Clinical Ethics >
Volume 3, Number 1 >
Pp. 37-41
Papers |
* Dumfries and Galloway Royal Infirmary, Dumfries, UK
Department of Obstetrics and Gynaecology, Ysbyty Gwynedd, UK
School of Population, Community and Behavioural Sciences, University of Liverpool, UK
E-mail: Frith{at}liverpool.ac.uk
Labioplasty is a surgical procedure performed to alter the size and shape of the labia minora. The reasons for women requesting this procedure remain largely unknown and recently girls and young women under the age of 18 years have been requesting this type of surgery. This paper examines the ethical acceptability of performing this procedure on under 18s. We will first discuss whether labioplasty can be considered to be a therapeutic technique. We will claim that, while it is difficult to offer a definitive definition of what constitutes a therapeutic technique, in our view labioplasty cannot be considered as such. This conclusion has relevance for the ethical acceptability of the procedure, its legal status in regard to the Female Genital Mutilation Act and the debates over who can give consent for it. It will be concluded that in our current state of knowledge, the benefits of labioplasty are far from clear, whereas the harms are demonstrable and therefore this procedure should not be offered to those aged under 18 years.
 | Introduction |
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 Top Introduction Is labioplasty a therapeutic...The legal implicationsConclusionsReferences |
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Recently, girls and young women under the age of 18 have been requesting this type of surgery within the NHS. If there is a little understanding and controversy surrounding why adult women seek this surgery, the picture is even less clear with the under 18s. There is a paucity of data on the numbers of children involved and therefore it is impossible to estimate the extent of the problem nationally. A recent study found that in one hospital, 17 women had undergone the procedure between 2004–2006 and this included one girl aged under 18 years.2
Based on the unpublished observation within the practice of one of the authors (CC), there seem to be two distinct groups of under 18s that request surgery. The younger age group (usually between the ages of 9 and 13 years) have often been unconcerned about their appearance. Generally, there are two main reasons why these children had been referred: the child complains of symptoms, such as rubbing and chaffing and/or their mother is convinced they are abnormal. There is an uncertainty about the pubertal changes to the vulva and the mother requests ‘normalization’ before it is ‘too late’ and the child is psychologically scarred. In a study on the reasons why women undergo labial reduction surgery, the child informant said, ‘I told my mum and she said it wasn't normal, so ... because I didn't know if it was normal or not’.2 The mother has generally done little to reassure the child that she looks normal or considered practical measures to reduce symptoms. It has been argued that when adult women are referred by general practitioners to a gynaecologist for reassurance that they are normal, women perceive this referral as a confirmation of the fact that they are not normal and do require surgery.1 If this is the case, then the mother's lack of reassurance is likely to compound the situation further in children. The older age group (usually aged 14–17 years) have often discussed their concerns with their mother, but have generally not asked their mother to inspect their appearance. This age group are often concerned about their appearance and fear that a sexual partner will find them abnormal and repulsive.
Little is know about why doctors are undertaking this procedure. It could be argued that they are responding to requests that have been given legitimacy because they are offered in the private sector and publicized in the media. But, this is only speculation. There is also no specific professional guidance on this issue to aid doctors in their decision-making.
This article will argue that labioplasty procedures performed on under 18s are unethical and genital surgery should never be offered by any clinician, except perhaps in very specific clinical circumstances such as congenital anomaly.6 Carrying out this procedure on children produces a ‘yuk factor’ – an immediate emotional reaction that this type of operation is unethical. However, as Mary Midgley points out, a strong emotional reaction against something does not necessarily mean that such a reaction is irrational and what she calls ‘solid thoughts’ may underlie this type of response.7 We argue that there are sound arguments why such a procedure should not be undertaken. We will first examine whether labioplasty can be considered to be a therapeutic technique. We will claim that, while it is difficult to offer a clear-cut definition of what constitutes a therapeutic technique, in our view labioplasty cannot be considered as such. This conclusion has relevance for both the ethical acceptability of the procedure and its legal status in regard to the Female Genital Mutilation Act. Finally, we will consider how our conclusion, that labioplasty in under 18s is not a therapeutic procedure, impacts on the legality of consent for this procedure in this age group.
