Reducing the incidence of burn injuries to Indigenous Australian children

Burns are a specific health burden, but understanding the detail is vital to finding solutions

It is undisputed that Aboriginal and Torres Strait Islander (Indigenous Australian) children are over-represented in statistics for injury and death caused by trauma. The incidence of each of the major mechanisms of fatal trauma in Australian children — drowning and low speed vehicle run-overs — is higher among Indigenous children.1,2 Burn injuries are also more prevalent among Indigenous children.3

In this issue of the MJA, Möller and his colleagues report a population data linkage study they undertook in New South Wales.4 Their results not only confirm that the incidence of hospitalisation of children for burn injuries is higher among Indigenous than non-Indigenous children. The authors also found that the proportion of burn injuries affecting more than 20% of total body surface area (TBSA) was greater for Indigenous than for non-Indigenous children, as was that of burns to the feet or ankles; that the incidence of being treated in a tertiary burns facility was lower and their median overall hospital stay longer for Indigenous children; and that they were less likely to undergo surgery, but more frequently received treatment from allied health professionals. This important epidemiological study not only supports the hypothesis that burn injuries constitute a significant health burden in Indigenous children, it is also the prelude to a much larger prospective study.5 Paediatric burns services throughout Australia are currently collaborating in a study funded by the National Health and Medical Research Council to examine the journey of the Indigenous child with a burn injury through the health system, including pre-hospital care and outpatient follow-up.5

The report by Möller and co-authors is initially somewhat disturbing, but more detailed analysis identifies factors that explain some of the disparities described. The proportion of Indigenous Australians living in rural and remote geographic locations, and therefore a long distance from tertiary burns facilities, is higher than for other Australians. It is consequently not surprising that many Indigenous children are treated in their local hospital, which has the advantage of keeping the family unit closer to home, with clear psychosocial and financial benefits. With the advent of telehealth services linking major burns services and local hospitals, and the application of digital photography to record wound status at each dressing change, a high standard of care can now be achieved even in remote locations.6,7

Whether a child needs to be admitted to hospital for a burn injury depends on many factors apart from the proportion of TBSA burned. One-third of children are admitted because of the impact of the injury on their family, not because immediate treatment of the burn is needed.8 It is often in the interest of the Indigenous child and family to be admitted to hospital when factors such as remoteness of the family home and socio-economic disadvantage would prevent the families traveling to outpatient appointments for dressing changes. Not only is admission to hospital more likely under these circumstances, the duration of stay will also be longer.

The region of the body affected by a burn is very much related to the mechanism of injury. For example, hot beverage scalds usually affect the face, neck and torso, whereas burns by hot embers and ash from campfires and burn-offs typically affect feet and ankles. Indigenous children have different patterns of burn injury types to other Australian children because of cultural and socio-economic differences. The higher proportion of foot and ankle burns in the report by Möller and colleagues is possibly explained by a higher incidence of campfire burns to Indigenous children.

The estimated TBSA burned is probably the greatest source of inaccuracy when documenting a burn injury.9 Areas of superficial burn (erythema only) are often erroneously included, leading to grossly overestimating the extent of the burn. Burn depth can also progress with time, but the TBSA is often not re-calculated, so that the initial estimate is the only value documented by hospital coders. Overestimation of burn extent would probably occur more frequently in non-tertiary facilities. Lund and Browder charts have traditionally been employed for calculating TBSA, but they are cumbersome to use and should therefore be replaced by mobile phone apps that accurately estimate TBSA by digitally shading on the screen the areas affected. The New South Wales Institute of Trauma has developed an app for this purpose that is free, quick and easy to use; the age and weight of the child are entered, and the degree of fluid resuscitation required (using the Parkland formula) is also calculated.10

People from populations with darker skin colour are reported to re-epithelialise burn injuries up to 25% more quickly than those from populations with lighter skin.11 However, darker skin has a higher propensity for hypertrophic scarring, explaining why the Indigenous children in this study had fewer operations for skin grafting, but significantly greater requirements for management by allied health professionals.

Preventing burns must be part of any intervention to reduce the burden of burn injuries in Indigenous children, alongside optimal first aid. Campaigns to prevent burn injuries will only be successful if they are targeted at specific populations that are at greater risk, and it is important they include collaboration between injury prevention advocates, Indigenous leaders, and health care workers.

[Obituary] Alexis Shelokov

Physician scientist specialising in infectious disease. He was born in Harbin, China, on Oct 18, 1919, and died with aplastic anaemia in Dallas, TX, USA, on Dec 16, 2016, aged 97 years.

Breast implants

Update – additional confirmed cases of anaplastic large cell lymphoma

Body dysmorphic disorder: are surgeons too quick to nip and tuck?

Most of us have some insecurities about how we look, and some aspects of our appearance that we might secretly wish were different. But for people with body dysmorphic disorder, these issues become an obsession and constant focus of concern.

