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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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Esse I, Kincaid CM, Terrell CA, Mesinkovska NA. Female genital mutilation: Overview and dermatologic relevance. JAAD Int 2024; 14:92-98. [PMID: 38352964 PMCID: PMC10862004 DOI: 10.1016/j.jdin.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2023] [Indexed: 02/16/2024] Open
Abstract
Female genital mutilation (FGM) is a common cultural practice, which involves the partial or complete removal of the external female genitalia. With increasing immigration from regions where the practice is endemic, there has been a growing prevalence of FGM in the United States and other developed nations. However, most medical professionals lack the baseline knowledge regarding FGM and its associated health complications. Given this increasing trend, dermatologists should anticipate an increasing number of patients with a history of FGM in their practice. While some of the obstetric, gynecologic, and psychologic consequences of FGM have been well-reported, the dermatologic findings are less characterized. Thus, this review article aims to provide dermatologists with a fundamental understanding of the prevalence, cultural significance, and health implications of FGM with a focus on the associated dermatological findings and provides recommendations on how dermatologists can address this sensitive matter.
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Affiliation(s)
- Ilhan Esse
- Department of Dermatology, University of California, Irvine, California
| | - Colin M. Kincaid
- Department of Dermatology, University of California, Irvine, California
| | - Carrie Ann Terrell
- Department of Obstetrics, Gynecology and Women’s Health, University of Minnesota, Minneapolis, Minnesota
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Şahin Ö, Varlı EN, Moallim AO, Tolunay HE. A long-term complication of clitoral cyst after female genital mutilation. Pan Afr Med J 2023; 46:23. [PMID: 38107336 PMCID: PMC10724032 DOI: 10.11604/pamj.2023.46.23.31939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/15/2023] [Indexed: 12/19/2023] Open
Abstract
Female genital mutilation (FGM) was seen in 30 countries, especially in Africa and also in Asia and the Middle East. According to WHO data, Somalia is where FGM is performed most frequently. Our study aimed to evaluate the recordings of patients with FGM who were diagnosed with a traumatic clitoral cyst. We identified the clitoral cyst cases between February 2015 and August 2020. We collected clinical, surgical, sociodemographic, and histopathological details such as age, marital status, patient resume, age at which FGM was performed, complaints, size of the cyst consultation reasons, FGM procedural long-term complications, sexual function, husband polygamic relationship status, and histological findings. A total of 21 patients diagnosed with clitoral cysts were included in the study. The technique was easily applied in every patient, and the cysts were removed intact, except in 2 patients. There were no intraoperative complications; only minimal bleeding was seen. Except for one patient, all had unilocular cysts, and the final pathological examination revealed an epidermal inclusion cyst. We observed a neuroma developed due to genital trauma due to FGM in one of our patients. Female circumcision and its consequences are not familiar to many healthcare professionals in the developed world. We want to increase awareness of female circumcision and its long-term complication of clitoral cysts among healthcare professionals worldwide.
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Affiliation(s)
- Özgür Şahin
- Recep Tayyip Erdogan Somalia Mogadishu Training and Research Hospital, Department of Obstetrics and Gynecology, Mogadishu, Somalia
| | - Erol Nadi Varlı
- Etlik Zübeyde Hanım Maternity and Women´s Health Teaching and Research Hospital, Perinatology Department, Ankara, Turkey
| | - Abdirahman Omar Moallim
- Recep Tayyip Erdogan Somalia Mogadishu Training and Research Hospital, Department of Obstetrics and Gynecology, Mogadishu, Somalia
| | - Harun Egemen Tolunay
- Etlik Zübeyde Hanım Maternity and Women´s Health Teaching and Research Hospital, Perinatology Department, Ankara, Turkey
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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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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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Manin E, Taraschi G, Berndt S, Martinez de Tejada B, Abdulcadir J. Autologous Platelet-Rich Plasma for Clitoral Reconstruction: A Case Study. ARCHIVES OF SEXUAL BEHAVIOR 2022; 51:673-678. [PMID: 34779981 PMCID: PMC8858308 DOI: 10.1007/s10508-021-02172-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Emily Manin
- Weill Cornell Medical College, New York, NY, USA
| | - Gianmarco Taraschi
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, 30 Blvd de la Cluse 1211, 14, Geneva, Switzerland
| | - Sarah Berndt
- Regen Lab SA, En Budron b2, 1052, Le Mont-sur-Lausanne, Switzerland
| | - Begoña Martinez de Tejada
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, 30 Blvd de la Cluse 1211, 14, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jasmine Abdulcadir
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, 30 Blvd de la Cluse 1211, 14, Geneva, Switzerland.
