Through his practice, Dr. Goodman receives many questions from patients and colleagues regarding genital plastics and related topics. Below is a recent question from a Licensed Sexual Therapist in Great Britain and what follows is Dr. Goodman’s response:
I have a question regarding a patient one of my supervisees is seeing. The patient is a 24-year old female with severe body dysmorphia. This is a result of over hearing her brother and some of his friends discussing female genitals as disgusting when she was a teenager. She wants surgery on her labia majora because she thinks they are ‘not right’. My Supervisee is a gynecologist who runs a psychosexual clinic and has looked and said the vulva is absolutely normal, indeed many would choose her vulva if they needed surgery. My supervisee is not happy to refer her for surgery for what is a perfectly normal and indeed ‘tidy’ vulva.
We have thought about working with her body image and are attempting that, but she is convinced that she is disfigured and will not hear opinions to the contrary. She has been shown photos and DVD of other vulvas by my supervisee, which has had little effect. We have used CBT on the obsessive thoughts.
Dr. Goodman’s Response:
It is an issue more complex than one may think at first blush. We all admit that when it comes to body parts there is a very wide variation in “normality.” And I think we can agree that just because it is “normal” does not mean the “wearer” is satisfied or comfortable with the appearance, or that she would not wish to alter the appearance.
Few of us would be very disturbed if our patient wished to enlarge very normal, perhaps “A” or “B” cup-sized breasts to a size she feels she will be more confident in. Same thing applies to someone wanting to alter a quite normal but perhaps slightly hooked nose or have liposuction of a very normal midlife paunch, or to have a smallish, but normal 4-inch erect-sized penis enlarged. It may not be what you or I or the doctor down the hall would do, but we would not deny the person his or her decision to alter the body part and, for the most part, we would not pin the label of “Body Dysmorphia” (BDD) on him/her solely because he/she wished to alter a body part we thought was fine.
Where do we draw the line between a personal and acceptable request for a body alteration, and a DSM diagnosis of Dysmorphia? Who is to say? Who is the arbitrator?
Why do the same persons who might not themselves have “body work” not get terribly upset when their patient invites our opinion of a good plastic surgeon for their augmentation of very normal but small breasts, but have serious issues if their patient with a largish but “normal” sized vulva inquires about labial or vaginal alteration?
Aahhh….here’s where parental and puritanical overtones often come into play. This is a female’s intensely personal, forbidden and sexual area, and modification for reasons of cosmetics, or to gain additional comfort, or to tighten for improved sexual satisfaction is anathema to so many of us.
In a very interesting and revealing study entitled “Ratings of Female Genital Attractiveness Pre- and Post-Genital Cosmetic Surgery Differ by Age and Gender” (submitted for publication), data from Cindy Meston’s group from Austin shows that women with positive genital self-image experience higher levels of sexual functioning and lower levels of sexual distress. It also reveals that female genitalia modified by genital cosmetic surgery are considered more attractive by a large sample (>900), including young women, mid/older age women, and men.
Gynecologists in particular, perhaps because we see so many more vulvae than any other group of individuals, are inured to the variability in vulvar size, know that “it’s all normal,” and wonder why on earth anyone would like to alter (ouch!) such a sensitive and sexual area. In fact, we are not afraid to lecture our patients against affecting any change. But this is not our body, our genitalia, or our sexual sensibility.
Let’s for the moment “objectivise” (sic.) and think of the vulva solely as a “body part”—no different from one’s nose, breasts, belly, phallus, hair (color, style, etc.). I know, it’s hard to do.
In my opinion, the vast majority of women requesting genital alteration do not have Body Dysmorphia. In a small pilot study to be published this fall in the Journal of the American Academy of Cosmetic Surgery, Lori Brotto, Samantha Fashler and I found, based on a widely validated instrument for diagnosing BDD (the YBOCS-BDD), that 48% of women requesting vulvar alteration qualified for “moderate body dysmorphia.” However, six months after their single genital procedure, this percentage had fallen to 7%, indeed slightly lower than the control group.
Did these women truly have Body Dysmorphia based on their desire to alter one specific body part and the resulting high score on the BDD instrument? Or did they only have a significant cosmetic or (even more frequently) functional, concern about a specific body area, carrying with it all the cache that society has given the female genitalia? Perhaps they wanted what so many normal individuals want: instant gratification and a solution to their specific discomfort— not lectures about their normality, or to be told to “live with it,” or to spend time with their therapist discussing how to fit comfortably into the body that they have.
What does all this blather have to do with your supervisee’s patient? In genital plastic/cosmetic surgery, the mantra should be “the right procedure on the right patient for the right reasons.” (Really, this should be the mantra of all plastic and cosmetic surgeons!)
Certainly, Body Dysmorphia or requesting a surgical fix for a psychosexual insult is NOT the right reason. I would suggest the following for this specific individual:
- Ask the supervisee: How have you arrived at your diagnosis of “severe body dysmorphia?”
- Ask your supervisee to re-evaluate the size and configuration of her/his patient’s genitalia (you stated her labia majora). Is there indeed some wrinkling/pouching/protrusion that, while entirely normal, might cause the patient distress about appearance?
- Additionally, you might administer to her a couple of validated instruments for Body Dysmorphia and ask her to fill out each instrument twice—once for her feelings “in general” about herself presently, and the second set of data for herself if her self-perceived vulvar enlargement were totally resolved. Does she still qualify for dysmorphia?
- Additionally, in view of her history of psychosexual trauma from remarks made by a family member, I would require of her several uncovering sessions with a therapist skilled in evaluating and treating Body Dysmorphia.
At first glance, this patient is the proverbial individual that a surgeon should not touch with a ten-foot pole, who has “danger” stamped all over her. Whatever you and your supervisee determine to do, of course, work with her body image! Tell her that you are not rejecting her request out of hand and fully respect her feelings about her body, but that first you would like her to gain more understanding about the possible deep effects of these insensitive comments.
However, if she indeed appears to have an isolated anatomical “splinter,” is not truly dysmorphic, has understood the trauma inflicted by her sibling’s insensitive remark, and still requests removal of that “splinter” that is psychosexually so traumatic to her, we should not reject her request out of hand.
By the way, I congratulate you on the use of CBT, a therapeutic modality that shows increasing promise in enabling individuals to live well in their current skin. But isn’t the use of CBT acknowledging that indeed this is a true and chronic problem for her (the self-perceived “abnormal” labia) that perhaps can be ameliorated by good, intuitive therapy and/or (in the right patient) genital plastics?
For more information on a wide range of topics from menopausal medicine to general health and wellness to the specific topic of labiaplasty in California, visit https://www.drmichaelgoodman.com/.