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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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Gutierrez-Ontalvilla P, Andjelkov K, Ruiz-Valls A. Invited Discussion on: Clinical and Patient Reported Outcomes of 19 Patients Undergoing Clitoral and Labial Reconstruction After Female Genital Mutilation/Cutting. Aesthetic Plast Surg 2022; 46:478-479. [PMID: 34859272 DOI: 10.1007/s00266-021-02696-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 11/21/2021] [Indexed: 11/30/2022]
Affiliation(s)
- P Gutierrez-Ontalvilla
- Department of Plastic and Reconstructive Surgery, La Fe University Hospital, Tower E, 2th Floor, 106 Avenida Abril Martorell, 46026, Valencia, Spain.
| | - K Andjelkov
- Faculty of Medicine and BelPrime Clinic, University of Belgrade, Belgrade, Serbia
| | - A Ruiz-Valls
- Department of Plastic and Reconstructive Surgery, La Fe University Hospital, Tower E, 5th Floor, 106 Avenida Abril Martorell, 46026, Valencia, Spain
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Wilson AM, Zaki AA. Novel Clitoral Reconstruction and Coverage With Sensate Labial Flaps: Potential Remedy for Female Genital Mutilation. Aesthet Surg J 2022; 42:183-192. [PMID: 33956086 DOI: 10.1093/asj/sjab218] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Complications caused by female genital mutilation (FGM), such as clitoral pain, reduced sensation, and diminished sexual function, can be alleviated by clitoral reconstruction, which can also improve the aesthetics and restore the anatomy of the genitalia. OBJECTIVES The aim of this study was to create sensate labial flaps to cover the neoclitoris and assess the outcome of the procedure. METHODS Between December 2018 and July 2020, 40 patients with FGM underwent clitoral reconstruction and coverage with sensate labial flaps donated by the remnant of the labia minora and were followed prospectively. Flaps were mapped on the less-mutilated labia minora according to recent descriptions of arterial anatomy and innervation. Before the surgery, the patients' clitoral sensation was assessed on a 6-point scale and they were also given the Female Sexual Functional Index (FSFI) questionnaire to complete. Eight and 24 weeks postoperatively, the same assessment was repeated and the data compared. RESULTS The mean Female Sexual Functional Index score increased significantly from 11.64 (range, 2.8-25.6) preoperatively to 29.14 (range, 12.8-35.4) postoperatively. Similarly, clitoral sensation increased significantly from 2.35 (range, 1-4) before the surgery to 4.9 (range, 2-6) after the surgery. In total, 95% of patients benefited from the surgery. CONCLUSIONS Clitoral reconstruction with sensate labial flaps after FGM resulted in significant improvements in sexual function, clitoral sensation, genital aesthetics, and self-esteem. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Adel M Wilson
- Department of Plastic Surgery, Cairo University Hospitals, Giza, Egypt
| | - Amr A Zaki
- Department of Plastic Surgery, Cairo University Hospitals, Giza, Egypt
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Earp BD. Protecting Children from Medically Unnecessary Genital Cutting Without Stigmatizing Women's Bodies: Implications for Sexual Pleasure and Pain. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:1875-1885. [PMID: 31965452 DOI: 10.1007/s10508-020-01633-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 01/04/2020] [Accepted: 01/08/2020] [Indexed: 05/21/2023]
Affiliation(s)
- Brian D Earp
- Yale-Hastings Program in Ethics and Health Policy, Yale University, New Haven, CT, 06511, USA.
- The Hastings Center, Garrison, NY, USA.
