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The Brussels Collaboration On Bodily Integrity. Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024:1-50. [PMID: 39018160 DOI: 10.1080/15265161.2024.2353823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and nonvoluntary procedures and focus on nonvoluntary procedures, specifically in prepubescent minors ("children"). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or "endosex" females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians' widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.
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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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Byard RW, Behnia-Willison F. Female genital mutilation - An overview for forensic practitioners. J Forensic Leg Med 2024; 101:102624. [PMID: 38011766 DOI: 10.1016/j.jflm.2023.102624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/12/2023] [Accepted: 11/18/2023] [Indexed: 11/29/2023]
Abstract
Female genital mutilation (FGM) refers to all procedures that partially or totally remove the external female genitalia, or to all other deliberate injuries to the female genital organs for non-medical reasons. It is thought that over 200 million girls and women have had some form of FGM, with more than three million girls being at risk annually. The procedure varies in severity from partial or complete removal of the clitoris (Type 1) to oversewing of the vaginal opening, so-called infibulation (Type 3). There are no medical benefits from FGM, with complications increasing with the amount of tissue damage that has been inflicted. Side effects may be psychological and physical including excessive scarring, pain, infections, sexual dysfunction with significant obstetrical complications such as fistulas and increased risks of stillbirth, as well as increased neonatal and maternal morbidity and mortality. Although primarily originating in countries in Africa, the Middle East and Asia, mass migrations in recent years have made FGM a feature in most societies. For this reason, forensic practitioners and pathologists should be aware of the anatomical features of FGM and the potential medical and psychological side effects. Accurate recording of cases is required to enable appropriate resources to be allocated for instituting preventive measures.
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Affiliation(s)
- Roger W Byard
- School of Biomedicine, The University of Adelaide, Adelaide, South Australia, 5000, Australia.
| | - Fariba Behnia-Willison
- School of Electrical and Mechanical Engineering, The University of Adelaide, Adelaide, South Australia, 5000, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, 5042, Australia; Desert Flower South Australia, Ashford, South Australia, 5035, Australia; FBW Gynaecology Plus, Ashford, South Australia, 5035, Australia
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Gnofam M, Crequit S, Renevier B, Abramowicz S. Prognostic factors of poor surgical outcome after clitoral reconstruction in women with female genital mutilation/cutting. J Sex Med 2023; 21:59-66. [PMID: 38014807 DOI: 10.1093/jsxmed/qdad150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/04/2023] [Accepted: 09/27/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Complications of surgical clitoral reconstruction for female genital mutilation/cutting (FGM/C) are a rare occurrence, but there has been reports of patients experiencing chronic pain or clitoral burial. AIM This study aims to assess which factors are predictive of the occurrence of surgical complications in women who had surgical reconstruction for FGM/C (type 1, 2, or 3). METHODS This monocentric retrospective study was conducted among patients who underwent clitoral reconstruction after FGM/C from January 2016 to March 2020. Demographic and clinical data were abstracted from the medical records. OUTCOMES The primary outcome was the occurrence of chronic pain (defined as occurrence or persistence of any clitoral pain >3 months after surgery), and the secondary outcome was the occurrence of clitoral burial. RESULTS A total of 87 women were included in the analysis. Univariate analysis indicated significantly higher rates of a history of physical abuse in the group of women who experienced chronic pain after surgery (4 [100%] vs 2 [37.1%], P = .049). Patients with clitoral burial were significantly younger than the rest of the sample in univariate analysis (median [IQR], 29.6 years [24.6-30.2] vs 33.8 [28.2-37.9]; P = .049). CLINICAL IMPLICATIONS Surgical treatment of women who underwent FGM/C should include the entire history of the patient and especially a record of experiencing physical abuse. STRENGTHS AND LIMITATIONS The study stands out for its originality, the extensive sample size gathered over nearly 4 years, the surgical clitoral reconstructions conducted by an experienced surgeon, and the minimal amount of missing data. However, because the occurrence of these complications was rare, the number of patients in the subgroups was extremely low, preventing a valid multivariate analysis to be conducted. CONCLUSION The study suggests that women with a history of physical abuse could be at greater risk for chronic pain after surgery and that younger women tend to experience more clitoral burial.
