Astrid Pascal

No (wo)man is an island--the influence of physicians' personal predisposition to labia minora appearance on their clinical decision making: a cross-sectional survey.

INTRODUCTION Physicians are increasingly presented with women requesting a labia minora reduction procedure. AIM To assess the influencing factor of personal predisposition in general practitioners, gynecologists, and plastic surgeons to labia minora appearance in relation to their willingness to refer for, or perform, a surgical labia minora reduction. METHODS Cross-sectional self-administered questionnaire survey. Between May 2009 and August 2009, 210 physicians were surveyed. Primary care: general practitioners working in the north of the Netherlands. Secondary care: gynecologists and plastic surgeons working in five hospitals in the north of the Netherlands. MAIN OUTCOME MEASURES A five-point Likert scale appraisal of four pictures showing a vulva, each displaying different sizes of labia minora, indicating a physicians personal predisposition, manifesting as willingness to refer for, or perform, a labia minora reduction. RESULTS A total of 164/210 (78.1%) physicians completed the questionnaire, consisting of 80 general practitioners, 41 gynecologists, and 43 plastic surgeons (96 males, 68 females). Ninety percent of all physicians believe, to a certain extent, that a vulva with very small labia minora represents societys ideal (2-5 on the Likert scale). More plastic surgeons regarded the picture with the largest labia minora as distasteful and unnatural, compared with general practitioners and gynecologists (P < 0.01), and regarded such a woman as a candidate for a labia minora reduction procedure (P < 0.001). Irrespective of the womans labia minora size and the absence of physical complaints, plastic surgeons were significantly more open to performing a labia minora reduction procedure than gynecologists (P < 0.001). Male physicians were more inclined to opt for a surgical reduction procedure than their female colleagues (P < 0.01). CONCLUSIONS The personal predisposition of physicians (taking account of their specific gender and specialty) concerning labia minora size and appearance influences their clinical decision making regarding a labia minora reduction procedure. Heightened awareness of ones personal predisposition vis-à-vis referral and willingness to operate is needed.

Comparatively low attendance during Human Papillomavirus catch-up vaccination among teenage girls in the Netherlands: Insights from a behavioral survey among parents

BackgroundThe Dutch Human Papillomavirus (HPV) catch-up vaccination program in 2009 appeared less successful than expected. We aimed to identify the most important determinants of refusing the vaccination.MethodsTwo thousand parents of girls born in 1996 targeted for HPV vaccination received an invitation letter to participate in a questionnaire study. Two study groups were defined: the first group consisted of parents of girls who had accepted the vaccine and already received the first dose of HPV vaccination. The second group consisted of parents whose daughters were not vaccinated. The questionnaire consisted of a broad spectrum of possible determinants that were revealed after literature search and discussions with the stakeholders.ResultsFour hundred sixty nine questionnaires (24%) were returned, 307 (31%) from those who accepted and 162 (16%) from those who declined the vaccine. The decision not to accept the vaccine was largely determined by: (i) perception that the information provided by the government about the vaccine was limited or biased (OR 13.27); (ii) limited trust, that the government would stop the vaccination program if there were serious side effects (OR 9.95); (iii) lack of knowledge about the effectiveness of the vaccine (OR 7.67); (iv) concerns about the side effects of the vaccine (OR 4.94); (v) lack of conviction that HPV can be extremely harmful (OR 3.78); (vi) perception that the government is strongly influenced by vaccine producers (OR 3.54); and (vii) religious convictions (OR 2.18).ConclusionsThis study revealed several determinants for HPV vaccination uptake after implementation of the HPV vaccine for adolescent girls. These determinants should be taken into consideration in order to successfully implement HPV vaccination into National Immunization Programs.

18-Year Experience in the Management of Men With a Complaint of a Small Penis

In many cultures, the erect penis has been a symbol of masculine qualities. Because of this symbolism, a penis that is less than average size can cause insecurity or embarrassment. This series reports the authors’ 18-year experience in the management of 60 men with a complaint of a small penis. For 44 of these 60 men, counseling was sufficient; the other 16 had surgery, and of these, 9 were satisfied with the result. Despite limitations, the authors conclude that those men who already achieve a penis length of no less than 7.5 cm (2.95 in) in erection, have only limited benefit from penis-enhancing surgery. This particular patient category should therefore be dissuaded from surgery.

Penile Enlargement: From Medication to Surgery

Penis lengthening pills, stretch apparatus, vacuum pumps, silicone injections, and lengthening and thickening operations are available for men who worry about their penis size. Surgery is thus far the only proven scientific method for penile enlargement. In this article, we consider patient selection, outcome evaluation, and techniques applied. In our view, sexological counseling and detailed explanation of risks and complications are mandatory before any operative intervention.

Economy of Honour

As the world turns slowly but surely into one large civil society, not to mention a global village, it would appear that all aspects of life, including healthcare, become increasingly liberal. This is particularly the case for those areas of expertise which are traditionally on the cutting edge of increased possibilities and cultural influences, such as Obstetrics and Gynaecology. Unfortunately these changes can often result in ambivalent feelings. On the one hand this change in society has lead to huge increases in personal freedom, allowing individuals for the first time in history to become the very person they desire to be, pushing the boundaries of possibilities. Yet at the same time, professionals working in their respective fields of healthcare are therefore not only increasingly confronted with their own professional value-systems, but also with the boundary-pushed value-systems of their patients. Add to this the invisible hand of market-forces, as well as cultural diversity, and doctors may experience ethical dilemmas, which in turn may lead to tensions. For example, is a colleague who performs labium corrections without medical indication a bad doctor, or indeed is he or she a respectable businessperson? Furthermore, when can one speak of genital mutilation and when can one speak of personal freedom, either in a cultural or religious context? Many healthcare professionals experience an ethical and mental discomfort-zone on this subject. On the one hand one wishes to fully respect the integrity and emancipation of women in general, but equally one does not want to diminish or disrespect the traditional or new-age culture of others. Chen et al. (in this issue) show how routine actions of a gynaecologist, such as performing a gynaecological examination, are very much influenced by local cultural norms. In addition, verbal communication between doctor and patient are also not necessarily without anxiety, as some words can be misconstrued as sexually tinted, and may therefore be perceived as crossing an invisible line of appropriate behaviour. In essence, professionals are at all times expected to act and behave ‘correctly’ according to their professional standing. However, that correct behaviour is prone to being perceived subjectively; subject to personal interpretation by both doctors themselves, as well as their patient’s interpretations. Many professionals have been caught up and caught out by this ethical dilemma of ‘what is right and what is wrong’. As a result there have been health-professionals demanding outright clarity, by wishing for iron rules such as government guidelines, since being without them may result in professional vulnerability. However, the cry for hard and fast rules on traditional and new-age cultures and whether gynaecological operations should or should not be performed, does not offer a scot-free answer to the problem. For every health-professional who does not wish to be lead by market-forces nor by ancient cultural heritage (and not by government rules either) there is another directive force that can be adhered to: The powerful force of professional honour. The reciprocity of social appreciation, to and from significant colleagues in their respective fields of expertise, is a most powerful instrument. Indeed, the values and norms that we wish to pass forward to our medical students make a direct appeal to their sense of honour. Evidence shows that this type of grading works very effectively. Even without explicit education on this subject, students quickly identify with the interpersonal aspect of receiving professional honour, which further stimulates their own ethical and honour awareness. The obvious downside of honour as a steeringmechanism is that feelings of honour are not tangible and hence not quantifiable, unlike services or goods. A true sense of honour can only be born from purity Journal of Psychosomatic Obstetrics & Gynecology, December 2008; 29(4): 223–224