 Good evening everybody and welcome to another mental health professionals network webinar tonight we're looking at identifying body dysmorphic disorder and psychological assessments for people seeking cosmetic surgery and I Would like to welcome the over 500 participants that we have already have joined us for tonight's webinar and the viewers who are watching the Podcast later on down the track. We have over two thousand registrants for tonight So we'll see how many people actually join us live great to have so many people and is a testament to another relevant topic from MHP and MHP and wishes to acknowledge the traditional custodians of the lands across Australia upon which our webinar present presenters and Participants are located. We wish to pay respect to the elders past presence and future for the memories traditions cultures and hopes of indigenous Australia My name is Mary Emily I'm going to move this slide And I'll be facilitating tonight's session My background is as a GP and then I worked for a long time in youth mental health and now I'm a trainee in psychiatry I'm based in North Queensland I'm really interested in this topic tonight From both of my background in general practice and working with young people and it's also something I feel really passionately about And it's been a privilege to meet tonight's panel who I would be pleased to introduce to you shortly I just want to acknowledge that many people have themselves had difficult Experiences in their interactions with the health care system whether we're health care professionals or any other kind of person We are all our self-patients at different times We may not have received the kind of best practice care that you're going to hear about in this webinar The purpose of this webinar is to give a broader group of health professionals the skills they need so they can help people more effectively in the future Personal stories of illness are very important and MHP and does often include consumers and carers on our panels However, the chat box this evening is not a forum for personal stories It's designed to complement the panel discussion by allowing professionals to share resources and their experiences of practice Thank you all for respecting this and if any content in tonight's webinar does cause this Distress, please take care if you need it So you can call lifeline or triple zero if you really need to be on blue or contact your GP or local mental health service Or just reach out to someone who's close to you Um, I would like to now introduce our panellists now Their bios were sent to you beforehand and in the interest of time. We're going to not not go over them individually But I'd first of all like to introduce Magda Simonus. He's a GP now Magda. I understand that you're in Melbourne and You're involved in setting up a really interesting project called the labia library. Can you tell us how that came about? in 2013 There was a white paper that was issued by women's health Victoria on labia plant and cosmetic surgery and I attended the forum and also contributed to the white paper research as a GP and We talked about how we could counter the biased representation of female genitals on the internet and The recommendation the suggestion was one of the suggestions I made was that we actually had something like a an online Library library, which we actually all agreed to and then Proceeded with that and it's been very successful. So it's a tool that health professionals and young women older women men can access for free And it is a great resource and it's really handy because you can just pull it up on your desktop when you've got a patient with you And on the note of resources all of the resources for tonight Whether now are in the middle resources tab down in the bottom right hand corner So I'd like to now introduce Gemma sharp Gemma You're a psychologist with a special interest in this area and I understand that you've actually developed a mobile app Which helps people to address Genital appearance concern. Can you tell us a little bit about that? That's right, Mary. So we're launching this app later this year through my work at Monash University And it's basically just to address the fact that there's no real I suppose psychological therapies for women with genital appearance concerns, which we know are a little bit different from broader body image Concern so with it being a mobile app Women can access it from the comfort of their own home with Without any sort of shame and stigma attached to it So we hope that it'll be really helpful for women who are experiencing these types of concerns Thank you, and I do want to acknowledge that while our case based around someone having a Woman with concerns about genital appearance The the whole topic of the webinar is about cosmetic surgery in general So we were focusing a lot on labia because that's our case But many of these issues apply to people with all kinds of Concerns about body image and on that note, I'd like to invite George who is a psychiatrist from Queensland and A key issue in the webinar George is about recognizing the patient who actually has body dysmorphic disorder So from a psychiatric perspective wise that's so important Yeah, no, thanks Mary Body dysmorphic disorder isn't a straightforward condition as it might appear in fact, it's typically Surprisingly complex conditioners can have quite a high level of psycho psychopathology sitting behind it and the condition itself has a fair degree of morbidity and It can be a bit of a minefield for the unsuspecting clinician that particularly those working in cosmetic surgery Nexopatial surgery done the colleges will see a bit later on but conditionally really need to have a pretty clear sense of and The capacity to recognize because it's one of those sleepers that can come up and bite us and cause significant issues, you know both for course the patient and the clinicians who are trying to work with and Georgia, I know you're going to be going through that in a bit more detail during the webinar So thanks for that. It's going to be really important for all of us It's great to have such an interesting and really expert panel I just want to give the audience a little bit of ground rules and just Advice about how to use the platform so the chat box that you can see in the The bottom of your screen is for general chat amongst health professionals in the audience So you may have resources or things you'd like to say We have over 700 of you online now We'll discuss our resources towards the end of the webinar But as I mentioned, they are in that resource box in the bottom If you have any difficulties with technical support, please contact look at the FAQ tab for help and The number for the different call for help is in there, too. If you can't answer it just in the question and We really value your feedback So please before you hang up tonight complete the feedback survey Which is loaded under the survey tab at the top of the screen before you leave And I'd just like to run through the ground rules as well So again, just respectful of other participants and the panelists and as though you would at a public meeting Interact with each other via the chat box Keeping your comments on topic and notice that if you do post your technical issues in the participant chat box by accident No one might see them. So if it's technical, make sure you go across to the technical chat box There's a phone number there. You can call if you're still having problems and If there is a significant issue that affects everybody, you will be alerted by an announcement It's very occasionally. There's some kind of technical problem. You will be looked after Just wait for the instructions. It's like you do on the aeroplane And just briefly reminding of our learning outcome So we're going to have the opportunity to evaluate when a client is required to have a psychological assessment prior to cosmetic surgery Identify the importance of collaboration when assessing a client for cosmetic surgery and