Female Genital Mutilation and Clitoral Reconstructive Surgery

Female Genital Mutilation (FGM) is a practice by various cultures in a number of countries of Africa, Asia, and now immigrant locations including Europe and Australia. There are four types of FMG (also sometimes referred to as FGM/C where the C denotes that the mutilation has been done by cutting).

  • Type I is the excision of the prepuce with or without the excision of the whole clitoris.
  • Type II is the excision of the entire clitoris with or without the scraping or removal of the labia minora.
  • Type III involves the excision of all or part of the external genitalia including the clitoris and labia minora and infibulation (the stitching together of the vulva).
  • Type IV includes the pricking, piercing, cauterization, or incision of the clitoris or labia; the scraping of the tissue surrounding the vaginal orifice or cutting of the vaginal wall; and the introduction of corrosive chemicals or herbs into the vagina to cause tightening and narrowing of the vagina.

These mutilative practices are thought to have been around since the ancient times of the Egypt and the Arab world and today it is estimated that two million girls undergo a form of this mutilative procedure each year, usually between the ages of five to nine years.

While many women choose this ritualistic procedure to agree with their cultural traditions and for acceptance and initiation within their societies as “true women,” there are often many health risks and complications with the procedure. Immediate consequences include infection, hemorrhage, shock and death. Long term consequences include abscess, scars, neuromas, keloid and dermoid cysts, urinary incontinence, dysmenorrhea, vaginal stenosis, and general pain and loss of sensation, just to name a few. Many women end up feeling like the procedure has stolen their female identity.

Luckily, for the women who have undergone FGM and who now wish to reverse it, clitoral reconstructive surgery exists. This reconstructive procedure is being practiced and outcomes are being studied, most notably in various regions of France. The research studies that have come out of this look at how FGM affects the lives of women who have undergone FGM compared to women who have not undergone FGM, as well as the before and after quality of life of FGM women who receive the reconstructive clitoral surgery.

ExH Study

A study published in 2014 compared self-perceived health surveys of women who had not undergone FGM to women who had undergone FGM. The ExH (Excision and Handicap) is a cross-sectional survey created to document the past and current situation of women with FGM as compared to that of women who have not been affected. The “situation” is delineated by socioeconomic background, reproductive life and sexuality, lesions, functional disorders and other long term consequences of FGM.

A total of 2,882 women were given the survey. They were not asked their FGM status until the end of the survey in order to preserve the openness of their responses for the previous questions. From that response, the women were grouped to either an FGM group or a non-FGM/control group. Data was collected over two years in various regions of France where there are high populations of people from FGM performing countries. The final study consisted of 678 FMG cases and 1,706 non-FGM controls. Women in both groups were similar in age, marital status and migratory status. Questions asked on the questionnaire included their type of FGM as well as other health indicators.

The results showed that the group of women who underwent FGM experienced forced marriage at twice the rate at which the non-FGM women did. The FGM group had a greater number of children and a greater age difference to their partner than did the control group. The FGM group was also more significantly associated with increased risks of urinary or gynecological infections, fatigue, headaches and episodes of intense pain. As far as sexual life goes, the FGM group had significantly higher scores for painful first intercourse, unsatisfactory sexual life, frequent pain, lack of desire and burning sensation during intercourse. For daily life affects, the FGM group was at significantly greater risk by reports for limitations in work or domestic activities. During childbirth, the FGM group had greater instances of tearing after delivery. To determine accuracy of physical reports, as per consent allowed, women were asked to seek gynecological examinations and have their doctors fill out forms reporting the status of FGM as well as any other diagnosed conditions.

FGM and Sexual Function in Women

Another study has compared sexual function in women with FGM before and after their surgeries. A total of 12 women were included, nine of whom had previously undergone Type II mutilations. The type of mutilations of the remainder of the women in the study were unspecified by the research article. The women ranged from 27–36 years of age. The majority of the women (nine) came from Guinea and the rest were unspecified. Before the women received their reconstructive surgery, each completed a FSFI (Female Sexual Function Index) questionnaire. This questionnaire included questions optimally illustrating desire, arousal, lubrication, orgasm, satisfaction and pain.