| Is labioplasty a therapeutic technique? |
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TopIntroductionIs labioplasty a therapeutic...The legal implicationsConclusionsReferences |
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The normal variation in adult female external genitalia has only recently been described in medical literature5 and even this is limited as it was restricted to 50, mainly Caucasian, women. Despite these limitations, this data is extremely useful as it demonstrates that the ‘ideal appearance’ that women request (whereby the labia minora are reduced so as not to protrude beyond the labia majora, thus rendering the appearance of the vulva to appear more childlike) is far from the norm. There is nothing abnormal about the labia minora protruding beyond the labia majora and there is some evidence that this so-called ‘ideal’ stems from highly selective images that are seen in pornography.1,3,5 A content analysis of pictures in women's magazines found that they presented the invisibility of women's genitalia as a social norm.9 Therefore, this childlike ‘ideal’ appearance is something against which women judge themselves as abnormal.10
The development of external genitalia, particularly the labia minora, during puberty has never been charted. The main description of pubertal development of the female was in an important paper11 describing, in detail, stages of breast and pubic hair development in puberty based on an inspection of girls in a British orphanage, published almost 40 years ago. However, it is clear that the external genitalia of prepubertal girls look very different to the adult woman. The labia minora grow considerably in puberty and often asymmetrically, with one side developing often two years after the initial side (again observed in the practice of CC). Asymmetry is often considered to be aesthetically unpleasing and requests for surgery to ‘even things up’ are not uncommon. The pressure to perform surgery is immense and the authors are aware of one case where the clinician bowed to this pressure and reduced the labium on the developed side to match that of the undeveloped side. Unfortunately, the undeveloped side later grew and further surgery then had to be performed to produce symmetry.
When a child under the age of 18 years presents requesting a labioplasty procedure, there is no clear measure for determining, if they are developing properly or if there is a pathology present. Therefore, it is far from clear whether performing labioplasty has any therapeutic benefit. If there is no clear pathology then there is no clear therapy for it. It would be useful if an evidential base could be begun that would chart this developmental process. Such evidence would enable general practitioners, gynaecologists and plastic surgeons to be better informed and help them to educate mothers and girls about the range of variation that characterizes ‘normal’ genitalia. There would be obvious ethical difficulties in carrying out such research, but nevertheless the need for it is clear. However, at our current state of knowledge it is uncertain if labioplasty is a therapeutic technique.
Evidence and the benefits of labioplasty
Several surgical techniques for labioplasty are described in the literature and these are essentially limited to small case series, with generally short-term follow-up, measuring outcomes in ways that have little scientific rigor. Trimming,12 wedge excision,13,14 ‘z’ plasty,15 ‘w-shaped’ resection16 and central depithelialization17 techniques have been described. None have been compared with each other, or indeed to non-surgical approaches, and none subjected to randomized trials with a ‘no treatment group’ to act as a control. Hence, there is no scientific evidence of the benefits of performing labioplasty, as judged by evidence-based medicine criteria, in any age group.
Feminizing genitoplasty is frequently performed in young girls born with medical conditions such as intersex, in order to prevent psychological harm later in life as a result of having external genitalia that have a male appearance.6 There is no evidence to suggest that surgery achieves the aim of reducing psychological harm when there is a clear abnormality in a child.6,13 Therefore, it could be argued that labioplasty is highly unlikely to be of any therapeutic benefit to a child or young woman who has no abnormality.
Although the benefits of labioplasty cannot be demonstrated, the potentially harmful effects are known. The risk of dissatisfaction with appearance after surgery,2 short- and long-term pain, bruising, bleeding and infection are potential risks. The labia are particularly sensitive and carry many nerve fibres and blood vessels, which contribute to erotic sensation and pleasure and hence sexual satisfaction. The disruption of these nerves and blood vessels can lead to long-term sexual dissatisfaction3,5 which can be irreversible. This can be challenging to explain to a child, who has little comprehension of herself as a sexual being later in life. The mother may be more focused on the child's apparent complaint of the labia rubbing on underwear, or may see her child as so abnormal (even though it is likely she is not) that this outweighs the risk of future sexual dissatisfaction. The older child may be mature enough to understand this to some extent, but again may consider herself to be so abnormal in appearance that the risk is worth taking.