Analyze when it's appropriate to refer a client seeking cosmetic surgery and when there's an indication of an underlying psychological problem So you've all had the case About Melanie who's a young woman who is concerned about the appearance of her external genitalia the labia and And she's presenting to her GP to talk about the possibility of having cosmetic surgery So what we're going to do is hear from each of our practitioners About how they would think about responding to Melanie from a discipline perspective and then The panelists are going to have a conversation with each other and with you So it's first of all like to invite Magda to respond from the perspective of the GP. Thank you. Thank you, Mary well for most general most general practitioners see patients that they've seen before and Patients prefer to see it from the GP. So I think that Melanie has taken a very big step in choosing to see GP She's not met before and to take out a Medicare card on her own Now traditionally if the standard appointment to run for 15 minutes, so it's really important that Staff be aware that when a teenager books an appointment that you need to really book a longer appointment to actually address the issues that might be encountered both billing Teenagers encourages them to attend on their own again And that's really what you want. You want to have an adolescent waiting friendly waiting room And you want to encourage an environment that that makes them feel welcome Nearly all GPs in a research piece that I've conducted That had been interviewed had been asked about genital normality in women of all ages And what was interesting was that of those GP 35% of them had been asked About female genital cosmetic surgery by girls under the age of 18 and statistically the incidence of labiaplasty in the 15 to 25 year old age group is equal to the labiaplasty rate of women 26 to 45 so this has raised several concerns which were raised also by the medical board in 2016 with And they subsequently Issued some recommendations about how we manage teenage But with respect to Melanie's presentation from a general practice perspective it's really really really important that the GP listen to Melanie let her speak and Regardless of what she's Expressing and how she's expressing herself. It's really important not to make us feel silly or embarrassed for attending however Minimal or it might appear to the doctor. It's important not to brush off her concerns of trivial It's important for a general practitioner to use language and terms that the 15 year old will understand and try to avoid using really medical terms or medicalised terms And being patient and listening to Melanie will enable the doctor to determine the extent of Melanie's problem Like questioning things further into you know Has she been Has she had a history of eating disorders? Does she vomit? Does she help self harm? Helps the GP sort of put in the context of whether or not this young woman Is developing or showing science is something more profound than generalized anxiety or an anxiety regarding her appearance and And it's important to assess how this is affecting her life and her confidence and her relationship It's also important to understand what she knows about normality because this impact of You know the worldwide web and access to internet and information you know regarding fashion and changing being tight and and Clothes being tight and pornography being accessed easily online Impacts the the decisions that People take and especially young people. They they are impacted Musically by what they see online that's where they get a lot of information So it's important to find out what she understands about genital anatomy diversity what the function of the genital Structures is and whether or not she understands that her body is actually undergoing changes that are very normal for a young person this age Um, it's important to also allow her to know that if it's about the length of her labia menora extending beyond the margin of the labia majora Which is primarily the concern that women present with That 30 to 50 percent of women have labia menora that extend beyond the line of the labia majora So she fits within the normal range even though when she looks on the internet she might feel that she's abnormal They're going into sensitive questioning about You know her past sexual experiences and or her current sexual relationship with this boy and her readiness to have sex are important and it is important also to Find out whether or not there's been any sexual abuse that has not surfaced or has not been talked about and using the third person With young people such as some people who are concerned about, you know, their appearance have had certain experiences You know, would you, you know, has it actually occurred to you? Then it's it's also important for the gp to find out what she knows about her boyfriend's experiences and how it how he's You know arrived to this, uh, you know decision or perception that she's unusual um, a lot of uh adults don't realize that pornography is uh is uh is accessed by teenagers and that Up to 70 percent of males the younger than the age of 13 have accessed online porn And by 15 100 percent have and porn these days is not what it was like probably 30 years ago And certainly not online porn. So this is going to have a significant impact on the perception that this that these young people have The opportunity to educate young people exists in the context of the general practice Uh setting and uh, we need to take that advantage of that opportunity I use a simple diagram just a sketch diagram, which is norm threatening um, and just or sometimes if I can't access one I just draw one very basically and say, you know, this is the labia matura. This is this is that Can you or and or draw a diagram and then ask The patient to actually identify the structures so that you know exactly what they know About themselves or about anatomy And I would also offer to show or look at some images online or Use a diagram from a book If they felt comfortable to do that A physical examination naturally should be offered. You know, what is the problem? Would you you know, do you mind if we have a look and we can discuss this? If um as a female GP with a female patient Sometimes they're comfortable being alone with you and uh, you're being examined but offer them also a chaperone such as a practice nurse And never coerce a young person or any person's thanks for a physical examination When you're conducting the examination help her Talk about what it is that she doesn't like help her define what she just likes an often melanie and mirror um, and Encourage her to point out what it is that she's concerned about and This is also an opportunity to Determine any degree of self-disgust or shame And you know something as extreme as you know, I hate myself for discussing. I can't you know, I don't want to look Uh, would really alert the GP to some deepest psychosocial issues and you're thinking, you know What's this in the spectrum of anxiety? Is it anxiety? Is it watering on body dysmorphic disorder? Where along these lines that she really fit? I always offer reassurance Choice of words and the tone that the doctor uses really do count not just What you say, but how you say it and the confidence with which you examine the person If you're not confident or comfortable examining a young person Then I would strongly recommend that you actually refer them to someone that you know would be confident in doing that And explain to them that you know, you'd send them to a specialist Female Women's health expert or a gynecologist Not for any reasons of Abnormality, but because that's really their area of specialty and not necessarily yours So gps do need to know their limitations and then you would touch upon the complications of female genital cosmetic surgery or labia fasting Doctors need to know that Not knowing that we have to know about Referring patients onto counseling if they're under the age of 18 is