Historical and Ethical Perspectives on Vulvoplasty.

INTRODUCTION: Surgical and other procedures to alter the shape of the female external genitalia, especially the labia minora, are increasingly popular and controversial worldwide. OBJECTIVES: This article aims to delineate and complicate the medical and moral controversy around these vulvoplasty procedures, by describing how female genital aesthetics, their interpretation, and alteration vary over time, space, and culture. METHODS: The history of the Hottentot Venus is used as a pivot about which to consider current biomedical, anthropological, and ethical literatures regarding female genital appearance and its manipulation. Intersectionality describes how different systems influence each other to affect the agency of certain individuals or groups, and is therefore an ideal analytic method for biopsychosocial concerns of sex and informed consent. RESULTS: The 19th century anatomic study and display of Sarah "Saartjie" Baartman, the Hottentot Venus, defined a European vulvar ideal by demonstrating its opposite. Today, the ideal appearance of the labia minora is variable across cultures and nationalities, and various mechanical and surgical manipulations are sought or imposed upon women to bring their bodies into conformity with these ideals. CONCLUSION: For European audiences, Baartman exemplified a stereotypical association between genital appearance, sexual availability, and accessibility as a biomedical subject. These logical linkages were a by-product of sexist, racist, and colonial ideologies that have since fallen out of favor. However, their genital effects continue to influence bioethical considerations of genitoplasty into the present day. Chubak B. Historical and Ethical Perspectives on Vulvoplasty. Sex Med Rev 2020;8:542-547.

Might Reinfibulation be Medically Plausible in Carefully Screened Cases?

In light of the relational account of autonomy and the modern (holistic and phenomenological) account of health, this paper examines ethical justifications for ̳consensual' reinfibulation. Significant and constant discomfort in the body following deinfibulation might make a case for reinfibulation (considered as medical treatment in the traditional sense of the term). In any other case, the following requirements should be met for reinfibulation to be considered medically plausible: a) strong evidence that reinfibulation could help effectively improve woman's relational well-being, b) insignificant complications are expected, c) congruence between first-order and second-order autonomy or -in the context of political liberalism- strong second-order autonomy, d) an -open door‖ for the woman to exit an oppressive context, e) rigorous scrutiny of woman's psychology, and f) woman's practical wisdom to organize her identity-related values, find a balance between her extreme emotions and realize her own goal of meaningful life in accordance with her own conception of the good. Conclusively, in carefully screened cases and individually judged requests for reinfibulation, it should not be ruled out that, after having been conducted a multi-disciplinary in- depth investigation at social, psychological and medical level may be met conditions that make a case for reinfibulation.

Surgeon Volume in Benign Gynecologic Surgery: Review of Outcomes, Impact on Training, and Ethical Contexts.

It is becoming increasingly clear that surgeon volume affects surgical outcomes. High-volume surgeons demonstrate reduced perioperative complications, shorter operative times, and reduced blood loss during multiple modalities of benign gynecologic surgery. Furthermore, high-volume surgeons consistently demonstrate higher rates of minimally invasive approaches, low rates of conversion to laparotomy, and lower per-procedure case costs. It is suggested that surgeons who have completed postresidency training have improved surgical outcomes, although these data are limited. Surgical exposure in obstetrics and gynecology residency is varied and does not consistently meet demonstrated surgical learning curves. Deficiencies in residency surgical training may be related to the volume-outcome relationship. We suggest reforming residency surgical training and tracking postresidency practice to provide optimal surgical care. Additionally, surgeons may have an ethical obligation to inform patients of their surgical volume and outcomes, with options for referrals if needed.

"I Don't See That as a Medical Problem": Clinicians' Attitudes and Responses to Requests for Cosmetic Genital Surgery by Adolescents.

Labiaplasty is a form of genital surgery to reduce large or protruding labia minora. Internationally, the rates of this surgery among women and girls is increasing and is viewed as a worrying trend. Currently, the main clinical strategy is to reassure adolescents that they are normal by talking about the variation of labia size and appearance and showing pictures demonstrating the wide range of normal female genital appearance. For the most part, policy documents recommend against labiaplasty in adolescents, claiming that it is medically non-essential surgery. In this paper, we contrast findings from our interviews with clinicians with the existing literature and policy documents and we point out areas needing more thought. This is qualitative research using semi-structured interviews. We set out to find out on what basis clinicians decide how to treat or manage adolescent patients seeking labiaplasty. We interviewed clinicians who are likely to be approached by under-eighteens requesting labiaplasty. We use interpretive content analysis and thematic analysis to analyse the data. Our findings support the emphasis on education and reassurance as the first step for all patients, but other issues that have not figured previously in the literature that would alter clinical strategies for managing patients emerge as well. Key findings are that reassurance does not always work and that the distinction between functional and appearance concerns is not a solid foundation in itself for deciding whether surgery is ethically appropriate. We conclude that the distinction between functional and appearance concerns is not ethically relevant. It is open to different interpretations and is not regarded by all clinicians as the definitive factor in relation to surgery. The focus of clinicians should be on relieving distress whatever the cause. Appearance reasons may sometimes justify surgery but, also, functional reasons may sometimes not be sufficient justification for surgery.

