Merle Spriggs & Lynn Gillam. 2016. Bioethics; 30(9): 706-713. This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278 BODY DYSMORPHIC DISORDER: CONTRAINDICATION OR ETHICAL JUSTIFICATION FOR FEMALE GENITAL COSMETIC SURGERY IN ADOLESCENTS ABSTRACT: Is Female Genital Cosmetic Surgery for an adolescent with Body Dysmorphic Disorder ever ethically justified? Cosmetic genital surgery (specifically labioplasty) for adolescent girls is one of the most ethically controversial forms of cosmetic surgery and Body Dysmorphic Disorder is typically seen as a contraindication for cosmetic surgery. Two key ethical concerns are (1) that Body Dysmorphic Disorder undermines whatever capacity for autonomy the adolescent has; and (2) even if there is valid parental consent, the presence of Body Dysmorphic Disorder means that cosmetic surgery will fail in its aims. In this paper, we challenge, in an evidence-based way, the standard view that Body Dysmorphic Disorder is a contraindication for genital cosmetic surgery in adolescents. Our argument gathers together and unifies a substantial amount of disparate research in the context of an ethical argument. We focus on empirical questions about benefit and harm, because these are ethically significant. Answers to these questions affect the answer to the ethical question. We question the claim that there would be no benefit from surgery in this situation, and we consider possible harms that might be done if treatment is refused. For an adolescent with Body Dysmorphic Disorder, the most important thing may be to avoid harm. We find ourselves arguing for the ethical justifiability of cosmetic labioplasty for an adolescent with Body Dysmorphic Disorder, even though we recognize that it is a counter intuitive position. We explain how we reached our conclusion.
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
BODY DYSMORPHIC DISORDER: CONTRAINDICATION OR ETHICAL JUSTIFICATION FOR FEMALE GENITAL COSMETIC SURGERY IN ADOLESCENTS
ABSTRACT: Is Female Genital Cosmetic Surgery for an adolescent with Body
Dysmorphic Disorder ever ethically justified? Cosmetic genital surgery (specifically
labioplasty) for adolescent girls is one of the most ethically controversial forms of
cosmetic surgery and Body Dysmorphic Disorder is typically seen as a
contraindication for cosmetic surgery. Two key ethical concerns are (1) that Body
Dysmorphic Disorder undermines whatever capacity for autonomy the adolescent
has; and (2) even if there is valid parental consent, the presence of Body
Dysmorphic Disorder means that cosmetic surgery will fail in its aims. In this paper,
we challenge, in an evidence-based way, the standard view that Body Dysmorphic
Disorder is a contraindication for genital cosmetic surgery in adolescents. Our
argument gathers together and unifies a substantial amount of disparate research in
the context of an ethical argument. We focus on empirical questions about benefit
and harm, because these are ethically significant. Answers to these questions affect
the answer to the ethical question. We question the claim that there would be no
benefit from surgery in this situation, and we consider possible harms that might be
done if treatment is refused. For an adolescent with Body Dysmorphic Disorder, the
most important thing may be to avoid harm. We find ourselves arguing for the
ethical justifiability of cosmetic labioplasty for an adolescent with Body Dysmorphic
Disorder, even though we recognize that it is a counter intuitive position. We explain
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
Keywords: Female Genital Cosmetic Surgery; Labioplasty; Body Dysmorphic
Disorder; Ethics; Bioethics; Adolescent.
INTRODUCTION
Female Genital Cosmetic Surgery is controversial even for adults, but the
controversy and complexity increases when adolescents request cosmetic genital
surgery. In the context of Female Genital Cosmetic Surgery and cosmetic surgery
generally, a preoccupation with perceived defects or flaws in appearance, referred to
as Body Dysmorphic Disorder, is typically seen as a strong contraindication. The
reasons are essentially ethical: firstly, that Body Dysmorphic Disorder undermines
autonomy to such an extent that the person wanting cosmetic surgery does not have
the capacity to make a valid informed choice, because their perception of reality is so
skewed; and secondly, that surgery will do more harm than good, because the
fixation of one aspect of bodily experience will soon be replaced by another one,
leading to more distress, not less. This second reason is based on an assumption
about an empirical matter, namely that performing genital cosmetic surgery on
someone with Body Dysmorphic Disorder will not improve it, and so would not result
in overall benefit. Beyond these issues lies the as-yet unasked empirical question of
the effects of being refused treatment. There are possible harmful effects here that
also need to be included in the ethical analysis. Answers to these empirical
questions affect the answer to the overall ethical question of whether Female Genital
Cosmetic Surgery for an adolescent with Body Dysmorphic Disorder could ever be
ethically justified. This is not the open-and-shut issue that it might first appear.
