How many OB/GYNs does it take to get facts right?

This answer is certainly more than the number of OB/GYNs who sign off on ACOG Committee Opinions, which are the most authoritative guidelines in the field.

According to the ACOG website:

“Committee Opinions are ACOG committee assessments of emerging issues in obstetric and gynecologic practice and are reviewed regularly for accuracy.”

Unfortunately, these opinions consistently contain misinformation.

I previously emailed ACOG regarding Opion 378. I appreciate that they have withdrawn this opinion (with no apology or admission of their mistakes). I also appreciate that the new opinion does not contain the previous problems I identified.

Hwoever, they have replaced it with a new opinion with new harmful misinformation. This should be an embarrassment to OB/GYNs and to the medical field as a whole.

The new opinion is Opinion 795. I will address problems with both. This is generally exhausting.

Problems with Opinion 795

They misrepresent reasons for women seeking surgery. Research on women seeking surgery show that women’s impressions of normal genital aesthetics are primarily influenced by medical sources, as I’ve discussed previously.

I appreciate ACOG drawing attention to the sites that promote female genital cosmetic surgery. Those sites are operated by or approved by surgeons who do female genital cosmetic surgery. What needs to be addressed here is the problem of doctors misinforming patients online in efforts to aggressively market this procedures. Neither ACOG nor any other professional organization will address this clear public health problem.

They cite one study where older participants were more likely to say they considered surgery than younger patients, saying, “This is not surprising given the societial emphasis on reversing the effects of normal aging.” This is a misrepresentation, given no positive correlations between labia size and age have been found. Also, in this study, the older patient group reported more satisfaction with the appearance of their vulvas than the younger patient group! However, though no significant difference was found.

What ACOG fails to mention is that this study also found that sources of information on normal vulvar appearance were predominately medical. What’s most notable about this study is the group that relied less on porn and more on medical sources for information was more likely to consider surgery.

Meanwhile, in studies of labia minora aesthetics, including the one cited in this opinion, no positive correlations between labia size and age have ever been found. Only negative correlations between age and labia minora size have ever been reported. This is because the labia minora decrease in size with decreasing estrogen levels.

The ACOG Committee Opinion 795 also referencees a study of 33 women who sought labia reduction surgery at a London gynecology clinic. In the same paragraph where they imply labia enlargement occurs with aging, they neglect to mention the average age of women in that study was 23!

I very much appreciate the following statement:

In 2013, the Royal College of Obstetricians and Gynaecologists recommended, and the American College of Obstetricians and Gynecologists agrees, that women should be given accurate information about normal variations in genital anatomy and that advertisement of female genital cosmetic surgery should not mislead women on what is considered to be normal or what is possible with surgery.

Unfortunately, there are no consequences for doctors who misinform patients. For example, there should be consequences for OB/GYNs who engage in genital shaming, such as saying that “protruding labia minora are considered unfeminine and embarrassing” or who spread misinformation about causes of labia enlargement. Attributions of labial hypertrophy to aging, androgens, sexual activity, and masturbation are not supported by any evidence and constitute misinformation.

OB/GYNs who engage in this misinformation in order to promote FGCS should be denied membership in ACOG. Better yet, their board certification should be revoked. Unfortunately, professional organizations, including ACOG, have neglected to establish any consequences for this unethical behavior, which precludes informed consent.

ACOG says, “aside from labiaplasty, it is difficult to know how often these procedures are being performed.” This statement is inaccurate because no one knows how many labiaplasties are done. There are actually no numbers for how many labiaplasties are performed by OB/GYNs. ACOG does not keep track. There is also no procedure code for labiaplasty, so again, no one knows how many are done.

The most problematic part of this opinion is the inclusion of a table delineating the goals and risks of each procedure. They demonstrate a gross misunderstanding of basic anatomy involved, as well as the associated risks.

First of all, the clitoral hood includes all the skin externally covering the clitoris, and is not limited to the free, retractable end. Most of the clitoral hood is the skin of the clitoral body. Most of the skin operated on in clitoral hood reductions is the skin of the clitoral body, which can clearly be seen in the literature on clitoral hood reduction techniques.

