Sexual Anatomy and Function in Women With and Without Genital Mutilation: A Cross-Sectional Study

Neoclitoral location may affect sexual function in transgender women: a preliminary pelvic MRI study

Assigned female at birth with anorgasmia possess a smaller clitoral glans and clitoral components farther from the vagina lumen than women with normal orgasmic function. There are no studies evaluating this correlation in operated transgender women. We evaluated whether differences in MRI measurements of neoclitoris volume and distance between the neoclitoris and the neovagina were correlated with differences in sexual function. We recruited for a prospective survey study 40 operated male to female patients (oMtF) who had undergone genital gender affirming surgery and postoperative pelvic MRI. Individual pelvic MRIs were reviewed by two blinded investigators, the three axes of the neoclitoris were measured and the volume was calculated using the ellipsoid formula. The distance between the neoclitoris and the neovagina was also measured. Sexual functioning was assessed using the Female Sexual Function Index (FSFI) and the operated Male to Female Sexual Function Index (oMtFSFI). Mean scores differences in FSFI, oMtFSFI were examined; associations with clitoral size, location, sexual functioning and demographical variables were investigated as well. The response rate was 55%, 11 MtFs operated with pubic neoclitoris technique (PNT) and 11 with neo-urethroclitoroplasty according to Petrović (NCP). The NCP group presented a neoclitoris mean volume of 1.04 (SD 0.39) cc vs 1.31 (SD 0.78) cc of the other group (p = 0.55). The mean distance between neoclitoris and neovagina was 4.20 (SD 0.57) cm in the PNT group and 2.55 (SD 0.45) in the NCP group (p < 0.001). Patients who had undergone NCP achieved a higher FSFI and oMtFSFI mean Total Score than those operated with the previous technique (FSFI 25.81 SD 3.02 vs 18.62 SD 9.92 p = 0.08; oMtFSFI 37.63 SD 8.28 vs 43.36 SD 13.02 p = 0.23). According to pelvic MRI measurements, this study suggests a correlation between neoclitoral location and oMtF sexual satisfaction.

Sensitivity after Clitoral Reconstruction in Patients with Female Genital Mutilation

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.

Beyond the tip of the iceberg: A meta-analysis of the anatomy of the clitoris

An understanding of ranges in clitoral anatomy is important for clinicians caring for patients including those who have had female genital mutilation, women seeking genital cosmetic surgery, or trans women seeking reconstructive surgery. The aim of this meta-analysis is to investigate the ranges in clitoral measurements within the literature. A meta-analysis was performed on Ovid Medline and Embase databases following the PRISMA protocol. Measurements of clitoral structures from magnetic imaging resonance, ultrasound, cadaveric, and living women were extracted and analyzed. Twenty-one studies met the inclusion criteria. The range in addition to the average length and width of the glans (6.40 mm; 5.14 mm), body (25.46 mm; 9.00 mm), crura (52.41 mm; 8.71 mm), bulb (52.00 mm; 10.33 mm), and prepuce (23.19 mm) was calculated. Furthermore, the range and average distance from the clitoris to the external urethral meatus (22.27 mm), vagina (43.14 mm), and anus (76.30 mm) was documented. All erectile and non-erectile structures of the clitoris present with substantial range. It is imperative to expand the literature on clitoral measurements and disseminate the new results to healthcare professionals and the public to reduce the sense of inadequacy and the chances of iatrogenic damage during surgery.

Our Body Our Health (Jirkeena, Caafimaadkeena): Somali Women's Narratives on Sexual Health

Women across the globe have been subject to female genital cutting (FGC), with the highest rates in Somalia. FGC can result in sexual concerns, especially sexual pain and lower pleasure. Due to ongoing civil war and climate disasters, there is a large number of Somali immigrants and refugees living in countries where healthcare providers may be unfamiliar with the impact of FGC. In this qualitative study, sixty Somali women between the ages 20 and 45 and living in the U.S. shared their perspectives on how FGC has affected their sexual lives, including how they have coped with any complications attributed to FGC. Participants were recruited through convenience sampling and interviewed by a bilingual community researcher in either Somali or English. Data were analyzed through a participatory analysis process by academic and community researchers. Themes included sexual desire, arousal, and pleasure; sexual satisfaction; sexual pain at first intercourse; coping with sexual pain at first intercourse; long-term sexual pain, coping with long-term sexual pain. Results are discussed with a focus on agency of the participants, role of partners, and implications for healthcare professionals.

Beautiful vulvas: expanding illustrative visual imagery of female genital cutting types

BACKGROUND

Visual imagery has been used to educate healthcare providers, patients, and the lay public on female genital cutting (FGC) typology and reconstructive procedures. However, culturally inclusive, diverse, and anatomically accurate representation of vulvas informed by women possessing lived experience of FGC is lacking.

AIM

We sought to apply World Health Organization (WHO) FGC typology to the development of type-specific visual imagery designed by a graphic artist and culturally informed by women with lived experience of FGC alongside a panel of health experts in FGC-related care.

METHODS

Over a 3-year process, a visual artist created watercolor renderings of vulvas with and without FGC across varying WHO types and subtypes using an iterative community-based approach. Somali women possessing lived experience of FGC were engaged alongside a team of clinician experts in FGC-related care. Women and clinicians provided descriptive input on skin color variation, texture, and skin tone, as well as the visual depiction of actions necessary in conducting a genital examination.

OUTCOMES

A series of vulvar anatomic illustrations depicting WHO FGC typology.

RESULTS

FGC types and subtypes are illustrated alongside culturally informed descriptors and clinical pearls to strengthen provider competency in the identification and documentation of FGC WHO typology, as well as facilitate patient education, counseling, shared decision making, and care.

CLINICAL IMPLICATIONS

Ensuring equitable representation of race, gender, age, body type, and ability in medical illustrations may enhance patient education, counseling, and shared decision making in medical and/or surgical care. FGC provides a lens through which the incorporation of patient-informed and culturally relevant imagery and descriptors may enhance provider competency in the care of FGC-affected women and adolescents.

STRENGTHS AND LIMITATIONS

The strengths of this study include the development of visual imagery through an iterative community-based process that engaged women with lived experience of FGC alongside clinicians with expertise in FGC-related care, as well as the representation of historically underrepresented bodies in the anatomical literature. Study limitations include the lack of generalizability to all possible forms or practices of FGC given the focus on one geographically distinct migrant community, as well as the reliance on self-report given the inability to clinically verify FGC status due to the community-based methodology employed.

CONCLUSION

Patient-informed and culturally representative visual imagery of vulvas is essential to the provision of patient-centered sexual health care and education. Illustrations developed through this community-engaged work may inform future development of visual educational content that advances equity in diverse representation of medical illustrations.

