Perverse Incentives

Image credit: Stephen Savage

Though the recession has blunted overall demand for cosmetic surgeries, one subcategory appears to be entering a growth phase, at least judging from the fifth annual Congress on Aesthetic Vaginal Surgery, held late last year in a luxury resort outside Tucson. There, about 60 doctors, most of them OB-GYNs, converged to discuss the expanding field of “cosmetic-gyn”—elective surgeries for women seeking to “rejuvenate” and/or “beautify” their vaginas. Attendance at the conference has been increasing by about 20 percent each year—one doctor there explained that his services are in such demand, he has multiple operating rooms so he can move quickly from one surgery to the next—and last year a competing conference was held at the Venetian in Las Vegas.

The affable organizer of the Tucson event, Dr. Red Alinsod, was an early entrant into cosmetic-gyn, and is recognized for inventing the procedure in which the labia minora are completely amputated to create a “smooth” genital look known in the field as “the Barbie.” Though he began his career by winning a prestigious fellowship in gynecology-oncology at Yale in 1990, Alinsod now spends his days making genitalia “look pretty” for the wealthy patients who flock to his Southern California practice from all over the world. He is also an evangelist for the field, spreading its lucrative gospel to fellow doctors tired of toiling in the time-intensive and high-liability fields of traditional obstetrics and gynecology.

Interest in cosmetic-gyn has been explained by such cultural shifts as the trickle-up effect of porn aesthetics and, relatedly, the popularity of the “Brazilian” wax, which leaves the genital area bare and thus subject to closer scrutiny. But the breakthrough moment for the field, cited by several presenters at the conference, was the appearance on the reality-TV plastic-surgery show Dr. 90210 of David Matlock, an OB-GYN turned full-time cosmetic-gyn specialist.

Cosmetic-gyn is part of a broader trend in medicine, away from the traditional model of insurer-reimbursed, professionally sanctioned procedures and toward a simple fee-for-service model. The surgeries themselves are controversial: in 2007, the American Congress of Obstetricians and Gynecologists issued an opinion advising against vaginal cosmetic procedures, and one committee member scathingly declared, “The absence of data supporting the safety and efficacy of these procedures makes their recommendation untenable.” The American Board of Obstetrics and Gynecology, meanwhile, refuses to recognize cosmetic-gyn as a legitimate subspecialty.

As a practical matter, this rejection by medical gatekeepers means that, for now at least, cosmetic-gyn has virtually no oversight and no credentialing requirements. At the conference, doctors were encouraged to view themselves as entrepreneurs marketing their services to consumers, with all that entails: sessions covered everything from search engine optimization for doctors’ Web sites to “The Blue Plate Special,” a urogynecologist’s advice on how to persuade a patient to add cosmetic-gyn to an incontinence surgery. The Web site of one ahead-of-the-curve doctor featured not only a $500 coupon but also “Patriot Program” discounts for federal employees and military personnel. One conference presenter summed up the new dynamic: “Retail plus medicine equals ‘retailicine.’”

But for all the talk at the conference about “giving patients what they want,” it was clear that patients aren’t the only—or necessarily the primary—driving force behind the cosmetic-gyn boom. Many of the conference’s OB-GYNs groused that even after they’ve amassed hundreds of thousands of dollars in medical-training debt, their insurance reimbursements are lousy. One doctor said he receives just $1,700 in fees for prenatal care and delivery, and a mere $800 for a hysterectomy. By contrast, a labiaplasty can be done in just a few hours, in-office, for a fee upwards of $5,000 and no “income socialism” to spread the proceeds among hospitals, insurers, and group-practice partners. Underscoring just what this can mean, one conference presenter left his computer’s wallpaper—rotating images of him with his red Porsche 911—up in the background during his PowerPoint lecture. The message was tough to miss: practice cosmetic-gyn, and you too can live the life of a plastic surgeon.

Some doctors at the conference expected, after merely watching videos of the procedures, to return home and begin performing the surgeries immediately, without any further training. But Alinsod and other presenters insisted that the skills necessary to perform these operations can be achieved only through mentored training. Perhaps in recognition of some doctors’ inexperience, one presentation tutored how to avoid malpractice suits and another, on labiaplasty disasters, offered tips on the secondary market of “revision surgery.” Alinsod himself described a trompe l’oeil procedure he had come up with to create the appearance of resurrected labia in the event that a simple trimming job accidentally became a Barbie.

For now, the cosmetic-gyn phenomenon seems confined largely to the coasts, and especially to body-conscious Southern California. But the feeling at the conference was that opportunity abounds. As one presenter noted, “The Midwest is a wide-open market!”