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
In this paper, we combine thorough examination of the empirical evidence with
ethical analysis starting from a neutral position; and on this basis, we argue that
genital cosmetic surgery for an adolescent with Body Dysmorphic Disorder may be
ethically justified. We recognize that this is a counter-intuitive position and we
explain how we reach this conclusion. We challenge, in an evidence-based way, the
typical view that Body Dysmorphic Disorder is a clear contra-indication for genital
cosmetic surgery in adolescents.
OVERVIEW OF CURRENT HEALTH LITERATURE ABOUT COSMETIC
LABIOPLASTY
Almost every article written on Female Genital Cosmetic Surgery makes the claim
that increasing numbers of women and girls are seeking genital cosmetic surgery.
The main procedure being performed in under 18s is reduction of the labia minora
(labioplasty) for large or protruding labia minora. This trend has been observed in the
United Kingdom1 and in the United States, where, in 2013, labioplasty had a 44%
increase compared to 2012.2 The highest number of procedures in the United States
was in 19-34 year olds (51%) and 3.1% occurred in females 18 and under.3 In
Australia, Medicare data shows that the rate of FGCS has more than doubled over
the past decade with the biggest increase among 15 to 24 year olds. However,
actual numbers will be higher because available data are for surgeries done in the
1 R. Deans, L.M. Liao, N.S. Crouch & S. M. Creighton. Why are Women Referred for Female Genital
Cosmetic Surgery? Med J Aust 2011; 195: 99-99: 99. 2 American Society for Aesthetic Plastic Surgery. 2014b. Americans Spent Largest Amount on
Cosmetic Surgery Since the Great Recession of 2008 [Press release]. Available at: http://www.surgery.org/media/news-releases/the-american-society-for-aesthetic-plastic-surgery-reports-americans-spent-largest-amount-on-cosmetic-surger#.VP4eMpTaVIU.email [Accessed 21 Dec 2015]. 3 American Society for Aesthetic Plastic Surgery. 2014a. 2013 Cosmetic Surgery National Data Bank
Statistics. New York. Available at: http://www.surgery.org/sites/default/files/Stats2013_4.pdf [Accessed 21 Dec 2015].
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
public health care system and hence rebated by Medicare, but many procedures are
done privately.4 Labioplasty is performed mainly by gynaecologists, plastic and
cosmetic surgeons and some urologists.
Reasons for increasing rates
In the literature, three main reasons why women and girls are requesting labioplasty
are reported.5 These are:
Functional / physical discomfort. This is discomfort that can occur during sexual
intercourse, during exercise such as bike riding, and also physical discomfort
caused by some clothing.
Appearance concerns. Women and girls may feel that they are not normal or
they may simply not like the way that they look.
Psychological and emotional distress
Of course it is not always easy to clearly distinguish these: all three may be tangled
up together in what a patient feels and thinks, or says to a doctor. Also, it is possible
that some patients may believe that dissatisfaction with genital appearance would
not be regarded as a good enough reason to access surgery, so they may
4 V. Braun. Female Genital Cosmetic Surgery: A Critical Review of Current Knowledge and
Contemporary Debates. J Womens Health 2010; 19: 1393-1407; Deans et al., op. cit. note 1; K. Hagan. 2012. Genital Surgery on the Rise: Doctors, The Age Available at: http://www.theage.com.au/national/health/genital-surgery-on-the-rise-doctors-20121214-2bfde.html (Accessed 21 Dec 2015).
5 L.M. Liao, N. Taghinejadi & S.M. Creighton. An Analysis of the Content and Clinical Implications of
Online Advertisements for Female Genital Cosmetic Surgery. BMJ Open 2012; 2(6): e001908; L.M. Liao & S.M. Creighton. Requests for Cosmetic Genitoplasty: How Should Healthcare Providers Respond? Br Med J 2007; 334: 1090-1092; L.M. Liao, L. Michala & S. M. Creighton.. Labial Surgery for Well Women: A Review of the Literature. BJOG 2010; 117: 20-25.
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
emphasise physical difficulties to add ‘legitimacy’ to requests for surgery.6 For these
reasons, the real motivations behind increasing rates of labioplasty cannot be
identified with certainty.
CONCERNS ABOUT THE ETHICS OF PERFORMING LABIOPLASTY
How autonomous are women’s decisions?
In terms of the ethics of cosmetic labioplasty, some authors take the view that the
decision to have labioplasty (at least in adults) is an individual decision; a matter of
autonomy.7 Others argue that it involves broader social issues and that there is a
need for a broader debate. Their position is that various social phenomena, such as
the effect of pornographic images propagated as the ideal, negative representations
of women’s genitalia, disease mongering and coercive influences undermine the
autonomy of women’s decisions.8 Further, some suggest that there is a ‘vicious
cycle’ which compounds the undermining of autonomy in relation to women’s
attitudes and decisions about genital appearance and surgery. The claim is that
providing surgery narrows the view in the general public of what is ‘normal’ genital
appearance, which in turn increases the demand for surgery even more, which then
further undermines the ‘development of other ways’ to help women and girls deal
with appearance concerns.9 The ethical status of women’s choices is one of the
major debates around Female Genital Cosmetic Surgery.
