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Almadori A, Palmieri S, Coho C, Evans C, Elneil S, Albert J. Reconstructive surgery for women with female genital mutilation: A scoping review. BJOG 2024; 131:1604-1619. [PMID: 38923662 DOI: 10.1111/1471-0528.17886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/24/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Female genital mutilation (FGM) is a global public health concern. However, reconstructive surgery remains unavailable in many countries. OBJECTIVES This scoping review, guided by Joanna Briggs Institute (JBI) principles, explores indications, referral routes, eligibility, care pathways and clinical outcomes of reconstructive surgery for FGM. SEARCH STRATEGY Medical Subject Headings (MeSH) terms and subject headings were searched in EMBASE, MEDLINE, SCOPUS, Web of Science and publicly available trial registers. SELECTION CRITERIA Any primary experimental and quasi-experimental study addressing reconstructive surgery for FGM, and its impact on women, published before June 2023. DATA COLLECTION AND ANALYSIS After removing duplicates from the search results, titles and abstracts were screened and data were extracted. Disagreements were resolved through panel discussion. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram depicts the search results and inclusion process. MAIN RESULTS A total of 40 studies were included. Multidisciplinary teams were involved in 40% (16/40) of the studies, and psychosexual counselling was offered in 37.5% (15/40) of studies. Clitoral reconstruction using Foldes' technique was predominant (95%, 38/40). A total of 7274 women underwent some form of reconstruction. Post-surgery improvement was reported in 94% of the cases (6858/7274). The complication rate was 3% (207/7722 women with reconstruction). CONCLUSIONS Further research and clinical trials are needed. Although the outcomes suggest improved sexual function and quality of life post-surgery, the evidence remains limited. Advocating surgical reconstruction for survivors of FGM is vital for addressing health disparities and potential cost-effectiveness.
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Affiliation(s)
- Aurora Almadori
- Division of Surgery and Interventional Science, University College of London, London, UK
- Department of Plastic Surgery, NHS Royal Free Hospital London Trust, London, UK
| | - Stefania Palmieri
- University College London, Hospitals NHS Foundation Trust, London, UK
| | | | - Catrin Evans
- The Nottingham Centre for Evidence Based Healthcare, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Soheir Elneil
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Juliet Albert
- University of Nottingham, Nottingham, UK
- Division of Womens, Children and Clinical Support, Imperial College Healthcare NHS Trust (ICHNT), London, UK
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von Fritschen U, Strunz C, Scherer R, Fricke A. Sensitivity after Clitoral Reconstruction in Patients with Female Genital Mutilation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5851. [PMID: 38881961 PMCID: PMC11177814 DOI: 10.1097/gox.0000000000005851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/08/2024] [Indexed: 06/18/2024]
Abstract
Background In the past decades, reconstructive choices after female genital mutilation extended beyond de-infibulation and scar release. The current trend to expand techniques addressing sexual and aesthetic aspects by reconstructing the clitoris and prepuce, and dissecting the clitoral nerves raises concern, as there is a paucity of evidence on the functional outcomes and suspected iatrogenic lacerations. Methods A total of 128 female genital mutilation patients were included in the study. To evaluate clitoral sensitivity after elevation, the Semmes-Weinstein-monofilament test was performed before and after genital reconstruction. Results Preoperatively, patients with a visually intact clitoris showed significantly better sensitivity compared with patients with a mutilated clitoris or infibulation (P < 0.0001). Surgery was performed in 84 patients. After clitoral reconstruction (CR), 70 of 73 patients were able to perceive 2.83 monofilaments (95.9%), whereas three perceived 3.61. Patients with a visually intact clitoris served as control, and 95.0% perceived 2.83 monofilaments. We showed a significant improvement of clitoral sensitivity (P = 0.0020) in the subgroup consisting of patients with a mutilated clitoris in whom the test was performed before and after reconstruction. Conclusions Clitoral sensitivity improves significantly after CR. Seventy of 73 patients attained the same sensitivity as unharmed women. No patient showed a decreased sensitivity compared with their preoperative findings. Therefore, our study supports the argument that CR offers sufficient improvement of objective clitoral sensitivity without additionally addressing clitoral nerves.
