are important disclosures for women to consider in making such decisions. 8. Failure to share knowledge regarding distinctive techniques openly with professional colleagues, and to thereby allow independent repetition of techniques to validate outcomes, adds to the lack of effectiveness data. This violates medical professional duties of transparency, of allowing independent peer review, and of inclusive teaching. 9. A wider ethical concern, at a national and international level, is the impact of diversion of skilled gynecologic talent toward cosmetic surgery when the needs of women for necessary

http://dx.doi.org/10.1016/j.ijgo.2014.10.003 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.

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gynecologic services remain unmet. This inequity raises local and global health ethics questions concerning equity of access to essential services that require all levels of service providers to justify this practice. 10. There is an additional human rights concern that the right to selfchoice and autonomous decision-making may be interfered with by inadequate education, personal or cultural coercion from partners with limited knowledge of genital normative anatomy, or inability of women to make their healthcare choices. Lack of economic independence may further inhibit autonomous decision-making, particularly when the nontherapeutic change in appearance or supposed change in sexual function is linked to the woman’s personal and economic well-being.

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Recommendations 6. 1. Gynecologists must differentiate between therapeutic and medically nonindicated or cosmetic genital surgery, and assure that women seeking such surgeries are able to distinguish the difference. As part of informed consent and respect for autonomous decision-making, they must seek to dissuade patients from unjustified beliefs regarding unsupported sexual, social, or functional outcomes of cosmetic genital surgery. 2. Professional societies, standard-setting organizations, and credentialing bodies have a responsibility to monitor and issue standards for cosmetic gynecologic surgery, indicating whether it may ethically be recommended, and create guidelines for members regarding media portrayal or advertising for female genital cosmetic surgery that reflects the evidence base and normative anatomy. They additionally have a responsibility to promote education in basic normative genital anatomy and function. 3. All gynecologists, having acquired the skills for surgery through the gift of having women consent to inclusion in procedures in order to

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advance their skills, have an obligation to assure that women continue to have access to medically indicated procedures. The availability of and women’s access to needed gynecologic procedures ethically takes precedence over access to cosmetic procedures. Advertising and enticements for cosmetic surgery can easily cross the line into unprofessional conflict of interest, and should be avoided. Ethically, the goal must remain a medical professional model of practice for the benefit and protection of patients, rather than a competitive business or commercial model designed to maximize investor income. Gynecologists must ensure that a woman’s decision for surgery is informed by adequate knowledge of normative anatomy and function. A gynecologist must disclose the potential for dysfunction from surgery itself, the related risks, and the state of evidence of risks and benefits of the surgery proposed. Physicians practicing in an area where evidence of efficacy and complications is limited have a heightened obligation for patient safety to be transparent regarding the procedures they provide, as well as to contribute to research and systematic outcome monitoring for these procedures. These data need to be peer reviewed and published to establish the evidence for safe practices. If offering cosmetic genital surgery, the gynecologist must have knowledge of body dysmorphic and other disorders that may influence desires for surgery, and appropriately refer women with these disorders for appropriate support and treatment, as part of their ethical responsibility for adequately informed consent. Gynecologists who intend to offer cosmetic surgical procedures must also meet the standard training required not only for cosmetic and/or plastic surgery in this area but also for the exploration of underlying disorders such as body dysmorphic disorders before offering such procedures.

London, March 2014

Ethical considerations regarding requests and offering of cosmetic genital surgery.

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