6 R. Bramwell, C. Morland & A.S. Garden. Expectations and Experience of Labial Reduction: a
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
Lack of evidence for effectiveness
Lack of evidence for ‘clinical effectiveness’ is another issue that gets a lot of
attention, although ‘clinical effectiveness’ is not clearly defined in the literature. The
empirical literature focuses on anatomical outcomes and surgical techniques rather
than outcomes and effectiveness. It does not adequately document risks and there
is a lack of long-term outcome data.10 Key authors in this field who set out to
conduct a systematic review of the empirical data, found that the available literature
was ‘extremely rudimentary and precluded the use of recommended methodology.’
They conclude that ‘[m]edically nonessential surgery to the labia minora is being
promoted as an effective treatment for women’s complaints, but no data on clinical
effectiveness exists’.11 Their claim is that this lack of evidence and follow-up, as well
as lack of information on risks, undermines the possibility of informed consent.12
These authors do not give a specific definition of ‘clinical effectiveness’, except to
say that it is something other than patient satisfaction. Interestingly, the literature
reports a high degree of consumer satisfaction. In the clinical literature, labioplasty is
described as a ‘simple surgical procedure’13 with a ‘low incidence of complications’14
and the potential to produce physical and psychological benefits.15 It is not clear why
10 L. Michala, S. Koliantzaki & A. Antsaklis. Protruding labia minora: abnormal or just uncool? J
Psychosom Obstet Gynaecol 2011; 32: 154-156; M.P. Goodman. Female Genital Cosmetic and Plastic Surgery: A Review. J Sex Med 2011; 8: 1813-1825; C. Iglesia, L.Yurteri-Kaplan & R. Alinsod. Female Genital Cosmetic Surgery: A Review of Techniques and Outcomes. Int Urogynecol J 2013; 24: 1997-2009; Liao & Creighton 2011, op. cit. note 8; J. Reddy & M. Laufer. Labiaplasty: Surgical correction in adolescents. The Female Patient 2011; 36(4): 50-53. 11 Liao, Michala & Creighton, op. cit. note 5, pp.20-22. 12 Ibid: 23. 13 Reddy & Laufer, op. cit. note 10, p.53. 14 A. Lynch, M. Marulaiah & U. Samarakkody. Reduction Labioplasty in Adolescents. J Pediatr
Adolesc Gynecol 2008; 21: 147-149: 149. 15 F. Lista, B.D. Mistry, Y. Singh & J. Ahmad. The Safety of Aesthetic Labiaplasty: A Plastic Surgery
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
clinical effectiveness for a cosmetic procedure could not be characterized by
consumer satisfaction. Nevertheless, Liao et al express concern that the two are
being confused.16
Concerns about genital cosmetic surgery specifically in adolescents
Some professional bodies recommend against labioplasty until growth is complete,
because further growth may lead to the need for further genital operations. Growth
is thought to be complete around 18 years – but that isn’t known for sure.17
Remarkably, there is a lack of knowledge about the development of the external
female genitalia, particularly the labia minora. Influential authors in the field report
that there are ‘surprisingly few descriptions of normal female genitalia in the medical
literature’ and ‘[d]etailed representations of female genitals are rare’.18 There is also
no information on normal variations and changes of the labia minora during
adolescence.19
Ethical authority for consent to labioplasty is also seen as a problem. Adolescents,
even when they have adult-level cognitive capacity, are generally held to lack
maturity. This is seen to reduce their capacity for autonomy, bringing the validity of
their consent into question. Despite an increasing focus and weight being given to
adolescent autonomy, there is still ‘recognition’ that adolescents are not as
competent as adults in making decisions about things that ‘could affect their health
16 Liao, Michala & Creighton 2007, op. cit. note 5. 17 Royal College of Obstetricians & Gynaecologists Ethics Committee. 2013. Ethical opinion paper:
Ethical Considerations in relation to female genital cosmetic surgery. Available at: https://www.rcog.org.uk/globalassets/documents/guidelines/ethics-issues-and-resources/rcog-fgcs-ethical-opinion-paper.pdf [Accessed 21 Dec 2015). 18 J. Lloyd, N.S. Crouch, C.L. Minto, L.M. Liao & S.M. Creighton. Female Genital Appearance:
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
for the rest of their lives.’20 However, if parental consent is sought, either alone or in
addition to the adolescent’s consent, there are ethical concerns about the ethical
legitimacy of parent consenting for a procedure that is not considered medically
necessary. Such a decision arguably exposes the adolescent to unjustified risk of
harm, and may thus violate the Harm Principle, or fall outside the Zone of Parental
Discretion.21
Adolescents are also regarded as more vulnerable to outside pressures than adults.
