Reconstructive Surgery Corrects Female Genital Mutilation

Steven Fox

June 11, 2012

June 11, 2011 — Reconstructive surgery appears to reduce pain and increase sexual pleasure in women who had undergone genital mutilation, according to results from the first large prospective cohort study to assess long-term outcomes of the technique. The study was published online June 12 in the Lancet.

Pierre Foldès, MD, from Poissy Saint Germain Hospital in Laye, France, helped develop the procedure and coauthored the Lancet report.

Almost 98% of the woman experienced an increase in sexual pleasure after the surgery, and 98% also reported an improvement in pain, or at least no worsening.

"Women who have undergone female genital mutilation [FGM] rarely have access to the reconstructive surgery that is now available," the authors write. "Our objective was to assess the immediate and long-term outcomes of this surgery."

It is estimated that between 130 and 140 million women have undergone FGM during the past decade, more than 90 million of them in Africa. The practice, which is usually carried out for religious or cultural reasons, is also common among immigrant communities in North America and Europe.

In addition to exacting emotional and psychosexual costs, genital mutilation can also be deadly. In some areas of Africa where antibiotics are unavailable, about a third of girls who undergo mutilation die from infectious complications, the authors note.

In this prospective study, researchers enrolled 2938 consecutive female patients who underwent reconstructive surgery from 1998 to 2009 in the Poissy Saint Germain Hospital. The mean age of the women was 29.2 years, and all had been subjected to either type 2 or type 3 mutilation, as defined by World Health Organization criteria.

According to the WHO, type 2 FGM involves partial or total removal of the clitoris glans and the labia minora, with or without excision of the labia majora (excision). Type 3 corresponds to narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).

Most of the women who took part in the study were from Mali, Senegal, and Ivory Coast. However, 564 of the participants had undergone FGM in France.

The authors explain their corrective surgical technique as follows: "The skin covering the stump was resected to reveal the clitoris. The suspensory ligament was then sectioned to mobilise the stump, the scar tissue was removed from the exposed portion and the glans was brought into a normal position."

Before surgery, the women completed a questionnaire about their individual characteristics, their expectations regarding the surgery, and the degree of clitoral pleasure or pain they had been experiencing since undergoing FGM.

In response to the questionnaire, 99% of the women said they were hoping the surgery would help in recovery of their sexual identity, 81% said they had expectations of improved sex life, and for almost a third of the patients (29%) reduction in pain was a primary aim in undergoing surgery.

One year after undergoing the procedure, 866 of the women (29%) returned for follow-up exams. During that appointment, they were again asked about their current levels of pain and functionality.

Of those, 363 women (42%) were observed to have a hoodless glans, 239 (28%) had a normal clitoris, 210 (24%) had a visible projection, 51 (6%) had a palpable projection, and 3 (0.4%) had experienced no change.

Moreover, virtually all of the women who had a follow-up exam and responded to questions reported improvements or at least no worsening of pain (821/840; 97.7%). In addition, 815 (97.7%) of 834 of the women reported improvements in clitoral pleasure. Just under half of the women (407/840; 48%) said they were experiencing orgasms.

There were some complications associated with the procedure. About 5% of patients experienced problems soon after surgery, including hematomas, failure of sutures, or fever, and 4% of women who underwent surgery were briefly readmitted to hospital, the authors report.

"Clitoral reconstruction after female genital mutilation is feasible," they write. They add that it can improve women's pleasure, lessen their pain, and help them recover their sexual identity.

"Reconstructive surgery needs to be made more readily available in developed countries by trained surgeons," they conclude.

In a comment linked to the study, Jasmine Abdulcadir, MD, from the Department of Obstetrics and Gynecology, University Hospitals of Geneva, Switzerland, and colleagues agree on the need for better-informed patients and practitioners.

However, they emphasize that FGM is a complex issue, and that even though some progress has been made in reducing FGM, significant efforts are still needed to change such a long-established traditional practice.

"Cultural education and specific training of medical professionals are lacking in many countries," they write. When that is the case, they add, women with FGM rarely hear about remedial procedures that are available.

The commentators conclude, "Prevention and good quality care of complications associated with [FGM/cutting] require a multidisciplinary team approach by well trained and respectful medical professionals, including psychologists, sexologists, urologists, obstetricians, gynaecologists, and pediatricians."

The authors and the commentators have disclosed no relevant financial relationships.

Lancet. Published online June 12, 2012. Abstract

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