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Clitoral Reconstructive Surgery After Female Genital Cutting

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Clitoral Reconstructive Surgery After Female Genital Cutting FEATURE Clitoral reconstructive surgery after female genital cutting BY AMR SEIFELDIN emale genital mutilation / cutting (FGM/C), aka female circumcision, is defined by the World Health FOrganization (WHO) as “All procedures that involve partial or total removal of the external female genitalia for non-medical reasons” [1]. Practised in Africa and other parts of the world, the WHO recently estimated that over 250 million females have been circumcised so far, and an additional three million are at risk of circumcision each year, nearly 8000 cases a day [2]. First recorded in Egypt in the 5th Century BC, and noted on a papyrus from Memphis in 2nd Century BC, its historic background goes back more than 3000 years. Some ancient Egyptian mummies were found to World Health Organization Classification of Female Genital Mutilation have been circumcised. Type I: Partial or total removal of Type Ia: Removal of the clitoral hood or prepuce FGM/C awareness has increased globally the clitoris and / or the prepuce only in the past 20 years, due to an increased (clitoridectomy) influx of African immigrants and refugees, Type Ib: Removal of the clitoris with the prepuce with 680,000 cases in Europe and 513,000 Type II: Partial or total removal of the Type IIa: Removal of the labia minora only in the United States, putting a heavy burden clitoris and the labia minora, with or Type IIb: Partial or total removal of the clitoris and on the healthcare systems of the host without excision of the labia majora (excision) the labia minora countries. It is a destructive procedure, Type IIc: Partial or total removal of the clitoris, the criminalised by law in most countries, and labia minora and the labia majora considered a crime against humanity [3]. Type III: Narrowing of the vaginal orifice Type IIIa: Removal and apposition of the labia with creation of a covering seal by cutting minora The area excised usually includes the: and apposition the labia minora and / or • clitoris the labia majora, with or without excision Type IIIb: Removal and apposition of the labia • clitoral hood of the clitoris (infibulation) majora • labia minora Type IV: Unclassified All other harmful procedures to the female genitalia • labia majora. for non -medical purposes, for example, pricking, piercing, incising, scraping and cauterisation FGM/C has no medical benefits, the reason Figure 1: WHO classification of FGM. for the practice is purely traditional with a false religious pretext in some cases. It is cutting, ranging from a simple nick on the infibulation, and in some cases the opening usually performed before puberty, but can prepuce, clitoral excision, labial (minora is too narrow to allow consummation of be done at any age [4]. and majora) amputation, to complete marriage and a surgical procedure known as infibulation. defibulation is performed to open the vulva FGM/C in practising communities is Under this classification, simple aesthetic skin cover to allow sexual contact [5]. regarded as: gynaecology procedures such as labiaplasty • purification and cleanliness Complications of FGM/C: and clitoral hood reduction are unjustifiably • perquisite for growing into womanhood • haemorrhage, neurogenic shock, categorised as FGM. • preserves virginity and family honour sometimes leading to death In some African communities, the • provides better marriage prospects for • infection by HIV, hepatitis and tetanus girls clitoral body is partially excised and both • trauma to surrounding structures • prevents promiscuity and adultery labia (minora and majora) are cut and the (urethra and vagina) • saves face for family within the skin gap is sutured together forming a • implantation inclusion cysts, keloid and community. covering skin seal acting as a chastity belt scar tissue formation and creating a small opening at the lower • decreased clitoral response in desire, Types: The WHO classifies FGM/C in four end of the vagina for urine and menstrual arousal and orgasm types (Figure 1) with varying degrees of flow (Figure 2). This is called Pharaonic • increased materno-fetal morbidity and The PMFA Journal | APRIL/MAY 2018 | VOL 5 NO 4 | www.thepmfajournal.com FEATURE a b Figure 2: Pharaonic infibulation. Figure 3: a) Releasing clitoris from adhesions. b) Mobilising