no excuse for not doing so So as of october 2016 gps are expected to refer People under the age of 18 who request major cosmetic surgery for counseling and that's either with A psychologist a psychiatrist or even another gp who is not involved with the actual surgical procedure that's being discussed We're going to be performed And there needs to be a minimum of the three months calling off period before the actual major surgery is conducted But counseling is mandatory now the British and royal college of the British colleges are A pediatric and adolescent gynecologists along with the royal college of obstetricians and gynecologists have issued recommendations regarding surgery in Girls under the age of 18 Um and recommend that it be delayed until after the age of 18 because genital maturity is not Achieved until after 18 and that removing genital tissue before this age might result in an outcome that is unsatisfactory to the person And and that the genital tissue actually continues to change and and develop so Referring to a gynecologist a special stateless and gynecologist is a pursued way rather than to a straight plastic surgeon And it involves team care the gp the gynae the psychologist psychiatrist and the parental carers and And then you know This is all to be achieved in a relatively Short consultation time So you might need to bring the person back to have a chat again after you've actually given them I think from here my In in this sort of setting I would then refer the patient on to the psychologist or psychiatrist to assess for for any mental health issues And and then also bring them back to have a chat after they've actually had that consultation Thanks So much. Magda. I I know that I've been learning a lot through listening to that And I'm sure that the audience have been as well and we'll come back to a couple of things that you raised there in the discussion to get us Now Gemma, I'd like to invite you to come in and talk about Melanie from the perspective of the psychologist. Thank you. Thanks, Mary So as magda was saying Because Melanie is under the age of 18 and maybe a plus is a major procedure She would need to be assessed by a psychologist psychiatrist or gp who's independent of the treatment So if Melanie was to come to me as a psychologist, I'd be very understanding first up of her concern It seems like she's been dismissed by her gp as well as her mother Which is really sad But I know from my own research and also clinical practice That there's a growing number of girls and women who are concerned about their genital appearance just like broader body image concerns So she's she's not strange in this. She's certainly not alone But what I would like to find out is first off how her particular labial concerns developed And how it's manifested since that time I'd also like to get an understanding of how it's been impacting on her life It seems like it's really affecting her self-esteem As well as her relationships and it's also affecting her physically too She's talked about not being able to wear a bikini and chafing in underwear So there's both psychological and physical concerns here for her I'd also really like to know why she wants surgery right now Like why is it that she's come to uh to ask for this request now? There's probably a range of internal and external motivation So external motivation might be potentially the influence of her boyfriend Making that comment as well as all those psychologically driven motions Motivations too I think it's also really important to ask Melanie about what she expects labia plasti will achieve We know that patients who have really unrealistic expectations for surgery thinking it'll revolutionize their life Are really likely to be disappointed So it would be very important to check that she doesn't think her life will be perfect after having this Because it's probably unlikely to be the case It's also really important to to bring other important people in Melanie's life in as well Particularly her mom and get their perspective on Melanie's request for labia plasti And I'd also check in on whether labia um whether Melanie was concerned about other body parts Not just her labia Because this might be a bit of an indication of body dysmorphic disorder Which magda's already mentioned and I know george will pick up on quite a bit more But basically we don't want to set Melanie up to become a bit of a cosmetic surgery junkie quote unquote And and sort of setting her up for a lifelong Journey of getting multiple procedures. So really good to check in on that early And in the resources, there's actually a specific screener for body dysmorphic disorder related to the labia So I'd encourage people to to use that as a patient reported very quick measure that That you can give to patients if you're worried about this And finally in terms of specific concerns, I'd take on Melanie's ability to consent Considering she's under 18 I mean in addition to all of these specific concerns that Melanie's Put forward I'd also like any psychological assessment assess her developmental history Probably involve her mum in that as well as well as educational history Her relationship history. We've heard a little bit about her Most recent relationship, but was there any relationships before that that we should know about as well as a mental state examination And really importantly a risk assessment Because we know that people with body dysmorphic disorder are At high risk for taking their life as well as Sometimes engaging in DIY surgery. So is Melanie thinking she might cut her own labia? Like this is a really big concern if she can't access surgery might she take matters into her own hand So it's very important to put safety measures in place if this is what she's thinking of doing So while we have Melanie with us, it's a really good opportunity to check her understanding And also provide her with some education like Magda was saying So we check like Melanie's found labia plasti on the internet What does she really know about the procedure? What is involved? Does she know about the complications both in the short term and long term? Does she know that revision surgeries can sometimes be needed as well as the research findings? Which I've published myself We know that while women may be happier with how their genitals look afterwards They don't tend to experience those improvements in their self-esteem and sexual relationships that they might be expecting after surgery So it's really important to tell Melanie that she's probably not going to have those broader life impacts Even if she does have surgery And it's also a really good chance to check in on Melanie Melanie's understanding of just normal genital anaesthesia She's gone through puberty and she's probably noticed that her labia has changed And so it's a good idea to tell her that that's that's normal and that's what should happen And that there's a huge diversity in normal labial appearance, but that's not necessarily shown in the media It really only tends to be small Symmetrical labia that's shown and that's probably skewed her perception of what acceptable labia minora should be And this of course is a great opportunity to collaborate with other health professionals to give this education And so we've got we've got Melanie here and she's very concerned about her labia And even after reassurance of normality of her labial appearance. She might still be really concerned about it So how do we how do we kind of help her? What what can we offer her besides surgery? Well her physical symptoms could be addressed through use of emollients and Some looser fitting clothing but I think the really hard work here has to be done by the psychologist or the psychiatrist and I mentioned before about an online psycho educational program I'm running initially for adults, but hopefully For younger people In the future rolled out later this year got my email address on there If you've got any patients who you think might be suitable for this But basically just using