J. Marion Sims and the Vesicovaginal Fistula: Historical Understanding, Medical Ethics, and Modern Political Sensibilities.

OBJECTIVES: To review the historical background surrounding the early work of Dr. J. Marion Sims, who developed the first consistently successful surgical technique for the repair of obstetric vesicovaginal fistulas by operating on a group of young, enslaved, African American women who had this condition between 1846 and 1849. METHODS: Review of primary source documents on Sims and his operations, early 19th century clinical literature on the treatment of vesicovaginal fistula, the introduction of ether and chloroform anesthesia into surgical practice, and the literature on the early 19th century medical ethics pertaining to surgical innovation. The goals are to understand Sims's operations within the clinical context of the 1840s and to avoid the problems of "presentism," in which beliefs, attitudes, and practices of the 21st century are anachronistically projected backward into the early 19th century. The object is to judge Sims within the context of his time, not to hold him accountable to standards of practice which were not developed until a century after his death. RESULTS: A narrative of what Sims did is presented within the context of the therapeutic options available to those with fistula in the early 19th century. CONCLUSIONS: Review of the available material demonstrates that Sims' first fistula operations were legal, that they were carried out with express therapeutic intent for the purpose of repairing these women's injuries, that they conformed to the ethical requirements of his time, and that they were performed with the patients' knowledge, cooperation, assent, and assistance.

ACOG Committee Opinion No. 759 Summary: Ethical Considerations for Performing Gynecologic Surgery in Low-Resource Settings Abroad.

Global surgical care programs present obstetrician-gynecologists with important opportunities to address disparities in women's health and health care worldwide. However, these programs also present a unique set of practical and ethical challenges. Obstetrician-gynecologists are encouraged to participate in surgical care efforts abroad while taking the necessary steps to ensure that their patients can make informed decisions and receive benefit from and are not harmed by their surgical care. In this document, the Committee on Ethics highlights some of the ethical issues that may arise when providing surgical care in low-resource settings to help guide obstetrician-gynecologists in providing the best care possible. This document has been updated to broaden its focus beyond the example of obstetric fistulae, to address issues pertinent to medical trainees, and to include new information to guide physicians' return home from participation in global surgical care programs. Although clinical research has an important role in the surgical care of patients in global settings, a complete discussion of the conduct of ethical research in global settings is beyond the scope of this document.

ACOG Committee Opinion No. 759: Ethical Considerations for Performing Gynecologic Surgery in Low-Resource Settings Abroad.

Global surgical care programs present obstetrician-gynecologists with important opportunities to address disparities in women's health and health care worldwide. However, these programs also present a unique set of practical and ethical challenges. Obstetrician-gynecologists are encouraged to participate in surgical care efforts abroad while taking the necessary steps to ensure that their patients can make informed decisions and receive benefit from and are not harmed by their surgical care. In this document, the Committee on Ethics highlights some of the ethical issues that may arise when providing surgical care in low-resource settings to help guide obstetrician-gynecologists in providing the best care possible. This document has been updated to broaden its focus beyond the example of obstetric fistulae, to address issues pertinent to medical trainees, and to include new information to guide physicians' return home from participation in global surgical care programs. Although clinical research has an important role in the surgical care of patients in global settings, a complete discussion of the conduct of ethical research in global settings is beyond the scope of this document.

Hymenoplasty and Muslim Patients: Islamic Ethico-Legal Perspectives.

BACKGROUND: Hymenoplasty, commonly called "revirginization," is a controversial procedure that pushes the scope of medical practice to satisfy cultural and/or religious "needs." AIM: To outline the sociocultural contexts underlying patient requests for hymenoplasty and present Islamic juridical views on the moral status of hymenoplasty for Muslim patients. METHODS: Narrative review of the extant bioethics literature and leading Islamic ethico-legal verdicts. OUTCOMES: We identified "Western" and Islamic bioethical debates on hymenoplasty and the critical concepts that underpin ethical justifications for and against the procedure. RESULTS: From a Western-ethics perspective, the life-saving potential of the procedure is weighed against the role of the surgeon in directly assisting in a deception and in indirectly promoting cultural practices of sexual inequality. From an Islamic bioethical vantage point, jurists offer two opinions. The first is that the surgery is always impermissible. The second is that although the surgery is generally impermissible, it can become licit when the risks of not having postcoital bleeding harm are sufficiently great. CLINICAL IMPLICATIONS: Patient requests for hymenoplasty should be approached by surgeons with a willingness to understand patients' social contexts and reasons for pursuing the procedure and are ethically justified by leading Islamic jurists in particular circumstances. STRENGTHS AND LIMITATIONS: This article presents emic and etic perspectives on hymenoplasty in Muslim patients, although our review of the Islamic bioethical stances might have missed some juridical opinions and important considerations. Further, Muslims, even devout ones, might not be beholden to Islamic juridical views on medical procedures and thus physicians should not make assumptions about the rationale for, and ethical views of, patients seeking hymenoplasty. CONCLUSION: This article provides critical insight into how Muslim patients, and Islamic jurists, evaluate the moral contexts of hymenoplasty. Bawany MH, Padela AI. Hymenoplasty and Muslim Patients: Islamic Ethico-Legal Perspectives. J Sex Med 2017;14:1003-1010.