clitoris by cutting suspensory ligament. mortality during labour Platelet rich plasma (PRP) injections, directly References • pain, dyspareunia and dysmenorrhea into the clitoris, improve clitoral sensitivity 1. World Health Organization, Department of Reproductive Health and Research (2008) Eliminating • psycho-sexual disturbances: by increasing blood flow, growth factors and female genital mutilation: an interagency statement. - low self esteem, shame, stimulating stem cells in the region [3]. OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, embarrassment with partner Postoperative follow-up, counselling and UNHCR, UNICEF, UNIFEM, WHO. World Health Organization, p Geneva. - post-traumatic stress disorder reassurance provide a holistic management 2. WHO (2012) Female genital mutilation, Fact sheet N241. - anxiety and psychosomatic disorders protocol for FGM victims. World Health Organization, Geneva, Switzerland. - flash back to traumatic event. 3. Seifeldin A. Genital reconstructive surgery after female Results: Our study included 107 patients; genital mutilation. Obstet Gynecol Int J 2016;4(6):00129. Management: The complexity of symptoms results vary from no improvement to 90% 4. Foldès P, Cuzin B, Andro A. Reconstructive surgery after female genital mutilation: a prospective cohort study. are best managed by a multidisciplinary improvement in sexual desire, arousal, Lancet 2012;380(9837):134-41. approach provided by a group of lubrication, orgasm and decrease in pain. 5. Foldes P. Reconstructive surgery of the clitoris after ritual gynaecologists, psychologists, midwives and Better results were found in younger excision. J Sex Med 2006;3(6):1091-4. social workers. Main guidelines are psycho- women with better education and higher 6. Abdulcadir J, Rodriguez MI, Petignat P, Say L. Clitoral reconstruction after female genital mutilation/cutting: sexual assessment, sexual education, socio-economic status. These marked case studies. J Sex Med 2015;12(1): 274-81. comprehensive physical exam, and surgery improvements were especially noted in young 7. Thabet SM, Thabet AS. Defective sexuality and female (defibulation and clitoral restoration) if adult women with type I and type II FGM/C, circumcision: the cause and possible management. needed [6]. and probably attributed to the psychological J Obstet Gynaecol Res 2003;29(1):12-9. benefits of the procedure, which may exceed Clitoral reconstructive surgery the physical benefits [3]. (CRS) FGM/C victims still retain the ability to Conclusion reach orgasm after clitoral excision, the FGM rates are declining globally due to clitoris is a highly sensitive organ and can be changing socio-cultural and economic factors. modified to function as a new clitoris [7]. Genital restorative surgeries have provided AUTHOR Although many FGM/C victims are hope for FGM/C victims to regain their unaware of the availability of genital dignity, improve sexuality and quality of life. reconstructive surgeries, the demand We have noted an improvement in aesthetic for genital reconstructive surgery both appearance and reported functional outcome, for functional and aesthetic reasons, self-confidence, female self-image, partner has dramatically risen in past years due and parent relationships after the procedure to increased patient awareness, better and support. education, and modern aesthetic and sexual We therefore suggest that the clitoral health trends (Figure 3). reconstructive procedure should be made available to FGM/C victims. The possibility of Amr Seifeldin, MD, Method: such surgery should be more widely promoted • removing peri-clitoral adhesions in the community and also in hospitals Head of Urogynecology & Pelvic Reconstructive Surgery unit, El Galaa Teaching Hospital for Women; • releasing and mobilising the clitoris by when patients are presenting with aesthetic Director, Cosmetic Gynecology Egypt, Cairo, Egypt. cutting the suspensory ligament and sexual function complaints. Finally, it E: [email protected] / [email protected] • preserving the dorsal neurovascular is important to be able to meet increased bundle demand through the training of more Declaration of Competing Interests: None declared. • restoring clitoris to its normal anatomical surgeons in the art and practice of female position in the frenulum (if present). genital reconstructive surgery. The PMFA Journal | APRIL/MAY 2018 | VOL 5 NO 4 | www.thepmfajournal.com.
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