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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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Blayney F, Camuzard O, Klein A, Perchenet AS, Bertrand B, Philandrianos C, Massin V, Abellan-Lopez M, Casanova D. Anatomical study of the clitoris and its implications on female genital mutilation and surgical repair. J Plast Reconstr Aesthet Surg 2021; 74:3394-3403. [PMID: 34253487 DOI: 10.1016/j.bjps.2021.05.034] [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: 11/14/2020] [Revised: 03/29/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Worldwide, 200 million girls and women have been subjected to female genital mutilation. To restore the clitoral function and vulvar anatomy, clitoral repair has been performed since the 2000s. Nevertheless, there is a lack of precise and comprehensive data on the clitoral anatomy during surgical repair. This study aimed to precisely describe the terminal anatomies of the dorsal nerve and artery of the clitoris, and the clitoral neurovascular flap advancement for reconstruction in patients with female genital mutilation. METHODS This study was performed on seven fresh female cadavers. The site of origin, diameter, length, and trajectory of each nerve and artery were recorded. The clitoral neurovascular flap advancement was measured after a midline transection of the suspensory ligament was performed and after extensive liberation of the dorsal bundles at their emergence from the pubic rami. RESULTS At the distal point of the clitoral body, the width of the dorsal nerve and artery was 1.9 ± 0.3 mm and 0.9 ± 0.2 mm, respectively. The total length of the dorsal bundles was 6.6 cm (± 0.4). The midpart of the suspensory ligament was sectioned, which allowed a mean anteroposterior mobility of 2.7 cm (± 0.2). Extensive dissection of the neurovascular bundles up to their point of emergence from the suspensory ligament allowed a mean mobility of 3.4 ± 0.2 cm. CONCLUSION We described the anatomical characteristics of the dorsal nerve and artery of the clitoris and the mobility of the clitoral neurovascular flap for reconstruction post clitoridectomy. This was done to restore the anatomic position of the glans clitoris while preserving and potentially restoring clitoral function in patients with female genital mutilation.
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Affiliation(s)
- Fanny Blayney
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France.
| | - Olivier Camuzard
- Pasteur universitary hospital, Plastic surgery department and Hand Reconstruction, 30 voie Romaine, 06001 Nice Cedex 1, France
| | - Arthur Klein
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France
| | | | - Baptiste Bertrand
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France
| | - Cécile Philandrianos
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France
| | - Valentin Massin
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France
| | - Maxime Abellan-Lopez
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France
| | - Dominique Casanova
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France
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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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Botter C, Sawan D, SidAhmed-Mezi M, Spanopoulou S, Luchian S, Meningaud JP, Hersant B. Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: Anatomy, Technical Innovations and Updates of the Initial Technique. J Sex Med 2021; 18:996-1008. [PMID: 33931348 DOI: 10.1016/j.jsxm.2021.02.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 02/01/2021] [Accepted: 02/16/2021] [Indexed: 09/30/2022]
Abstract
INTRODUCTION Female genital mutilation (FGM) includes all procedures that involve partial or total removal of the female external genitalia or any other injury of the female genitalia that is performed for nonmedical reasons. FGM is classified into 4 types. Surgical clitoral reconstruction was first described by Thabet and Thabet in Egypt and subsequently by Foldès in France. The technique was then modified by different authors. AIM This article aims to provide a detailed description of clitoral surgical reconstruction and the modifications which have been made over time to improve the procedure while recalling current knowledge in the anatomy of the clitoris. METHODS We performed a broad systematic search in PubMed/Medline and EMBASE bibliographic databases for studies that report the surgical technique of clitoral reconstruction. From the anatomical point of view, we examined available evidence (from 1950 until 2020) related to clitoral anatomy, the clitoral role in sexual functioning, female genital mutilation/cutting, and surgical implications for the clitoris. MAIN OUTCOMES A review of the surgical techniques for clitoral reconstruction after female genital mutilation/cutting RESULTS: We described the current anatomical knowledge about the clitoris, and the procedures based on the surgical technique by Pierre Foldès, We included the technical modifications and contributions described in articles published subsequently. CONCLUSION Surgical repair of the clitoris for FGM offers anatomical and functional results although they still have to be evaluated. However, it should not be the only therapeutic solution offered to women with FGM. Botter C, Sawan D, SidAhmed-Mezi M, et al. Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: Anatomy, Technical Innovations and Updates of the Initial Technique. J Sex Med 2021;18:996-1008.