ACOG Scientific Integrity Deficiency in Recommendation for the Practice of Cosmetic-Plastic Gynecology Misleads Other Gynecological Societies, Inhibits Clinical Education and Research, and Jeopardizes Women's Health.

OBJECTIVE: To analyze scientific integrity (scientific quality, objectivity, credibility, and appropriate transparency) of recommendations of gynecologic societies for female genital cosmetic surgery (FGCS) and their references, which were used to support these recommendations. STUDY DESIGN: The scientific integrity of recommendations for FGCS published by gynecologic societies has never been subjected to scientific scrutiny. Electronic and manual searches for FGCS literature published in the English language were conducted and analyzed for the period of the recommendations. A methodological scientific review of recommendations of gynecologic societies for FGCS was performed. The scientific quality, objectivity, credibility, and appropriate transparency within recommendations of gynecologic societies for FGCS were evaluated. RESULTS: Overt prejudice and residual bias were found in the recommendations of gynecologic societies relating to FGCS. Scientific imprecise interpretations and omissions of references called current recommendations into questions. CONCLUSION: Recommendations issued by gynecologic societies relating to FGCS did not meet the scientific integrity norms for scientific quality, objectivity, credibility, and appropriate transparency.

Cosmetic Labiaplasty in an Adolescent Population.

Labiaplasty (defined as the surgical reduction of the labia minora) is the most common procedure under the umbrella of female genital cosmetic surgery with the prevalence increasing over the past 10-15 years. However, the concept of labial hypertrophy holds an arbitrary definition, with no research into labial size undertaken within the pediatric and adolescent populations. Under the tenets of medical ethics there is acceptance of the need to avoid harm and so, for reasons to be outlined, performance of labiaplasty in children and adolescents should be avoided. This Mini-Review does not extend to pathological conditions that affect the labia minora.

The Value of Virginity.

Hymen reconstruction surgery is a simple procedure to repair a woman's hymen, requested by women who, for religious and cultural reasons, believe they must appear to have an intact hymen on their wedding night. Debates surrounding possible ethical justification for the procedure are complex and heated. These articles from the Harvard Ethics Consortium present and explore the case of a young woman who asked a young female physician on call for a referral for the procedure.

When Bleeding Is Vital: Surgically Ensuring the "Virginal" State.

A young woman called me to ask for a referral to a physician who provided hymen reconstruction surgery. She had had premarital intercourse and came from a cultural background in which it was very important to "prove virginity" on the wedding night. This article deals with my internal struggle whether or not to provide the referral. I felt that providing it would have made me complicit in supporting gender inequality, as men are not required to "prove virginity" to get married. At the same time, I was concerned about the repercussions of not being able to "prove virginity" would have on the caller. I had no explicit guidance on what to do in such a situation--it was not covered by the professional responsibilities I had as a research assistant.

A Hymen Epiphany.

The hymen is a structure of the female genitalia that is poorly understood even by many medical professionals. Despite the significant anatomical variation in the hymen and no guarantee that rupture or bleeding will occur at first coitus, it has come to hold major cultural significance around the world as a perceived biological indicator of virginity. The persistence of such myths around the hymen causes real harm, including the increase in so-called revirgination surgical procedures.

On Hymenoplasty.

Some traditional cultural practices assure expected wedding night bleeding, to help preserve the honor of all parties.

Hymen Restoration: "My" Discomfort, "Their" Culture, and Women's Missing Voice.

The discourse among medical and scientific communities on hymen restoration is largely missing the voice of women affected. This article calls for a more nuanced reflection on women's real life experiences and the complexities inherent in the negotiation process about the surgery going beyond "ideologies" and the extremes of rape and threats to life. By taking the clinical experience of a woman who requests restoration surgery before her arranged marriage, this article illuminates the grey zone beyond these extremes and explores an individual woman's options for making her own choices.

The Value of Virginity and the Value of the Law: Accommodating Multiculturalism.

Hymenoplasty is a minor surgical procedure requested by women who, for cultural or religious reasons, need to remain a virgin until marriage. In this article I assess whether the public healthcare system of a liberal state should provide it as part of a policy of multicultural accommodation. I conclude that, in order to remain loyal to certain ethical ideals linked to the rule of law, liberal states should give access to hymenoplasty only to women for whom premarital virginity is a precondition for their flourishing within their community and who say they are victims of sexual assault.

Is Hymenoplasty Anti-Feminist?

Hymenoplasty is a practice that must be judged from within its cultural confines and not only from outside. It offers women who have grown up within the sexual norms of a Western society the chance to return to their parental culture, with its female-specific virginity expectations. Hymenoplasty allows women to be sexually active prior to marriage, which equalizes the discrepancy between gender norms on premarital sexual experience. Caution is needed when comparing hymenoplasty to female genital mutilation. However, comparing hymenoplasty to other cosmetic genital modification procedures raises unique ethical, social, and medical quandaries that highlight the importance of patient's autonomy.