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Affiliation(s)
- Mayi Gnofam
- Département d'obstétrique et de gynécologie, Hôpital Louis Mourier (Assistance Publique Hôpitaux de Paris), Colombes, 92700, France
- Département d'obstétrique et de gynécologie, Hôpital Maison Blanche (Centre hospitalier universitaire de Reims), Reims, 51092, France
| | - Simon Crequit
- Département d'obstétrique et de gynécologie, Centre hospitalier intercommunal André Grégoire, Montreuil, 93100, France
| | - Bruno Renevier
- Département d'obstétrique et de gynécologie, Centre hospitalier intercommunal André Grégoire, Montreuil, 93100, France
| | - Sarah Abramowicz
- Département d'obstétrique et de gynécologie, Centre hospitalier intercommunal André Grégoire, Montreuil, 93100, France
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Rodríguez-Sánchez V, Ventura-Miranda MI, Berthe-Kone O, Hernández-Padilla JM, Fernández-Sola C, Molina JG, Morante-García W, García-González J. Understanding the consequences of Female Genital Mutilation: a phenomenological study in sub-Saharan women living in Spain. Midwifery 2023; 123:103711. [PMID: 37172409 DOI: 10.1016/j.midw.2023.103711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 03/20/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Female Genital Mutilation (FGM), which is culturally accepted in some African communities, has serious consequences on the physical, psychological, urogynecological, obstetrical and sexual health of girls and women. It is therefore important to understand women's experiences of the consequences of FGM. OBJECTIVE to understand the experiences of the consequences of female genital mutilation in sub-Saharan female survivors living in Spain. DESIGN a qualitative study based on Merleau-Ponty's hermeneutic phenomenology. PARTICIPANTS AND SETTING 13 sub-Saharan female survivors of female genital mutilation participated. The study was carried out in two south-eastern Spanish provinces where many jobs in the agricultural and service industry are done by African immigrants originating from ethnic groups in which FGM is still prevalent. FINDINGS In-depth interviews were carried out for data collection. ATLAS.ti was used for inductive analysis, from which two main themes were developed that represent the experiences of the consequences of FGM: (a) The impact of FGM: Hijacked sexual health and (b) The difficult process of genital reconstruction: overcoming the aftereffects and regaining integrity. CONCLUSION AND IMPLICATIONS FOR PRACTICE The mutilated women experienced serious consequences in their sexual, psychological and obstetrical health. Genital reconstruction was a difficult decision but contributed to regaining their sexual health and identity. The professionals involved play an important role in the care provided for the associated consequences of FGM, in identifying risk groups and in providing advice that allows the women to regain their sexual and reproductive health.
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Affiliation(s)
| | | | | | | | - Cayetano Fernández-Sola
- Department of Nursing Science, Physiotherapy and Medicine. University of Almeria. Spain; Associated Reseacher, Facultad de Ciencias de la Salud. Universidad Autónoma de Chile. Santiago, Chile.
| | - José Granero Molina
- Department of Nursing Science, Physiotherapy and Medicine. University of Almeria. Spain; Associated Reseacher, Facultad de Ciencias de la Salud. Universidad Autónoma de Chile. Santiago, Chile.
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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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Comment on: "Health outcomes and female genital mutilation/cutting: how much is due to the cutting itself?". Int J Impot Res 2023; 35:228-230. [PMID: 36759655 PMCID: PMC10159839 DOI: 10.1038/s41443-023-00667-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 02/11/2023]
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Villani M. Clitoral reconstruction: challenges and new directions. Int J Impot Res 2022; 35:196-201. [PMID: 35418603 PMCID: PMC10159845 DOI: 10.1038/s41443-022-00572-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 03/22/2022] [Accepted: 03/24/2022] [Indexed: 01/18/2023]
Abstract
Clitoral reconstruction (CR) has been the subject of several studies in recent years, mainly in the medical field. Women with female genital mutilation or cutting (FGM/C) seek clitoral reconstructive surgery to improve their sexual well-being, but also because they are affected by poor self- and body image. CR is supposed to help women with FGM/C reconstruct their sense of self, but the benefits and risks of this surgery have not been sufficiently explored. There are currently no recommendations supporting CR from mainstream medical bodies, and there have been very few ethical studies of the procedure. This article critically discusses the principal studies produced in the medical field and available reflections produced in the social sciences. Through the theoretical frameworks of postcolonial and feminist studies, the article discusses sexuality and pleasure, gender and identity, and race and positionality, with the aim of promoting collaborative work on CR between researchers and social and health professionals.
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Affiliation(s)
- Michela Villani
- HES-SO, School of Social Work Fribourg, Delémont, Switzerland.
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Bazzoun Y, Aerts L, Abdulcadir J. Surgical Treatments of Chronic Vulvar Pain After Female Genital Mutilation/Cutting. J Sex Med 2022; 19:290-301. [PMID: 35000888 DOI: 10.1016/j.jsxm.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/18/2021] [Accepted: 11/19/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Vulvar and in particular clitoral pain can affect women with Female Genital Mutilation/Cutting (FGM/C). To date, there is no comprehensive study on the different available treatments for vulvar pain after FGM/C. AIM To study the outcome of surgical treatments of vulvar and/or clitoral pain among women living with FGM/C. METHODS Retrospective review of the consecutive medical files of all 506 women who consulted at a specialized outpatient clinic for women with FGM/C between April 1, 2010 and December 31, 2017. OUTCOME Subjective change in chronic vulvar pain after surgical treatment. RESULTS In total, 36.1% of women (n = 183) experienced chronic pain, all types included, among which 2.8% (n = 14) experienced provoked or unprovoked chronic vulvar pain. Among the 14 women with provoked or unprovoked chronic vulvar pain, ten (71.4%) underwent surgical treatment: 7 underwent resection of vulvar scar complications (cysts, bridles, adhesions) with (n = 4) or without (n = 3) concomitant defibulation, 3 had clitoral reconstruction and one had labium reconstruction with removal of peri-clitoral adhesion. Nine out of ten (90%) experienced resolution of pain after surgery and the remaining woman (10%) was lost to follow-up. CLINICAL IMPLICATIONS Safe and effective surgical treatments exist and patients with chronic vulvar pain post-FGM/C should be referred to specialists who would consider appropriate indications for surgery and support informed decision-making and treatment. STRENGTHS & LIMITATIONS The strengths of this research are the big sample size of women from diverse cultural and religious backgrounds, as well as the availability of pre- and postsurgery iconographic material and histology. Limitations include a subjective reporting of pain without validated questionnaires. CONCLUSION Effective surgical treatments for provoked or unprovoked chronic vulvar pain post-FGM/C are clitoral reconstruction, defibulation, cystectomy, and bridle removal. Surgical treatments should be combined with a culturally sensitive multidisciplinary care and follow-up. Bazzoun Y., Aerts L., Abdulcadir J. Surgical Treatments of Chronic Vulvar Pain After Female Genital Mutilation/Cutting. J Sex Med 2022;19:290-301.
