Clitoral Surgery After Female Genital Mutilation/Cutting

Chang et al report their interesting preliminary results after clitoral restoration procedures on 3 women having undergone female genital mutilation/cutting (FGM/C).¹ The authors conclude that “currently, there is no published literature regarding reconstructive management of FGM and, their early experience can provide a straightforward, short, and effective approach to improve the lives for women who have suffered from FGM.”¹ Indeed, among the seven references cited, no recent evidence on surgical management of FGM/C is provided.

It is crucial to clarify that since clitoral reconstruction after FGM/C was first reported in Egypt by Thabet² and in France by Foldès^3,4 more than ten years ago, multiple scholarly publications on the surgery have been published including case reports,⁵ case series,^3,4,6-11 a case-control study,² and systematic¹² and scoping reviews.^13,14 These publications have addressed the surgical techniques as well as safety, sexual and pain outcomes, and multidisciplinary management. Recommendations and best practice statements on clitoral surgery are available in the Guidelines on Management of Female Genital Mutilation of the Royal College of Obstetricians and Gynecologists (RCOG) of 2015¹⁵ and of the World Health Organization (WHO) of 2016.¹⁶ Neither the RCOG nor the WHO could support clitoral reconstruction based on the paucity of the evidence base. Both groups stressed the need for future, multicenter studies.^15,16

Clitoral reconstruction seems a promising technique to address chronic pain by removing posttraumatic neuromas and fibrous tissue within the scar.¹⁷ The technique may also improve sexual pleasure and body image.¹² However, there is growing evidence that women who do not suffer from pain, but request surgical management for other concerns, have their needs met by counseling, psychosexual therapy, health education to clarify sexual anatomy and function, and dispel cultural misconceptions and myths on the clitoris. According to available studies, when such multidisciplinary care is available before surgery, clitoral reconstruction is performed in less than 20% of the women who initially request it.^5,6,18

Chang et al state that clitoral surgery “is not technically demanding and all plastic surgeons should be able to offer this option.”¹ We find this assertion troubling. In addition to minor and, less frequently, major complications reported in the literature, the surgery is highly complex in terms of its impact on future psychosexual function, social acceptance, and genital self-image. Negative psychological outcomes (eg, relapse of posttraumatic stress disorder on postoperative pain) have also occurred.¹⁹ This is why clitoral surgery is increasingly offered in multidisciplinary referral centers where interprofessional teams include medical and cultural experts in FGM/C as well as sexual counselors, psychologists, psychiatrists, and sex therapists. Women living with FGM/C are often a vulnerable migrant population with a history of pasttraumatic events other than FGM/C such as war, rape, and forced marriage. These needs should be addressed without or in association with surgical management.⁶

Women who request clitoral reconstruction deserve multidisciplinary, honest, respectful, nonstigmatizing, holistic, and evidence-based care. Surgeons offering this technique are responsible for being familiar with the available evidence. Further rigorous research via multicenter, interprofessional collaborations are needed to obtain more conclusive evidence on clitoral reconstruction and to improve the comprehensive care and information offered to women who ask for it.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.