Female genital cutting (FGC) type: proposing a multifaceted, interactive method for FGC self-assessment

BACKGROUND

Self-reporting female genital cutting (FGC) status and types by patients and clinicians is often inconsistent and inaccurate, particularly in community settings where clinically verifiable genital exams are not feasible or culturally appropriate.

AIM

In this study we sought to discern whether integrating multiple dimensions of participant engagement through self-reflection, visual imagery, and iterative discourse informed the determination of FGC status by a panel of health and cultural experts using World Health Organization (WHO) typology.

METHODS

Using community-based participatory research, we recruited 50 Somali women from the Minneapolis-St. Paul, MN, metropolitan area through convenience and snowball sampling to participate in semi-structured interviews. Participants were asked to discuss their recollection of their original circumcision-including the procedure itself and their assessment of the type of circumcision they experienced. Anatomical drawings of uncircumcised and circumcised vulvas were shown to participants to assist them in identifying their FGC type. A panel of health and cultural experts reviewed and independently assessed participant FGC type. Interrater reliability and degree of concordance between participants and panel were determined.

OUTCOMES

Outcomes included the following: (1) development of WHO-informed, anatomically accurate visual depictions of vulvas representing FGC typology, (2) development of an iterative, self-reflective process by which participants self-described their own FGC status aided by visual depictions of vulvas, (3) application of WHO FGC typology by a panel of health and cultural experts, and (4) determination of the degree of concordance between participants and panel in the classification of FGC type.

RESULTS

High interrater reliability (kappa = 0.64) and concordance (80%) between panel and participants were achieved.

CLINICAL TRANSLATION

Incorporation of FGC visual imagery combined with women's empowered use of their own self-described FGC status would optimize clinical care, patient education, and informed decision making between patients and their providers when considering medical and/or surgical interventions, particularly among women possessing limited health and anatomic literacy.

STRENGTHS AND LIMITATIONS

Strengths of this study include the incorporation of anatomically accurate visual representations of FGC types; the iterative, educational process by which participants qualitatively self-described their FGC status; and the high interrater reliability and concordance achieved between panel and participants. Study limitations include the inability to conduct clinical genital exams (due to the community-based methodology used), recall bias, and small sample size (n = 50).

CONCLUSION

We propose a new patient-informed educational method for integrating anatomically accurate visual imagery and iterative self-reflective discourse to investigate sensitive topics and guide clinicians in providing patient-centered, culturally informed care for patients with FGC.

Health Care Providers' Readiness to Adopt an Interactive 3D Web App in Consultations About Female Genital Mutilation/Cutting: Qualitative Evaluation of a Prototype

BACKGROUND

Comprehensive and appropriate health care provision to women and girls with female genital mutilation or cutting (FGM/C) is lacking. Use of visuals in health care provider (HCP) consultations facilitates the communication of health information and its comprehension by patients. A web app featuring a 3D visualization of the genitourinary anatomy was developed to support HCPs in conferring clinical information about FGM/C to patients.

OBJECTIVE

The aim of this study was to explore HCP perspectives on the use of visuals in discussion about FGM/C with their patients as well as to obtain their feedback on whether an interactive 3D web app showing the genitourinary anatomy would be helpful in patient consultations about FGM/C, identifying key features that are relevant to their clinical practice.

METHODS

We evaluated the web app through a semistructured interview protocol with seven HCPs from various disciplines experienced in care for women and girls with FGM/C in migration-destination settings. Interviews were audio- and video-recorded for transcription, and were then analyzed thematically for contextualized data regarding HCPs' willingness to use a 3D web app visualizing anatomy in FGM/C consultations with patients.

RESULTS

All but one of the seven participants expressed keen interest in using this web app and its 3D visuals of anatomy in FGM/C consultations with patients. Participants shared the common contexts for the use of visuals in health care for FGM/C and the concepts they are used to support, such as to help describe a patient's genitals after FGM/C and reinforce an understanding of clitoral anatomy, to illustrate the process of defibulation, or to explain the physiological effects of FGM/C. Participants also highlighted the benefit of using visuals that patients can relate to, expressing approval for the ability to customize the vulva by FGM/C subtype, skin tone, and complexity of the visual shown in the web app. Despite critiques that the visualization may serve to perpetuate idealistic standards for how a vulva should look, participants largely agreed on the web app's perceived usefulness to clinical practice and beyond.

CONCLUSIONS

Evaluation of the web app developed in this study identified that digital tools with 3D models of the genitourinary anatomy that are accessible, informative, and customizable to any specific patient are likely to aid HCPs in communicating clinical information about FGM/C in consultations. Universal access to the web app may be particularly useful for HCPs with less experience in FGM/C. The app also prompts options for applications such as for personal use, in medical education, in patient medical records, or in legal settings. Further qualitative research with patients is required to confirm that adoption of the web app by HCPs in a consultation setting will indeed benefit patient care for women and girls with FGM/C.

A Summary of Female Genital Mutilation/Cutting for the Pediatric and Adolescent Care Provider

The World Health Organization defines female genital mutilation/cutting as any medically unnecessary procedure involving partial or total removal of the external female genitalia or other injury to the female genital organs. It is a violation of human rights and associated with serious complications and lifelong impact on health. This review article summarizes for the pediatric and adolescent care provider the incidence worldwide, the impact of cultural practices, appropriate screening and diagnosis, interventions, and treatment, along with legal and ethical issues.

Autologous Platelet-Rich Plasma in Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: A Pilot Case Study

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

"Damaged genitals"-Cut women's perceptions of the effect of female genital cutting on sexual function. A qualitative study from Sweden

Female genital cutting (FGC) is a traditional practice, commonly underpinned by cultural values regarding female sexuality, that involves the cutting of women's external genitalia, often entailing the removal of clitoral tissue and/or closing the vaginal orifice. As control of female sexual libido is a common rationale for FGC, international concern has been raised regarding its potential negative effect on female sexuality. Most studies attempting to measure the impact of FGC on women's sexual function are quantitative and employ predefined questionnaires such as the Female Sexual Function Index (FSFI). However, these have not been validated for cut women, or for all FGC-practicing countries or communities; nor do they capture cut women's perceptions and experiences of their sexuality. We propose that the subjective nature of sexuality calls for a qualitative approach in which cut women's own voices and reflections are investigated. In this paper, we seek to unravel how FGC-affected women themselves reflect upon and perceive the possible connection between FGC and their sexual function and intimate relationships. The study has a qualitative design and is based on 44 individual interviews with 25 women seeking clitoral reconstruction in Sweden. Its findings demonstrate that the women largely perceived the physical aspects of FGC, including the removal of clitoral tissue, to affect women's (including their own) sexual function negatively. They also recognized the psychological aspects of FGC as further challenging their sex lives and intimate relationships. The women desired acknowledgment of the physical consequences of FGC and of their sexual difficulties as "real" and not merely "psychological blocks".