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Bazzoun Y, Aerts L, Abdulcadir J. Chronic Vulvar Pain After Female Genital Mutilation/Cutting: A Retrospective Study. Sex Med 2021; 9:100425. [PMID: 34520933 PMCID: PMC8498950 DOI: 10.1016/j.esxm.2021.100425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Chronic vulvar pain is a condition that affects many women during their lifetime, including women with Female Genital Mutilation/Cutting (FGM/C). AIM To study the prevalence and possible etiologies of chronic vulvar pain among women living with FGM/C. METHODS We conducted a retrospective review of consecutive medical files of 506 women who consulted our specialized clinic for women with FGM/C between April 1, 2010 and December 31, 2017. We collected sociodemographic and clinical data including information on the type of FGM/C and its complications. We focused on studying the prevalence, etiologies and characteristics of chronic vulvar pain. MAIN OUTCOME MEASURES Prevalence and etiologies of vulvar pain in women with FGM/C. RESULTS Chronic vulvar pain was present in 14 women (2.8%). Pain was unprovoked in one case (7.1%) and provoked in the 13 other cases (92.9%). In most of the cases, women presented vulvar pain related to scar complications such as clitoral or peri-clitoral adhesions or scar tissue (n = 3, 21.4%), bridle scars (n = 1, 7.1%), post-traumatic neuromas (n = 2, 14.3%) and vulvar cysts (n = 6, 42.9%), the latter being found more frequently in women with FGM/C type III. In 2 cases (14.3%) of chronic vulvar pain, no lesions other than FGM/C were visible at clinical examination. Among these 14 women, 12 suffered from superficial dyspareunia as well. The remaining ones had not had any sexual contact for several years. Dyspareunia was present in 126 women (24.9%), among which 75 patients (14.8%) suffered from superficial dyspareunia and 25 patients (4.9%) complained of deep dyspareunia. Fourteen women (2.8%) reported both superficial and deep dyspareunia. Twelve women (2.3%) reported dyspareunia with no specified localization documented in the medical charts. Dyspareunia was significantly more frequent among infibulated women compared to women with FGM/C different from type III (P = .014). CONCLUSION Chronic vulvar pain after FGM/C is probably associated with scar complications and FGM/C type III (infibulation). Dyspareunia is more frequent in women with FGM/C type III. Bazzoun Y, Aerts L, Abdulcadir J. Chronic Vulvar Pain After Female Genital Mutilation/Cutting: A Retrospective Study. Sex Med 2021;9:100425.
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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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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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Young J, Nour NM, Macauley RC, Narang SK, Johnson-Agbakwu C. Diagnosis, Management, and Treatment of Female Genital Mutilation or Cutting in Girls. Pediatrics 2020; 146:peds.2020-1012. [PMID: 32719089 DOI: 10.1542/peds.2020-1012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Janine Young
- Department of General Pediatrics, Denver Health Refugee Clinic, and Human Rights Clinic, Denver Health and Hospitals and School of Medicine, University of Colorado Denver, Denver, Colorado;
| | - Nawal M Nour
- African Women's Health Center, Department of Obstetrics and Gynecology, Brigham and Women's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Robert C Macauley
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Sandeep K Narang
- Division of Child Abuse Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and
| | - Crista Johnson-Agbakwu
- Refugee Women's Health Clinic, Department of Obstetrics and Gynecology, Valleywise Health Medical Center and Office of Refugee Health, Southwest Interdisciplinary Research Center, School of Social Work, Watts College of Public Service and Community Solutions, Arizona State University, Phoenix, Arizona
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11