Body dysmorphic disorder is a psychiatric condition that leads people to adopt extremely distorted negative beliefs about their appearances: seeing themselves to be ugly, malformed, misshapen or hideous. Such beliefs do not reflect the reality of how they appear to others. The degree of concern and distress they may feel about their appearance is vastly out of proportion to any actual physical “defect”.

A small minority of the population is believed to experience the condition. One study found about 2.3% of participants had the condition.

The mirror is a major problem for people with body dysmorphic disorder. Some sufferers become fixated with mirror checking, with hours of their day absorbed in inspecting their appearance. Mostly this checking is counter-productive, making them feel worse and increasing their distress.

Body dysmorphic disorder should not be dismissed as extreme vanity.
fixersuk/flickr

Other people with the condition may avoid mirrors altogether. Some can even have catastrophic reactions should they happen to glance at themselves in a reflective surface such as a shop window. Lots of sufferers conceal themselves under hats, scarves, wigs, dark glasses or excessive layers of makeup or concealing clothing in an attempt to hide their supposed defects.

Body dysmorphic disorder should not simply be dismissed as an expression of extreme vanity or insecurity about looks. This condition often leads to substantial distress and social and occupational impairment. Rates of depression are high, while suicide is not an uncommon outcome for those who do not receive appropriate treatment. Many avoid social situations for fear of others judging them negatively because of how they look.

Cosmetic solutions?

Because people with body dysmorphic disorder “see” themselves as having a cosmetic problem, it’s not surprising they often seek a cosmetic “solution”.

The highest rates of body dysmorphic disorder are found among people using cosmetic services like plastic surgeons, cosmetic dermatologists and cosmetic dentists. One study found up to 70% of people with body dysmorphic disorder had sought cosmetic procedures, and half had received such interventions.

Cosmetic procedures of all types are becoming increasingly available and accessible to a wider public.
From www.shutterstock.com’

The tragedy is that cosmetic procedures – by definition – do not solve the underlying psychological problem. They leave a majority of sufferers worse off: they pay for the procedure and suffer the pain and inconvenience of it, yet “see” the resulting cosmetic outcome as unsatisfactory, even if objectively the result is excellent.

This often leads to requests for more treatments, with ensuing worsening of the mental state of the patient and increasing frustration on behalf of the cosmetic specialist. The situation can become so heated that legal action, physical threats and even homicide have been known to be perpetrated by body dysmorphic disorder patients.

How can these outcomes be avoided?

Cosmetic interventions of all types are becoming increasingly accessible to a wider public. Therefore, it would be ideal for cosmetic specialists routinely to screen for body dysmorphic disorder.

Australian cosmetic specialists are not mandated to screen for body dysmorphic disorder and there’s no available information on the proportion of cosmetic clinics that screen for the condition. From my experience of speaking to patients who have sought cosmetic intervention, screening is variable at best.

There are certainly some practitioners who are very aware of the risks associated with body dysmorphic disorder and ensure their clients are screened and offered referral for further help if required. Unfortunately, too often screening is not performed and patients suffer as a consequence.

Screening should be mandated for people seeking any cosmetic procedure that might be seen as “enduring”: this includes surgical procedures. My colleagues and I have developed a questionnaire for practitioners, which through a series of simple questions can help diagnose body dysmorphic disorder.

For those who may body dysmorphic disorder, careful further questioning and referral to a body dysmorphic disorder specialist is required. A range of psychological therapies (such as cognitive behaviour therapy) and medications (mostly antidepressants) can be very effective at treating the condition’s underlying problems.

Simply providing cosmetic clinics with screening tools won’t guarantee all doctors accurately assess for body dysmorphic disorder. This is because we cannot expect all clients to answer questionnaires truthfully. However, in my experience, having seen hundreds of people with body dysmorphic disorder, they usually do.

At the end of the day, it would be ideal if cosmetic specialists did everything in their power to fulfil their ethical obligations. To not screen and then deliver cosmetic procedures to people who may have body dysmorphic disorder goes against the medical dictum “first do no harm”.

David Jonathan Castle, Chair of Psychiatry, University of Melbourne

This article was originally published on The Conversation. Read the original article.

Not alarmist, just the boring truth

DR JOHN ZORBAS, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING

The truth is often incredibly boring. It doesn’t sell papers. It doesn’t get people tuning in. It doesn’t win votes. And thus it follows that when things don’t make sense, one should assume incompetence before malice. But I’m finding it incredibly hard to suspend my disbelief when I stand back and take a look at the medical training system that we have in front of us today.