cbt principles to help address those unhelpful thoughts about unhelpful thoughts and behaviors about her labial appearance And help her live a more fulfilling life because it sounds like she's having a bit of a tough time at the moment So yeah, let's let's give her some options besides surgery that'll help alleviate her concerns right now That's all from me. Thanks Thanks very much Gemma. I just want to acknowledge one of the things with um, you know mhpn is actually Involving lots of different therapeutic disciplines and we know that Lots of people can do cbt as well and so and and other forms of therapy So I might actually I will come back and ask magda So I'll just put the question on notice for later about whether the guidelines actually include other kinds of counselors so for example if we had a social worker or a general counselor or an ot who had a special interest in this area or or knowledge or Had a good therapeutic alliance with a patient who was asking about this Does that counseling meet the needs of the guidelines? So I will come back and ask that of magda a bit later on But right now I would really like to welcome George to come and speak to us about how he would respond And think about melanie from the perspective of psychiatry. Thanks George Thank you, Mary Okay, so what I thought I'd do here is start by walking us through how the attempt by Is conceptualizing body to smallest disorder previously none of the smaller Now the first thing to note is that it's it's now ranked under the obsessive compulsive disorder section of the file and as we're going to see in a moment We're probably at the more complex end of that obsessive compulsive disorder spectrum Now this in five typically organizes the diagnostic criteria around starting off with with the first criteria a Which typically is designed to capture the essence of the diagnosis And so when we look at criteria a here for bdb We've got this preoccupation with one or more perceived defects. So generally spoken to looking for no the possibility of other perceived concerns that The patient may be presenting with And so it's a perceived defect of one of the physical parts that are not observable or appear slight to others now The crux of this issue particularly in this case sit with those two words appear slight You know With melamine, I just have to interrupt for half a second someone of our presenters doesn't have their phone on mute So we just need to put that on mute so everyone can hear george. Please Please go ahead. Thank you Um, so yeah, so with melamine when we look at criteria a here We have to remember that her lips her older lips are large enough to cause chomping And her boyfriend ryan and i'm budding gynecologist here Well somewhat questionably qualified to make a judgment We have to remember that of all the things he could have commented on with a naked 15 year old girl beside him He chose to comment on her labia So the prima facie level they're clearly observable to others And this would probably we're all out of a diagnosis of bdb And while we can debate whether, you know, her Her labia may be abnormal to a greater or lesser than a slight degree We also have to be cognizant of the fact that right now ryan's opinion Is going to outweigh the opinion of a noble prize winning gynecologist That's it's going to be weighing very heavily on this young This This very, um, susceptible to other people who can be young girls Young girls So that's the sort of opening I guess sort of position on the start to think about this If we now drop into the remaining three criteria that this So here you can see the real link with criterion b to ocb You're looking for The A preoccupation A high level of repetitive behavior for mental acts Which are of course in common with with other obsessive conditions So you've got a you've actually got to have evidence of that now of course this particular case is a little bit violent When it comes to looking for those particular symptoms, so we probably can't conjecture too much in that regard criterion c is a fairly Boiler plate criterion it's looking as it does with most conditions that They're being an observable A recognized degree of the functional impairment social occupational and to this girl My biggest concern in saying her would be an impact Which is likely to have on her psychosexual function We'll come back to that and then criterion d looks at the overlap with eating disorders, which is You know a very common overlap The criterion is a little bit complex here because I love those words they're better explained by So you can actually diagnose an eating disorder as co-morbid with bdb And it really comes down to a judgment as to whether which condition Better explain You know what is in front of you? Okay, so if we now jump into the specifiers, which bfm 5 gives us the most condition We're looking out in many ways the male equivalent of this most common presentation Uh, we'll come to the second one the moment, but is this one of muscle this small phobia? And this is typically where you've got young guys who just think they're not big enough Not must feel enough and of course this way it's not just the then becoming Jim junky But this is still another problematic car I think this is rather surprising when I really Drilled down on this this next one, which is really the specifiers looking at the degree of inside So we have the first specifier, which is good affair inside We have poor inside and then we have completely absent inside or or indeed delusional beliefs And it's rather impressive to find that you can have this In up to a third of these people That's a significant percentage of this of this cohort That have actually got a really significant level of psychopathology Now if we look at the associated features of this condition Again, where the first one that I've put in here is The delusions of reference again, we're looking at a degree of psychopathology That is well away now from the dimensions that we would typically see in an anxiety or depressed condition Where we're looking at something quite a bit more than that In terms of what it's co-morbid with we've got the usual suspects there The other interesting findings about this condition is that these these young people often have On psychometric and other forms of investigation executive dysfunction Where they have difficulty identifying holistic image, whether it be the face or body or whatever And they they have these bias for focusing on detail Similarly, if there is ambiguity in the In the messages that they're getting they have a preponderance for negatively interpreting That that information And I've just made a particular note here about shame. I think we're going to appreciate people with a case like Melanie How shame that is going to play a significant role And if you just see the world of psychopathology at the moment Or picnic on the work in the world of psychotherapy How much we're coming to appreciate the role of shame You know, thanks for the work of people like Brony Brown Where shame is is really a powerful powerful force when it comes to interfering with both the help-seeking behavior And then the engagement in therapy subsequently, so we need to um You know, we need to recognize that these people are typically carrying an authors shame And we have to handle that very delicately Who's both Magda and Gemma touch on prevalence I thought the surprising finding here was how the this isn't a western world You know first world problem, you know 2.4 percent in the usa not a big gender difference 1.8 percent in other cultures So do you coyote? is Is japanese or A phobia of the deformed body So this is the condition that seems to transcend transcend cultures As we've touched on With women, we expect to find a co-morbid eating disorder not infrequently and with men It's typically Genital concerns. Although, let's be honest When we're talking about genitals, we're typically talking about Penis is here. Very rarely a guy is concerned about the size of their testicles Because