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Affiliation(s)
- Yara Bazzoun
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Leen Aerts
- Division of Gynaecology, Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Jasmine Abdulcadir
- Division of Gynaecology, Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland.
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Christopher AN, Othman S, Morris MP, Broach RB, Percec I. Clinical and Patient-Reported Outcomes of 19 Patients Undergoing Clitoral and Labial Reconstruction After Female Genital Mutilation/Cutting. Aesthetic Plast Surg 2022; 46:468-477. [PMID: 34729638 DOI: 10.1007/s00266-021-02648-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/24/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Female genital mutilation/cutting (FGM/C) is the intentional alteration, removal, or injury of female genitalia for non-medical reasons. Approximately 200 million females have been victims of FGM/C, and genital reconstructive procedures are increasing in demand. OBJECTIVES The objectives of this study were to assess clinical and patient-reported outcomes after FGM/C reconstruction to help guide treatment practices. METHODS Adult patients undergoing anatomic reconstruction after FGM/C were retrospectively identified. Outcomes included clitoral, labial, and donor site surgical site occurrences (SSO) and the need for revision operations. Patient-reported outcomes were assessed using an adapted version of the Female Sexual Function Index (FSFI), a validated outcomes instrument that assesses sexual function through 6 domains, with each domain having a maximum score of 6. RESULTS Nineteen patients were identified in our review. Patients presented for reconstruction due to dyspareunia, inability to orgasm, chronic infections, to normalize appearance, and/or to "feel normal." There were no SSOs and two revision operations for adhesions. 74% of patients completed the FSFI postoperatively. Despite most patients seeking repair for inability to orgasm and/or dyspareunia, the median scores for these domains were 4.6 and 5.2. Patients' desire to engage in sexual activity scored lowest (3.9), and patients reported concerns over the appearance of their genitalia (50%) that affected self-confidence (85.7%). CONCLUSION FGM/C reconstruction is safe and contributes to improvements in physical sexual health. Psychological trauma may contribute to lessened sexual desire and self-confidence even after reconstruction. Multidisciplinary treatment is important to address the long-term psychological effects of this practice. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Berthe-Kone O, Ventura-Miranda MI, López-Saro SM, García-González J, Granero-Molina J, Jiménez-Lasserrotte MDM, Fernández-Sola C. The Perception of African Immigrant Women Living in Spain Regarding the Persistence of FGM. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:13341. [PMID: 34948950 PMCID: PMC8704587 DOI: 10.3390/ijerph182413341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 11/27/2022]
Abstract
Approximately 200 million women and girls have undergone female genital mutilation (FGM) worldwide. Migration has spread the practice of FGM around the world, thus making it a global public health issue. The objective of this descriptive qualitative study was to explore the perceptions of Sub-Saharan immigrant women in Spain in relation to the causes of the persistence of FGM. In-depth interviews were carried out with 13 female FGM survivors of African origin, followed by inductive data analysis using ATLAS.ti software. Two main themes emerged from the analysis: (1) A family ritual symbolic of purification and (2) a system of false beliefs and deception in favour of FGM. The FGM survivors living in Europe are aware that FGM is a practice that violates human rights yet persists due to a system of false beliefs rooted in family traditions and deception that hides the reality of FGM from young girls or forces them to undergo the practice. The ritualistic nature of FGM and the threat of social exclusion faced by women who have not had it performed on them contributes to its persistence nowadays.
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Affiliation(s)
- Ousmane Berthe-Kone
- Surgical Critical Resuscitation, Torrecárdenas University Hospital, 04009 Almeria, Spain;
| | - María Isabel Ventura-Miranda
- Department of Nursing, Physiotherapy and Medicine, University of Almeria, 04120 Almeria, Spain; (J.G.-G.); (J.G.-M.); (M.d.M.J.-L.); (C.F.-S.)
| | | | - Jessica García-González
- Department of Nursing, Physiotherapy and Medicine, University of Almeria, 04120 Almeria, Spain; (J.G.-G.); (J.G.-M.); (M.d.M.J.-L.); (C.F.-S.)
| | - José Granero-Molina
- Department of Nursing, Physiotherapy and Medicine, University of Almeria, 04120 Almeria, Spain; (J.G.-G.); (J.G.-M.); (M.d.M.J.-L.); (C.F.-S.)
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Santiago 7500000, Chile
| | - María del Mar Jiménez-Lasserrotte
- Department of Nursing, Physiotherapy and Medicine, University of Almeria, 04120 Almeria, Spain; (J.G.-G.); (J.G.-M.); (M.d.M.J.-L.); (C.F.-S.)
| | - Cayetano Fernández-Sola
- Department of Nursing, Physiotherapy and Medicine, University of Almeria, 04120 Almeria, Spain; (J.G.-G.); (J.G.-M.); (M.d.M.J.-L.); (C.F.-S.)