Puberty is a time when peer opinion and influences have the greatest impact.22 Then
there is the question of who or what is being treated in these circumstances. In the
literature, there is some evidence that it is mothers who are identifying concerns
about their daughter’s appearance,23 in which case it may be the mother’s concerns
about appearance that are driving labioplasty. Boraei and colleagues wonder
whether the issue is ‘the child not coming to terms with pubertal body changes’ or,
perhaps it is the ‘child’s or mother’s poor self-esteem’ that is being treated.24
ALTERNATIVE FORMS OF MANAGEMENT
Education and reassurance about the normal range of appearance is recommended
in the literature. This is thought to be of particular value, because of the lack of
20 S. Boraei, C. Clark & L. Frith. Labioplasty in Girls Under 18 years of Age: An Unethical Procedure?
Clin Ethics 2008; 3: 37-41: 40. 21 D.S. Diekema. Parental Refusals of Medical Treatment: The Harm Principle as Threshold for State
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
knowledge about diversity in female genital appearance.25 A good example of this
kind of education is the Labia Library developed by Women’s Health Victoria.26 Also
suggested are existing evidence-based services for ‘resolving personal or
relationship dissatisfaction and distress’. This is in response to a view that women
and girls may seek surgery in the expectation or hope that it will repair a failing
relationship or psychological distress.27
Psychiatric treatments such as Cognitive Behavioural Therapy (CBT), serotonin
reuptake inhibitors (SRIs) and antipsychotic medications have been suggested.28
Also proposed is intervention at the sociocultural level where distress is
‘socioculturally learned’ rather than ‘a natural response to physiology.’29 However,
this suggestion is obviously intended as a preventative measure, rather than a way
to deal with an individual experiencing distress.
LABIOPLASTY IN THE PRESENCE OF BODY DYSMORPHIC DISORDER
Those who think that female genital cosmetic surgery is ethically dubious in general,
are likely to think it is much worse if Body Dysmorphic Disorder (BDD) is also
present. Genital cosmetic surgery is expected to be particularly problematic when
25 Lloyd et al. op. cit. note 18, p.645. 26 Women’s Health Victoria. 2013. The Labia Library. Available at: labialibrary.org.au [Accessed 21
Dec 2015]. 27 Lloyd et al. op. cit. note 18, p.645. 28 U. Buhlmann, H. Glaesmer, R. Mewes, J.M. Fama, S. Wilhem. E. Brahler & W. Rief. Updates on
the Prevalence of Body Dysmorphic Disorder: A Population-Based Survey. Psychiatry Res 2010; 178: 171-175; D.J. Castle, S. Rossell & M. Kyrios. Body Dysmorphic Disorder. Psychiatr Clin North Am 2006; 9: 521-538; C.E. Crerand, W. Menard & K.A. Phillips. Surgical and Minimally Invasive Cosmetic Procedures Among Persons with Body Dysmorphic Disorder. Ann Plast Surg 2010; 65: 11-16. 29 V. Braun. Petting a Snake? Reflections on Feminist Critique, Media Engagement and 'Making a
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
people have this condition. It is generally viewed as a contraindication; something to
be screened against when considering a request for labioplasty.30
What is Body Dysmorphic Disorder?
According to the fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders, BDD is characterised by: ‘preoccupation with one or more perceived
defects or flaws in physical appearance that are not observable or appear slight to
others’; ‘repetitive behaviours’ such as mirror checking or comparing one’s
appearance with that of others; and ‘the preoccupation causes clinically significant
distress or impairment in social, occupational, or other important areas of
functioning.’31
Body Dysmorphic Disorder is not the same as and does not include Body Identity
Integrity Disorder (apotemnophilia) which involves the desire to have a limb
amputated. The two disorders have sometimes been confused, most notably after
reports appeared in 2000 of a Scottish surgeon who amputated the healthy limbs of
two patients (at their request) and were said to be suffering from BDD.32
30 Crerand, Menard & Phillips, op. cit. note 28; M.P. Goodman, G. Bachmann, C. Johnson, J.L.
Fourcroy, A. Goldstein, G. Goldstein & S. Sklar. Is Elective Vulvar Plastic Surgery Ever Warranted, and What Screening Should be Conducted Preoperatively? J Sex Med 2007; 4(2): 269-276; Iglesia, Yurteri-Kaplan & Alinson, op. cit. note 11.
