Promoting Cosmetic Surgery

Editor's Choice
Promoting cosmetic surgery

Fiona Godlee, editor, BMJ

 

There’s a good debate in this week’s journal on whether advertising for cosmetic surgery should be banned. Advertising to the public is already illegal in France, and the UK Department of Health is currently reviewing cosmetic practices, including advertising. Tell us what you think in our poll on bmj.com and by sending a rapid response.

The debate gives me a chance to reignite, I hope, a related controversy. At its annual meeting in Rome last month, the Federation of International Gynaecologists and Obstetricians included for the first time ever a presentation on cosmetic gynaecology. The event and subsequent outcry passed the BMJ by, but, according to the programme, US plastic surgeon Adam Ostrzenski spoke on vaginal rejuvenation techniques and “G-spotplasty.” As Ostrzenski writes on Facebook, “This invitation by FIGO is unquestionably the highest recognition of the cosmetic-plastic gynecologic field … FIGO by its invitation of cosmetic-plastic gynecology has continued elevating the level of recognition of the cosmetic-plastic gynecologic field.”

He clearly thinks this is a good thing. Others do not. In a letter in September to FIGO’s president, Gamal Serour, the Medical Women’s International Association expressed its grave concern about the decision. “Women are being pressured into thinking that all labia need to look the same and that if they differ, it is cause for surgery,” it said. “Promoting and performing such surgery carries significant risks of physical and psychological harm to women and girls.”

The BMJ has form on this topic. Back in 2007, we published an article by Lih Mei Liao and Sarah Creighton on how to deal with requests for cosmetic genitoplasty. Demand was rising, they said. Their Google search on “labial reduction” produced around 490 000 results, with 47 of the first 50 being advertisements from clinics offering cosmetic genital surgery. Repeating that search today brings up over 2.7m results, with a similar overwhelming proportion of advertisements.

The authors concluded that surgery carried risks and there was no evidence of enduring psychological or functional benefit. Most of the women they interviewed were hesitant about recommending the procedures to other women. What was needed, said the authors, were alternative solutions to women’s concerns about the appearance of their genitals. Instead we have the world’s most prestigious gynaecological gathering giving unprecedented prominence to the practice. This does not look like an advance to me.

FIGO’s mission is “to promote the wellbeing of women and to raise the standards of practice in obstetrics and gynecology.” It does admirable work, including speaking out against female genital mutilation. Its website says it views female genital mutilation “of any type” as a violation of the human rights of girls and women and that it works actively with other global organisations to help to eliminate it. But I could find no statement about cosmetic gynaecological surgery. It would be good to hear from Professor Serour. Does he plan more sessions on vaginal rejuvenation at next year’s FIGO meeting, or might it be time for FIGO to speak out against the epidemic rise in such practices?

--------------------------------------------------------------------------------------------------------------------------
 

Cosmetic surgery and patient safety - a possible role for independent holistic accreditation?

17 December 2012

Stephen T. Green, Consultant Physician in Infectious Diseases and Tropical Mediicine

Royal Hallamshire Hospital - Sheffield Teaching Hospitals, Glossop Road, Sheffield S10 2JF

Advertising is one thing. What material is actually put into the advert to promote a service is another.

The missing link is very often the absence of some form of independent assessment and verification of the genuineness of the safety and fitness for purpose of the cosmetic surgery services being advertised.

 

For such assessment and verification to be truly meaningful, the process should not only include the education, qualifications, credential s and continuing professional training of surgeons, physicians and others actually performing the services, but also the adequacy of:

• the facilities within which the assessment of patients takes place and procedures is undertaken
• the nursing and other support staff
• the ethical framework within which services are offered
• the insurance and indemnity arrangements that are in place for supporting patients where things go wrong
• infection prevention and control
• audit
• and much else besides

 

In many parts of the world, independent holistic accreditation of clinics and hospitals – which undertakes to independently assess all of the factors mentioned above - is considered the gold standard.

 

The approach is somewhat analogous to an individual applying to a university to read for a degree, studying, and ultimately being examined – if the candidate does not make the grade, they are not granted a degree. With accreditation, hospitals and clinics can approach and commission recognised schemes such as JCI of the USA, ACHS from Australia, Accreditation Canada and the UK’s QHA Trent, who will then work with them and assess them and, if they prove to be truly safe and fit for purpose, accredit that healthcare service provider(1). On the other hand, if the healthcare provider cannot meet the standards, they are not granted accreditation.

 

If accreditation is granted, that success can be, and usually is, flagged up on the web site and in the promotional literature of the healthcare provider.