For these reasons, we argue that labioplasty cannot be considered to be a therapeutic technique. We will now consider the legal implications of the debate over the therapeutic nature of labioplasty in regard to the Female Genital Mutilation Act and consent procedures.
| The legal implications |
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The performance of labioplasty has been compared with the practice of female circumcision1,3 (generally seen in populations from sub-Saharan Africa) particularly when young girls are being operated on.14,17,18 Female circumcision (termed ‘female genital mutilation’) is defined as, ‘all procedures involving partial or total removal of the external genitalia or other injury to the female genital organs whether for ritual, cultural or other non-therapeutic reasons’19 and is illegal in the UK.20 The World Health Organization and UNICEF are committed to the eradication of this practice worldwide due to the physical and psychological long-term harm it causes young girls. Clearly, the comparison between labioplasty and female circumcision is not an exact one. There are a plethora of complex and cultural social factors that underpin female circumcision that are not present in the case of labioplasty. However, labioplasty does involve the partial removal of the external genitalia. Therefore, the key question becomes, ‘what are the reasons for performing labioplasties on under 18s?’
We have argued that labioplasty is a non-therapeutic procedure. The acquisition of external genitalia to conform to a preconceived ‘ideal’ is hardly therapeutic, if that is the underlying reason.10 Hence, it could be argued that this surgery is being performed for cultural reasons and is therefore illegal under the 2003 Female Genital Mutilation Act.20 It must be recognized, however, that whether labioplasty for under 18s falls within the remit of the legislation has not been tested in the courts. Those requesting the procedure do so on the grounds of their physical and mental health and therefore it is hard to totally disregard their intentions. Although, in our view, a persuasive case can be made for saying the procedure is not a therapeutic one, as there is no clear definition of a ‘therapeutic’ technique, other medical experts and the courts could, of course, take a different view.
Capacity and consent for under 18s
This paper is specifically discussing the ethical acceptability of labioplasty for under 18s and therefore it is necessary to consider the legal status of this groups consent to medical treatment.
The law on consent divides children into two groups: those aged under 16 years and those aged between 16 and 17 years. The Family Law Reform Act 1969 lowered the age of majority from 21 years to 18 years and provided at s 8(1) that the consent of a minor who has attained the age of 16 should be as effective as an adult's. Such a provision for this group of children (between 16 and 17 years) has caused considerable debate. If they can consent as if they have reached the age of majority then why have a special provision for them? The answer to this is seen in case law. In Re P, a 16-year-old boy refused a blood transfusion because he was a Jehovah's Witness. The court ruled in favour of allowing the hospital to administer a blood transfusion if the need arose.21 In Re W, a girl with anorexia nervosa, the court over-ruled her refusal of life-saving treatment.22 From both cases, it was clear that children aged between 16–18 years could consent to treatment, but could not withhold consent if their parents or guardians approved the treatment and, in these particular cases, the treatment was potentially lifesaving.
The Gillick case empowered younger children below the age of 16 years to consent to treatment without their parents' approval. In this case, Lord Scarman states: ‘A minor's capacity to make his or her own decision depends on the minor having sufficient understanding and intelligence to make the decision and is not to be determined by reference to any judicially fixed age limit’.23 This is different from adults (and arguably the 16 to 18-year age group) in that the child has to prove that they are capable of understanding the procedure offered and are able to weigh the benefits and risks associated with it. The same stipulation that the child cannot veto a life-saving treatment, thought to be necessary, holds as in the cases mentioned above. Thus, those aged under 18 years can, in many circumstances, replicate the consent giving processes of adults.
There has also been a move to extend an autonomy-based model of health care to children. The Government is attempting to give children a more central role in health-care policy-making.24 A recent article25 examining children's perceptions of their chronic illness, reported that children are capable of high levels of understanding about their condition and therefore are able to be more responsible for their own care in partnership with health-care professionals (although some prefer to defer to their parents). Thus, the debate over labioplasty for under 18s takes place in a context where a minor's autonomy is being given increasing weight.