31 American Psychiatric Association. 2013a. Diagnostic and Statistical Manual of Mental Disorders.
5th ed. Arlington, VA: American Psychiatric Association: 300.7 (F45.22). 32 G. Seenan. 2000. Healthy Limbs Cut Off at Patients’ Request. The Guardian 1 February. Available
at http://www.theguardian.com/society/2000/feb/01/futureofthenhs.health [Accessed 4 June 2016]; F. Tomasini. Exploring Ethical Justification for Self-Demand Amputation. Ethics & Medicine 2006; 22: 99-115: 114 endnote 1; T. Elliot. Body Dysmorphic Disorder, Radical Surgery and the Limits of Consent. Med Law Rev 2009; 17:149-182: 149; A. Bridy. Confounding Extremities: Surgery at the Medico-Ethical Limits of Self-Modification. J Law Med Ethics 2004; 32: 148-158: 149.
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
The difference between BDD and Body Integrity Identity Disorder (BIID) is made
clear in DSM-V. The focus for BDD is appearance, whereas the ‘driving desire’ of
BIID to have a limb amputated is ‘to correct an experience of mismatch between a
person’s sense of body identity and his or her actual anatomy’.33 For those with
BIID, ‘the concern does not focus on the limb’s appearance, as it would in body
dysmorphic disorder.’34 Furthermore, BIID is not included in DSM-5. In this paper,
we are discussing only dissatisfaction with appearance. It is important to make this
point, because some earlier ethical discussions have used the term BDD to refer to
situations in which the patient actually has BIID.35 BIID is ethically as well as
psychologically different from BDD, not least because it involves complete removal
of functioning body parts, causing significant disability. BDD only involves minor
changes in appearance – the body part is not removed.
Why is Body Dysmorphic Disorder a contraindication for cosmetic surgery?
First, there is a concern about surgical risk when there is lack of benefit. It is thought
that the presence of BDD in cosmetic surgery will lead to poor outcomes. The worry
is that surgery will not fix the problem; that new appearance preoccupations will
develop.36 Second, BDD is standardly viewed as undermining autonomy and the
capacity to make decisions. In other words, the desire for surgery is bizarre or
irrational so there must be something wrong with that person’s decision making
capacity.37 The standard view is that if there is BDD, then it would be clearly wrong
33 K.A. Phillips, S. Wilhelm, L.M. Koran, E.R. Didie, B.A. Fallon, J. Feusner, & D.J. Stein. (2010). Body
Dysmorphic Disorder: Some Key Issues for DSM-V. Depress Anxiety 2010; 27: 573-591:583. 34 American Psychiatric Association 2013a. op. cit. note 31, 300.7 (F45.22) 35 Elliot, op. cit. note 32. 36 Crerand et al. op. cit. note 28. 37 Elliot, op. cit. note 32.
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
to do labioplasty.38 Instead of surgery, psychiatric intervention is seen to be the more
appropriate response.
But is cosmetic surgery so clearly wrong in this situation? Ethics involves questioning
everything and challenging even apparently settled questions. When we asked
ourselves if it is wrong to do labioplasty for an adolescent with BDD, having in mind a
real individual young person in a real situation, a number of considerations pushed
us to think the other way.
CHALLENGING BODY DYSMORPHIC DISORDER AS A CONTRAINDICATION
FOR LABIOPLASTY
(A) Challenging the benefit / risk assessment
Not all cosmetic surgeries are the same
Labioplasty is not necessarily comparable to other cosmetic surgeries for which BDD
may be a contraindication. It is easier for patients to describe some appearance
concerns, the outcome they want and for the surgeon to understand their
expectations.39 Good examples are patients requesting reduction mammoplasty or
pinnoplasty (surgery to pin back prominent ears). These surgeries tend ‘to lead to
an overall decrease in preoccupation’ and to have good satisfaction ratings.40 We
suggest that labioplasty fits this category. The usual issue is that one or both labia
minora are seen to be too large, and the desire is to have them trimmed so that they
38 Crerand et al. op. cit. note 28; M.H. McGrath & S. Mukerji. Plastic Surgery and the Teenage
39 D. Veale, I. Naismith, E. Eshkevari, N. Ellison, A. Costa, D. Robinson, L. Abeywickrama, A. Kavouni
& L. Cardozo. Psychosexual Outcome after Labiaplasty: A Prospective Case-Comparison Study. Int Urogynecol J 2014; 25: 831-9; 838. 40 D. Veale. Outcome of Cosmetic Surgery and ‘DIY’ Surgery in Patients with Body Dysmorphic
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
do not protrude beyond the labia majora. It is relatively straightforward for a patient
to indicate what tissue they see as excess, and what they want done about it. The
issue is not the precise shape or curve of the labia, and once they no longer
protrude, their appearance would presumably not be noticeable anyway. Just as
with reduction mammoplasty and surgery to pin back the ears, we suggest that ‘the
patient can usually describe the problem that concerns them and their desired