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Santiago 7500000, Chile
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Jordal M, Sigurjonsson H, Griffin G, Wahlberg A. The benefits and disappointments following clitoral reconstruction after female genital cutting: A qualitative interview study from Sweden. PLoS One 2021; 16:e0254855. [PMID: 34288962 PMCID: PMC8294499 DOI: 10.1371/journal.pone.0254855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/05/2021] [Indexed: 11/23/2022] Open
Abstract
Female genital cutting or mutilation refers to the cutting of girls' external genitalia. Due to migration from contexts where female genital cutting is common, it is estimated that around 38 000 cut women and girls live in Sweden. Clitoral reconstruction, a relatively new form of surgical healthcare offered to women with female genital cutting, was established in Sweden in 2014. This surgery aims at restoring clitoral function and anatomy, but there is yet a dearth of evidence demonstrating the effects of the surgery. The aim of this study was to explore how women undergoing clitoral reconstruction in Sweden between 2016 and 2019 experienced the surgical process and its aftereffects from a physical, sexual and psychosocial perspective. Eighteen women who had undergone clitoral reconstruction at a university hospital in Sweden agreed to participate in the study. The women were interviewed using semi-structured interviews, which were recorded, transcribed and analysed using thematic analysis. The results, based on self-categorization and labelling theory, demonstrated both benefits and disappointments following the surgery. Several women reported positive outcomes in terms of sexual, psychosocial and aesthetic terms. They experienced reduced genital pain, improvements in their sex lives, and a sense of feeling more empowered and at ease in their bodies. Yet, some women reported aesthetic, functional and process-related disappointment related to clitoral reconstruction. Nonetheless, the women expressed gratitude for the possibility of undergoing the surgery. In conclusion, the women reported that they experienced physical, sexual and psychosocial benefits of the surgery.
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Affiliation(s)
- Malin Jordal
- Center for Gender Research, Uppsala University, Centrum för genusvetenskap, Uppsala, Sweden
- Department of Health and Caring Sciences, University of Gävle, Gävle, Sweden
| | - Hannes Sigurjonsson
- Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Gabriele Griffin
- Center for Gender Research, Uppsala University, Centrum för genusvetenskap, Uppsala, Sweden
| | - Anna Wahlberg
- International Maternal and Child Health, Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
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13
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Ahmed CA, Khokhar AT, Erlandsson K, Bogren M. Defibulated immigrant women's sexual and reproductive health from the perspective of midwives and gynaecologists as primary care providers in Sweden - A phenomenographic study. SEXUAL & REPRODUCTIVE HEALTHCARE 2021; 29:100644. [PMID: 34265570 DOI: 10.1016/j.srhc.2021.100644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/19/2021] [Accepted: 06/28/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To capture care providers' perceptions of defibulated immigrant women's sexual and reproductive health, illuminated by their experiences as care providers for these women. METHODS Individual interview study with 13 care providers at Swedish healthcare facilities: six gynaecologists and seven midwives caring for defibulated immigrant women, analysed with a phenomenographic method. FINDINGS One of the care providers' perceptions of women who had been defibulated was that they had an altered genital function, meaning a wider introitus, improved vaginal intercourse, and more ease urinating and menstruating. The care providers also perceived that women who were defibulated had to balance their wellbeing, struggling between a positive self-image and handling their emotions. Existing in-between cultural values led to a fear of being excluded while at the same time having a desire to be included in the new culture. CONCLUSION Defibulation affects women's sexual and reproductive health and calls for a holistic perspective when providing services, individualized according to the woman's care needs. Support and counselling, should include information about defibulation already during the adolescent years to promote sexual and reproductive health and well-being.
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Affiliation(s)
- Caisha Arai Ahmed
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
| | | | - Kerstin Erlandsson
- Women's and Children's Health, Karolinska Institutet, Solna, Sweden; School of Education, Health and Social Studies, Dalarna University, Dalarna, Sweden.
| | - Malin Bogren
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.
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Brady SS, Connor JJ, Chaisson N, Sharif Mohamed F, Robinson BBE. Female Genital Cutting and Deinfibulation: Applying the Theory of Planned Behavior to Research and Practice. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:1913-1927. [PMID: 31359211 PMCID: PMC6987000 DOI: 10.1007/s10508-019-1427-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 02/11/2019] [Accepted: 02/15/2019] [Indexed: 05/09/2023]
Abstract
At least 200 million girls and women across the world have experienced female genital cutting (FGC). International migration has grown substantially in recent decades, leading to a need for health care providers in regions of the world that do not practice FGC to become knowledgeable and skilled in their care of women who have undergone the procedure. There are four commonly recognized types of FGC (Types I, II, III, and IV). To adhere to recommendations advanced by the World Health Organization (WHO) and numerous professional organizations, providers should discuss and offer deinfibulation to female patients who have undergone infibulation (Type III FGC), particularly before intercourse and childbirth. Infibulation involves narrowing the vaginal orifice through cutting and appositioning the labia minora and/or labia majora, and creating a covering seal over the vagina with appositioned tissue. The WHO has published a handbook for health care providers that includes guidance in counseling patients about deinfibulation and performing the procedure. Providers may benefit from additional guidance in how to discuss FGC and deinfibulation in a manner that is sensitive to each patient's culture, community, and values. Little research is available to describe decision-making about deinfibulation among women. This article introduces a theoretically informed conceptual model to guide future research and clinical conversations about FGC and deinfibulation with women who have undergone FGC, as well as their partners and families. This conceptual model, based on the Theory of Planned Behavior, may facilitate conversations that lead to shared decision-making between providers and patients.