Reconsidering the role of patriarchy in upholding female genital modifications: analysis of contemporary and pre-industrial societies

According to the World Health Organization (WHO), customary female genital modification practices common in parts of Africa, South and Southeast Asia, and the Middle East are inherently patriarchal: they reflect deep-rooted inequality between the sexes characterized by male dominance and constitute an extreme form of discrimination against women. However, scholars have noted that while many societies have genital modification rites only for boys, with no equivalent rite for girls, the inverse does not hold. Rather, almost all societies that practice ritual female genital modification also practice ritual male genital modification, often for comparable reasons on children of similar ages, with the female rites led by women and the male rites led by men. In contrast, then, to the situation for boys in various cultures, girls are not singled out for genital modification on account of their sex or gender; nor do the social meanings of the female rites necessarily reflect a lower status. In some cases, the women's rite serves to promote female within-sex bonding and network building-as the men's rite typically does for males-thereby counterbalancing gendered asymmetries in political power and weakening male dominance in certain spheres. In such cases, and to that extent, the female rites can be described as counter-patriarchal. Selective efforts to discourage female genital modifications may thus inadvertently undermine women-centered communal networks while leaving male bonding rites intact. Scholars and activists should not rely on misleading generalizations from the WHO about the relationship between genital cutting and the social positioning of women as compared to men. To illustrate the complexity of this relationship, we compare patterns of practice across contemporary societies while also highlighting anthropological data regarding pre-industrial societies. Regarding the latter, we find no association between the presence of a female initiation rite and a key aspect of patriarchy as it is classically understood, namely, social endorsement of a gendered double-standard regarding premarital sexual activity. We situate this finding within the broader literature and discuss potential implications.

3D quantitative analysis of normal clitoral anatomy in nulliparous women by MRI

INTRODUCTION AND HYPOTHESIS

We present a 3D computational approach for automated clitoral measurements. We hypothesized that computationally derived measurements would be comparable and less variable than reported manual measures.

METHODS

In this retrospective study, MRIs of 22 nulliparous women age 20-49 years with normal vaginal and clitoral anatomy were collected. Manual segmentations were performed to reconstruct 3D models of the whole clitoris (glans, body, crura, and bulbs) and vagina. The length, width, and volume of the clitoral structures and the distance between the vagina and clitoral structures were calculated. Computed clitoral morphometrics (length, width) were compared to median [range] values from a previously published cadaver study (N = 22) using the median test and Moses extreme reaction test. Calculated distances were compared to mean (± SD) reported by a 2D MRI study (N = 20) using independent t-test and Levene's test.

RESULTS

Overall, computed clitoral morphometrics were similar to manual cadaver measurements, where the majority of length and width measures had ~1-2 mm difference and had less variability (smaller range). All calculated distances were significantly smaller and had smaller SDs than manual 2D MRI values, with two-fold differences in the means and SDs. Large variation was observed in clitoral volumetric measures in our cohort.

CONCLUSIONS

The proposed 3D computational method improves the standardization and consistency of clitoral measurements compared to traditional manual approaches. The use of this approach in radiographic studies will give better insight into how clitoral anatomy relates to sexual function and how both are impacted by gynecologic surgery, where outcomes can assist treatment planning.

Economic burden of female genital mutilation in 27 high-prevalence countries

BACKGROUND

Female genital mutilation (FGM) is a traditional harmful practice affecting 200 million women and girls globally. Health complications of FGM occur immediately and over time, and are associated with healthcare costs that are poorly understood. Quantifying the global FGM-related burden is essential for supporting programmes and policies for prevention and mitigation.

METHODS

Health complications of FGM are derived from a meta-analysis and stratified by acute, uro-gynaecological, obstetric and psychological/sexual. Treatment costs are calculated from national cohort models of 27 high-burden countries over 30 years. Savings associated with full/partial abandonment are compared with a current incidence reference scenario, assuming no changes in FGM practices.

RESULTS

Our model projects an increasing burden of FGM due to population growth. As a reference scenario assuming no change in practices, prevalent cases in 27 countries will rise from 119.4 million (2018) to 205.8 million (2047). Full abandonment could reduce this to 80.0 million (2047), while partial abandonment is insufficient to reduce cases. Current incidence economic burden is US$1.4 billion/year, rising to US$2.1 billion/year in 2047. Full abandonment would reduce the future burden to US$0.8 billion/year by 2047.

CONCLUSION

FGM is a human rights violation, a public health issue and a substantial economic burden that can be avoided through effective prevention strategies. While decreasing trends are observed in some countries, these trends are variable and not consistently observed across settings. Additional resources are needed to prevent FGM to avoid human suffering and growing costs. The findings of this study warrant increased political commitment and investment in the abandonment of FGM.

Autologous Platelet-Rich Plasma for Clitoral Reconstruction: A Case Study

Clitoral reconstruction after female genital mutilation/cutting (FGM/C) is associated with significant post-operative pain and months-long recovery. Autologous platelet-rich plasma (A-PRP) reduces the time of healing and pain in orthopedic and burn patients and could also do so in clitoral reconstruction. In the present case, a 35-year-old Guinean woman who had undergone FGM/C Type IIb presented to our clinic for clitoral reconstruction. Her request was motivated by low sexual satisfaction and body image. We surgically reconstructed the clitoris using the Foldès method and applied plasma and glue of A-PRP. The patient was highly satisfied with the procedure. Two months post-operatively, her pain had ceased entirely and re-epithelialization was complete. We conclude that A-PRP may improve pain and healing after clitoral reconstruction. Extensive studies investigating long-term outcomes are needed.

Understanding Women's Responses to Sexual Pain After Female Genital Cutting: An Integrative Psychological Pain Response Model

The World Health Organization estimates that over 200 million women and girls have experienced female genital cutting (FGC). Many women and girls who have undergone FGC have migrated to areas of the world where providers are unfamiliar with the health needs associated with FGC. Both providers in Western healthcare systems and female immigrant and refugee patients report communication difficulties leading to distrust of providers by women who have experienced FGC. Sexual pain is one common problem requiring discussion with healthcare providers and possible intervention. Yet, existing clinical and research literature provides little guidance for assessment and intervention when sexual pain is a result of FGC. Several conceptual frameworks have been developed to conceptualize and guide treatments for other types of pain, such as back pain and headaches. In this article, we integrate four prominent models-the fear avoidance model, eustress endurance model, distress endurance model, and pain resilience model-to conceptualize sexual pain in women who have experienced FGC. The resulting integrative psychological pain response model will aid in providing culturally responsive clinical management of sexual pain to women who have experienced FGC. This integrative model also provides a theoretical foundation for future research in this population.