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Affiliation(s)
- Uwe von Fritschen
- From the Department of Plastic and Aesthetic Surgery, Hand Surgery, HELIOS Hospital Emil von Behring, Berlin, Germany
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - Cornelia Strunz
- Desert Flower Center, Center of Colorectal and Pelvic Floor Surgery, Hospital Waldfriede, Berlin, Germany
| | - Roland Scherer
- Desert Flower Center, Center of Colorectal and Pelvic Floor Surgery, Hospital Waldfriede, Berlin, Germany
| | - Alba Fricke
- From the Department of Plastic and Aesthetic Surgery, Hand Surgery, HELIOS Hospital Emil von Behring, Berlin, Germany
- Department of Plastic and Hand Surgery, University of Freiburg Medical Centre, Medical Faculty of the University of Freiburg, Freiburg, Germany
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Albert J, Wells M, Spiby H, Evans C. Examining the key features of specialist health service provision for women with Female Genital Mutilation/Cutting (FGM/C) in the Global North: a scoping review. Front Glob Womens Health 2024; 5:1329819. [PMID: 38840583 PMCID: PMC11150566 DOI: 10.3389/fgwh.2024.1329819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 05/07/2024] [Indexed: 06/07/2024] Open
Abstract
Background Health care for women with Female Genital Mutilation/Cutting (FGM/C) in the Global North is often described as sub-optimal and focused on maternity care. Specialist FGM/C services have emerged with little empirical evidence informing service provision. The objective of this scoping review is to identify the key features of FGM/C specialist care. Methods The review was conducted in accordance with JBI methodology. Participants: organisations that provide specialist FGM/C care. Concept: components of specialist services. Context: high-income OECD countries. Eligibility criteria included primary research studies of any design from 2012 to 2022, providing a comprehensive description of specialist services. Seven bibliographic databases were searched (MEDLINE, EMBASE, CINAHL, Web of Science, SCOPUS, Cochrane Library and MIC). The components of "specialist" (as opposed to "generalist") services were defined and then applied to an analysis of FGM/C specialist care. FGM/C specialist provision was categorised into primary (essential) and secondary features. Data were extracted and analysed descriptively through charting in tables and narrative summary. Results Twenty-five papers described 20 unique specialist services across eleven high income countries. Primary features used to identify FGM/C specialist care were:-(i) Named as a Specialist service/clinic: 11/20 (55%); (ii) Identified expert lead: 13/20, (65%), either Midwives, Gynaecologists, Urologist, or Plastic Surgeons; (iii) Offering Specialist Interventions: surgical (i.e., reconstruction and/or deinfibulation) and/or psychological (i.e., trauma and/or sexual counselling); and (iv) Providing multidisciplinary care: 14/20 (70%). Eleven services (in Spain, Sweden, Switzerland, Germany, Italy, Netherlands, France, Belgium, and USA) provided reconstruction surgery, often integrated with psychosexual support. No services in UK, Norway, and Australia offered this. Six services (30%) provided trauma therapy only; 25% sexual and trauma therapy; 15% sexual therapy only; 30% did not provide counselling. Secondary features of specialist care were subdivided into (a) context of care and (b) the content of care. The context related to concepts such as provision of interpreters, cost of care, community engagement and whether theoretical underpinnings were described. Content referred to the model of care, whether safeguarding assessments were undertaken, and health education/information is provided. Conclusion Overall, the features and composition of FGM/C specialist services varied considerably between, and sometimes within, countries. Global guidelines advocate that specialist care should include access to deinfibulation, mental health support, sexual counselling, and education and information. The review found that these were rarely all available. In some high-income countries women cannot access reconstruction surgery and notably, few services for non-pregnant women mentioned safeguarding. Furthermore, services for pregnant women rarely integrated trauma therapy or psychosexual support. The review highlights a need for counselling (both trauma and psychosexual) and culturally-appropriate sensitive safeguarding assessments to be embedded into care provision for non-pregnant as well as pregnant women. Further research is needed to extract the features of specialist services into a comprehensive framework which can be used to examine, compare, and evaluate FGM/C clinical specialist care to determine which clinical features deliver the best outcomes. Currently a geographical lottery appears to exist, not only within the UK, but also across the Global North.
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Affiliation(s)
- Juliet Albert
- University of Nottingham and Division of Womens, Children and Clinical Support, Imperial College Healthcare NHS Trust (ICHNT), London, United Kingdom
| | - Mary Wells
- Nursing Directorate, Department of Surgery and Cancer, Imperial College Healthcare NHS Trust (ICHNT), Imperial College London, London, United Kingdom
| | - Helen Spiby
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Catrin Evans
- The Nottingham Centre for Evidence Based Healthcare, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, United Kingdom
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von Fritschen U, Strunz C, Scherer R, von Fritschen M, Fricke A. Postoperative Course of Reconstructive Procedures in FGM Type III-Proposal for a Modified Classification of Type III Female Genital Mutilation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4439. [PMID: 36901456 PMCID: PMC10002091 DOI: 10.3390/ijerph20054439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Reconstruction after female genital mutilation (FGM) has developed from being merely a therapy for complications to addressing body perception and sexuality. However, evidence regarding a direct correlation between FGM and sexual dysfunction is scarce. The present WHO classification provides an imprecise grading system, which makes it difficult to compare present studies with treatment outcomes. The aim of this study was to develop a new grading system based on a retrospective study of Type III FGM, evaluating operative time and postoperative results. METHODS The extent of clitoral involvement, operative time of prepuce reconstruction and lack of prepuce reconstruction, and postoperative complications of 85 patients with FGM-Type III were retrospectively analyzed at the Desert Flower Center (Waldfriede Hospital, Berlin). RESULTS Even though universally graded by the WHO, large differences in the degree of damage were found after deinfibulation. In only 42% of patients, a partly resected clitoral glans was found after deinfibulation. There was no significant difference in operative time when comparing patients who required prepuce reconstruction and patients who did not (p = 0.1693). However, we found significantly longer operative time in patients who presented with a completely or partly resected clitoral glans when compared to patients with an intact clitoral glans underneath the infibulating scar (p < 0.0001). Two of the 34 patients (5.9%) who had a partly resected clitoris required revision surgery, while none of the patients in whom an intact clitoris was discovered under the infibulation required revision. However, these differences in the complication rates between patients with and without a partly resected clitoris were not statistically significant (p = 0.1571). CONCLUSIONS A significantly longer operative time was found in patients who presented with a completely or partly resected clitoral glans when compared with patients with an intact clitoral glans underneath the infibulating scar. Furthermore, we found a higher, though not significantly significant, complication rate in patients with a mutilated clitoral glans. In contrast to Type I and II mutilations, the presence of an intact or mutilated clitoral glans underneath the infibulation scar is not addressed in the present WHO classification. We have developed a more precise classification, which may serve as a useful tool when conducting and comparing research studies.