I’m not trying to be alarmist. I’m not here to tell you all that medical training is broken, and we should burn the books, burn the witches and behead Ned Stark. But I hope that I can convince you at the very least that the current progression to Fellowship is entirely unnatural and is fertile ground for unhealthy professional culture. To really understand this progression, I want you to pair up with each other, junior and senior doctors alike, and I want you to compare your respective paths through your medical journey. I find that often people have no idea what is or was on the other side of the fence. Let’s begin.

We finish medical school as the ultimate in medical pluripotency: the intern. We complete a year of heavily regulated and supervised training where we meander through medicine, surgery, emergency and whatever else might lie in our path that year. We then transition to residency, where without the pressure of training progression, we expand our medical buffet of specialisation and become more attuned to our final path in the journey. Armed with the knowledge of our experiences in areas such as general practice, ICU and plastics, and well rested from the safe hours worked, we apply for a training college. We get onto a program and begin to complete the pathway to specialty. Along the way, we have kids, and we do this by working part time at points along the way to balance the load. We complete our final exams and we become a Fellow of our chosen College, and apply for jobs in what is a reasonably well-balanced workplace. Right? Wrong. The truth is boring, but the truth is the truth, and this picture definitely isn’t the truth.

We finish medical school as the ultimate in medical pluripotency: the intern. We apply for internships, and a number of us will fail to get them as State governments are defaulting on their COAG agreement to provide medical graduates with internships. Without an internship, a number of doctors are unable to progress to general registration and are out before they begin. Those who remain become residents. With no national body to oversee PGY2+ terms, and with health services hungry to provide services to increasing populations with shrinking budgets, these residents work terms that don’t provide any meaningful experience. This veritable army of night cover and discharge summary monkeys are forced to scrounge around for the breadcrumbs falling off the training table. The smart ones quit, locum and complete further study, but not without further financial and temporal penalty. We’ve built a system in which the best way to advance your career is to quit the system for a while; a perverse incentive. This of course leaves behind fewer residents to fill the gaps in the roster, who are already at breaking point due to being denied leave for three years.

Nevertheless, you move towards a College. You identify the entry requirements and you undertake the extra mile to become a candidate with a chance. In some instances, that means completing a $5000 exam before you’re even a trainee. Once in, you work full-time and then the rest of it. You complete graduate diplomas, Masters and PhDs to progress. You fill your CV with publications and courses that cost thousands of dollars to progress. But you do it anyway. Because at this point you’re the blackjack player with a hard twelve. You’ve sunk enough cost into this game that you can’t quit, and there’s a glimmer of a nine sitting on top of that deck. But there are many more face cards, and maybe it’s just me, but I swear I’m seeing more and more doctors folding and busting around me.

So, you make it through. With everyone else. You’ve completed a number of extra qualifications and courses. With everyone else. You’ve participated in the medical arms race, and you’re surrounded by tens of thousands of other nuclear nations who’ll do anything for that job. The fat has been trimmed and now we’ve hit muscle. Welcome to exit block; a nation of Australian Fellows who can’t move on to consultant positions because we’re doing more with less, in every sense of the phrase. Competition is one thing, but when you’ve got multiples of trainees to every consultant position, you don’t have a competition. You’ve got a war.

I told you I wasn’t going to be alarmist and I stand by that. My examples above are all based on real life cases. I believe firmly in having a competitive workplace. I believe that smart hard work should be rewarded in the workplace. But this is not the system we currently have. We have a system that rewards the single-minded.

This is nobody’s fault. But it’s definitely our problem. It’s up to us as a profession to recognise that this isn’t about doctors eschewing hard work. It isn’t about people wanting an easy life. This is about a culture that has not kept up with the times and it’s important for those working in well-run institutions to recognise that this is not the norm anymore.

[Seminar] Thyroid cancer

Thyroid cancer is the fifth most common cancer in women in the USA, and an estimated over 62 000 new cases occurred in men and women in 2015. The incidence continues to rise worldwide. Differentiated thyroid cancer is the most frequent subtype of thyroid cancer and in most patients the standard treatment (surgery followed by either radioactive iodine or observation) is effective. Patients with other, more rare subtypes of thyroid cancer—medullary and anaplastic—are ideally treated by physicians with experience managing these malignancies.

Women don’t always get what they want from labiaplasty

Labiaplasty is the most common form of female genital cosmetic surgery and involves surgical reduction of the labia minora or the inner lips of the vulva.

However we still don’t really know what impact the procedure has on the lives of women who choose to have it. This is not that surprising given female genitals are still considered taboo. The words “vulva” and “vagina” are difficult to say for most people, never mind an entire discussion on the topic!

But these questions can be addressed through research. Our latest study shows although women are pleased with how their genitals look after labiaplasty, their self-esteem and general sexual confidence do not improve. This sort of information is vital to help women weigh up whether labial surgery is the right option for them.