There is no evidence that clitoral hood reductions improve sexual function. This claim is equivalent to saying circumcision and cosmetic penile shaft skin surgery improves sexual function in men. The logic is that increasing exposure to the clitoral glans will improve sexual function, but the free end of the clitoral hood serves a protective function. Also, again, most of the clitoral hood involved in clitoral hood reduction procedures is clitoral shaft skin. It is the skin overlying the clitoral body.

Because most of the clitoral hood is the shaft skin of the clitoral body, and because the dorsal nerves of the clitoris are just under the skin of the clitoral hood, the biggest risk of clitoral hood reductions is denervation of the clitoris. Chronic clitoral pain can also result. Again, this is because the dorsal nerves of the clitoris, which travel along the clitoral body, under the hood, are put at risk, unless the surgeon stays very superficial and takes special care to avoid them. So, again, it is not “glans damage” or “hypersensitivity” that are the biggest risks. Complete denervation can result, which is functionally equivalent to FGM. OB/GYNs consistently fail to recognize this, despite the clear anatomical reality and despite the experiences of patients like me and others who have contacted me.

Anecdotally, according to experts, the most common complication of labiaplasty is complete amputation of the labia minora. In fact, in the Atlas of Pelvic Anatomy and Gynecologic Surgery, one of the most popular textbooks used in OB/GYN training, a woman is shown having her labia minora completely amputated.

In my 2018 letter to Dr. Christopher Zahn, I said:

“Clitoral neuroanatomy is absent from all OB/GYN literature (except when presented incorrectly by Rachel Pauls). This anatomy is put at risk during clitoral hood reductions. However, because doctors often perform these surgeries without consideration of this anatomy, dorsal nerve injuries occur, resulting in loss of clitoral sensation, even at the hands of otherwise qualified OB/GYN surgeons — even fellows of ACOG. This is very traumatic and 100% preventable.

I would really appreciate it if you would take it under consideration and publish a new committee opinion with proper terminology, no factual errors, guidelines for safe surgery practice, etc. OB/GYNs need to know they should not be performing these surgeries without training in safe techniques (such as to avoid the frequent mutilating outcome of complete amputation) and without in depth knowledge of the surgical anatomy involved.

OB/GYNs need to know the labia minora have both protective and sexual (biomechanically and as sensory receptors) functions. They need to know that the proximal clitoral hood is essentially shaft skin and that the course of the dorsal nerve along the descending segment of the clitoral bodies is superficial enough to be at risk during clitoral hood reductions.”

ACOG Opinion 795 neglects to address any of the above issues.

ACOG says:

“Obstetrician–gynecologists who perform cosmetic procedures should be adequately trained, experienced, and clinically competent to perform the procedure (31). Extensive familiarity with appearance and function, as well as the ability to manage complications, are expected from obstetrician–gynecologists who perform these procedures.”

I appreciate this. However, they do not define what consistutes “adequate trianing.” Last I checked, ACOG refused to offer CME for labiaplasty. What this means is there are still no formalized avenues by which OB/GYNs can get training in these procedures. Training in labiaplasty during OB/GYN residency is rare. Typically it is assumed that training in vulvectomy is sufficient to qualify OB/GYNs to do labiaplasties.

While I appreicate ACOG’s attempt to dispel ideas about what labial hypertrophy, they manage to present data from the normative study with the smallest labia dimensions ever reported. However, they fail in this regard by grossly misinterpreting the study’s results. They say:

“Although labia minora longer than 30–40 mm is currently marketed as hypertrophic, in a study of 657 adolescent and adult females, the mean length of the labia minora (measured from clitoris to the lower margin of the labia) exceeded that estimate in more than 50% of the individuals.”

This is a misinterpretation of the study results and is thus false. Labiaplasty hypertrophy standards refer to the proximal to distal length of the labia minora. But the study cited clearly defined the proximal to distal length as “width,” and clearly reported that women a with a proximal to distal length of 30 mm were over 2 standard deviations above the mean, which means that length was exceeded in less than 2.3%.

This study also only included measurements for the clitoral glans. Adequate retraction of the hood did not likely precede measurement.