Anatomical study of the clitoris and its implications on female genital mutilation and surgical repair

BACKGROUND

Worldwide, 200 million girls and women have been subjected to female genital mutilation. To restore the clitoral function and vulvar anatomy, clitoral repair has been performed since the 2000s. Nevertheless, there is a lack of precise and comprehensive data on the clitoral anatomy during surgical repair. This study aimed to precisely describe the terminal anatomies of the dorsal nerve and artery of the clitoris, and the clitoral neurovascular flap advancement for reconstruction in patients with female genital mutilation.

METHODS

This study was performed on seven fresh female cadavers. The site of origin, diameter, length, and trajectory of each nerve and artery were recorded. The clitoral neurovascular flap advancement was measured after a midline transection of the suspensory ligament was performed and after extensive liberation of the dorsal bundles at their emergence from the pubic rami.

RESULTS

At the distal point of the clitoral body, the width of the dorsal nerve and artery was 1.9 ± 0.3 mm and 0.9 ± 0.2 mm, respectively. The total length of the dorsal bundles was 6.6 cm (± 0.4). The midpart of the suspensory ligament was sectioned, which allowed a mean anteroposterior mobility of 2.7 cm (± 0.2). Extensive dissection of the neurovascular bundles up to their point of emergence from the suspensory ligament allowed a mean mobility of 3.4 ± 0.2 cm.

CONCLUSION

We described the anatomical characteristics of the dorsal nerve and artery of the clitoris and the mobility of the clitoral neurovascular flap for reconstruction post clitoridectomy. This was done to restore the anatomic position of the glans clitoris while preserving and potentially restoring clitoral function in patients with female genital mutilation.

Female Genital Mutilation/Cutting among Somali Women in the U.S. State of Arizona: Evidence of Treatment Access, Health Service Use and Care Experiences

BACKGROUND

Female genital mutilation/cutting (FGM/C) is associated with adverse sexual, reproductive and psychological sequelae. The aim of this study was to quantitatively explore factors related to satisfaction with FGM/C-related care in the US focusing on access to care, health service utilization, and women's experiences.

METHODS

A community-based survey of 879 Ethnic Somali and Somali Bantu women using snowball sampling was conducted in Arizona. Bivariate, multivariable and ordered logistics analyses assessed the relationship between the aforementioned factors measured along six dimensions: non-discrimination, physical, economic, informational, health system accessibility and individual-level health service use factors.

FINDINGS

Most participants possessed FGM/C (77.4%), namely Type III (40.2%). FGM/C related health service use was low (14.3%). Perceived discrimination was associated with reduced satisfaction in care (OR = 0.22; CI 0.13-0.37). For FGM/C-specific variables, only recollection of adverse physical or psychological events at the time of circumcision predicted service use (OR = 3.09; CI 1.67-5.68). Somali Bantu (OR = 0.10; CI 0.02-0.44) and highly acculturated women (OR = 0.39; CI 0.17-0.86) had lower odds of service use.

CONCLUSIONS

Achieving respectful care and outreach to women affected by FGM/C has contextual complexity. However, the clinical implications and insights provided may have broader impacts on advancing health equity for FGM/C-affected women.

Swedish Gynecologists' Positioning in Relation to Clitoral Reconstruction After Female Genital Cutting. A Qualitative Interview Study

Background: Clitoral reconstruction (CR) is surgical reparation of the clitoris cut as part of the practice of female genital cutting (FGC) available in a handful of countries, including Sweden. The surgery aims at restoring the clitoris esthetically and functionally, thus has implications for sexual health. Gynaecological examinations can be an opportunity for dialogue regarding women's sexual health. Gynecologist play a role in referring patients experiencing FGC-related problems, including sexual, to specialist services such as CR. Aim: The aim of this study was to explore how gynecologists position themselves in relation to CR. Method: Eight gynecologists were interviewed using semi-structured interviews. The interviews were tape-recorded, transcribed and analyzed using thematic analysis. Results: The gynecologists positioned themselves in three different ways in relation CR; outright negative, uncertain or positive toward the surgery. Those positioning themselves as negative thought CR was a harmful fraud and denied any possible benefits, at least sufficient for referral for CR. Those positioning themselves as uncertain did not deny possible benefits, but were skeptical toward CR improving cut women's sexual health and function. Those positioning themselves positive considered the potential physical, psychological/emotional, esthetic, or symbolic aspects of CR as important for general well-being and sexual health. Conclusion: There was a great variety in how the gynecologists positioned themselves toward CR, and many were skeptical toward the functional benefits in relation to sexual health. This is likely to diverge cut women's access to CR surgery.

Facilitating Factors of Professional Health Practice Regarding Female Genital Mutilation: A Qualitative Study

Introduction: According to figures released by UNICEF (United Nations Children's Fund), more than 200 million girls and women have suffered female genital mutilation (FGM) in 30 African and Middle East countries. An increasing number of African women who come from ethnic groups where FGM is practised are arriving in Western countries. Healthcare professionals play a fundamental role in its prevention. Goals: To learn about the factors that healthcare professionals consider as facilitators for prevention and action when faced with female genital mutilation. Methods: A cross-sectional descriptive study developed on the basis of the qualitative methodological perspective, where 43 healthcare professionals participated. A series of analysis dimensions were established, based on which, the interview and discussion group scripts were designed. Results: Addressing FGM requires a series of structural adaptations of the healthcare system that facilitate the recording and monitoring of cases, both for treatment and for prevention. In addition, it is necessary to establish coordination between the healthcare, social services and education sectors. Conclusions: The existence of a protocol of action and training in its use is one of the key tools to take into account.

Association of female genital mutilation and female sexual dysfunction: A systematic review and meta-analysis

OBJECTIVE

To meta-analyze possible associations between female genital mutilation (FGM) and female sexual dysfunction, dyspareunia and pelvic pain.

METHOD

A systematic literature search was performed in PubMed, EMBASE, Scopus, Web of Science, African Index Medicus and Cochrane Library. The PICO protocol included Population: Studies evaluating girls or women; Intervention/Exposure: participants with FGM; Comparison: participants without FGM; Outcomes: female sexual function, dyspareunia or pelvic pain using validated tests. Random effect models were used for meta-analyses, and standardized mean differences (SMDs) and their 95 % confidence intervals (CIs) for any of the measured continuous outcomes were calculated when possible. Risk of bias was assessed with the Newcastle-Ottawa Scale.

RESULTS

Fifteen studies (n = 6672 participants) reported on the outcomes of the 19-item Female Sexual Function Index (FSFI). The meta-analysis of the total FSFI score showed a SMD of -1.43 (95 % CI -2.17, -0.69) suggestive of female sexual dysfunction. In addition, scores for the six FSFI domains were significantly lower in women with FGM: SMDs for desire -0.62 (95 % CI -1.01, -0.22), arousal -0.88 (95 % CI -1.41, -0.35), lubrication -0.95 (95 % CI -1.45, -0.46), orgasm -1.07 (95 % CI -1.63, -0.50), satisfaction -0.96 (95 % CI -1.52, -0.41) and pain -0.48 (95 % CI -0.91, -0.05). Estimation of the prevalence of female sexual dysfunction with the FSFI was not possible since different cut-offs values were used in those studies that reported for this outcome. No other searched outcomes using other tools were reported.