the old joke goes what well it may be desirable to have big balls the problems they're going to make your penis look smaller But that is it mate. What what we've got with the next is the The clinics that we're going to find the preponderance of these people In the waiting room all So dermatology 9 to 15 percent of course cosmetic surgery and then orthodontia maxillofacial surgery So in terms of some more context around this condition median onset is age 15 But we typically see see symptoms beginning as early 12 or 13 And I thought this was a rather surprising finding that we're looking typically six to 10 years before these people first Have their first consult and I think that speaks to the powerful wall of shame in this condition Particularly when we're talking about Of course, we want to go looking for histories of neglect and abuse because you're going to find a preponderance of that And genetically we're going to find more first-degree relatives with those people If under the age of 18 There's going to be that gradual onset often with the symptoms starting in the pre-teen years And we've got to keep an eye out for Suicide now let's just move to the next slide where we'll pick up on that a little bit more Psychosocial impairment is a real issue with this condition. You're at 20 percent of kids dropping out Now up to 40 percent of them becoming homebound. I mean this is I panic disorder leading to agriphobia This is probably a higher number than you would typically get with that panic disorder who end up being homebound And then we got up to in some studies 58 percent requiring psychiatric hospitalization So said at the open this is a condition that carries significant psychopathology behind it It's not about a preoccupation with a big nose. It's so much more than it can happen And as Gemma touched on suicide risk is high for these kids 29 percent of adolescents will attempt So something we have to be particularly vigilant for And then for conditions that might find themselves working in this space where you're going to have a preponderance of people wondering what they're really doing We've got to remember that these people respond very poorly to surgery and cross-nose procedure And importantly They're more likely to take legal action or Quote become violent unquote. That actually came like that was in bfn 5 We commented about them becoming more violent than one might otherwise So therapy continuations as quickly Gemma has spoken to a lot of these as magda I'm thinking of it here more from the perspective if we had somebody with One of the considerations that we're going to have to look at um, of course, we want to keep an eye out for that that issue of suicidality medications We obviously want to treat any co-morbid condition that will be responsive to medication and remembering also That ocb is a condition that can respond to fsri But look at the end of the day. This is going to be primarily a psychotherapeutic intervention And we're going to be looking often for the underlying drivers that fit behind this This preoccupation of the individual has as often fine with eating disorders We're often looking at an underlying problem that's looking for a place to land And of course, we've got to keep a particular eye out as I've mentioned for abuse, but also fully in the creamer Look, I haven't got time to talk about the two theory technique at the moment There's the way the one picks up therapy with this kind of a problem They're telling us the number of reasons that later and of course Typically given the complexity of this condition and the dependent concern We're looking at longer term work here And when the teenagers that's really a challenge of engagement often it's a matter of finding Therapists who are good at relating to teenagers and looking for doctors, psychologists Because you really need to engage the on a non-going basis and that's kind of require a substantial therapeutic relationship And that's pretty much it for me Thanks very much George and I just want to um, it was really helpful to understand a complexity and the severity that can occur in body dysmorphic disorder and I know that you're by no means saying that Melanie has a body dysmorphic disorder But we need to be keeping that that serious condition can be In the background in someone who's presenting with a case a situation such as Melanie I'm sure Yeah, so I think I would just like to invite Gemma back in quickly. So one of the things that you I just made that comment about that there are other disciplines that that um Maybe appropriate to offer counseling for Melanie and you just made a comment about your app So I just wondered if you wanted to mention that Sure, I suppose Thanks for the opportunity Mary My app is based on my years of research in the field and and how to I suppose adapt CBT principles to address genital concerns specifically But certainly I would be I would encourage anyone any health professional With CBT skills can certainly engage with this app and um, I yeah I I think it would be great to have as many health professionals as possible assisting women with genital appearance concerns Thank you. And just to just to remind everybody that the webinar topic was actually about Both body dysmorphic disorder and counseling for cosmetic surgery So there there are kind of two parallel issues that are very much interwoven And I'd like to bring magda back in and ask you a question magda About you mentioned the guidelines So do you happen to know whether if there was a counselor of another discipline not a gp psychologist or psychiatrist Uh, and perhaps the dp referred a patient to that counselor. Would that meet the would that be Satisfactory to the medical board that was for magda. Do you know that? I'm not sure if I'm on the air yet Mary, but uh, yeah, you are we can get some great Yes, so, uh, if we if we are to interpret the medical board guidelines recommendations to the letter It has to be either a general practitioner a psychologist or a psychiatrist not affiliated with the surgeon who's conducting the surgery However, we are We're quite interested in team care arrangements. So if there were let's say a physiotherapist with pelvic floor interests who had expertise in this particular area as they do let's say with you know pelvic floor Exercisers and incontinence in some cases They may well also be in a position where they could actually advise a patient who's concerned But would that actually constitute an appropriate referral for counseling? If we're to observe the letter of the medical board, no, it would need to be a gp Psychologist or psychiatrist. Thank you. And um, I also wanted to ask you about We know that it's a requirement if somebody's under 18 But how do you make the decision about adult clients? How do you decide if you need to make that referral for them as well? in with respect to adults who are who you if you are, um, Concerned about their psychological state then you should Refer them for further assessment to professionals who could actually diagnose them Um, however, it's not mandatory It's really up to the surgeon themselves then to actually determine the fitness of that particular individual to consent to the procedure And that they have a full understanding of the implications and potential consequences of surgery So it it is important for the gp to actually make an assessment And if the gp has a high level of concern regarding the level of anxiety or any Suggestion or sufficient of body dysmorphic disorders and they should really include that in their referrals to either the surgeon And or recommend the person see a therapist before they proceed to surgery So it's not a mandatory requirement that they actually see a psychologist And I'm guessing in that situation certainly if you had a A therapist with which that patient with whom that patient had a good therapeutic alliance That would be perfectly appropriate if they had some expertise in the area So if they were seeing a social worker and OT a mental health nurse in general