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Affiliation(s)
- Charles Botter
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France.
| | - Dana Sawan
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Mounia SidAhmed-Mezi
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Sofia Spanopoulou
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Stefan Luchian
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Jean-Paul Meningaud
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Barbara Hersant
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
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Binkova A, Uebelhart M, Dällenbach P, Boulvain M, Gayet-Ageron A, Abdulcadir J. A cross-sectional study on pelvic floor symptoms in women living with Female Genital Mutilation/Cutting. Reprod Health 2021; 18:39. [PMID: 33581732 PMCID: PMC7881631 DOI: 10.1186/s12978-021-01097-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 01/31/2021] [Indexed: 12/29/2022] Open
Abstract
Background Female Genital Mutilation/Cutting (FGM/C) concerns over 200 million women and girls worldwide and is associated with obstetric trauma and long-term urogynaecological and psychosexual complications that are often under-investigated and undertreated. The aim of this study was to assess the pelvic floor distress and the impact of pelvic floor and psychosexual symptoms among migrant women with different types of FGM/C. Methods This cross-sectional study was conducted between April 2016 and January 2019 at the Division of Gynaecology of the Geneva University Hospitals. The participants were interviewed on socio-demographic and background information, underwent a systematic gynaecological examination to assess the presence and type of FGM/C and eventual Pelvic Organ Prolapse (POP), and completed six validated questionnaires on pelvic floor and psychosexual symptoms (PFDI-20 and PFIQ7 on pelvic floor distress and impact, FISI and WCS on faecal incontinence and constipation, PISQ-IR and FGSIS on sexual function and genital self-image). The participants’ scores were compared with scores of uncut women available from the literature. The association between selected variables and higher scores for distress and impact of pelvic floor symptoms was assessed using univariate and multivariable linear regression models. Results 124 women with a mean age of 31.5 (± 7.5), mostly with a normal BMI, and with no significant POP were included. PFDI-20 and PFIQ-7 mean (± SD) scores were of 49.5 (± 52.0) and 40.7 (± 53.6) respectively. In comparison with the available literature, the participants’ scores were lower than those of uncut women with pelvic floor dysfunction but higher than those of uncut women without such disorders. Past violent events other than FGM/C and forced or arranged marriage, age at FGM/C of more than 10, a period of staying in Switzerland of less than 6 months, and nulliparity were significantly associated with higher scores for distress and impact of pelvic floor symptoms, independently of known risk factors such as age, weight, ongoing pregnancy and history of episiotomy. Conclusions Women with various types of FGM/C, without POP, can suffer from pelvic floor symptoms responsible for distress and impact on their daily life. Trial registration. The study protocol was approved by the Swiss Ethics Committee on research involving humans (protocol n°15-224).
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Affiliation(s)
- Alzbeta Binkova
- Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1211, Geneva, Switzerland
| | - Marion Uebelhart
- Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1211, Geneva, Switzerland
| | - Patrick Dällenbach
- Division of Gynaecology, Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Boulevard de la Cluse 30, 1211, Geneva, Switzerland
| | - Michel Boulvain
- Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1211, Geneva, Switzerland
| | - Angèle Gayet-Ageron
- Clinical Research Center & Division of Clinical Epidemiology, Department of Health and Community Medicine, University of Geneva & Geneva University Hospitals, Geneva, Switzerland
| | - Jasmine Abdulcadir
- Division of Gynaecology, Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Boulevard de la Cluse 30, 1211, Geneva, Switzerland.