CONCLUSION

FGM seriously alters female sexual function as assessed with the FSFI, globally and per domain.

Diagnosis, Management, and Treatment of Female Genital Mutilation or Cutting in Girls

Female genital mutilation or cutting (FGM/C) involves medically unnecessary cutting of parts or all of the external female genitalia. It is outlawed in the United States and much of the world but is still known to occur in more than 30 countries. FGM/C most often is performed on children, from infancy to adolescence, and has significant morbidity and mortality. In 2018, an estimated 200 million girls and women alive at that time had undergone FGM/C worldwide. Some estimate that more than 500 000 girls and women in the United States have had or are at risk for having FGM/C. However, pediatric prevalence of FGM/C is only estimated given that most pediatric cases remain undiagnosed both in countries of origin and in the Western world, including in the United States. It is a cultural practice not directly tied to any specific religion, ethnicity, or race and has occurred in the United States. Although it is mostly a pediatric practice, currently there is no standard FGM/C teaching required for health care providers who care for children, including pediatricians, family physicians, child abuse pediatricians, pediatric urologists, and pediatric urogynecologists. This clinical report is the first comprehensive summary of FGM/C in children and includes education regarding a standard-of-care approach for examination of external female genitalia at all health supervision examinations, diagnosis, complications, management, treatment, culturally sensitive discussion and counseling approaches, and legal and ethical considerations.

In Vivo Imaging-Based 3-Dimensional Pelvic Prototype Models to Improve Education Regarding Sexual Anatomy and Physiology

BACKGROUND

Myths, misconceptions, and taboos about sexual anatomy and physiology are common and can affect sexual health and maintain harmful practices and beliefs.

AIM

To construct a female and a preliminary male 3-dimensional (3D) pelvic model on the basis of in vivo imaging, which could be studied in sex education and clinical practice.

METHODS

We retrospectively studied the images of 200 female pelvic magnetic resonance examinations and reviewed the literature to choose the optimum magnetic resonance imaging (MRI) protocol for the study of the clitoris and surrounding organs. We also conducted a cross-sectional study of 30 women who were undergoing a pelvic MRI. 15 women had undergone female genital mutilation/cutting involving the clitoris and 15 had not. The best-quality MRI images of 3 uncut and 1 cut clitoris, together with the principal surrounding pelvic organs, were selected to generate 3D reconstructions using dedicated software. The same software was used to reconstruct the anatomy of the penis and the principal surrounding pelvic organs, based on contrast-enhanced computer tomography images. Images of both models were exported in .stl format and cleaned to obtain single manifold objects in free, open source software. Each organ model was sliced and 3D printed. A preliminary feedback was collected from 13 potential users working in urology, gynaecology, sexual medicine, physiotherapy, and education.

OUTCOMES

The main outcomes of this study are a kit of 3D pelvic models, 2-dimensional figures of female and male sexual anatomy, and files for 3D printing.

RESULTS

We present a kit containing 3D models and 2-dimensional figures of female and male sexual anatomy, based on in vivo imaging and, feedbacks and suggestions received from potential users.

CLINICAL TRANSLATION

Our kit can be used in anatomy and sex education among and by health professionals, teachers, sex educators, students, and the general population.

STRENGTHS & LIMITATIONS

The strengths are that the models were based on in vivo imaging, can be dismantled/reassembled, and show analogous anatomic structures of the clitoris and the penis. The female models represent diversity, including women with female genital mutilation/cutting. The limitations are that the male model is preliminary and can be improved if based on an MRI; that imaging-based anatomic representations can differ from anatomic dissections; and that the models represent the sexual organs at rest or during an unknown state of arousal only.

CONCLUSION

Our kit can be studied in anatomy, biology, and sex education, as well as in clinical practice. Abdulcadir J, Dewaele R, Firmenich N, et al. In Vivo Imaging-Based 3-Dimensional Pelvic Prototype Models to Improve Education Regarding Sexual Anatomy and Physiology. J Sex Med 2020;17:1590-1602.

'Putting salt on the wound': a qualitative study of the impact of FGM-safeguarding in healthcare settings on people with a British Somali heritage living in Bristol, UK

OBJECTIVES

This research documents the experiences of people with Somali heritage with female genital mutilation (FGM)-safeguarding services in healthcare and whether such services are considered appropriate by the people who encounter them.

DESIGN

Six focus groups conducted with ethnic Somalis living in Bristol, during the summer of 2018, divided by gender and whether people had experienced FGM-safeguarding as adults or children.SettingParticipants experienced FGM-safeguarding in primary and secondary care.

PARTICIPANTS

30 people (21 women and 9 men), identified through local organisations or snowball sampling. All participants were of Somali heritage and aged over 18.

RESULTS

Government priorities to support those who have experienced female genital cutting/mutilation (FGC/M) are being undermined by their own approaches to protect those considered at risk. Participants argued that approaches to FGM-safeguarding were based on outdated stereotypes and inaccurate evidence which encouraged health and other service providers to see every Somali parent as a potential perpetrator of FGC/M. Female participants described providers in a range of healthcare settings, including Accident and Emergency Departments (A&E), antenatal care and general practice, as 'fixated' with FGC/M, who ignored both their health needs and their experience as victims. Participants felt stigmatised and traumatised by their experience. This undermined their trust in health services, producing a reticence to seek care, treatment delays and reliance on alternative sources of care. Associated recommendations include developing more accurate evidence of risk, more appropriate education for healthcare providers and more collaborative approaches to FGM-safeguarding.

CONCLUSION

All the participants involved in this study are committed to the eradication of FGC/M. But the statutory approaches currently adopted to enable this are considered ill-conceived, unnecessarily heavy-handed and ultimately detrimental to this. Recognising these common aims can enable the development of services better able to protect and support those at risk of FGC/M in ways which are culturally competent and sensitive.

Current critiques of the WHO policy on female genital mutilation

In recent years, the dominant Western discourse on "female genital mutilation" (FGM) has increasingly been challenged by scholars. Numerous researchers contest both the terminology used and the empirical claims made in what has come to be called "the standard tale" of FGM (also termed "female genital cutting" [FGC]). The World Health Organization (WHO), a major player in setting the global agenda on this issue, maintains that all medically unnecessary cutting of the external female genitalia, no matter how slight, should be banned as torture and a violation of the human right to bodily integrity. However, the WHO targets only non-Western forms of female-only genital cutting, raising concerns about gender bias and cultural imperialism. Here, we summarize ongoing critiques of the WHO's terminology, ethicolegal assumptions, and empirical claims, including the claim that non-Western FGC as such constitutes an extreme form of discrimination against women. To this end, we highlight recent comparative studies of medically unnecessary genital cutting of all types, including those affecting adult women and teenagers in Western societies, individuals with differences of sex development (DSD), transgender persons, and males. In so doing, we attempt to clarify the grounds for a growing critical consensus that current anti-FGM laws and policies may be ethically incoherent, empirically unsupportable, and legally unsustainable.