Rising rates of labiaplasty

Labiaplasty has become increasingly popular over the last 10-15 years in Western countries, including in Australia. From 2001 to 2013, the number of these procedures more than doubled from 640 to 1,605 in public patients across Australia. These numbers do not include women undergoing procedures in the private sector, for whom we have no national data.

In NSW specifically, numbers in both public and private hospitals rose from 256 in 2001 to 421 in 2013, representing a total increase of 64%.

Although there is a common misconception teenagers are the age group most interested in labiaplasty, women are most often aged between 25 and 34 when they undergo surgery.

Why do women have ‘the Barbie surgery’?

Although there are physical or functional reasons for having labiaplasty (discomfort participating in sports like cycling or during sexual intercourse), most women do it due to reported unhappiness with their genital appearance.

Women desire a smooth genital surface, with labia minora (the inner lips) that do not protrude beyond the labia majora (the outer lips). As a result, this surgery is sometimes nicknamed the “Barbie surgery” as these dolls have no obvious genital features.

The way women’s genitals are portrayed in the media – particularly in pornography and on the internet – may be promoting this “ideal”. And men appear to be picking up on this too, prompting some to criticise their partner’s genitals. As a result, an increasing number of women are becoming concerned their genitals are unacceptable and need to be surgically altered.

But what happens to women after undergoing labiaplasty – do they really get what they were hoping for?

Labiaplasty won’t fix your sex life

In our most recent research published in Plastic and Reconstructive Surgery, we applied a forward-looking study design to examine psychological outcomes of labiaplasty. We found women experienced significant improvements in satisfaction with their genital appearance from pre- to post-surgery. But we found no significant improvements in any other psychological domains, such as self-esteem and sexual confidence.

Labiaplasty is often advertised online as a way for women to restore self-confidence and esteem, and improve their sexual relationships: our results suggest this is not necessarily the case. Instead, it appears although labiaplasty allows women to stop worrying about their genital appearance, it does not radically change how they view themselves and their intimate relationships.

Our research was the first to examine preoperative characteristics of women who are likely to be dissatisfied with their surgical outcomes. We found women who were more psychologically distressed – showing depression and anxiety symptoms in particular – or were currently involved in an intimate relationship were more likely to be dissatisfied after labiaplasty.

Although further investigation is required, we reasoned these women may have had unrealistic expectations for how labiaplasty might improve their psychological well-being or their relationship with their partner, and when this did not happen, they were dissatisfied.

It’s important for doctors to be able to identify these women before they undergo labiaplasty so they can be guided into another form of treatment that may be more beneficial, such as psychological therapy.

Avoiding disappointment after surgery

It looks like most women are getting what they want out of labiaplasty in terms of becoming more comfortable with their genital appearance.

But when women have unrealistic expectations for improvements in other areas of their lives such as their self-esteem and sexual relationships, they are more likely to be disappointed. For this reason, we recommend doctors thoroughly explore their patients’ motivations and expectations for labiaplasty so women can get treatment that will best address worries about their genital appearance.

Now we’ve started to identify some of the issues related to women’s dissatisfaction with labiaplasty, we hope our findings might assist doctors when they’re considering a patient’s suitability for cosmetic genital surgery.

Gemma Sharp, PhD candidate (submitted), Flinders University and Julie Mattiske, Senior Lecturer , Flinders University

This article was originally published on The Conversation. Read the original article.

Latest news

[Perspectives] Black gold, dark future

“My father rode a camel. I drive a car. My son flies a jet airplane. His son will ride a camel”, a Saudi saying goes, summing up the fact that although current generations have never experienced a world where there is no availability of oil, the idea of infinite progress with finite natural resources to fuel it is unattainable. So what will happen when global oil resources finish? Will it be the end of plastic and its use for disposable medical devices? How will people warm themselves, fuel their transport, and cook their food?

[Perspectives] Silver eye bath

In biology structure and function are intimately linked, as they are in so many other things. The simple eye bath is an instance. Made since the 16th century, these small hand-held objects have been valued by people whose eyes troubled them. They were fashioned from a variety of materials. Silver, porcelain, and hand-blown glass serviced the top end of the market in the 17th and 18th centuries. Mass production during the 19th century created pressed glass eye baths in a variety of colours. Aluminium had its day in the early 20th century before plastic overtook metal in the manufacture of so many goods.

Vulvoplasty in New South Wales, 2001–2013: a population-based record linkage study

The known The number of vulvoplasty procedures in NSW has been rising over the past decade.

The new One in 23 women who had vulvoplasty had repeat procedures; one in ten had had, or will have, other cosmetic surgery. One in 14 procedures resulted in serious adverse events. The caesarean delivery rate for primiparous women was about 30% higher among those who had had vulvoplasty. Vulvoplasty had no effect on perineal outcomes of a subsequent vaginal first birth.

The implications Our population-based study provides important information that can inform pre-surgery counselling.