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Sharif Mohamed F, Wild V, Earp BD, Johnson-Agbakwu C, Abdulcadir J. Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate. J Sex Med 2020; 17:531-542. [PMID: 31932257 DOI: 10.1016/j.jsxm.2019.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 11/14/2019] [Accepted: 12/04/2019] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Clitoral reconstruction (CR) is a controversial surgical procedure performed for women who have undergone medically unnecessary, often ritualistic genital cutting involving the clitoris. Such cutting is known by several terms; we will use female genital mutilation/cutting (FGM/C). Treatments offered to women affected by complications of FGM/C include defibulation (releasing the scar of infibulation to allow penetrative intercourse, urinary flow, physiological delivery, and menstruation) and CR to decrease pain, improve sexual response, and create a pre-FGM/C genital appearance. AIM In this study, our aim is to summarize the medical literature regarding CR techniques and outcomes, and stimulate ethical discussion surrounding potential adverse impacts on women who undergo the procedure. METHODS A broad literature review was carried out to search any previous peer-reviewed publications regarding the techniques and ethical considerations for CR. MAIN OUTCOME MEASURE The main outcome measure includes benefits, risks, and ethical analysis of CR. RESULTS While we discuss the limited evidence regarding the risks and efficacy of CR, we did not find any peer-reviewed reports focused on ethical implications to date. CLINICAL IMPLICATIONS CR can be indicated as a treatment for pain and potential improvement of associated sexual dysfunction when these have not responded to more conservative measures. Women must be appropriately informed about the risks of CR and the lack of strong evidence regarding potential benefits. They must be educated about their genital anatomy and disabused of any myths surrounding female sexual function as well as assessed and treated in accordance with the current scientific evidence and best clinical practices. STRENGTH & LIMITATIONS This is the first formal ethical discussion surrounding CR. This is not a systematic review, and the ethical discussion of CR has only just begun. CONCLUSION We present a preliminary ethical analysis of the procedure and its potential impact on women with FGM/C. Sharif Mohamed F, Wild V, Earp BD, et al. Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate. J Sex Med 2020;17:531-542.
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Affiliation(s)
- Fatima Sharif Mohamed
- Department of Obstetrics and Gynecology, Maricopa Integrated Health System, Phoenix, AZ, USA
| | - Verina Wild
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Brian D Earp
- Yale-Hastings Program in Ethics and Health Policy, Yale University and The Hastings Center, New Haven, CT, USA
| | - Crista Johnson-Agbakwu
- Department of Obstetrics and Gynecology, Maricopa Integrated Health System, Phoenix, AZ, USA; Office of Refugee Health, Southwest Interdisciplinary Research Center, Arizona State University, Phoenix, AZ, USA
| | - Jasmine Abdulcadir
- Department of Woman, Child and Adolescent, Division of Gynecology, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Symptomatic Clitoral Neuroma within an Epidermal Inclusion Cyst at the Site of Prior Female Genital Cutting. Case Rep Obstet Gynecol 2019; 2019:5347873. [PMID: 31467745 PMCID: PMC6699281 DOI: 10.1155/2019/5347873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/21/2019] [Indexed: 11/18/2022] Open
Abstract
Background Clitoral neuromas occurring after female genital mutilation/cutting (FGM/C) can vary in presentation and may require surgical management. Case A 39-year-old East African female with a history of FGM/C presented during pregnancy with a progressively enlarging mass and worsening periclitoral pain. Postpartum surgical excision restored cosmesis and resolved the discomfort with pathology confirming the presence of a neuroma within the epidermal inclusion cyst. Conclusion We present the first published case of a symptomatic clitoral neuroma within an epidermal inclusion cyst. This unique pathology demonstrates that complications of female genital cutting can present in complex and varied ways. Considering the prevalence of FGM/C and increasing rates of emigration from countries in which FGM/C is performed, complex clitoral neuromas are an important long-term complication which providers in Africa or internationally must be aware of.