Sexual norms and the intention to use healthcare services related to female genital cutting: A qualitative study among Somali and Sudanese women in Norway

Background

Female Genital Cutting (FGC) is a traditionally meaningful practice in Africa, the Middle East, and Asia. It is associated with a high risk of long-term physical and psychosexual health problems. Girls and women with FGC-related health problems need specialized healthcare services such as psychosexual counseling, deinfibulation, and clitoral reconstruction. Moreover, the need for psychosexual counseling increases in countries of immigration where FGC is not accepted and possibly stigmatized. In these countries, the practice loses its cultural meaning and girls and women with FGC are more likely to report psychosexual problems. In Norway, a country of immigration, psychosexual counseling is lacking. To decide whether to provide this and/or other services, it is important to explore the intention of the target population to use FGC-related healthcare services. That is as deinfibulation, an already available service, is underutilized. In this article, we explore whether girls and women with FGC intend to use FGC-related healthcare services, regardless of their availability in Norway.

Methods

We conducted 61 in-depth interviews with 26 Somali and Sudanese participants with FGC in Norway. We then validated our findings in three focus group discussions with additional 17 participants.

Findings

We found that most of our participants were positive towards psychosexual counseling and would use it if available. We also identified four cultural scenarios with different sets of sexual norms that centered on getting and/or staying married, and which largely influenced the participants’ intention to use FGC-related services. These cultural scenarios are the virgin, the passive-, the conditioned active-, and the equal- sexual partner scenarios. Participants with negative attitudes towards the use of almost all of the FGC-related healthcare services were influenced by a set of norms pertaining to virginity and passive sexual behavior. In contrast, participants with positive attitudes towards the use of all of these same services were influenced by another set of norms pertaining to sexual and gender equality. On the other hand, participants with positive attitudes towards the use of services that can help to improve their marital sexual lives, yet negative towards the use of premarital services were influenced by a third set of norms that combined norms from the two aforementioned sets of norms.

Conclusion

The intention to use FGC-related healthcare services varies between and within the different ethnic groups. Moreover, the same girl or woman can have different attitudes towards the use of the different FGC-related healthcare services or even towards the same services at the different stages of her life. These insights could prove valuable for Norwegian and other policy-makers and healthcare professionals during the planning and/or delivery of FGC-related healthcare services.

Exploring barriers to seeking health care among Kenyan Somali women with female genital mutilation: a qualitative study

Background

Female genital mutilation/cutting (FGM/C) is a cultural practice associated with health consequences, women rights and deprivation of dignity. Despite FGM/C-related health consequences, circumcised women may encounter additional challenges while seeking interventions for reproductive health problems. Experiences of women/girls while accessing health services for reproductive health problems including FGM/C-related complications in poor, remote and hard to reach areas is poorly understood. We sought to explore barriers to care seeking among Somali women with complications related to FGM/C in public health facilities in Kenya.

Methods

We drew on qualitative data collected from purposively selected women aged 15–49 years living with FGM/C, their partners, community leaders, and health providers in Nairobi and Garissa Counties. Data were collected using in-depth interviews (n = 10), key informant interviews (n = 23) and 20 focus group discussions. Data were transcribed and analyzed thematically using NVivo version 12.

Results

Barriers were grouped into four thematic categories. Structural barriers to care-seeking, notably high cost of care, distance from health facilities, and lack of a referral system. Concerns regarding perceived quality of care also presented a barrier. Women questioned health professionals’ and health facilities’ capacity to offer culturally-sensitive FGM/C-specific care, plus ensuring confidentiality and privacy. Women faced socio-cultural barriers while seeking care particularly cultural taboos against discussing matters related to sexual health with male clinicians. Additionally, fear of legal sanctions given the anti-FGM/C law deterred women with FGM/C-related complications from seeking healthcare.

Conclusion

Structural, socio-cultural, quality of service, and legal factors limit health seeking for reproductive health problems including FGM/C-related complications. Strengthening health system should consider integration of FGM/C-related interventions with existing maternal child health services for cost effectiveness, efficiency and quality care. The interventions should address health-related financial, physical and communication barriers, while ensuring culturally-sensitive and confidential care.

Reconstructing Sexuality after Excision: The Medical Tools

Clitoral reconstructive surgery is not sufficient to restore women's sexual pleasure after excision. If the surgical technique aims at reconstructing the cut clitoris after type 2 female genital mutilation, the surgery alone cannot reconstruct other dimensions invoked by women in their requests for the procedure. In France, where clitoral reconstructive surgery since 2004 has been entirely covered by national insurance, a multidisciplinary approach precedes the surgery. Ethnographic fieldwork in one public hospital contributes a wider comprehension of the entire process of clitoral reconstruction, as well as the tools elaborated by the medical team. In particular, analysis of the assessments of the psychologist and sex therapist compiled in the medical folders shows how the multidisciplinary medical team developed specific tools. These tools are oriented at reconstructing the patient's sexual sensibility, at breaking through psychological blocks such as self-esteem and body image, and/or at addressing abusive intimate relationships.

Sexual health counselling targeting girls and young women with female genital cutting in Sweden: mind-body dualism affecting social and health care professionals' perspectives

Female genital mutilation (FGM), also referred to as female genital cutting (FGC), has become the subject of an intense debate exposing tensions between varying cultural values about bodies and sexuality. These issues are brought to the fore in settings where professionals provide sexual counselling to young circumcised women and girls in Western, multicultural societies. This article is based on interviews and focus group discussions with professionals in social and healthcare services. The aim of this study was to examine how professionals reflect upon and talk about sexuality and the promotion of sexual wellbeing in young circumcised women and girls. Policy documents guide their obligations, yet they are also influenced by culture-specific notions about bodies and sexuality and what can be called “the FGM standard tale”. The study found that professionals showed great commitment to helping the girls and young women in the best possible way. Their basic starting point, however, was characterised by a reductionist focus on the genitalia’s role in sexuality, thus neglecting other important dimensions in lived sexuality. In some cases, such an attitude may negatively affect an individual’s body image and sexual self-esteem. Future policy making in the field of sexual health among girls and young women with FGC would benefit from taking a broader holistic approach to sexuality. Professionals need to find ways of working that promote sexual wellbeing in girls, and must avoid messages that evoke body shame or feelings of loss of sexual capacity among those affected by FGC.