Vulvoplasty refers to surgery performed on the external female genitals, generally reducing the size or correcting the asymmetry of the labia minora.1 Increasing demand for this procedure has been reported over the past two decades, with the number of procedures rising in high income countries, including Australia,1 the United Kingdom2 and the United States.3

In Australia, the number of Medical Benefits Schedule (MBS) rebates linked with item number 35533 for vulvoplasty procedures doubled from 744 during 2003–04 to 1588 in 2012–13.1 This MBS item was specifically intended to cover medically indicated vulvoplasty procedures performed in or out of hospital in private care. However, as no guidance or objective measures for assessing medical necessity were available to clinicians, concern was raised that the increasing number of rebates claimed might reflect demand for vulvoplasty as a cosmetic service.1

A review of vulvoplasty services was consequently undertaken by the federal Department of Health,1 and changes to the MBS were made. The former Medicare item number 35533 (vulvoplasty) was replaced in November 2014 by two item numbers: 35533 (surgical repair of female genital mutilation and major congenital anomalies) and 35534 (surgical repair for localised gigantism causing significant functional impairment).4 Rebates were no longer available for out-of-hospital services, and were available for item 35534 only when there was documented evidence of a clinical need.4

The Department of Health review incorporated both Medicare data and information from the National Hospital Morbidity Database (NHMD). The NHMD contains data for vulvoplasty procedures in public and private hospitals and in day-stay units, with or without a medical indication, and provides additional information about the hospital stay. The review also reported the associated principal diagnoses and age profiles of patients at the time of vulvoplasty. However, as data were for procedures and not for individual women, analysis of re-admissions and repeat procedures was not possible. Apart from age, neither the characteristics of women undergoing vulvoplasty nor rates of adverse outcomes were reported. No other studies have had the capacity to investigate outcomes at the population level.

The increased number of vulvoplasty procedures has attracted discussion and debate in both the medical community and the popular media.5,6 Commentators have explored possible reasons for the rise,1,7,8 as well as the ethics of cosmetic surgery marketing.7,9–11 The low level of evidence for the reported short and long term outcomes, including adverse events, has been criticised.1,8,9,11,12 Studies have relied on surgeon-initiated questionnaires9,13 or anecdotal and case reports.11,13 Further, no studies of the effects of vulvoplasty on subsequent childbirth have been undertaken.13,14

The aims of our study were to compare the characteristics of women undergoing vulvoplasty with those of other women of reproductive age; to quantify serious short term adverse events; and to determine the effect of vulvoplasty on subsequent outcomes for women giving birth. We hypothesised that vulvoplasty might have an impact on perineal trauma and decisions about the mode of delivery.

Methods

The study population consisted of all women of reproductive age (15–54 years) who had had a vulvoplasty in a New South Wales hospital during 2001–2013. To explore the relationship between vulvoplasty and subsequent birth outcomes (birth type and perineal status), we also analysed a subpopulation that included women who had undergone vulvoplasty and subsequently given birth for the first time during 2001–2012.

Data were obtained from two routinely collected population-based data collections: the NSW Admitted Patients Data Collection (APDC, “hospital data”) for 2001–2013, and the NSW Perinatal Data Collection (PDC, “birth data”) for 1994–2012. The APDC, an administrative data collection, is a census of discharges from all public and private hospitals and day procedure centres. As well as demographic data, it includes clinical diagnoses coded according to the International Classification of Diseases, tenth revision, Australian modification (ICD-10-AM), and procedures coded according to the Australian Classification of Health Interventions (ACHI; based on the MBS).15 The NSW PDC is a statutory dataset with information for all births in NSW of at least 20 weeks’ gestation or in which the birthweight was at least 400 g. It contains demographic, medical and obstetric information, as well as details about labour, birth and infant condition. Longitudinal linkage of the hospital records and birth records was undertaken by the Centre for Health Record Linkage, enabling admissions, re-admissions, serious adverse outcomes and birth outcomes for individual women to be analysed. The linkage rate between hospital and birth data for mothers has previously been reported as 98.1%.16 De-identified records were provided to the investigators.

Vulvoplasty was identified by ACHI procedure code 35533-00 in the hospital data. The principal diagnosis at the time of each vulvoplasty was identified by ICD-10-AM diagnostic codes.

Factors potentially associated with vulvoplasty and available in hospital records for analysis included age, marital status, smoking history, country of birth and socio-economic status (residential postcode was used to classify each woman according to the Socio-Economic Indexes for Areas [SEIFA] Index of Relative Socio-Economic Disadvantage17). Data on cosmetic breast augmentation (for women without prior mastectomy or breast cancer), liposuction, and face or brow lifting were also included in the analysis if the procedures had been undertaken during the study period.