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Affiliation(s)
- Sonya S Brady
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, 1300 South Second Street, Suite 300, Minneapolis, MN, 55454, USA.
| | - Jennifer J Connor
- Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Nicole Chaisson
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Beatrice Bean E Robinson
- Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
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15
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Connor JJ, Brady SS, Chaisson N, Mohamed FS, Robinson BBE. Response to Commentaries: Understanding Women's Responses to Sexual Pain After Female Genital Cutting. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:1907-1912. [PMID: 34100144 DOI: 10.1007/s10508-021-02047-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 06/12/2023]
Affiliation(s)
- Jennifer Jo Connor
- Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, 1300 South Second Street, Suite 180, Minneapolis, MN, 55454, USA.
| | - Sonya S Brady
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Nicole Chaisson
- Smiley's Clinic, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Beatrice Bean E Robinson
- Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, 1300 South Second Street, Suite 180, Minneapolis, MN, 55454, USA
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16
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Abdulcadir J, Catania L. Conceptualizing Sexual Pain in Women with Female Genital Mutilation/Cutting. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:1871-1874. [PMID: 32279168 DOI: 10.1007/s10508-020-01691-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Jasmine Abdulcadir
- Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, 30 Bld de la Cluse, 1211, Geneva, Switzerland.
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Surgical management of female genital mutilation-related morbidity: A scoping review. J Plast Reconstr Aesthet Surg 2021; 74:2467-2478. [PMID: 34219039 DOI: 10.1016/j.bjps.2021.05.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 05/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Over 200 million women and girls worldwide have suffered from the partial to total removal of external female genitalia for nonmedical purposes, referred to as female genital mutilation (FGM). Survivors of FGM may develop debilitating physical and psychological long-term sequelae. This is the first study to examine the scope of the extant surgical literature on the management of FGM-related morbidity. METHODS A systematic scoping review of five major research citation databases was conducted. RESULTS A total of 190 articles from 29 countries met the inclusion criteria. The majority (76%) were primary source articles and from obstetrics and gynecology literature (71%). Reported interventions for FGM-related morbidity were defibulation, cyst excision, clitoral and vulvar reconstruction, urological reconstruction, peripartum procedures, labial adhesion release, and reinfibulation. CONCLUSIONS Surgery for FGM complications spans multiple specialties, which suggests multidisciplinary collaboration benefit. Plastic and reconstructive surgeons have a clear role in the multidisciplinary care team for these patients. This scoping review identified a paucity of high-quality evidence with respect to functional quality of life outcomes and long-term follow-up.
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Auricchio V, Garzon S, Pomini P, Laganà AS, Casarin J, Cromi A, Ghezzi F, Vigato E, Franchi M. Clitoral reconstructive surgery after female genital mutilation: A systematic review. SEXUAL & REPRODUCTIVE HEALTHCARE 2021; 29:100619. [PMID: 33845447 DOI: 10.1016/j.srhc.2021.100619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 03/01/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To summarize available evidence on clitoral reconstruction after Female genital mutilations/cut (FGM/C). STUDY DESIGN Systematic review of the literature to identify studies on clitoral reconstruction after previous FGM/C with at least 6 months of follow-up. The literature search was performed in the following databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. The period considered was from the database inception to June 30th, 2020. MAIN OUTCOME MEASURES Post-operative vulvar pain or dyspareunia, changes in sexual activity or orgasm, and the impact on self-image. RESULTS We identified 8 studies; four used the same "Foldès technique", and four adopted similar techniques based on the downward mobilization of the clitoral stump, with different reconstructions of glans and prepuce. The postoperative complication rate was reported at 5.3%. Sexual function is the only outcome investigated by all studies, which consistently suggest that clitoral reconstruction appear effective to improve clitoral pleasure/orgasm. Almost all studies assessed self-image, which appears improved. Only 2 studies provided data about pain and/or dyspareunia, which were improved by clitoral reconstruction. However, the risk of bias is high. Most patients were lost at follow-up, and validated instruments to assess outcomes were used only in a minority of studies. CONCLUSIONS Although clitoral reconstructive surgery for FGM/C appears safe and effective, caution is required to interpret available evidence due to significant limitations. Further studies are required to compare the proposed techniques and to confirm the effectiveness in terms of vulvar pain and/or dyspareunia, sexual activity and/or orgasm, and self-image improvement.
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Affiliation(s)
- Valeria Auricchio
- Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, VR, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, VR, Italy.