Psychosexual Consequences of Female Genital Mutilation and the Impact of Reconstructive Surgery: A Narrative Review

Purpose: We aim to provide a comprehensive overview of the health consequences of female genital mutilation/cutting (FGM/C), with a particular focus on the psychosexual implications of this practice and the overall impact of reconstructive plastic surgery.

Methods: A MEDLINE search through PubMed was performed to identify the best quality evidence published studies in English language on long-term health consequences of FGM/C.

Results: Women with FGM/C are more likely to develop psychological disorders, such as post-traumatic stress disorder, anxiety, somatization, phobia, and low self-esteem, than those without FGM/C. Most studies showed impaired sexual function in women with FGM/C. In particular, women with FGM/C may be physiologically less capable of becoming sexually stimulated than uncut women. Reconstructive surgery could be beneficial, in terms of both enhanced sexual function and body image. However, prospective studies on the impact of reconstructive surgery are limited, and safety issues should be addressed.

Conclusion: Although it is clear that FGM/C can cause devastating immediate and long-term health consequences for girls and women, high-quality data on these issues are limited. Psychosexual complications need to be further analyzed to provide evidence-based guidelines and to improve the health care of women and girls with FGM/C. The best treatment approach involves a multidisciplinary team to deal with the multifaceted FGM/C repercussions.

'Birds of the same feathers fly together': midwives' experiences with pregnant women and FGM/C complications - a grounded theory study in Liberia

Background

In Liberia, approximately 70% of the women of the North-Central and North-Western regions could have undergone female genital mutilation/cutting (FGM/C) in their childhood during a traditional ceremony marking their entrance into Sande, a secret female society. Little is known about FGM/C from Liberian women’s perspective. This study aimed to understand the health implications of FGM/C as perceived by qualified female midwives.

Methods

This qualitative study was conducted in 2017 in Monrovia, Liberia’s capital. Twenty midwives were approached. Of these, seventeen consented to participate in in-depth interviews. A thematic guide was used to gain insights about their knowledge on FGM/C and their experiences attending women victims of FGM/C. A feminist interpretation of constructivist grounded theory guided data generation and analysis.

Results

The midwives participants described how clitoridectomy was the most common FGM/C type done to the girls during the Sande initiation ceremonies. Sexual impairment and intrapartum vulvo-perineal laceration with subsequent hemorrhage were described as frequent FGM/C-attributable complications that some midwives could be unable to address due to lack of knowledge and skills. The majority of midwives would advocate for the abandonment of FGM/C, and for the preservation of the traditional instructions that the girls in FGM/C-practicing regions receive when joining Sande. The midwives described how migration to urban areas, and improved access to information and communication technologies might be fuelling abandonment of FGM/C.

Conclusion

Liberian midwives need tailored training to provide psychosexual counseling, and to attend the obstetric needs of pregnant women that have undergone FGM/C. In spite of FGM/C being seemingly in the decline, surveillance at clinic-level is warranted to prevent its medicalization. Any clinic- or community-based training, research, prevention and awareness intervention targeting FGM/C-practicing populations should be designed in collaboration with Sande members, and acknowledging that the Liberian population may place a high value in Sande’s traditional values.

International continence society white paper regarding female genital mutilation/cutting

Female genital mutilation/cutting (FGM/C)-also known as Female Genital Cutting or Mutilation-is defined as the partial or total removal of the female external genitalia for non-therapeutic reasons. This White Paper, prepared under the auspices of the International Continence Society (ICS), is intended by the ICS as a statement promoting the abandonment of this practice. The ICS also supports the respectful and evidence-based care or treatment of women and girls already affected by FGM/C, in keeping with the World Health Organization (WHO) Guidelines on the Management of Health Complications from Female Genital Mutilation. Our members specialize in pelvic floor disorders from perspectives within a range of specialties; we encounter and treat women living with FGM/C and its consequences-particularly incontinence, infections, voiding dysfunction, sexual dysfunction, chronic pelvic pain, and obstetric trauma. Understanding the ethical, sociocultural, medical and surgical factors surrounding FGM/C is central to caring for women and girls with a history of FGM/C. The ICS voices herein state strong opposition to FGM/C. We encourage members to apply their skills to improve prevention strategies and the management of those affected.

Female Genital Mutilation Reconstruction for Plastic Surgeons-A Call to Arms

The practice of female genital mutilation (FGM) is performed for historically engrained cultural beliefs with no recognized health benefits. FGM continues to be practiced secondary to motivating factors based on cultural beliefs, the majority of which aim to maintain the “purity” of the female victim. The World Health Organization has classified FGM into 4 types ranging from partial clitoral resection to complete clitoral excision along with the majority of the vulva. The list of short and long-term complications is extensive and morbid, including injury to the patient’s sexuality and feminine identity. Reconstructive surgery can be an important addition to psychotherapy for these women with the goal of correcting the appearance of the vulva to achieve a more normal appearance, and to restore clitoral function. We suggest that this represents an opportunity for plastic surgeons to use our wealth of reconstructive knowledge to provide restoration of form and function to FGM victims.

False beliefs predict increased circumcision satisfaction in a sample of US American men

Critics of non-therapeutic male and female childhood genital cutting claim that such cutting is harmful. It is therefore puzzling that 'circumcised' women and men do not typically regard themselves as having been harmed by the cutting, notwithstanding the loss of sensitive, prima facie valuable tissue. For female genital cutting (FGC), a commonly proposed solution to this puzzle is that women who had part(s) of their vulvae removed before sexual debut 'do not know what they are missing' and may 'justify' their genitally-altered state by adopting false beliefs about the benefits of FGC, while simultaneously stigmatising unmodified genitalia as unattractive or unclean. Might a similar phenomenon apply to neonatally circumcised men? In this survey of 999 US American men, greater endorsement of false beliefs concerning circumcision and penile anatomy predicted greater satisfaction with being circumcised, while among genitally intact men, the opposite trend occurred: greater endorsement of false beliefs predicted less satisfaction with being genitally intact. These findings provide tentative support for the hypothesis that the lack-of-harm reported by many circumcised men, like the lack-of-harm reported by their female counterparts in societies that practice FGC, may be related to holding inaccurate beliefs concerning unaltered genitalia and the consequences of childhood genital modification.

Addressing Female Genital Mutilation/Cutting (FGM/C) in the Era of Clitoral Reconstruction: Plastic Surgery

PURPOSE OF THE REVIEW

The aim of this review is to give an overview of the recent evidence on clitoral reconstruction and other relevant reconstructive plastic surgery measures after female genital mutilation/cutting (FGM/C).

RECENT FINDINGS

Recent publications present refinements and modifications of the surgical technique of clitoral reconstruction along with reconstruction of the labia majora and clitoral hood. Novel approaches with reposition of the clitoral nerve, anchoring of the labia majora, fat grafting, and full thickness mucosa grafts have been introduced. The current evidence on outcomes of clitoral reconstruction shows potential benefits. However, there is a risk of postoperative complications and a negative outcome. Experts in the field advocate for a multidisciplinary approach including psychosexual counseling and health education with or without subsequent clitoral reconstructive surgery.