It could be questioned whether it is ethical to perform labioplasty on adult women, as there is no more evidence that it performs a therapeutic function for them than for those under 18s. However, there is a well-worn precedence that we allow adults to make such decisions for themselves. For example, adults are able to consent to procedures, such as cosmetic surgery, that carry a reasonably high level of risk, are purely elective and are of no clear demonstrable therapeutic benefit. However, it is questionable whether those aged under 18 years should be allowed to make such decisions themselves. Despite the greater focus on children's autonomy, there are important differences between what a minor under the age of 18 years can consent to and what an adult can consent to. As noted above, those aged under 18 cannot refuse life-saving treatment in the same way an adult can, so there is a recognition that children are less able than adults to make important decisions that could affect their health for the rest of their lives. For example, the 1969 Tattooing of Minors Act makes it illegal to have a tattoo under the age of 18 years.26 Thus, this legislation embodies the view that there are some procedures that should only be carried out on adults. Newer procedures such as cosmetic surgery and body piercings have not yet been the subject of age-related prohibitions. For instance, it is not illegal in the UK to perform cosmetic surgery such as breast augmentation on under 18s. However, internationally some countries have such prohibitions27 and in the UK one private cosmetic surgery clinic has set the minimum age for treatment at 18 years.28
Adolescence is a state during which both sexual, physical and emotional maturity is developing and physical changes tend to occur before emotional maturation. Teenagers are highly conscious of their physical appearance and undergo considerable changes in external appearance from child to woman very quickly and they need time to adjust psychologically to these changes. We would argue that due to the difference in the legality of consent for those under 18 and adults, labioplasty should only be performed once the girl has reached 18 years. Once someone has reached the age of 18 years they are presumed to have matured adequately to at least have the capacity for more reasoned reflection on whether the procedure is appropriate for them. Due to these reasons, performing an irreversible procedure before this adjustment has occurred is unethical.
If the girls are not able to give consent for labioplasty themselves it might be argued that their parents could give consent on their behalf. However, as an example of the potential problems of parents choosing these types of procedures for their children, it has been found that in cases where feminizing genitoplasty has been performed for congenital anomaly in childhood these patients, when adult, have felt damaged by procedures their parents consented to on their behalf.6,29 It can be conjectured that it is likely that when there is no abnormality present the same could be true if labioplasty is performed. Parents cannot consent to any procedure that is not in the child's best interests and this turns the debate back on to the discussion of whether labioplasty can be considered to be a therapeutic procedure. As argued above, in our view, the procedure is not therapeutic and therefore not in any child's best interests. Also, doctors cannot be forced to do any procedure they do not think is in their patient's (either adult or child) best interest.30 Hence, we believe it is unethical for parents to give consent for altering what are arguably the normal labia of children and for doctors to perform the surgery.
It is not certain what or who is being treated in these circumstances: the mother; the child not coming to terms with pubertal body changes; the child's or mother's poor self-esteem; or the desire for all women to conform to a pornographic ‘ideal’. Further, it has been argued that often the problem that needs to be addressed is purely a psychological one,1 and research into whether psychological interventions should be the first port of call in these circumstances is urgently required.2 Therefore, the performance of an elective surgical procedure on a minor with no evidence base, that has potentially very harmful long-term adverse effects, cannot be justified.
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To ensure that this problem is fully understood, treatment for adult women should not solely be performed in the private sector. If these women are turned away from the NHS, the extent of this problem will never be understood. Research is unlikely to be undertaken within the private sector where the motivation for clinicians to perform these procedures is purely financial. The benefits and risks of labioplasty must acquire an evidence base and if it proves to be beneficial in adults, the potential benefits in children could then be researched. However, in our current state of knowledge, we argue that the benefits of labioplasty are far from clear, whereas the harms are demonstrable, and therefore this should not be a procedure offered to under 18s.
| Footnotes |
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Chris Clark was brought up and educated in North Wales. She graduated from Liverpool University Medical School in 1991 and trained as an Obstetrician and Gynaecologist in Liverpool and later North Wales. While training, she undertook an MSc in Medical Science, which incorporated two modules in Health Care Ethics, which sparked an interest in this type of writing. She was appointed as a Consultant Obstetrician and Gynaecologist at North West Wales NHS Trust in 2004. Her special interests include Paediatric and Adolescent Gynaecology, Gynaecological and Early Pregnancy Ultrasound, and Emergency Gynaecology. She also holds the post of Honorary Consultant in Paediatric and Adolescent Gynaecology at Alder Hey Children's Hospital, Liverpool, undertaking regular clinics there and is a member of the North West Wales Research Ethics Committee.
Lucy Frith is a Lecturer in Health Care Ethics in the School of Population, Behavioural and Community Sciences in the Faculty of Medicine at the University of Liverpool. She has edited books on the ethics of midwifery and general practice and written on topics such as reproductive ethics, evidence-based medicine and HIV testing. Her current research interests are methods in bioethics with a particular focus on the use of empirical methods for approaching ethical issues.
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