outcome and the cosmetic surgeon can understand their expectations.’41 In contrast,
a procedure such as rhinoplasty where the desired change and the result is more
subjective, is associated with more dissatisfaction.42
The effects of being refused treatment
The stakes are high when an adolescent’s request for genital cosmetic surgery is
denied. People with BDD have a ‘markedly high’ rate of ‘completed suicide’
compared to the general population.43 A prospective observational study of
suicidality in BDD cites a completed suicide rate of approximately 45 times higher
than the general population.44 Added to this, the Diagnostic and Statistical Manual
(DSM-5) notes that the most common age of onset is 12-13 years and those with
onset before 18 ‘are more likely to attempt suicide’.45
If a young person really has BDD, being refused treatment is very likely to be
traumatic, and hence increase the already high risk of suicide. So why not do a
simple procedure to avoid trauma, and at least not escalate suicide risk? The harm
41 Ibid: 220. 42 Veale et al. op. cit. note 39, p.838. 43 K.A. Phillip & W. Menard. Suicidality in Body Dysmorphic Disorder: A Prospective Study. Am J
Psychiatry 2006; 163: 1280-1282; 1280. 44 Ibid: 1281. 45 American Psychiatric Association 2013a, op. cit. note 31, p. 300.7 (F45.22)
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
(distress in a person already at increased risk of suicide) done by refusing surgery
may be much greater than any harm or risk from the surgery.
When evaluating the effect of being refused treatment, an essential consideration is
alternative forms of management and whether these could effectively ameliorate the
distress and other negative effects. An important aspect of this is whether
alternatives to surgery are even acceptable to adolescents requesting cosmetic
labioplasty, let alone effective to any degree. Education and reassurance about the
wide range of ‘normal’ female genital appearance and referral to other specialists are
all part of good practice. We are not arguing against those things. Our concern is
for an adolescent with BDD who does not respond to these practices. There is a
distinction that can be made between what is considered ‘normal’ and ‘abnormal’,
and what a particular adolescent likes or dislikes. The mere fact that something is
normal (in the statistical sense), does not mean that an adolescent will therefore like
it. It is not inconsistent for her to say ‘It may be normal, but I don’t like the look of it,
and I want it changed’. So, for some, education and reassurance may have little
effect.
Other forms of management suggested include psychiatric treatments. These
include medications such as SRIs and antipsychotics and talking therapies such as
Cognitive Behavioural Therapy and psychosexual counselling. These treatments
require the co-operation of the patient and they are likely to be resisted by patients
‘who see the problem as physical.’46 In addition, waiting lists and costs can be
obstacles with the result that some of these options may not always be readily
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
accessible when needed, especially in countries where health insurance programs
are absent or inadequate.
The questionable quality of evidence about outcomes is a concern with Female
Genital Cosmetic Surgery, but we argue that poor quality of evidence is a significant
issue also when considering alternative forms of management, especially if there is
BDD. Body Dysmorphic Disorder is an understudied psychiatric condition.47
According to Castle, funding bodies view BDD as a trivial issue and for that reason, it
is difficult to get funding for research.48 In terms of treatment, there is only weak
evidence for Cognitive Behavioural Therapy and SRIs as a treatment for BDD – the
best that can be said is that they ‘appear to be effective’ or they are potentially
effective.49
Research on treatment for BDD is ‘scarce’,50 and there is virtually no adolescent
specific evidence.51 In addition to this, we know that psychotropic drugs have
significant side-effects. Side effects experienced by adolescents include ‘increased
appetite, sedation, tics, self-harm and suicidality’.52 In addition, side effects or even
the fear of side effects can lead to patients stopping treatment altogether. For
47 Castle, Rossell & Kyrios, op. cit. note 28, p.535. 48 D. Castle. Ugliness is in the Eye of the Beholder. Workshop presentation, Cosmetex 2015, The Cosmetic Surgery and Medical Expo. Melbourne, Australia. 49 Crerand et al. op. cit. note 28, p.16; G. Krebs, C. Turner, I. Heyman & D. Mataix-Cols. Cognitive
Behaviour Therapy for Adolescents with Body Dysmorphic Disorder: A Case Series. Behav Cogn Psychother 2012; 40: 452-461. 50 S. Wilhelm, K.A. Phillips, J. Fama, J. L. Greenberg & G. Steketee. Modular Cognitive-Behavioral
Therapy for Body Dysmorphic Disorder. Behav Ther 2011; 42: 624-633: 315. 51 Krebs et al. op. cit. note 49; D. Mataix-Cols, L. Fernandez de la Cruz, K. Isomura, M. Anson, C.