Problems with Opininon 378 (sent in email, I will fill in references if this article gets interest)

ACOG’s Committee Opinion 378: Vaginal “Rejuvenation” and Cosmetic Vaginal Procedures fails to adequately address the issues surrounding these surgeries. While it effectively denounces radical, medically preposterous surgeries such as “G-Spot amplification,” it does not communicate any criticism for labiaplasty. Rather, this opinion specifically condones labiaplasty as “treatment for labial hypertrophy” without providing any standard definition for hypertrophy. Thus, it leaves it to the discretion of the individual surgeon to decide when labiaplasty is appropriately indicated. Given that hypertrophy has been liberally applied in the literature even to labia under 2 cm in length, this is not, by any means, a limiting condition. Additionally, this committee opinion contains factual errors that effectively stigmatize large labia, and terminological innaccuracies that promote ignorance and negative genital self-image among women.

Notably Opinion Number 378 states, “Medically indicated surgical procedures may include […] treatment for labial hypertrophy or asymmetrical labial growth secondary to congenital conditions, chronic irritation, or excessive androgenic hormones.” This statement is problematic for a number of reasons. First of all, it allows hypertrophy and asymmetry to be defined at the surgeon’s discretion. An example of what one surgeon considers “treatment” for “asymmetrical hypertrophy” is shown.

Secondly, the ascription of large labia to “congenital conditions” may be somewhat inaccurate as “congenital” is described as “present from birth.” However, labia minora hypertrophy is rarely, if ever, present at birth. There is no record of labia minora hypertrophy in the neonate. Rather, it is well known that labial development generally occurs a puberty due to rising estrogen levels, as previously discussed (pages __) [cite]. Labial hypertrophy is extremely uncommon in preadolescent girls [30][cite other re: precocious puberty]. Preadolescent girls generally have labia minora that do not protrude, as previously discussed (pages)[cite].

Additionally, the attribution of labial hypertrophy to “chronic irritation” is not supported by any evidence. The earliest articles cited in support of this claim are those published by Radman and Kato. Radman’s claim is merely hypothetical and likely derives from Dickinson. In fact, “chronic irritation” appears to have derived from “chronic mechanical irritation,” which appears to have arisen as a medical euphemism for “chronic masturbation,” which has been prejudicially linked to large labia despite lack of evidence, as previously discussed (pages __)[cite]. Kato, meanwhile, reports hypertrophy in 3 myelodysplastic women and concludes that “female myelodysplastic patients are sometimes annoyed by hypertrophy of the labia minora, possibly caused by long-term diaper dermatitis” [113]. However, no effort is made to demonstrate whether hypertrophy is more common in myelodysplastic patients than in normal women. Additionally, the attribution of hypertrophy to dermatitis is merely conjectural. In addition, the authors fail to explain how increased labia minora development might result from irritation. Nevertheless, this article has been cited over 40 times in reference to the cause of labial hypertrophy. Most of the time, however, when irritation is associated with hypertrophy, no reference is cited. This is the case with Opinion 378. Fundamentally, the claim that chronic irritation causes hypertrophy is no more evidence-based than a potential claim that chronic irritation causes atrophy.

Most deplorably, the ACOG Committee Opinion predictably cites “excessive androgenic hormones” as a cause of labia hypertrophy. The implication of this statement is that larger labia minora are masculine. This is the very same misunderstanding that often motivates women seek surgery in the first place. However, as previously discussed, such alleged causality is absurd and contradicts available evidence including basic known principles of endocrinology and sex differentiation (pages _). The claim that excess androgen exposures causes labial enlargement is traceable only to one case study, as previously explained (pages ___) [102]. This study is cited 33 times in explaining indications for labiaplasty. No other evidence is cited anywhere.

RE: Androgens from other chapters:

It is notable that, contrary to what is published in the labiaplasty literature, overexposure to androgens during fetal development causes the labia minora to be underdeveloped or absent altogether, as with congenital adrenal hyperplasia [24][25]. One study has indicated that in addition to adequate estrogen exposure, insulin-like growth factor-1 is also essential for development of the labia minora [26].