SUMMARY

The evolution of reconstructive treatment for women with FGM/C is expanding, however at a slow rate. The scarcity of evidence on clitoral reconstruction halters availability of clinical guidelines and consensus regarding best practice. Clitoral reconstruction should be provided by multidisciplinary referral centers in a research setting with long-term follow-up on outcomes of postoperative morbidity and possible benefits.

The Impact of Migration on Attitudes to Female Genital Cutting and Experiences of Sexual Dysfunction Among Migrant Women with FGC

Purpose of Review

The purpose of this review was to explore current research on the impact of migration on issues related to female genital cutting and sexuality.

Recent Findings

There is growing evidence that migration results in a broad opposition to female genital cutting among concerned migrant groups in western countries. In addition, after migration, affected women live in the midst of a dominant discourse categorizing them as "mutilated" and sexually disfigured. There is also, in contrast to what is shown by most research, a public discourse saying that female genital cutting (FGC) leads to lost capacity to enjoy sex. Concurrently, a vast body of research demonstrates a strong correlation between a negative body image or body shame and sexual dysfunction.

Summary

Care for women with FGC needs to be holistic and, while offering medical care when needed, the health care providers should avoid feeding into self-depreciatory body images and notions about lost ability to enjoy sexual life.

The 'heat' goes away: sexual disorders of married women with female genital mutilation/cutting in Kenya

BACKGROUND

Female genital mutilation/cutting (FGM/C) has been implicated in sexual complications among women, although there is paucity of research evidence on sexual experiences among married women who have undergone this cultural practice. The aim of this study was to investigate the sexual experiences among married women in Mauche Ward, Nakuru County.

METHODS

Quantitative and qualitative data collection methods were used. Quantitative data were obtained from 318 married women selected through multistage sampling. The women were categorized into: cut before marriage, cut after marriage and the uncut. A questionnaire was used to collect demographic information while psychometric data were obtained using a female sexual functioning index (FSFI) tool. The resulting quantitative data were analyzed using SPSS® Version 22. Qualitative data were obtained from five FGDs and two case narratives. The data were organized into themes, analyzed and interpreted. Ethical approval for the study was granted by Kenyatta National Hospital-University of Nairobi Ethics and Research Committee.

RESULTS

The mean age of the respondents was 30.59 ± 7.36 years. The majority (74.2%) had primary education and 76.1% were farmers. Age (p = 0.008), number of children (p = 0.035) and education (p = 0.038) were found to be associated with sexual functioning. The cut women reported lower sexual functioning compared to the uncut. ANOVA results show the reported overall sexual functioning to be significantly (p = 0.019) different across the three groups. Women cut after marriage (mean = 22.81 ± 4.87) scored significantly lower (p = 0.056) than the uncut (mean = 25.35 ± 3.56). However, in comparison to the cut before marriage there was no significant difference (mean = 23.99 ± 6.63). Among the sexual functioning domains, lubrication (p = 0.008), orgasm (p = 0.019) and satisfaction (p = 0.042) were significantly different across the three groups. However, desire, arousal and pain were not statistically different.

CONCLUSION

Generally, cut women had negative sexual experiences and specifically adverse changes in desire, arousal and satisfaction were experienced among cut after marriage. FGM/C mitigating strategies need to routinely provide sexual complications management to safeguard women's sexual right to pleasure subsequently improving their general well-being.

Clitoral reconstruction: Understanding changing gendered health care needs in a globalized Europe

The migratory flows of recent decades that have exercised Europe as a socio-political and economic entity have produced extensive responses and interventions from European gender scholars. One relatively recent phenomenon in this context is the question of reparative surgical interventions, specifically clitoral reconstruction, in cases where women who have migrated to Europe have experienced female genital cutting. Clitoral reconstruction, which this article begins to explore, is recent in part because the related surgery was only established in the 1990s and is to date only practised in a few European countries, and in part because the research with women who ask for and have undergone such surgery has also only recently begun. This article is therefore an initial attempt to map some of the related terrain and to suggest further work that needs to be done in this increasingly important area.

Sexual counselling for treating or preventing sexual dysfunction in women living with female genital mutilation: A systematic review

BACKGROUND

Female sexual dysfunction is the persistent or recurring decrease in sexual desire or arousal, the difficulty or inability to achieve an orgasm, and/or the feeling of pain during sexual intercourse. Impaired sexual function can occur with all types of female genital mutilation (FGM) owing to the structural changes, pain, or traumatic memories associated with the procedure.

OBJECTIVES

To conduct a systematic review of randomized and nonrandomized studies into the effects of sexual counseling with or without genital lubricants on the sexual function of women living with FGM.

SEARCH STRATEGY

Cochrane Central Register of Controlled Trials, MEDLINE, African Index Medicus, SCOPUS, LILACS, CINAHL, ClinicalTrials.gov, Pan African Clinical Trials Registry, and other databases were searched to August 2015. The reference lists of retrieved studies were checked for reports of additional studies, and lead authors contacted for additional data.

SELECTION CRITERIA

Studies of girls and women living with any type of FGM who received counselling interventions for sexual dysfunction were included.

DATA COLLECTION AND ANALYSIS

No relevant studies that addressed the objective of the review were identified.

CONCLUSIONS

Despite a comprehensive search, the authors could not find evidence of the effects of sexual counseling on the sexual function of women living with FGM. Studies assessing this intervention are needed.

PROSPERO REGISTRATION

CRD42015024593.

Female genital mutilation: the role of medical professional organizations

Female genital mutilation (FGM) refers to alteration of the external genitalia of girls without medical benefit. It is estimated by United Nations agencies that 200 million living girls and women have been subjected to different forms of FGM worldwide. Despite the criminalization of the procedure in the vast majority of countries where it is practiced, the decline in the incidence of this ritual is far from satisfactory. Immediate and long-term ill effects are well documented. Most publications of relevance originate from countries outside the map of FGM. In addition, there are major gaps in research related to this issue, considering the magnitude of the problem. International medical organizations and societies should assume their responsibility by providing a platform to professionals engaged in the prevention and treatment of the consequences of FGM, especially those living in the communities where the practice is endemic.

Female genital mutilation: a urology focus

Female genital mutilation (FGM) is a collective term for the deliberate alteration, removal and cutting of the female genitalia. It has no known health benefits and can have negative physical and psychological consequences. The number of women and girls in the UK that are affected by FGM is unknown. Recent NHS data suggested that FGM has been evident (declared or observed) in women who have accessed health care; however, there are gaps in knowledge and a limited evidence base on the health consequences of FGM. This article explores the urological complications experienced by women who have undergone this practice, and the effects this can have on their health and wellbeing.