counsellor That is a good therapeutic relationship in which to talk about those intimate kind of potentially shame-based concerns Exactly and with major surgery then with adults they all they require really is a seven-day cooling off period so For major surgery whereas for and a minor under the age of 18. They need to have a three month cooling off period before your major surgery George raised a really good question when we were preparing for the webinar. Why is labia plasti class as major surgery? Major surgery is considered anything's involved cutting through the full thickness of the skin Okay, which includes anything technical definition It's a technical definition and it also includes things like liposuction and rhino plasti And also he also asked the question about what are the complications? Complications of labia plasti are as with any surgical procedure. So there's you know, the you know, the immediate potential Complications of infection hemorrhage Deheasants of the wound which is breakdown of the as a suture line There are other complications that can arise because of course the labia minora if it is labia minora that are actually cut They they are They are enriched with a very rich supply of nerve fibres and blood vessels and Sometimes in the healing process the nerve fibres can actually form nodules Which are called neuromas and they can be very very painful Sometimes also the there is too much of the labial tissue is removed and it exposes the clitoral hood which means that the clitoris is constantly exposed to undergarments and Patients can experience chronic pain as a consequence of their clitoris right as it turns their clothes There it can be obviously Change in color there can be irregularities of scar line along with the nodularity and Disasthesia or constant pain so altered sensation reduced sensation or constant pain they are they are complications and The complication rate is anything up to well There there's only one real study that has been conducted over the unit New South Wales which indicates that complication rates are anywhere from 18 to 14 to 8 to 14 percent Which is a significant complication rate Whereas when you look online at surgeons for instance you who perform the surgery they tend to Understate the complication rate and they say you know that they have 98 percent satisfaction satisfied patient Thank you. It's really important for us to get that accurate information and um George I think that I stole your questions there I wanted to bring I apologize for that want to bring you back in with another one So we've had a question from the Before we go on yeah, go on Can I can I just say when Magda ran through what she's just shared with us there You know when we're having a chat about this last week I was really quite stunned at how You know these aren't minor potential complications that we're talking about here Now these are complications that could affect you know a woman's sexual functioning for the years. It's not you know Belong to I don't know how you go about correcting some of those Problems when they are fair And it was yeah, it was really an eye opener to me that this is You know, this isn't just about cutting the last semester skin. What's my long term? Yeah, I found myself sitting listening to it with it with sadness on my face to be honest I can use anyway So George, I wanted to ask you from the audience about whether there's any do you know of any psychometric sort of screening tools for body dysmorphic disorder around any Not just around labial plastic, but just so that Like more generalist colleagues can have a way of identifying it Look, I must nothing that I don't live in the world of psychometric testing as much as Gemma does So maybe I could handle that one off to Gemma. I think that's a great idea Gemma. Can you answer that one? Sure. Yeah, there's actually quite a few patient self-report Psychometric questionnaires that people can give to Patients in the waiting room, which are really short sharp and shiny. There's the cosmetic procedure screening scale So the the labia plastic version of this is in the resources, but there is also the generic version as well There's the body dysmorphic disorder questionnaire bddq again freely available online. Just google it As well as the more structured interviews like from the mini So, yeah, there's definitely screeners out there both for patients and then structured clinical interviews too Thanks, that's really helpful And I I know that there was I will invite you to just add to what Magda was talking around around complications. There was something Sure Yeah, like as Magda was saying the clitoris can definitely become exposed in labia plastic And so what often happens is labia plastic is done together with a clitoral hood reduction Because it can make the the labia look really unbalanced So that's a main reason for people going back for labia plastic revisions that the clitoris actually ends up looking like a Micro penis And people are just really really upset with that outcome. So sometimes labia plastic is offered together With the clitoral hood reduction to avoid that situation, but it can certainly look very very odd down there after labia plastic Yes, it's quite Confronting isn't it and I think it's just it's so refreshing to be able to have a conversation of this nature In such a public forum where people can really ask questions Magda, I know you've got something else to add around that Yes, well, what's interesting is that In many cases women are not aware that the clitoral hood is actually trimmed along with the labia minora when they're actually having their labia minora so-called trimmed and it is really the surgeon who actually makes an aesthetic call at the time of the procedure And that can result in an outcome that the woman didn't actually initially agree to But they don't really fully understand the implications of this Until they have say some Some complications or if they're unhappy with physical appearance now interestingly online in america There is a website which is called www.bachtlabiaplasty and the fellow who actually performs the Labia Plasty revisions is a fellow called Gary Ulter who actually has performed the largest number of labia pasties in the world and he's actually the one that's written to have a lot of the papers on You know wedge resection of the labia minora and he's developed various techniques for this and he openly states that The up to 50 percent of the labia pasties that he sees have actually not been performed by people who have adequate training And that is one very important consideration when a referral is made for this and when meet women are making decisions around this That there are no formal qualifications required to perform this surgery And that anyone who has a medical degree Can actually conduct this surgery and with minimal training And I noticed that you did also specify earlier that if someone is having um You know for example in Melanie's case It it may be a decision that she does go ahead with labia plasty if they are significantly a problem for her and that's What her you know everybody agrees is the right thing you did comment about going to a specialist gynecologist Rather than a general cosmetic surgeon And I guess that's along the lines of what you're saying well Certainly for adolescents the specialist pediatric and adolescent gynecologist is the way to go for the opinion regarding Surgery whether or not it's wanted and there are rare cases where that is wanted And it is really up to that particular Surgeon to make that call along with the parents and the and the child Great, thank you And I I realize we're we're doing talking a lot of sort of technical medical things But I actually think this is often the stuff that as generalists were not aware of It's very helpful and I guess a little along those lines I would like to invite George back just to talk about like how do we If someone is making a decision of of any age let's say it's an adult um How do we know that they're