Information about the vulvoplasty procedure and health service factors included hospital location, whether the woman had received public or private care, how many nights she had spent in hospital, the use of general anaesthesia, and whether she had been re-admitted to hospital within 14 days of the vulvoplasty surgery. Serious adverse events and complications ascertained from hospital records included haemorrhage, infection, and adverse urinary tract events, all of which have previously been reported in smaller, non-population studies.7 Information ascertained from the birth data included birth mode (non-instrumental vaginal, forceps, vacuum, and intrapartum or pre-labour caesarean delivery), episiotomy, and degree of perineal trauma.

The total number of vulvoplasties and the change in number over time were calculated for public and private hospitals, with the overall annual change estimated by Poisson regression. The characteristics of women with a first record of a vulvoplasty were described, and compared with 2011 NSW reference populations of all women aged 15–54 years (N = 1 982 710), including Australian census data for age and marital status18 and Australian migration data for country of birth.19 Data from the NSW Population Health Survey for women aged 15–54 years (N = 3258) were used as reference population data for smoking status.20 Rates of other cosmetic procedures were determined for all women of reproductive age who had no record of vulvoplasty and had been admitted to hospital for any other reason during the study period (N = 2 053 760), and compared with those for women who had undergone vulvoplasty. The characteristics of the vulvoplasty procedures and associated health service factors are described.

Women with a primiparous birth after a vulvoplasty were identified, and their birth characteristics compared with primiparous women without prior vulvoplasty by χ² analysis. Primiparous women were chosen for this analysis to minimise any obstetric history effect on birth outcomes.

Ethics approval

Ethics approval for the study was obtained from the NSW Population Health and Health Services Research Ethics Committee (reference, 2012-12-430).

Results

During 2001–2013, 4592 vulvoplasty procedures were performed on 4381 women in NSW hospitals and day-stay centres; 1198 were performed in public hospitals, 3394 in private hospitals. The number performed in public hospitals peaked in 2006 (122 procedures), while the number performed in private hospitals was still rising in 2013 (345 procedures) (Box 1). Of the 4381 women, 4193 (95.7%) had had only one vulvoplasty, 170 (3.9%) a total of two vulvoplasties, and 18 (0.4%) three or more. The total number of procedures rose from 256 in 2001 to 421 in 2013, a total increase of 64.5% and an annual increase of 3.3% (95% CI, 2.5–4.2%).

The two most frequent principal diagnoses linked with vulvoplasty were “hypertrophy of vulva” (26.1% of procedures in private hospitals, 23.1% in public hospitals) and “non-inflammatory disorders of vulva or perineum” (19.7% in private hospitals, 21.2% in public hospitals). “Plastic surgery for unacceptable cosmetic appearance” was the third most frequently cited indication in private hospitals (8.1%), and 23rd for procedures in public hospitals (0.7%).

Compared with the general population of NSW women aged 15–54 years, more women undergoing a first vulvoplasty were born in Australia (74.6% v 67.6%) and were 25–34 years of age (32.6% v 25.2%); fewer were married or in de facto relationships (42.5% v 55.4%) or aged 45–54 years (16.3% v 25.5%). A higher proportion lived in areas of higher socio-economic status, and six times as many had other cosmetic procedures performed during the study period (Box 2).

Most vulvoplasty procedures were performed in private hospitals in Sydney (59.4%); 13.9% were performed in public hospitals in Sydney, 14.5% in private hospitals outside Sydney, and 12.2% in public hospitals outside Sydney (Box 3). Most women (68.9%) had a day-only admission. Of the 679 women (14.8%) who were in hospital for two nights or more, 365 (53.7%) had gynaecological surgery other than vulvoplasty recorded as the principal procedure, including repair of uterine prolapse, pelvic floor or enterocoele (156 women), and vaginal hysterectomy (101 women).

Serious adverse events at the time of the vulvoplasty admission or during re-admission within 2 weeks of the initial admission were associated with 332 procedures (7.2%). For vulvoplasties with concomitant gynaecological surgery, the serious adverse event rate was 12.7%; for other vulvoplasties it was 5.0%. The most common events were urinary tract problems and complications (54.5% of complications; Box 3). One hundred and twenty-one women (2.6%) were re-admitted to hospital within 2 weeks of the procedure, with haemorrhage or haematoma complicating a procedure (30 women) and a variety of diagnoses related to wound complications or infection (29 women) being the most frequent principal diagnoses. A total of 4.3% of women had repeat vulvoplasties, with seven having a repeat procedure within 2 weeks of the first.

Of all vulvoplasty procedures, 3157 (68.7%) were for women who had not previously given birth in NSW. Women with one prior birth accounted for 694 of all vulvoplasties (15.1%), women with two prior births for 494 (10.8%), and women with three prior births for 247 procedures (5.4%).