Turner, B. Monzani, J. Cadman, L. Bowyer, I. Heyman, D. Veale & G. Krebs. A Pilot Randomized Controlled Trial of Cognitive-Behavioral Therapy for Adolescents with Body Dysmorphic Disorder. J Am Acad Child Adolesc Psychiatry 2015; 54: 895-904. 52 R.J. Hilt, M. Chaudhari, J.F. Bell, C. Wolf, K. Doprowicz & B.H. King. Side Effects from Use of One
or More Psychiatric Medications in a Population-Based Sample of Children and Adolescents. J Child Adolesc Psychopharmacol 2014; 24:83-89:88-89
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
instance, obesity which is a common side effect of antipsychotic medications is
recognised as a primary reason that people cease to comply with treatment.53
Overall, then, it is not clear at all that any of these alternatives are preferable to
surgery in terms of effectiveness in dealing with the distress being experienced by an
adolescent with BDD.
Evidence that labioplasty eliminates Body Dysmorphic Disorder
The author of a recent study of psychosexual outcomes after labioplasty suggest that
‘a diagnosis of BDD is not a contraindication’ for labioplasty.54 In fact, it can eliminate
BDD which would presumably eliminate the accompanying suicide risk. In that study
of women aged between 18-60 years, nine out of 49 women wanting labioplasty met
the diagnostic criteria for BDD prior to surgery, but only one retained the diagnosis at
follow-up 3 months later. The woman who did not lose the diagnosis started out with
two preoccupations. Although her primary preoccupation with her genitals went
away after having the labioplasty, she retained the BDD diagnosis because she still
had a preoccupation with her nose.55 Four women in the study were able to be
followed up in the long term and they ‘continued without a diagnosis of BDD’.56
The participants in this study were adult women, but there is no obvious reason to
believe that the situation would be significantly different for adolescents. Labioplasty
for an adolescent with BDD could be compared to puberty- suppression treatment for
an adolescent with Gender dysphoria: in the latter case, the benefit that comes from
53 P.J. Weiden, J.A. Mackell & D.D. McDonnell. Obesity as a Risk Factor for Antipsychotic
Noncompliance. Schizophr Res 2004; 66:51-57. 54 Veale et al. op. cit. note 39, p.838. 55 Ibid: 837. 56 Ibid.
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
the relief of distress may make us wonder if it really matters if the surgery is not
‘medically necessary’ in any physical sense. For BDD, a condition ‘with strikingly
high suicidality rates in adolescents, with a reported 21% to 44% of patients
attempting suicide,’57 there is a point at which the distress a condition causes
becomes medically significant.58 As it is with Gender Dysphoria, one major goal of
treatment is surely reduction in or resolution of distress.
We take the position that ‘medical necessity’ should be interpreted broadly, and
should include reduction of psychological distress just as much as restoring physical
function. There are disputes about what constitutes treatment, enhancement, health
and disease59 and disagreement about whether medicine has a single overarching
end (health) rather than ‘multiple (and sometimes) conflicting ends’.60 Our
understanding of medical necessity fits well with the WHO definition of health.61 This
is not controversial. There are many accepted uses of drugs and procedures where
there is no strict physical necessity. For example, aiding a woman in childbirth,
contraception, sterilization, laser surgery for short-sightedness.
Concern about new appearance preoccupations developing
What of the worry that after surgery, new appearance preoccupations will develop?
Firstly, it is important to note this outcome would not necessarily be disastrous. It
simply puts the adolescent approximately back where they were, having BDD but
57 Mataix-Cols et al. op. cit. note 51, p.895. 58 AUTHOR 59 R. Wachbroit. 2001. Concepts of Health and Disease. In The Concise Encyclopedia of the Ethics of
New Technologies. R. Chadwick, ed. San Diego, California: Academic Press: 229-233. 60 G. Dworkin. 1998. The Nature of Medicine. In Euthanasia and Physician-Assisted Suicide. G.
Dworkin, R.G. Frey & S. Bok eds. Cambridge: Cambridge University Press:6-16:12-13. 61 World Health Organization (WHO). 2003. WHO Definition of Health. Available at:
http://www.who.int/about/definition/en/print.html [Accessed 9 June 2016].
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
with a different pre-occupation. At this point, a different approach can be taken, now
that there is reason to believe that surgery will not be effective. This does not mean
that trying surgery in the first instance was wrong, especially given that the
alternative is drugs, or having to wait six months for Cognitive Behavioural Therapy,
with the risk of the patient committing suicide in the meantime. The possibility that a
condition may reappear after surgery, is not in itself a good reason not to do the
surgery in the first place.
