The Attitude of Physicians Towards Female Genital Cosmetic Surgery

Introduction Female genital cosmetic surgery (FGCS) is a trending topic in the field of gynecology practice. It is defined as any genital procedure that is not medically indicated but is designed to improve the appearance of the genitals. With the increasing demand for FGCS, little is known about the attitudes of physicians, especially gynecologists, toward FGCS. The study objective is to assess physicians' attitudes towards female genital cosmetic surgeries in Jeddah, Saudi Arabia. Methods A cross-sectional survey was done among physicians in Jeddah, Saudi Arabia. Four-sectioned questionnaires were distributed to physicians. All board-certified consultants and registrars of obstetrics and gynecology, plastic, and reconstructive surgery in private/public hospitals were included in the study. Data management was done using the SPSS program version 19 (IBM Corp., Armonk, NY, USA). Results Out of 165 physicians, 40 were practicing physicians (female genital cosmetic surgery) (24.2%) while 125 were non-practicing physicians (75.8%). The age of practicing and non-practicing respondents ranges from 26 to 60 with a mean and standard deviation (42.6±8.6) and 24 to 60 (40.1±8.9) years old. Our study showed that there were females under 18 years old requesting FGCS from all physicians. Results of attitude towards FGCS showed that the majority of non-practicing physicians were more comfortable in providing advice about FGCS (N=53) and very confident about female anatomy (N=65). Non-practicing physicians also knew a lot more about the long and short-term risks of FGCS and discussed them all the time with their patients. In terms of giving advice on labiaplasty, clitoral hood reduction, perineoplasty, hymenoplasty, and G-spot augmentation procedures, practicing physicians were more confident compared to non-practicing physicians. Statistical analysis showed a significant difference between practicing and non-practicing physicians in terms of gender (p=0.001), career level (p=0.005) and type of work (p=0.006), giving advice on labiaplasty (p=0.001), clitoral hood reduction (p=0.001), perineoplasty (p=0.016) and G-spot augmentation (p=0.001), the number of patients per month, patients seeking advice about FGCS, knowledge about short-term and long-term risks and possible risks of FGCS, vaginal examination, offering referral/counseling and confidence in assessing female anatomy (all, p=0.001). Conclusion Physicians in Jeddah, Saudi Arabia showed an overall positive attitude towards FGCS. The study suggests that with enough training and knowledge about FGCS, physicians could exhibit a more positive attitude towards FGCS.


Introduction
Female genital cosmetic surgery (FGCS) nowadays is a trending topic in the field of gynecology practice. It is defined as any genital procedure that is not medically indicated but is designed to improve the appearance of the genitals. It is claimed that, after FGCS, sexual function may be improved [1]. The study objective is to assess physicians' attitudes towards female genital cosmetic surgeries in Jeddah, Saudi Arabia.
According to the American Society for Aesthetic Plastic Surgery, labiaplasty surgery (excluding vaginal rejuvenation) has increased by 23.2% from 2015 to 2016. Around half of the surgeries, 51.1%, were done on middle-aged patients ranging from 19 to 34 years old [3].
This increase in awareness for cosmetic surgery is most likely caused by media, in a research done by Crockett et al. about the influence of plastic surgery they found that four out of five patients revealed that TV shows influenced them to seek a cosmetic procedure, not to mention the high expectations after this kind of surgeries [4][5][6][7].
Trending of these surgeries will stress the physician to learn more about it and definitely the personal opinion of each physician will affect his own concept of a healthy vagina picture and his readiness in performing it [6].
In fact, this topic cannot be ignored by a general physician and especially gynecologist doctors, whether they agree with aesthetic gynecology or not, they will be consistently counseled by women who are dissatisfied or concerned about the appearance of their genitalia.
In order to organize the ethical dilemma in such a matter, the Royal College of Obstetricians and Gynecologists (RCOG), as well as the American College of Obstetricians and Gynecologists (ACOG), have released a paper about ethical considerations in relation to labial surgery. Although there are no controlled studies done to measure the effectiveness and long-term complications of such procedures, the first and most important step is to reassure and demonstrate to women requesting FGCS about the normal variations in female genitalia. Patients should also be screened and counseled about psychological body image problems, such as body image distress, and the treatment options for these problems. Sometimes a referral to a mental health professional or a psychiatrist is needed to fulfill a dull body image satisfaction [8,9].
There have been a number of researches done to assess the motivation behind women seeking FCGC. However, much uncertainty still exists about physician attitude and knowledge toward FGCS. In a study done in Australia to assess general physicians' knowledge and attitude toward FGCS, they found that 75% of general physicians feel like their knowledge is inadequate and their primary sources of information are basically the conferences, other physicians and media, respectively [10].
In the light of such information, the study aimed to assess physicians' attitudes towards female genital cosmetic surgeries in Saudi Arabia and to evaluate patient demand. The current study will contribute to our knowledge by addressing the following issues. First, to assess general gynecologists' attitudes toward FCGS, and how comfortable they feel when being asked to counsel about it or perform it. Second, to assess general gynecologists' knowledge about FGCS, and where they got their knowledge from.