Two hundred and fifty-seven women with a history of vulvoplasty subsequently gave birth for the first time during 2001–2012. The proportion of these women who had a caesarean delivery (40.0%) was significantly greater than for the 454 027 primiparous women with no history of vulvoplasty (30.3%; χ² test, P < 0.001). This difference was evident for births in both private hospitals (56% v 39.7%; χ² test, P = 0.004) and public hospitals (33% v 27.0%; χ² test, P = 0.04). A higher proportion of women with prior vulvoplasty had a pre-labour caesarean delivery than other women (20% v 11.0%), while the rates of intrapartum caesarean delivery were similar (20% v 19.3%). For vaginal births, there were no significant differences in the episiotomy rates or in perineal trauma for primiparous women with and without previous vulvoplasty (Box 4).

Discussion

The annual number of vulvoplasties performed in NSW hospitals on women aged 15–54 years increased by 64.5% between 2001 and 2013. However, the majority of Australian providers who advertise vulvoplasty surgery services indicate that these procedures are performed on an outpatient basis under local anaesthetic.1 During the same period, Medicare rebate data for NSW (which also captured clinically indicated, out-of-hospital procedures) indicated a 142% increase in the number of procedures, suggesting marked increases in the numbers of vulvoplasty procedures both in and out of hospital.21 Following changes to the MBS in 2014, restrictions of the eligibility for Medicare rebates for these procedures were tightened. The number of vulvoplasties recorded by Medicare subsequently declined, with 240 rebates paid in NSW in 2015, compared with 448 in 2013.4 Data have never been available for cosmetic out-of-hospital procedures (ie, those that are not clinically indicated), so that the total number of vulvoplasty procedures performed cannot be determined.

It is unlikely that a rise in the incidence of vulval pathology is driving the increase in surgery, and we cannot determine whether any vulvoplasties undertaken in NSW hospitals were for reversal of female genital mutilation. Dissatisfaction with physical aspects (such as chafing and discomfort), the appearance of their genitalia or with sexual activity, and feeling abnormal are reported as motives for women requesting surgery.13,22 However, there is a great deal of variability in normal vulval anatomy; in view of concerns that providers of surgery may exploit vulnerable women, there is a growing call from professional bodies to improve education and counselling.23,24 Our study found that six times as many women who have had a vulvoplasty have had other cosmetic procedures as have other women, which suggests that they have a lower tolerance for perceived physical imperfections. A similar difference was reported by a small UK study, in which 10 of 55 women who had undergone vulvoplasty were also diagnosed with body dysmorphic disorder (compared with none of the control group of 70 women).22 The authors recommended further studies for exploring this relationship, and others have called for more psychological screening of women who request vulvoplasty.23,25

The quality of evidence in studies of women’s satisfaction after vulvoplasty has been criticised in terms of the follow-up and the measures employed.9 Most studies have been undertaken by the surgeons who performed vulvoplasties, reporting data based on questionnaires sent to their own patients.9,13 Impaired sexual function caused by scarring and nerve damage has been mentioned as a potential problem after genital surgery.9,23 Satisfaction and long term outcomes warrant further investigation, especially as the number of women having the procedure outside hospitals is unknown.

In our study, one in 14 procedures was associated with a serious short term adverse event or complication within 2 weeks of surgery. Urinary tract problems were the most common, but these are rarely mentioned in the literature; wound dehiscence has instead been reported as the most frequent short term adverse event.1 The serious complication rate in our study (7.2%) was slightly higher than reported by small, surgeon-led studies (2.7–6.0%).7 However, other studies have also included longer term complications (eg, dyspareunia and delayed local pain) that would not be recorded in the population data upon which we based our study. By analysing hospital data, we could only detect complications or adverse events sufficiently serious to warrant a diagnosis or hospital admission, so we may have underestimated the overall complication rate. Women who experienced more pain than they anticipated, were unhappy with the aesthetic results of the procedure, or felt dissatisfied in other ways would not be definitively captured. About one in 23 women had a repeat procedure, perhaps reflecting wound healing problems after being discharged from hospital, or longer term dissatisfaction with the results of the procedure.

The relationship between vulvoplasty and subsequent birth outcomes has not previously been explored. For vaginal births, perineal outcomes were similar for women with and without vulvoplasty, so that women who have had a vulvoplasty can be reassured about their prospects for a vaginal birth. However, the caesarean delivery rate was 30% higher for women who had had vulvoplasty; the increase was predominantly in pre-labour caesarean deliveries, suggesting a higher rate of planned birth interventions. Vulvoplasty may have influenced decisions about birth plans; surgeons or the women themselves may have been worried that a vaginal birth might disturb the results achieved by vulvoplasty.

As routine data about procedures performed outside hospitals are not available, the overall frequency of vulvoplasty in NSW could not be determined, and women who had vulvoplasties performed outside NSW (including overseas) were not captured by our study. Nevertheless, our investigation was the first population-based study of vulvoplasty. It thereby avoided sampling bias, and analysed routinely collected data to provide a snapshot of the current situation in NSW hospitals. Further, it provides information about serious complications that can be useful for pre-surgery counselling of women considering the procedure.