| | - Paola Pomini
- Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, VR, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynaecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, VR, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynaecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, VR, Italy
| | - Antonella Cromi
- Department of Obstetrics and Gynaecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, VR, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynaecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, VR, Italy
| | - Enrico Vigato
- Department of Plastic and Reconstructive Surgery, AOUI Verona, University of Verona, Verona, VR, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, VR, Italy
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Taraldsen S, Vangen S, Øian P, Sørbye IK. Female genital mutilation/cutting, timing of deinfibulation, and risk of cesarean section. Acta Obstet Gynecol Scand 2021; 100:587-595. [PMID: 33719034 DOI: 10.1111/aogs.14111] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 01/24/2021] [Accepted: 02/03/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The impact of female genital mutilation/cutting on obstetric outcomes in high-income countries is not clear. In general, women with female genital mutilation/cutting type 3 (infibulation) seem to be most at risk of adverse outcomes such as cesarean section. Deinfibulation is recommended to prevent obstetric complications. Whether the timing of this procedure affects the complication risk is not known. The aims of this study were, first, to examine the association between female genital mutilation/cutting and the risk of cesarean section in Norway, and, second, whether the timing of deinfibulation affected the cesarean section risk. MATERIAL AND METHODS This was a historical cohort study of nulliparous Somali-born women who gave birth in Norway between 1990 and 2014. The Medical Birth Registry of Norway identified the women. Data were collected from medical records at 11 participating birth units. The exposures were female genital mutilation/cutting status and deinfibulation before pregnancy, during pregnancy, or no deinfibulation before labor onset. The main outcome was odds ratio (OR) of cesarean section. Type of cesarean section, primary indications, and neonatal outcomes were secondary outcomes. RESULTS Women with female genital mutilation/cutting type 3 had lower risk of cesarean section compared with women with no female genital mutilation/cutting (OR 0.54, 95% CI 0.33-0.89 P = .02). Among the 1504 included women, the cesarean section rate was 28.0% and the proportion of emergency operations was 92.9%. Fetal distress was the primary indication in approximately 50% of cases, across the groups with different female genital mutilation/cutting status. Women who had no deinfibulation before labor onset had lower risk of cesarean section compared with those who underwent deinfibulation before or during pregnancy (OR 0.64, 95% CI 0.46-0.88 P = .01). CONCLUSIONS High risk of cesarean section in Somali nulliparous women was not related to the type of female genital mutilation/cutting in the present study. Deinfibulation before labor did not protect against cesarean section. Our findings indicate that nulliparous Somali women are at high risk of intrapartum complications. Future research should focus on measures to reduce maternal morbidity and on how timing of deinfibulation affects the outcomes of vaginal births.
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Affiliation(s)
- Sølvi Taraldsen
- Norwegian National Advisory Unit on Women's Health, Division of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
| | - Siri Vangen
- Norwegian National Advisory Unit on Women's Health, Division of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Pål Øian
- Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
| | - Ingvil K Sørbye
- Norwegian National Advisory Unit on Women's Health, Division of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway.,Department of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
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20
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When Love Hurts: Evaluation and Management of Painful Intercourse in Women. CURRENT SEXUAL HEALTH REPORTS 2021. [DOI: 10.1007/s11930-020-00300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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21
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Chappell AG, Soriano AJ, Percec I. The Role of Plastic Surgeons in Female Genital Mutilation Reconstructive Surgery. World J Plast Surg 2021; 10:104-107. [PMID: 33833961 PMCID: PMC8016383 DOI: 10.29252/wjps.10.1.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The World Health Organization defines female genital mutilation (FGM) as any procedure involving partial or total removal of female external genitalia or other injury to genital organs for non-medical indications. Despite prohibitory legislation in the United States and significant morbidity related to FGM procedures, the practice continues throughout the globe with three million women at risk annually. Surgical care for women with FGM has historically been in the hands of obstetrician and Gynaecologists (OB GYNs), and mainly focused to help safe labor and delivery. Recent awareness of the need for improved reconstructive surgical care for FGM has developed in the plastic surgical literature. This Current Opinion article highlights the historical surgical care for FGM and the opportunity for plastic surgeons to get more involved in the multidisciplinary care of these patients.
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Affiliation(s)
- Ava G Chappell
- Division of Plastic and Reconstructive Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.,Institute of Global Health, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Alex J Soriano
- Division of Urogynecology, Department of Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ivona Percec
- Department of Plastic and Reconstructive Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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22
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Jordal M, Levin L, Påfs J, Griffin G, Wahlberg A. Swedish Gynecologists' Positioning in Relation to Clitoral Reconstruction After Female Genital Cutting. A Qualitative Interview Study. INTERNATIONAL JOURNAL OF SEXUAL HEALTH : OFFICIAL JOURNAL OF THE WORLD ASSOCIATION FOR SEXUAL HEALTH 2020; 33:76-87. [PMID: 38596474 PMCID: PMC10807807 DOI: 10.1080/19317611.2020.1853301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 04/11/2024]
Abstract
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.
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Affiliation(s)
- Malin Jordal
- Centre for Gender Research, Uppsala University, Uppsala, Sweden
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Department of Health and Caring Sciences, University of Gävle, Gävle, Sweden
| | - Linn Levin
- Centre for Gender Research, Uppsala University, Uppsala, Sweden
| | - Jessica Påfs
- Department of Social Work, University of Gothenburg, Gothenburg, Sweden
| | | | - Anna Wahlberg
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
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Evans C, Tweheyo R, McGarry J, Eldridge J, Albert J, Nkoyo V, Higginbottom G. Improving care for women and girls who have undergone female genital mutilation/cutting: qualitative systematic reviews. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07310] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background
In a context of high migration, there are growing numbers of women living in the UK who have experienced female genital mutilation/cutting. Evidence is needed to understand how best to meet their health-care needs and to shape culturally appropriate service delivery.
Objectives
To undertake two systematic reviews of qualitative evidence to illuminate the experiences, needs, barriers and facilitators around seeking and providing female genital mutilation-/cutting-related health care from the perspectives of (1) women and girls who have experienced female genital mutilation/cutting (review 1) and (2) health professionals (review 2).