actually giving informed consent? How do you determine that they have capacity to give informed consent the two separate questions, I guess yeah I guess we can we can think about it in terms of looking at capacity as you might for testimony capacity You obviously looking to make sure you know their cognitive ability to impact that they have the intellectual wherewithal to be able to make an evaluation of the option And and when when you're talking to people you want to ask them about you know, how well do they understand? The potential outcomes of course not the positive ones so much as the negative ones How much their capacity to sort of wave these things up and making a decision But you know, I do quite a lot of this kind of work in a different space I work with people who have facility problems and I'm good. We'll come to the sort of counseling end of that And one of the things I've learned over the decades of doing this kind of work is that the simplest thing to do often is to spend time with these people. You don't spend a lot of time but you want to spread out the assessments over time because often people move into a mental position around these things they can put a lot of ego behind And it's all being driven by something which they may or may not even be able to help you get in touch with But if you if you say okay, well, you know You go to all this to take a detail to see if you look at other considerations or other decisions that might need to be considered I find the simplest the most powerful thing to do is to get them back And get them back not you know a week later or two weeks later. There's about three weeks later. That's four weeks later and if if the Everybody will allow this to happen again another three or four weeks later And I just find that most of the time It just falls out. It becomes quite evident You know it's after you know eight weeks of then Seeing different professionals and yourself and they come back and they're still really committed to it And I seem to have a a balanced view of it Then you've got to be much more comfortable about you know recommending my go ahead you know But if you know Six weeks later they often have been gone and things that were issues for them just aren't So as I was thinking about this, I think one of the simplest and most profound things to do Is just to see these people overcome. I love to see medical legal assessment You know, it can be very efficient to see somebody, you know Twice in a week or this week and next week It's much more informative to see them this week and again in three weeks time Because cross-sectionally people are going through whatever they're going through at that point in time And you really want to just allow time to help you out Yeah Thank you. And I I'm also imagining that since since you raised the issue of shame I would think that having someone who's listened empathically not judged them and created a space where they feel safe to talk about it for some people that actually takes the energy out of the issue and so over time you might see that it's Not such a Distressing thing anymore. That's that's a really important point now, you know This is Shame is something that we're I think really finally Recognizing its power as I touched on before but equally When somebody comes along and talks to a professional they often expect to be judged by And I think you know, hopefully as profession, you know, when I say else, I mean all of the healthcare professionals And you know, we're all trained to be non-judgmental But it's very important to make sure that They see that that they're almost, you know Not overplayed but but make it really clear that you know, yeah, you don't really see this as anything to be ashamed about at all And when you do that when it's really surprising how when you see them the next time They've shifted and they've shifted because Of the way in which you responded to them You know in other settings, I bring people in who have been sexually abused and put them in a group therapy And I can tell you one of the most powerful things that happens in group therapy is just that they share this Incredibly shameful secret with other people But who aren't clinicians even better and who don't judge them and just Continue to relate to them as though they're normal human beings after revealing their deeper, starkest secret It's incredibly powerful and you're right just just Just letting them sit and then bring them back and see what they are. You know freely final That's really really helpful and I I wanted to um Bring magta back in because I mean the other thing that helps us create a space where Without shame is also just accurate information So we've had a question from the audience around Where would where would you find an expert surgeon who you can trust who's not just trying to promote their product So magta, how do we find such a person? um And there was another another thing that you raised there about just that I mean I certainly as a dp was not aware of all the complications that you raise So I guess the two questions Um, well, I guess they relate to where do we find a surgeon we can trust? Well, that's a very good question and very often what people will do is they will actually seek information for that online and what they'll find is that there's a host of surgeons to promote themselves as having some outstanding results and and aesthetic outcomes The difficulty with that however is that they actually market themselves as Well, they they see they see patients or they see women as consumers and those patients and and Women will often come to the GP having made some, you know having conducted this sort of research online And they will actually come to the GP and say look, you know, I'm considering having this done. What do you think? now GPs may or may not be equipped to advise the person regarding the Qualifications or the quality of surgery that they're going to have as a particular individual What we do within our own circles as GPs is we talk to one another and we talk to other specialists And we would actually sometimes pick up the phone and speak to someone that we trust and get their opinion on this One might opt to go for a gynecologist who they know has Expertise in the field rather than a plastic surgeon. So, you know, they're a gynecologist to perform the procedure They're a gynecologist to perform the procedure and there is that there is a range outside of the cosmetic surgeons that a GP will actually talk to the patient about A really good tool that's available for doctors is the RGP guide for health professionals on FGCS, which is easily, you know, easy to download And it talks about the complications because often patients will say look, you know, what do you think of this? Do you think that this is a good idea? I'm unhappy And and the list of complications are included in that guide But it has sort of caught GPs unaware because it's a relatively new phenomenon So 20 years ago in, you know, practicing in women's health. These were not discussions I had with patients Women all had pubic hair and now they don't mostly And especially the younger women. So, you know, this exposure of genital tissue to women who've actually never really had a full education Regarding genital anatomy from childhood all the way through to adulthood Then see this other part of themselves as new different and now are being told is abnormal So there's been a surge of interest in this So if caught GPs unaware just as it has caught women in this sort of whole marketing You know Marketing thing that promotes a particular look So that's really Yeah, I mean, I guess that is one of the things about Having much less pubic hair around to see you actually are much more likely to see people's labia Whereas in the past they were more hidden Although women tend to probably not get so much exposure to each other's genitals as Boys do growing up Yeah, I'd like to bring Gemma back in that George talked about the power of groups In reducing shame and I actually wondered