Study design, settings, and participants
The study design, setting and time frame were a cross-sectional survey done in Jeddah, Saudi Arabia from May to June 2019. The survey was distributed among general gynecologists and doctors of other specialties. The inclusion criteria were physicians from private and public hospitals in Jeddah of boardcertified obstetrics and gynecology, plastic and reconstructive surgery registrars, and consultants. The exclusion criteria were other specialties, medical students and hospital administrators. The emails were requested from the HR department of major hospitals in Jeddah, Saudi Arabia, and the questionnaires were sent to the participating doctors. Population size was around 250 physicians in the major hospitals, and when calculating the sample size it turned out to be 165. From the 165 physicians, only 40 were performing female genital cosmetic surgeries and they were labeled "practicing physicians". Participating physicians were those who accepted patients needing cosmetic gynecology, and performed cosmetic surgery. On the other hand were the non-practicing physicians, who do not perform female genital cosmetic surgery but are specialized in other fields of obstetrics and gynecology and accept patients seeking cosmetic gynecology for consultation only.

Data collection methods
Data collection was carried out by a pre-designed questionnaire. The questionnaire included four sections.
The first section was about socio-demographic data (gender, age, specialty, career level, type of work, degree), their background knowledge, and practice. The second part contained questions about FGCS, such as labiaplasty, clitoral hood reduction, perineoplasty, hymenoplasty, orgasm shot, vaginal rejuvenation, vulval liposuction, and G-spot augmentation. It addressed how confident the physicians feel when giving advice about the FGCS procedures, and how comfortable they feel when they give advice. The questionnaire also included how many patients they see every week, month, or year asking for FGCS, and the ages of women asking about it. The third section asked about the long-and short-term risks of FGCS, and if they talk about the possible risks with the patients.

Data analysis
Data analysis was done using IBM SPSS software version 19 (IBM Corp., Armonk, NY, USA). Results were presented as counts and percentages for categorical and nominal values while continuous variables were presented by mean and standard deviations. Statistical analysis was done to determine the difference between the two groups (practicing and non-practicing physicians). P-value <0.05 was considered significant.

Ethical approval
The questionnaire was distributed among physicians after the IRB approval from the research unit of biomedical ethics at King Abdulaziz University, under the IRB approval reference number 618-19. The approval was obtained on October 2, 2019.

Comparison among the participating physicians
As shown in Table 2, practicing physicians were in the range of 26 to 60 years, with a mean age of 42.6±8.6 years. For non-practicing physicians, age ranged from 24 to 60 years with a mean age of 40.1±8.9 years. Regarding their source of information about FGCS, the majority of the 40 practicing physicians got FGCS information from the media and online courses (N=16, 40%), and then from conferences. Moreover, most of the 125 non-practicing physicians were obstetrics and gynecology consultants, and they got their knowledge about FGCS mainly from the conferences they attended (N=77, 61.5%).  A comparison between the demographic characteristics of practicing physicians and the non-practicing ones was done. The results revealed that there was a statistically significant difference in regards to gender (p=0.001), career level (p=0.005), and type of work (p=0.006) with odds ratios of 0.249, 2.731 for gender and career level respectively. A significant difference was also observed between practicing and non-practicing physicians in regards to their source of information. On the other hand, no significant difference in age or specialty was observed.
Attitudes of physicians towards giving advice on different genital procedures is shown in Table 3. It was found that practicing physicians were more confident in giving advice about labiaplasty, clitoral hood reduction, perineoplasty, hymenoplasty, and G-spot augmentation compared to non-practicing physicians.
In terms of counseling about vaginal rejuvenation, both practicing and non-practicing physicians were equally confident. On the other hand, all physicians were not confident in giving advice on the orgasm shot procedures. Statistical analysis showed that there was a significant difference between practicing and nonpracticing physicians in terms of giving advice on labiaplasty (p=0.001), clitoral hood reduction (p=0.001), perineoplasty (p=0.016), and G-spot augmentation (p=0.001) procedures with odd ratios of 0.175, 0.014, 0.423, 0.300, respectively.    Table 5 showed that both practicing (N=23) and non-practicing physicians (N=93) performed vaginal examinations. The majority of the practicing (N=13) and non-practicing physicians (N=62) also offer referral/counseling. Regarding their confidence in assessing the female anatomy, most practicing physicians were confident (N=20), while the majority of the non-practicing obstetrics and gynecology respondents were very confident (N=65). In regards to how much teaching regarding female genital anatomy was received during medical training, the majority of practicing (N=18) and non-practicing physicians (N=71) received a lot. Further analysis showed that there was a significant difference between the attitudes of practicing and non-physicians in terms of vaginal examination, offering referral/counseling, and confidence in assessing female anatomy (all, p=0.001).