Review methods
The reviews were undertaken separately using a thematic synthesis approach and then combined into an overarching synthesis. Sixteen electronic databases (including grey literature sources) were searched from inception to 31 December 2017 and supplemented by reference list searching. Papers from any Organisation for Economic Co-operation and Development country with any date and in any language were included (Organisation for Economic Co-operation and Development membership was considered a proxy for comparable high-income migrant destination countries). Standardised tools were used for quality appraisal and data extraction. Findings were coded and thematically analysed using NVivo 11 (QSR International, Warrington, UK) software. Confidence in the review findings was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation – Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach. All review steps involved two or more reviewers and a team that included community-based and clinical experts.
Results
Seventy-eight papers (74 distinct studies) met the inclusion criteria for both reviews: 57 papers in review 1 (n = 18 from the UK), 30 papers in review 2 (n = 5 from the UK) and nine papers common to both. Review 1 comprised 17 descriptive themes synthesised into five analytical themes. Women’s health-care experiences related to female genital mutilation/cutting were shaped by silence and stigma, which hindered care-seeking and access to care, especially for non-pregnant women. Across all countries, women reported emotionally distressing and disempowering care experiences. There was limited awareness of specialist service provision. Good care depended on having a trusting relationship with a culturally sensitive and knowledgeable provider. Review 2 comprised 20 descriptive themes synthesised into six analytical themes. Providers from many settings reported feeling uncomfortable talking about female genital mutilation/cutting, lacking sufficient knowledge and struggling with language barriers. This led to missed opportunities for, and suboptimal management of, female genital mutilation-/cutting-related care. More positive experiences/practices were reported in contexts where there was input from specialists and where there were clear processes to address language barriers and to support timely identification, referral and follow-up.
Limitations
Most studies had an implicit focus on type III female genital mutilation/cutting and on maternity settings, but many studies combined groups or female genital mutilation/cutting types, making it hard to draw conclusions specific to different communities, conditions or contexts. There were no evaluations of service models, there was no research specifically on girls and there was limited evidence on psychological needs.
Conclusions
The evidence suggests that care and communication around female genital mutilation/cutting can pose significant challenges for women and health-care providers. Appropriate models of service delivery include language support, continuity models, clear care pathways (including for mental health and non-pregnant women), specialist provision and community engagement. Routinisation of female genital mutilation/cutting discussions within different health-care settings may be an important strategy to ensure timely entry into, and appropriate receipt of, female genital mutilation-/cutting-related care. Staff training is an ongoing need.
Future work
Future research should evaluate the most-effective models of training and of service delivery.
Study registration
This study is registered as PROSPERO CRD420150300012015 (review 1) and PROSPERO CRD420150300042015 (review 2).
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Catrin Evans
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Ritah Tweheyo
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Julie McGarry
- School of Health Sciences, University of Nottingham, Nottingham, UK
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24
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Abstract
Female genital mutilation (FGM) is an established cultural practice in over 30 countries. It has no health benefits, carries a high risk of physical and psychological harm, and is illegal in many countries including the UK. A sensitive approach is required, both in the management of complications and prevention of this practice. This article discusses the prevalence and classification of FGM, and offers practical advice to nurses and midwives involved in general and obstetric care. Legal aspects, including safeguarding responsibilities and the mandatory duty to report FGM in England and Wales, are outlined.
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Affiliation(s)
- Inez von Rège
- Specialty Registrar in Obstetrics and Gynaecology, Guy's and St Thomas' NHS Foundation Trust, London
| | - Daniel Campion
- Travel Medicine Specialist, Trailfinders Travel Clinic, Kensington, London
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25
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Jordal M, Griffin G, Sigurjonsson H. 'I want what every other woman has': reasons for wanting clitoral reconstructive surgery after female genital cutting - a qualitative study from Sweden. CULTURE, HEALTH & SEXUALITY 2019; 21:701-716. [PMID: 30345886 DOI: 10.1080/13691058.2018.1510980] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 08/08/2018] [Indexed: 05/22/2023]
Abstract
Female genital cutting (FGC) involves the removal of women's external genitalia for non-therapeutic reasons. An estimated 38,000 women living in Sweden have undergone some form of the procedure. These women often belong to marginalised minorities of immigrant women from countries where FGC is widespread. Clitoral reconstructive surgery following FGC has recently been introduced in Sweden. This study investigates women's perceptions of FGC and clitoral reconstructive surgery with a particular focus on: (1) reasons for requesting reconstructive surgery, and (2) FGC-affected women's expectations of the surgery. Seventeen women referred for clitoral reconstructive surgery at the Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, Stockholm, participated in the study. Findings revealed five factors motivating women's request for clitoral reconstruction (CR): (1) symbolic restitution - undoing the harm of FGC; (2) repairing the visible stigma of FGC; (3) improving sex and intimacy through physical, aesthetic and symbolic recovery; (4) eliminating physical pain; (5) and CR as a personal project offering hope. These factors were highly interconnected, suggesting that the reasons for seeking surgery were often multiple and complex.