whether you're aware of any Online groups or forums or women who have these concerns Sure, Mary there there aren't heaps of groups as you might expect with this I suppose a really sensitive issue of labial appearance concern, but there certainly are some There's the large labia project Where women can actually upload pictures of their labia and and ask if it you know, it looks okay And you know, it's a very very much a body positive block So they're not going to be shamed in any way in fact Labial appearance is celebrated on the large labia project There's also for a bit of a younger audience the scarlet team Which is like I suppose sex ed in the real world And there's some message boards there that people can post questions on and get advice So there are forums out there just not a huge number just yet And Gemma we you know the webinar is also about body dysmorphic disorder in general Do you know if there are such can't such forums for other types of body concern? That's absolutely. There's um, like there's endangered bodies. Um, which is a really excellent positive body image site So I think in terms of more general body image concerns, there's actually more support out there online For people to access Thank you Now I can't believe that we're nearly finished already So Gemma, I'm just going to put you a notice. I'm going to come back to you in a couple of minutes to give us some Final messages. First of all, I'd like to invite George back in So just um in in about one or two minutes Is there a couple of key messages that you would like to leave us with? And I know everyone is going to be inspired to go and look up a lot of this stuff But what would you like us to take away from tonight? George? You know, I was going to uh Obviously highlight the importance of being vigilant for Body dysmorphic disorder and going what to look for in terms of diagnosing it And I think probably people But it was the question before that you asked me Mary about You know the actual evaluative process I think the take on that I would like to offer people is So hadn't I just had thought about who you're asking was just the power of using time to assess somebody You know over a period You know, I think ideally at least three um three sessions to really allow You know clarity is to where this person is at in relation To their concerns about their condition and their desire for I guess in this case surgery. Yeah, I think I really Kind of such a Uh a simple manoeuvre that we can bring to bear on this very very Potentially complex And it's really helpful one thing I haven't mentioned tonight if we always have so many rural and remote practitioners on as well and um Those practical tips that apply to all of us are just invaluable. So thank you so much. Yes I I I have a lot of sympathy for um for our friends and and colleagues and regional and rural Australia I spent a bit of time out there myself and and so often we can talk about the clever, you know, the people we we refer to and and I know that for these, you know These guys and girls that they don't have anybody to refer to and any, you know Anything approaching the abundance that we have in in metropolitan areas. So yeah, I'll see if I can be a lot of practical tips To And I mean the resources are invaluable as well down in there. Yeah, that's right Um, so I'd like to now invite magda just to give us a couple of final comments. Thank you Thanks, mary. Well, actually in agreement with what george said As I mentioned at the beginning of my presentation Really teenagers need longer concentrations. That's a really important thing And it's really important that we listen and let them speak for at least the first three minutes To hear exactly what the range of their issues are and and is and and the consultation is actually an opportunity to educate the person and and Really talk about diversity and the range of normality. So It's the the GP is in a really prime position to provide education to refer to sites that can actually inform the person better And and also the GP has to make an assessment of whether or not this is Sort of a A sort of an abnormal degree of concern or a mild range of anxiety about that results in just ignorance Or whether or not it's actually bordering on some deeper psychosocial Mental health issues that need to be explored further and that of course requires another visit or a referral And examination is also a key part of the consultation with the doctor. So, you know, we we have we have it all really We we have to do the screening. We have to do the listening the assessment And we also had to do the physical examination And with that then offer the appropriate recommendations. So yes for the physical symptoms and signs. Yes But it is about engaging a team. So with the young persons about Involving parents. It's about looking at their history. It's about exposing risk that they're actually facing in their lives and education Thank you so much and I guess with that with that power comes a lot of responsibility and I I'm sure that Well, I know that often young people Can be actually wounded and harmed by things that GPs have said when they didn't understand something properly or didn't know enough so I think your Your thoughts about knowing your scope of practice Downloading the guidelines becoming familiar with this and the fact acknowledging that GPs have been a bit taken on the hot by this And I also was thinking what you said just then was also really valuable for any aspect of cosmetic surgery that You know to to Listen to people's concerns examine them give them accurate information So all of that's really helpful not only for labial plastic that's for anyone seeking cosmetic surgery Thank you so much magda and then um last but definitely not least I'd like to invite jemma back in to just give us your final comments. Thank you Thanks very much mary. So yeah, I agree with magda. Um, definitely giving people the facts And um reassuring them that they are uh, that their anatomy is normal But I think we all know that we can have concerns with normal anatomy. I don't really like my nose, for example But I know it's in the normal range Um, so yeah, what do we what do we do to help people who still have a concern? Even though they know they're normal and that's where we do need to dig a bit deeper And um, give them some other strategies besides cosmetic surgery Because cosmetic surgery is pretty much all about performing on normal anatomy and and improving it So I think um, that's where we all need to um Really understand the roots of people's concerns and design therapy whoever delivers it appropriately to address the where the Where the appearance concern came from in the first place Thank you very much And I would really like to acknowledge the research that both you and magda have done in this area and the contribution It's making to um, the care of our patients in Australia across the discipline so I just want to acknowledge that and It's really actually hard to end this webinar because it's been so informative and engaging But I do have to do that So I'll please invite everybody to complete the survey feedback before you go There's a tab at the top of your screen that you can open to complete that and it does inform The mhpn development of further webinar You will be emailed a certificate of attendance for the webinar within four weeks And you'll also be emailed a link to the online resources associated with the webinar In two weeks and you are of course able to access mhpn webinars in the library Retrospectively and there's a great library of things there We encourage you to join an mhpn network in your local area So remember that there are also face-to-face networks and you can see the link there to find out what's in your area In fact, if you want to start one you can contact mhpn And for more information about them, please go to that website And I just want to thank over 800 people for staying online with us tonight And thank you for everyone's contribution and participation. Good night