(B) Challenging autonomy-based concerns
Autonomy-based concerns about BDD and labioplasty are not convincing. First of all,
it is not clear that people with BDD lack autonomy because:
(a) Autonomy should be assessed according to the way a person reasons rather
than the content of their choice. The content of the choice is relevant only in so
far as ‘content’ refers to psychological considerations, e.g. content becomes
relevant only if the choice is unintelligible or lacks understanding.62
(b) Autonomous choices do not have to be good choices. They do not have to be
prudent or palatable – but they do need some minimal amount of rationality.63
(c) A person who is choosing autonomously, is able to critically reflect and make
decisions backed by reasons. If questioned, they are able to defend their choices
in terms of their own values.64 In principle, there is no reason to think that people
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
(d) People who make autonomous decisions have what Gerald Dworkin calls
‘procedural independence’.65 This means that they are not subject to influences
which seriously affect their ability to critically reflect (they are not brainwashed,
manipulated or coerced) and they are aware of influences on their deliberations.
Again, people with BDD would in principle meet this requirement.
There seems to be nothing about having BDD that is incompatible with autonomy.
Furthermore, a standard strategy for dealing with people requesting labioplasty who
are thought to have BDD, is to talk to them.66 Conversation or what Jay Katz refers
to as the ‘imposition of dialogue’ 67 assists with the rationality requirement and it
assists with procedural independence. Conversation is a way to clarify
misconceptions and misunderstandings and helps patients to act with an awareness
of the influences on their thinking.68 In other words, conversation helps with
assessing autonomy in the first instance, but also in promoting autonomy, e.g. by
getting patients to engage in self-reflection and reflection with others.
A second reason that autonomy-based arguments fail against BDD in relation to
labioplasty for adolescents is that it is not clear how applicable autonomy concerns
are for adolescents. We are not assuming that the adolescent is a mature minor
making her own decision about labioplasty. Therefore, the question of her capacity
for autonomous decision-making is not the issue. We are assuming that parents will
65 G. Dworkin. 1988. The Theory and Practice of Autonomy. Cambridge: Cambridge University Press. 66 Women’s Health Victoria. 2013. Women’s Health Issues Paper No. 9: Women and Genital
Cosmetic Surgery. Melbourne, Victoria. Available at: http://whv.org.au/static/files/assets/ca7e9b2f/Women-and-genital-cosmetic-surgery-issues-paper.pdf [Accessed 12 June 2016]. 67J. Katz. 1984. The Silent World of Doctor and Patient. London: Collier, Macmillan Publishers: 123. 68 AUTHOR: 238; Katz, op. cit. note 68.
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
be the ultimate decision-makers and their autonomy is not in question. Our focus is
on the comparative harms and benefits of labioplasty for an adolescent with BDD, on
the basis that parents and doctors together will be seeking the decision that
promotes the wellbeing of the adolescent by maximising benefits and minimising
harms.
CONCLUSION
Our argument about avoiding harm can be stated in a form very similar to Bayne &
Levy’s set of premises, which they used to justify a more extreme ‘medically non-
necessary’ form of surgery, namely limb amputation for BIID.69
(i) Adolescents with BDD who want labioplasty may endure serious suffering.
(Distress, suicidality);
(ii) Labioplasty will – or is likely to – secure relief from this suffering. (Empirical
research.70);
(iii) This relief cannot be secured by other less drastic means. (Lack of evidence for
alternative treatments.);
(iv) Securing relief from this suffering is worth the cost of labioplasty, i.e. the effect on
the person of the surgery, and the physical consequences of that. (Labioplasty is
a simple surgical procedure with low risk, and no on-going physically disabling
effects).
So we find ourselves pushed to arguing in favour of cosmetic labioplasty for
adolescents who have BDD. Initially, we did feel uncomfortable about this, as it is not
69 T. Bayne & N. Levy. Amputees by Choice: Body Integrity Identity Disorder and The Ethics of
This is the accepted version of the following article: Spriggs, M., and L. Gillam. 2016. Body Dysmorphic Disorder: Contraindication or ethical justification for Female Genital Cosmetic Surgery in adolescents. Bioethics 30(9): 706-713 which has been published in final form at https://doi.org/10.1111/bioe.12278
what we expected and is certainly counter-intuitive, at least to us. However, we have
reflected that this outcome shows the power of ethical reasoning. If pursued
thoroughly, using the available evidence and working from first principles, it is similar
to the scientific method, in that it leads to a logical conclusion, regardless of what
one might have expected at the outset.
As we have shown, the answers to empirical questions and the quality of evidence
play a crucial role in answering the ethical question of whether Female Genital
Cosmetic Surgery for an adolescent could ever be ethically justified. For an
adolescent with BDD, the most important thing may be to avoid harm and a simple