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Affiliation(s)
- Uwe von Fritschen
- Department of Plastic and Aesthetic Surgery, Hand Surgery, HELIOS Hospital Emil von Behring, Walterhöferstr. 11, 14165 Berlin, Germany
| | - Cornelia Strunz
- Desert Flower Center, Center of Colorectal and Pelvic Floor Surgery, Hospital Waldfriede, Argentinische Allee 40, 14163 Berlin, Germany
| | - Roland Scherer
- Desert Flower Center, Center of Colorectal and Pelvic Floor Surgery, Hospital Waldfriede, Argentinische Allee 40, 14163 Berlin, Germany
| | - Marisa von Fritschen
- Department of Plastic and Aesthetic Surgery, Hand Surgery, HELIOS Hospital Emil von Behring, Walterhöferstr. 11, 14165 Berlin, Germany
| | - Alba Fricke
- Department of Plastic and Aesthetic Surgery, Hand Surgery, HELIOS Hospital Emil von Behring, Walterhöferstr. 11, 14165 Berlin, Germany
- Department of Plastic and Hand Surgery, University of Freiburg Medical Centre, Medical Faculty of the University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
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Tognazzo E, Berndt S, Abdulcadir J. Autologous Platelet-Rich Plasma in Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: A Pilot Case Study. Aesthet Surg J 2023; 43:340-350. [PMID: 36251970 DOI: 10.1093/asj/sjac265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/07/2022] [Accepted: 10/07/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Postoperative healing after clitoral reconstruction (CR) for female genital mutilation/cutting can be long and painful due to prolonged clitoral re-epithelialization time (up to 3 months). Autologous platelet-rich plasma (A-PRP) might reduce postoperative clitoral epithelialization time and pain. OBJECTIVES The authors assessed postoperative clitoral re-epithelialization time and pain after intraoperative clitoral administration of A-PRP. METHODS Five consecutive women underwent CR (Foldès technique) followed by the administration of A-PRP Regen Lab SA (Le Mont-sur-Lausanne, Switzerland) plasma and glue, injected inside and applied above the re-exposed clitoris, respectively. We recorded surgical complications, postoperative clitoral pain (visual analogue scale), painkiller intake, time to complete re-epithelialization, and the experienced subjective changes in sexual response and perception of their own body image referred by women. RESULTS Sexual distress/dysfunction as well as the desire to be physically and symbolically "repaired" were the reasons behind women's requests for surgery. None of the women suffered from chronic vulvar or non-vulvar pain. All women achieved complete clitoral epithelialization by day 80, 3 women between day 54 and 70, and only 1 woman was still taking 1 g of paracetamol twice a day at 2 months postoperative. She had stopped it before the 3-month control. There were no short- or long-term complications. All women described easier access and stimulation of their clitoris as well as improved sexual arousal, lubrication, and pleasure and claimed to be satisfied with their restored body image. CONCLUSIONS A-PRP could expedite postoperative clitoral epithelialization and reduce postoperative pain after CR after female genital mutilation/cutting. LEVEL OF EVIDENCE: 4
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Gutierrez-Ontalvilla P, Andjelkov K, Ruiz-Valls A. Invited Discussion on: Clinical and Patient Reported Outcomes of 19 Patients Undergoing Clitoral and Labial Reconstruction After Female Genital Mutilation/Cutting. Aesthetic Plast Surg 2022; 46:478-479. [PMID: 34859272 DOI: 10.1007/s00266-021-02696-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 11/21/2021] [Indexed: 11/30/2022]
Affiliation(s)
- P Gutierrez-Ontalvilla
- Department of Plastic and Reconstructive Surgery, La Fe University Hospital, Tower E, 2th Floor, 106 Avenida Abril Martorell, 46026, Valencia, Spain.
| | - K Andjelkov
- Faculty of Medicine and BelPrime Clinic, University of Belgrade, Belgrade, Serbia
| | - A Ruiz-Valls
- Department of Plastic and Reconstructive Surgery, La Fe University Hospital, Tower E, 5th Floor, 106 Avenida Abril Martorell, 46026, Valencia, Spain
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