Box 1 –
Numbers of vulvoplasties performed in New South Wales private and public hospitals, 2001–2013

Box 2 –
Characteristics of 4381 women at their first record of vulvoplasty in New South Wales hospitals, 2001–2013, compared with a reference population of NSW women17–20

	Women undergoing first vulvoplasty	Reference population of NSW women

Country of birth
Australia	3269 (74.6%)	67.6%
Elsewhere/unknown	1112 (25.4%)	32.4%
Previous cosmetic procedures
Any cosmetic procedure, including:	444 (10.1%)	1.7%
Breast augmentation	236 (5.4%)	0.9%
Liposuction	230 (5.3%)	0.8%
Face/brow lift	44 (1.0%)	0.2%
Age
15–24 years	1109 (25.3%)	23.1%
25–34 years	1427 (32.6%)	25.2%
35–44 years	1132 (25.8%)	26.3%
45–54 years	713 (16.3%)	25.5%
Marital status
Never married	1884 (43.0%)	33.1%
Married/de facto	1861 (42.5%)	55.4%
Widowed/divorced/separated	439 (10.0%)	11.6%
Unknown	197 (4.5%)	—
Smoking status
Smoker	691 (15.8%)	14.2%
Socio-economic status (SEIFA score quintile)
1 (most disadvantaged)	643 (14.7%)	20.0%
2	633 (14.5%)	20.0%
3	779 (17.8%)	20.0%
4	800 (18.3%)	20.0%
5 (least disadvantaged)	1363 (31.1%)	20.0%
Unknown (residence outside NSW)	163 (3.4%)	—

SEIFA = Socio-Economic Indexes for Areas. * Based on postcode of residence at time of the procedure.

Box 3 –
Characteristics of vulvoplasty procedures performed in New South Wales hospitals, 2001–2013

	Vulvoplasty procedures, 2001–2013

Total number of procedures	4592
Hospital
Public: Sydney	638 (13.9%)
Private: Sydney	2729 (59.4%)
Public: outside Sydney	560 (12.2%)
Private: outside Sydney	665 (14.5%)
Hospital stay
Day only	3165 (68.9%)
1 night	748 (16.3%)
2 nights	299 (6.5%)
> 2 nights	380 (8.3%)
General anaesthesia	4363 (95.0%)
Any serious adverse event*	332 (7.2%)
Haemorrhage	82 (1.8%)
Infection	14 (0.3%)
Urinary tract	181 (3.9%)
Other^†	73 (1.6%)
Re-admission within 2 weeks of procedure	121 (2.6%)

* Serious adverse event occurring during procedure admission or re-admission within 2 weeks (some women had more than one serious adverse event). † Includes disruption of operation wound and other complications.

Box 4 –
Birth outcomes for primiparous women in New South Wales, 2001–2012, according to vulvoplasty history

Women with previous vulvoplasty

Women without previous vulvoplasty

Number

Percentage (95% CI)

Number

Percentage (95% CI)

Number of women

257

454 027

Hospital

0.33

Public

182

70.8% (65.0–76.0)

333 618

73.5% (73.3–73.6)

Private

29.2% (24.0–35.0)

120 409

26.5% (26.4–26.7)

Birth mode

< 0.001

Non-instrumental vaginal

118

45.9% (39.9–52.0)

225 042

49.6% (49.4–49.7)

Forceps

3.9% (2.1–7.0)

33 008

7.3% (7.2–7.3)

Vacuum

10.1% (7.0–14.4)

57 971

12.8% (12.7–12.9)

Intrapartum caesarean delivery

20.2% (15.8–25.6)

87 650

19.3% (19.2–19.4)

Pre-labour caesarean delivery

19.8% (15.4–25.1)

50 134

11.0% (10.9–11.1)

Missing data

222

< 0.05%

Episiotomy (vaginal births)^†

0.20

Yes

24.0% (18.0–31.4)

90 550

28.7% (28.5–28.8)

117

76.0% (69.6–82.0)

225 471

71.3% (71.2–71.5)

Perineal spontaneous tearing (vaginal births)^†

0.87

Intact/first degree tear

42.9% (35.3–50.8)

118 028

37.3% (37.2–37.5)

Second degree tear

29.9% (23.2–37.5)

90 690

28.7% (28.5–28.9)

Third/fourth degree tear

3.2% (1.4–7.4)

12 681

4.0% (3.9–4.1)

Other

19.5% (14.7–27.6)

58 042

18.4% (18.2–18.5)

* χ² test. † Numbers do not sum to 100% as episiotomy and perineal tearing categories were not mutually exclusive until 2007.