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Sex, Grief, and Psychic Trauma: Considering History and Politics in the Psychosexual Treatment of Women with FGC. CURRENT SEXUAL HEALTH REPORTS 2019. [DOI: 10.1007/s11930-019-00199-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Vaginal Vault Traumatic Neuromas. J Minim Invasive Gynecol 2019; 26:1219-1220. [PMID: 30980990 DOI: 10.1016/j.jmig.2019.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/05/2019] [Indexed: 11/20/2022]
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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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Christoffersen GM, Bruhn PJ, de Neergaard R, Engel S, Naeser V. Mapping the lack of public initiative against female genital mutilation in Denmark. Reprod Health 2018; 15:59. [PMID: 29625619 PMCID: PMC5889535 DOI: 10.1186/s12978-018-0499-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 03/27/2018] [Indexed: 11/30/2022] Open
Abstract
Background Female genital mutilation (FGM) is a harmful practice prevalent in 35 countries, mainly in Africa, as well as in some Middle Eastern countries and a few Asian countries. FGM comprises all procedures that involve partial or complete resection of, or other injury to, external female genitalia for non-medical reasons. The practice of FGM has spread to Western countries due to migration. The European Institute for Gender Equality recommend that FGM be combatted by nationally coordinated efforts through implementation of national action plans, guidelines for professionals as well as comprehensive research in the field. FGM was outlawed in Denmark 2003, but no national actions plan has been implemented. Instead, the task of combatting FGM is currently under the responsibility of local governments in the form of the 98 municipalities. The aim of this study is to investigate the Danish municipalities’ efforts to prevent FGM on the local level, and whether these initiatives are in accordance with international recommendations and standards. Methods All 98 Danish municipalities were invited to respond to a questionnaire regarding FGM in their respective municipalities. The inclusion process and questionnaire was designed after a pilot study, which included 29 municipalities. The questionnaire consisted of four overall areas of focus: “action plan”, “registration”, “information material” and “preventive initiatives”. Demographic data were gathered from the 2017 census by Statistics Denmark. Risk countries were defined as countries with a tradition for FGM, identified from the 2016 UNICEF definition. Results A total of 67 municipalities participated in the study. At the time of census, 1.8% of the Danish population was immigrants with origins in risk countries. A total of 10.4% of the responding municipalities indicated to have implemented a specific action plan against FGM. A total of 7,5% had implemented specific preventive initiatives against FGM. Registration of reported FGM cases were indicated to be performed in 73.1% of the responding municipalities; however, only 17.9% stated to perform registration of FGM specifically as such, and not as general child abuse. Conclusions Our study shows that the current situation of FGM registration and prevention being under local administrative responsibility in the 98 Danish municipalities has led to a severe lack of coordinated public initiative against FGM. Electronic supplementary material The online version of this article (10.1186/s12978-018-0499-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gro Møller Christoffersen
- University of Copenhagen, Faculty of Health and Medical Sciences, Blegdamsvej 3, 2200, Copenhagen N, Denmark
| | - Peter James Bruhn
- Department of Surgical Gastroenterology, Copenhagen University Hospital North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark.
| | - Rosanna de Neergaard
- Department of Emergency Medicine, Zealand University Hospital Slagelse, Ingemannsvej 50, 4200, Slagelse, Denmark
| | - Susanne Engel
- Department of Culture, Municipality of Sermersooq, Kuussuaq 2, 3900, Nuuk, Greenland
| | - Vibeke Naeser
- Department of Obstetrics and Gynecology, Zealand University Hospital Næstved, Ringstedgade 61, 4700, Næstved, Denmark
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Abdulcadir J, Abdulcadir O, Caillet M, Catania L, Cuzin B, Essén B, Foldès P, Johnsdotter S, Johnson-Agbakwu C, Nour N, Ouedraogo C, Warren N, Wylomanski S. Clitoral Surgery After Female Genital Mutilation/Cutting. Aesthet Surg J 2017; 37:NP113-NP115. [PMID: 29025234 DOI: 10.1093/asj/sjx095] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jasmine Abdulcadir
- Outpatient Clinic for Women with FGM/C, Department of Obstetric and Gynecology, Geneva University Hospitals
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Omar Abdulcadir
- Referral Centre for Preventing and Curing Female Genital Mutilation, Department of Maternal and Child Health, Careggi University Hospital, Florence, Italy
| | - Martin Caillet
- Outpatient Clinic for Women with FGM/C, Department of Obstetric and Gynecology, Geneva University Hospitals
- CeMAViE; Department of Gynecology and Obstetrics, University Saint Pierre Hospital, Brussels, Belgium
| | - Lucrezia Catania
- Referral Centre for Preventing and Curing Female Genital Mutilation, Department of Maternal and Child Health, Careggi University Hospital, Florence, Italy
| | - Béatrice Cuzin
- Division of Urology and Transplantation, Edouard Herriot Hospital, Lyon, France
| | - Birgitta Essén
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Pierre Foldès
- Institute of Reproductive Health, Saint Germain en Laye, Paris, France
| | | | - Crista Johnson-Agbakwu
- Refugee Women's Health Clinic, Obstetrics & Gynecology, Maricopa Integrated Health System
- Obstetrics and Gynecology, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Nawal Nour
- Global Ob/Gyn and African Women's Health Center, Ambulatory Obstetrics, Office for Multicultural Careers, Division of Global Obstetrics and Gynecology, Brigham and Women's Hospital
| | | | - Nicole Warren
- Department of Community Public Health Nursing, John Hopkins School of Nursing, Baltimore, MD, USA
| | - Sophie Wylomanski
- Department of Gynecology and Obstetrics, Nantes University Hospital, Nantes, France
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