The morphology of the labia minora varies throughout a woman’s lifetime due to changing estrogen levels. Specifically, enlargement of the labia minora occurs due to increased “estrogen action” [32]. Thus, increased labia minora development predictably occurs during puberty due to rising estrogen levels [33]. Conversely, the labia minora tend to atrophy with menopause. Studies have verified that post-menopausal women have significantly smaller labia minora than pre-menopausal women [34][35]

Enlargement of the labia minora is frequently attributed to “excessive androgenic hormones” [46][57][58][66][89][100][101]. However, to date, there is no evidence of any causal relationship. Only an invalid causal inference from one case study is ever cited. Meanwhile, all available evidence and known principles of endocrinology and sex differentiation contradict this widely published claim. Asserting that labia minora hypertrophy results from excess androgen exposure, when all known evidence indicates otherwise, constitutes a negligent violation of standards of scientific journalism. In addition to violating standards of academic integrity, such unfounded assertions serve to stigmatize large labia by falsely associating them with masculinizing hormones. Fear of being seen as masculine creates an extremely strong incentive for women seeking surgery.

There is no report of androgen exposure causing hypertrophy except in one case study, where the authors draw a completely invalid causal inference. Specifically, they report, “In a woman with elongated, hypertrophic labia minora resulting from the childhood administration of androgenic medication, plastic surgical repair corrected the problem” [102]. However, all that is known in this case is that the patient took androgenic medication as a child, and that the patient presented with hypertrophic labia minora as an adult. Based on these observations, it cannot be logically concluded that the hypertrophy was a result of the androgenic medication. In this case, it is entirely possible that without the androgenic medication, the labia minora might have been even more hypertrophic[JP1] . This study has been cited frequently as the only “evidence” that androgens cause labia hypertrophy.

It has been shown that “distortions in the persuasive use of citation — bias, amplification, and invention — can be used to establish unfounded scientific claims as fact” [103] In this case, the aforementioned case study has been so often cited that its invalid causal inference has gained unfounded credibility. In fact, it has gained so much credibility that in recent publications, no citation has been deemed necessary, such as in ACOG Opinion 378 [89].

The claim that androgens cause labia enlargement causes hypertrophy is not only without evidence, but also contradicts principles of endocrine physiology and sex differentiation. Physiologically, it is well recognized that labia minora development is estrogen-mediated. Estrogen receptors, involved in the development of female genitalia, are “seen primarily in the stroma of the labia minora and in the periphery of the glans and interprepuce,” with the highest concentration observed in the labia minora [14][18][21][23][104]. Thus, “the appearance of a woman’s labia minora mirrors her level of estradiol” [105]. The labia minora increase in size during puberty due to increased estrogen levels and are representative of sexual maturation and fertility [32]. Conversely, they atrophy during menopause.

While there is no evidence that androgens cause labia minora enlargement, there is sufficient evidence that androgens do cause enlargement of the clitoris and labia majora. This effect has is consistently observed in women with congenital hyperplasia, polycystic ovarian syndrome, or other conditions that cause virilization of female genitals [24][25]. In all cases, it is clear that androgen does not cause enlargement of labia minora. Even if it did, this would not occur without corresponding enlargement of the clitoris. Rather, excess androgen causes fusion of the labia minora, and where levels are insufficient to cause fusion, and may be associated with underdeveloped labia minora, as in CAH. However, given that it appears that hormone replacement therapy in transgender women has no affect on the size of labia minora[JP2] , it is most likely that androgens simply do not play a significant role in determining the size of labia minora

As has been said before, large labia minora are common. It is not large labia that are the problem, but rather the negative meaning associated with them. This negative meaning is perpetuated by misconception that androgens cause labia minora enlargement. The false relationship between androgens and labia minora size is an archetypical example of how popular misconceptions influence medical literature and practice, and vice versa. In this case, the false association between androgens and labia size likely stems from popular misconceptions, specifically a notion of femininity as genital absence, as it is unsupported by actual scientific evidence. Furthermore, perpetuation of these ideas within the medical community further contributes to popular misconceptions. Fundamentally, this is a “chicken or egg” type situation. Regardless of what came first, it is unacceptable for medical literature and clinical knowledge base to be more informed by social bias than medical fact.

Finally, Committee Opinion 378 discusses labiaplasty under the umbrella term of “Cosmetic Vaginal Procedures.” This incorrect use of anatomic terminology is unacceptable in medical literature. Using “vagina” to refer to the vulva, and thus equating vagina with female genitalia in general, is a problem that contributes to ignorance and negative genital self-image among women, as previously discussed.