 

The independent accreditation system may not be perfect, and there may be other ways of achieving the same ends, but it is most definitely better than nothing. Accordingly it may be in the best interests of any members of the UK public who are contemplating undergoing not just a cosmetic procedure but also any other form of surgery (bariatric, transplantation, orthopaedic etc.) or procedures such as assisted conception/IVF to begin familiarising themselves with the concept, whether they are looking towards the private sector in the UK or overseas as a medical tourist for their healthcare needs.

It may also be of value if the GPs who are advising those patients were to take a look too.

 

1. Green, S.T. and King, H. (2012) 'Independent Health Care Accreditation: Medical Tourism and Other International Aspects', in Risks and Challenges in Medical Tourism: Understanding the global market for health services, Hodges, J.R., Turner L. and Kimball A. (eds), ABC Clio, pp. 230-250.

Competing interests:The author is a Director of QHA Trent UK.

 

--------------------------------------------------------------------------------------------------------------------------

 

Re: Promoting cosmetic surgery

20 November 2012

Susan H Walker, Senior Lecturer in Sexual Health

Anglia Ruskin University, Rivermead Campus, Bishop Hall Lane, Chelmsford, CM1 1SQ

 

The subject of female genital cosmetic surgery is a node at the intersection of a number of deep and complex debates within UK society.

 

The first is the issue of normality. Statistically normality is concerned with acceptable deviations from the mean but normality is more often socially defined in terms of tolerability. The crucial issue then becomes who or what decides what is tolerable. Should society define normality? Should normality be defined by the medical profession and if so should this be a collective decision or an individual one? Should normality be defined by the person who is paying the surgical bill? If this is the case, is cosmetic surgery unacceptable on the NHS but acceptable if paid for privately?

Cosmetic dentistry rarely attracts the same criticism as cosmetic genito-plasty.

This brings into consideration a second issue, which is the way in which the value of a woman is socially defined. Feminist sociology has argued that women are demeaned by visual objectification which defines their worth by their bodily appearance. Objectification can be internalised so that some women define their own worth, according to their appearance, judged on a scale of perceived masculine preference. The cultural trap created by this internalisation is that the appearance of feminine perfection is an artificial creation, aided by air-brushing, make-up, depilation and cosmetic surgery. It is ultimately unobtainable (or at any rate unsustainable). A strange aspect of the cultural subjection of women to value judgements based on unobtainable perfection is that any number of individual men and women may disagree with the judgement, but at a broad cultural level, it remains. Cosmetic genital surgery vividly feeds the myth of female bodily perfection, under the guise of ‘normality’. If the debate about cosmetic surgery focussed around teeth or ears, the underlying issue of cultural misogyny would be less apparent.

 

Finally the tension between autonomy, consent and non-malificence is pertinent for the medical profession. In general if a competent adult fully understands the risks and benefits of a procedure, consents to it, (and is able to pay for it), then respect for his or her autonomy would indicate that the procedure should be carried out. This is not always so straightforward. If an adult makes a request for surgery which seems to be against his or her best interest, we may question whether he or she is competent to consent. An example might be the refusal to operate on someone who requests extreme surgery because of underlying body dysmorphic disorder. We might also question whether the person has come under undue pressure to request the procedure, which is close to the stance the profession takes on requests for FGM, even if requested by the woman herself. Arguably a request for cosmetic genito-plasty could fall into this category, with the undue pressure arising from cultural expectation, interpreted by someone especially vulnerable. The problem with this approach is that it quickly slides into medical paternalism (or maternalism) and a rejection of women’s autonomy and capacity to consent. Any blanket diminution of female autonomy by the medical profession must be treated with the utmost caution.

 

As a woman and a doctor my gut instinct is to reject cosmetic genito-plasty and support measures which lead to it being restricted or banned. Nonetheless there are complex issues involved which deserve to be debated more fully, and which may lead to a greater understanding of the cultural context in which female cosmetic genital surgery occurs.

 

--------------------------------------------------------------------------------------------------------------------------

 

Re: Promoting cosmetic surgery

20 November 2012

Angela J Steele, GP

Sessional GP, Cambridge

 

It really concerns me that we are being driven by social fashion. I have had a mother describe her daughter's genitalia as 'large' and 'abnormal.' I took pains to reassure the child that we have so much variety and that she was normal. Beware the patient who is unhappy about their body image, too often have they had depression or needed help in accepting themselves. Surgery is not going to help that and would be hindering a psychological process.

 

Genitalia surgery is one of the causes of difficult postoperative pains to manage.

 

 www.bmj.com