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Affiliation(s)
- Malin Jordal
- a Center for Gender Research, Uppsala University , Uppsala , Sweden
| | - Gabriele Griffin
- a Center for Gender Research, Uppsala University , Uppsala , Sweden
| | - Hannes Sigurjonsson
- b Department of Plastic and Reconstructive Surgery , Karolinska University Hospital , Solna , Sweden
- c Department of Medicine , Karolinska Institute, Karolinska University Hospital , Solna , Sweden
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26
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Abstract
Female genital mutilation (FGM) is the ritualistic removal of parts of the external female genitalia. The extent of mutilation as well as the age at which it is performed vary depending on ethnicity. We recognise four forms of mutilation based on the extent of tissue resection, ranging from clitridectomy to resection of the entire soft tissue of the external genitalia. The vast majority of the estimated 200 million mutilated women live in Africa and the Middle and Far East. Due to migration an estimated 150,000 mutilated women live in Germany to date. In approximately 30% of cases FGM leads to urologic complications and the chances of urologists facing these complications is rapidly increasing. The focus lies on chronic infections, pain syndromes and obstructed micturition with all associated late complications. This situation is made more complex if any neighbouring organs were damaged during the mutilation.
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27
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Sigurjonsson H, Jordal M. Addressing Female Genital Mutilation/Cutting (FGM/C) in the Era of Clitoral Reconstruction: Plastic Surgery. CURRENT SEXUAL HEALTH REPORTS 2018; 10:50-56. [PMID: 29755298 PMCID: PMC5937872 DOI: 10.1007/s11930-018-0147-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
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.
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Affiliation(s)
- Hannes Sigurjonsson
- Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Malin Jordal
- Center for Gender Research, Uppsala University, Uppsala, Sweden
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29
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Johnsdotter S. The Impact of Migration on Attitudes to Female Genital Cutting and Experiences of Sexual Dysfunction Among Migrant Women with FGC. CURRENT SEXUAL HEALTH REPORTS 2018. [PMID: 29541003 PMCID: PMC5840240 DOI: 10.1007/s11930-018-0139-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Sara Johnsdotter
- Faculty of Health and Society, Malmö University, 205 06 Malmö, Sweden
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30
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Evans C, Tweheyo R, McGarry J, Eldridge J, McCormick C, Nkoyo V, Higginbottom GMA. What are the experiences of seeking, receiving and providing FGM-related healthcare? Perspectives of health professionals and women/girls who have undergone FGM: protocol for a systematic review of qualitative evidence. BMJ Open 2017; 7:e018170. [PMID: 29247096 PMCID: PMC5736050 DOI: 10.1136/bmjopen-2017-018170] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Female genital mutilation (FGM) is an issue of global concern. High levels of migration mean that healthcare systems in higher-income western countries are increasingly being challenged to respond to the care needs of affected communities. Research has identified significant challenges in the provision of, and access to, FGM-related healthcare. There is a lack of confidence and competence among health professionals in providing appropriate care, suggesting an urgent need for evidence-based service development in this area. This study will involve two systematic reviews of qualitative evidence to explore the experiences, needs, barriers and facilitators to seeking and providing FGM-related healthcare in high-income (Organisation for Economic Cooperation and Development) countries, from the perspectives of: (1) women and girls who have undergone FGM and (2) health professionals. REVIEW METHODS Twelve databases including MEDLINE, EMBASE, PsycINFO, ASSIA, Web of Science, ERIC, CINAHL, and POPLINE will be searched with no limits on publication year. Relevant grey literature will be identified from digital sources and professional networks.Two reviewers will independently screen, select and critically appraise the studies. Study quality will be assessed using the Joanna Briggs Institute Qualitative Assessment and Review Instrument appraisal tool. Findings will be extracted into NVivo software. Synthesis will involve inductive thematic analysis, including in-depth reading, line by line coding of the findings, development of descriptive themes and re-coding to higher level analytical themes. Confidence in the review findings will be assessed using the CERQual approach. Findings will be integrated into a comprehensive set of recommendations for research, policy and practice. DISSEMINATION The syntheses will be reported as per the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. Two reviews will be published in peer-reviewed journals and an integrated report disseminated at stakeholder engagement events. PROSPEROREGISTRATION NUMBER CRD42015030001: 2015 and CRD42015030004: 2015.
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Affiliation(s)
- Catrin Evans
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Ritah Tweheyo
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Julie McGarry
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Jeanette Eldridge
- Research and Learning Services, Faculty of Medicine and Health Sciences, University of Nottingham, UK
| | - Carol McCormick
- Consultant Midwife, Nottingham University Hospital Trust, Nottingham, UK
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Berg RC, Taraldsen S, Said MA, Sørbye IK, Vangen S. The effectiveness of surgical interventions for women with FGM/C: a systematic review. BJOG 2017; 125:278-287. [DOI: 10.1111/1471-0528.14839] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2017] [Indexed: 10/19/2022]
Affiliation(s)
- RC Berg
- Norwegian Institute of Public Health; Oslo Norway
- Department of Community Medicine; University of Tromso; Tromso Norway
| | - S Taraldsen
- Norwegian National Advisory Unit on Women's Health; Division of Gynaecology and Obstetrics; Oslo University Hospital HF Rikshospitalet; Oslo Norway
| | - MA Said
- Oslo University Hospital - Ullevål Hospital; Oslo Norway
| | - IK Sørbye
- Norwegian National Advisory Unit on Women's Health; Division of Gynaecology and Obstetrics; Oslo University Hospital HF Rikshospitalet; Oslo Norway
| | - S Vangen
- Norwegian National Advisory Unit on Women's Health; Division of Gynaecology and Obstetrics; Oslo University Hospital HF Rikshospitalet; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
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