Prior to the surgery, the average or global sexual dysfunction score was 17 out of a possible total of 36 – the lower the number, the more severe the female sexual dysfunction. The general consensus among researchers is that a score of 23 is the pertinent threshold. These results also showed that eight women had nonexistent clitoral sensation before the surgery. Other notable categories of dysfunction were desire, arousal, orgasm and pain. Eleven women were unhappy with the appearance of their genitalia, only seven had a sense of femininity, and five felt symptoms of depression. All surgeries had no adverse events except for one, in which a hematoma developed.

The FSFI questionnaire was again given at three months post surgery and six months post surgery along with an additional questionnaire rating clitoral sensations, symptoms of depression and anxiety and self esteem. At three months, the FSFI did not significantly change with a mean score of 25 (a range of 7-28 among the women). By six months post-surgery the mean FSFI had reached significant improvement with a score of 29 (range of 24-34) with none being below the threshold of 23. All categories improved except for the lubrication category. A total of 10 of the 12 women now had clitoral sensation and 11 were satisfied with their surgery (satisfied with the appearance of their genitalia and their sense of femininity). Only two women noted a decrease in their symptoms of depression.

FMG Women and Reconstructive Surgery

A third study took place over an 11 year span in France with women of FMG who consulted doctors at the Poissy-St Germain Hospital for reconstructive surgery. A total of 2,938 women were studied and operated on. These women had either Type II or Type III (with clitoral excision) mutilations. The actual operation consisted of creating an incision over the clitoral shaft, resecting the overlying skin from the clitoral stump, the sectioning of the suspensory ligament very close to the bone in order to mobilize the stump, the removal of scar tissue, and the bringing forward to a normal position of the glans clitoris. This procedure was done carefully to preserve the neurovascular bundle. The majority of these women were from the countries of Mali, Senegal and the Ivory Coast, though many had their mutilations performed within France.

Prior to their surgeries, these women completed a questionnaire and it was determined that 99 percent of the women expected identity recovery/the gaining back of their autonomy from this procedure that was imposed on them as children, Eighty-one percent expected an improved sex life and 28 percent expected pain reduction.

A follow up was conducted one year post-surgery, but only 866 of the women returned for it. At this follow up 42 percent of the women had a hoodless glans, 28 percent had a normal clitoris, 24 percent had a visible projection, six percent had a palpable projection and 0.4 percent (three women) had no change. Almost all of the women reported improvements with pain. 815 of 834 reported clitoral pleasure. 430 of 841 reported experiencing orgasm – of these, 129 were experiencing an orgasm for the very first time. On the downside, 20 patients reported that they had decreased clitoral pleasure after the surgery.

Although this study did not have a validated sensation and pain scale, they did use a pleasure scale that was clarified. For example, the options for pleasure were on the scale of “no sensation,” “minor sensation,” “pleasant without orgasm,” “restricted orgasm” and “normal orgasm.” Only minor complications occurred immediately after the surgery to five percent of the women. These complications included hematoma, suture failure and/or moderate fever.

An interesting correlation found was that the age of clitoral excision was related to the amount of preoperative pain experienced by the woman – women who had their clitoris removed at an older age (i.e. nine years rather than five years old) reported more pain before their operation. What these studies indicate is that women with female genital mutilation do indeed have a generally decreased quality of sexual life as well as a decreased sense of well-being compared to women who were not affected by genital mutilation.

These studies also show that the use of reconstructive surgery can significantly increase the quality of life in many areas including the ability to feel pleasure, the regaining of female identity and autonomy and the decrease of pain and thus a decrease in the interference of everyday life activities. Every woman should be given the education and options for the condition of her genitalia. While she may not have been able to make her own choice as a child, the options now exist for her to regain what she lost – a very empowering decision.

As a side note – since 2004 France has been offering all women with FGM/C, with total or partial excision of the clitoris, reconstructive surgery for free.

Author: Deanna Doctor