Discussion
In this study, physicians in Saudi Arabia showed an overall positive attitude towards FGCS. The majority of the physicians who responded to the survey were females, specializing in obstetrics-gynecology and at the consultant level. Also, most of the respondents were obstetrics and gynecology physicians, who do not practice FGCS, working in private institutions.
Obstetrics and gynecology physicians in this survey were classified into two types: practicing and nonpracticing physicians. This survey was designed to observe the differences between these two groups. Demographic characteristics and source of FGCS information of all physicians were statistically compared. Results showed that only gender, career level, and type of work were statistically different between practicing and non-practicing physicians. In terms of source of information, most of the practicing physicians knew about FGCS from the media and online workshops mainly, conferences and other sources, while the majority of the non-practicing physicians were consultants and got their information from conferences.
Findings showed that practicing physicians were more confident in giving advice on different genital procedures such as labiaplasty, clitoral hood reduction, perineoplasty, hymenoplasty, and G-spot augmentation. The results were similar to the American survey, in which the majority of the physicians accepted labiaplasty requests [10]. However, in a European study, physicians were more conservative in performing or offering such procedures [11]. In a Turkish study, physicians stated that there was a rare medical justification for performing hymenoplasty, G-spot augmentation, and clitoral hood reduction procedures [12]. This implies that culture and geography may affect physicians in performing or referring genital procedures.
With regards to age range, it was observed that the majority of the females seen by practicing physicians were between 20 and 25 years, while it ranged from 30 to 35 years for non-practicing physicians. These results were similar to the American 2016 survey [3]. Demand for FGCS was also observed in teenagers worldwide. This was evident in the study in which females under 18 years old were requesting FGCS. According to different groups and organizations, FGCS should not be conducted in females younger than 18 years old [13,14]. Based on the Royal Australian College of General Practitioners (RACGP) guidelines, FGCS can be done in patients under 18 years old but they should be referred to a physician specializing in adolescent gynecology.
Findings further revealed that physicians were overall confident in giving advice to women asking for FGCS. The majority of practicing physicians were more confident than non-practicing physicians. This positive attitude of practicing physicians may be attributed to their experience in the field and the knowledge from the conference they have attended. Also, both practicing and non-practicing physicians knew equally about the short-term and long-term risk of FGCS, which could be similar to other procedures' risks. They also discussed the possible risks of FGCS to their patients all the time. This kind of practice was in-line with RACGP recommendations in which physicians were required to discuss the FGCS procedures including risks and possible complications to their patients [13].
This study has some potential limitations. It is a cross-sectional study in which selection and socially desirable biases could be possible. Nevertheless, the sample size is large, thus it could give conclusive results and could be potentially used in future studies. Second, there was a noted difference between the number of female physicians and male physicians who responded which could possibly lead to response bias. Finally, the practicing responders were much fewer than the non-practicing.

Conclusions
Gynecologists in Jeddah, Saudi Arabia showed an overall positive attitude towards FGCS. A wide variety of female patients tend to ask their obstetrics and gynecology physicians about FGCS counseling. In our study the majority were obstetrics and gynecology consultants who were not practicing FGCS, however their knowledge enabled them to counsel their patients properly. This was done by informing them about longand short-term consequences, vaginally examining them, and by referring them to the practicing physicians. Practicing and non-practicing physicians are an important source of information, and could play an important role in educating patients. The results showed an overall positive attitude towards FGCS.

Appendices
Attitude of physicians towards female genital cosmetic surgery In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.