In summary, the content of this Opinion 378 fails to conform to standards of scientific journalism. First of all, it is inappropriate that the title of this opinion uses incorrect anatomical terminology. While a few female genital cosmetic procedures may actually involve the vagina, most do not. Secondly, while a number of assertions are made, only one cites supporting evidence. Only one reference is provided. Lastly, for an entire committee of Ob-Gyn’s to publish medical fallacies regarding potential causes of labia development is completely unacceptable.

Additionally, while this opinion claims to be a warning against these female genital cosmetic procedures, it explicitly condones labiaplasties for the treatment of hypertrophy or uneven labial growth. In addition, it leaves the diagnosis of such conditions to the discretion of individual practitioners. While citing the potential “need for surgical intervention,” it does not explicitly define what constitutes such need

In summary, ACOG opinion 378 effectively sanctions labiaplasty as treatment for hypertrophy and asymmetry, which can be diagnosed at the surgeon’s discretion. Given that hypertrophy has been ascribed to labia across the range of normal, even to labia under 2 cm, within the OB/GYN literature, this is not a limiting statement. In addition, ACOG manages to echo stigmatizing fallacies regarding large labia without even attempting to establish justification of these claims. In the end, ACOG only effectively denounces procedures that would be implicitly understood as risky and invasive to anyone with reasonable intelligence. However, realistically, none have as much potential to result in impaired sexual sensitivity as either labiaplasty or clitoral hood reductions, as the vulva is far more sensitive than the distal vagina [cite, Schober, Puppo, etc]. Furthermore, none of these other procedures are as common or as frequently published in high impact journals.

Opinion 378 does little to protect patients from unsafe practices. This opinion is primarily a denouncement of marketing practices rather than a warning against unsafe standards of care.

The ACOG committee explains, “It is deceptive to give the impression that vaginal rejuvenation, designer vaginoplasty, revirgination, G-spot amplication or any such procedures are accepted and routine surgical practices” [ACOG]. Note the obvious exclusion of labiaplasty from this list. It cannot be assumed to be implied by “any such procedures” as it is the only other cosmetic procedure mentioned in this article. It is also notable that “vaginal rejuvenation” has been commercially applied to labiaplasty, which is condoned by ACOG, presenting somewhat of a contradiction. Furthermore, the term “vaginal rejuvenation” is only used because so many women do not know the correct term for the labia minora. As previously addressed, Gynecologists do little to educate patients regarding correct terms (p. __).

ACOG Committee Opinion 378 is clearly a reaction to Matlock’s Laser Vaginal Rejuvenation Institute and it’s franchise practices. . While it is certainly clear that Matlock’s practices are unethical, ACOG’s Opinion appears more to be a reaction to his practice of ripping off OB/GYN’s than the effect his actual clinical practice may have on patients. After all, dozens of OB/GYNs have paid for continued education in so called “Vaginal Rejuvenation.” Realistically, ACOG’s Committee opinion appears to be a response to deceptive marketing practices that proportionately affect a greater number of physicians than they do patients. Ironically, given the inclusion of false claims used exclusively to justify labiaplasty procedures and online open access, this opinion can be arguably viewed as “deceptive marketing practice” as well. Furthermore, if this opinion were intended purely to caution patients and practitioners regarding female genital cosmetic surgery, then it would use correct anatomical terms in the title and throughout most of the opinion, instead of using registered marketing terminology: Vaginal Rejuventation®, G-Spot Amplification®, Designer Vaginoplasty® are all registered by the Laser Vaginal Rejuvenation Institute.

As for revirgination, evidence indicates a fully estrogenized hymen allows entry without breaking. Meanwhile, unbroken hymens are not exclusive to virgins, and broken hymens are not exclusive to non-virgins. In one study, 52% of sexually active subjects had non-disrupted, intact hymens. In this study, the mean width of the hymenal rim of girls who denied intercourse was actually larger than that of girls who admitted intercourse, though the difference was not significant [190]. Once again, accurate information would likely avert any reasonable patient’s motivation for surgery.