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In Vivo Imaging-Based 3-Dimensional Pelvic Prototype Models to Improve Education Regarding Sexual Anatomy and Physiology. J Sex Med 2020; 17:1590-1602. [PMID: 32675048 DOI: 10.1016/j.jsxm.2020.05.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 05/05/2020] [Accepted: 05/22/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Myths, misconceptions, and taboos about sexual anatomy and physiology are common and can affect sexual health and maintain harmful practices and beliefs. AIM To construct a female and a preliminary male 3-dimensional (3D) pelvic model on the basis of in vivo imaging, which could be studied in sex education and clinical practice. METHODS We retrospectively studied the images of 200 female pelvic magnetic resonance examinations and reviewed the literature to choose the optimum magnetic resonance imaging (MRI) protocol for the study of the clitoris and surrounding organs. We also conducted a cross-sectional study of 30 women who were undergoing a pelvic MRI. 15 women had undergone female genital mutilation/cutting involving the clitoris and 15 had not. The best-quality MRI images of 3 uncut and 1 cut clitoris, together with the principal surrounding pelvic organs, were selected to generate 3D reconstructions using dedicated software. The same software was used to reconstruct the anatomy of the penis and the principal surrounding pelvic organs, based on contrast-enhanced computer tomography images. Images of both models were exported in .stl format and cleaned to obtain single manifold objects in free, open source software. Each organ model was sliced and 3D printed. A preliminary feedback was collected from 13 potential users working in urology, gynaecology, sexual medicine, physiotherapy, and education. OUTCOMES The main outcomes of this study are a kit of 3D pelvic models, 2-dimensional figures of female and male sexual anatomy, and files for 3D printing. RESULTS We present a kit containing 3D models and 2-dimensional figures of female and male sexual anatomy, based on in vivo imaging and, feedbacks and suggestions received from potential users. CLINICAL TRANSLATION Our kit can be used in anatomy and sex education among and by health professionals, teachers, sex educators, students, and the general population. STRENGTHS & LIMITATIONS The strengths are that the models were based on in vivo imaging, can be dismantled/reassembled, and show analogous anatomic structures of the clitoris and the penis. The female models represent diversity, including women with female genital mutilation/cutting. The limitations are that the male model is preliminary and can be improved if based on an MRI; that imaging-based anatomic representations can differ from anatomic dissections; and that the models represent the sexual organs at rest or during an unknown state of arousal only. CONCLUSION Our kit can be studied in anatomy, biology, and sex education, as well as in clinical practice. Abdulcadir J, Dewaele R, Firmenich N, et al. In Vivo Imaging-Based 3-Dimensional Pelvic Prototype Models to Improve Education Regarding Sexual Anatomy and Physiology. J Sex Med 2020;17:1590-1602.
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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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Johansen REB, Ziyada MM, Shell-Duncan B, Kaplan AM, Leye E. Health sector involvement in the management of female genital mutilation/cutting in 30 countries. BMC Health Serv Res 2018; 18:240. [PMID: 29615033 PMCID: PMC5883890 DOI: 10.1186/s12913-018-3033-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 03/16/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND For the last decades, the international community has emphasised the importance of a multisectoral approach to tackle female genital mutilation (FGM/C). While considerable improvement concerning legislations and community involvement is reported, little is known about the involvement of the health sector. METHOD A mixed methods approach was employed to map the involvement of the health sector in the management of FGM/C both in countries where FGM/C is a traditional practice (countries of origin), and countries where FGM/C is practiced mainly by migrant populations (countries of migration). Data was collected in 2016 using a pilot-tested questionnaire from 30 countries (11 countries of origin and 19 countries of migration). In 2017, interviews were conducted to check for data accuracy and to request relevant explanations. Qualitative data was used to elucidate the quantitative data. RESULTS A total of 24 countries had a policy on FGM/C, of which 19 had assigned coordination bodies and 20 had partially or fully implemented the plans. Nevertheless, allocation of funding and incorporation of monitoring and evaluation systems was lacking in 11 and 13 of these countries respectively. The level of the health sectors' involvement varied considerably across and within countries. Systematic training of healthcare providers (HCP) was more prevalent in countries of origin, whereas involvement of HCP in the prevention of FGM/C was more prevalent in countries of migration. Most countries reported to forbid HCP from conducting FGM/C on both minors and adults, but not consistently forbidding re-infibulation. Availability of healthcare services for girls and women with FGM/C related complications also varied between countries dependent on the type of services. Deinfibulation was available in almost all countries, while clitoral reconstruction and psychological and sexual counselling were available predominantly in countries of migration and then in less than half the countries. Finally, systematic recording of FGM/C in medical records was completely lacking in countries of origin and very limited in countries of migration. CONCLUSION Substantial progress has been made in the involvement of the health sector in both the treatment and prevention of FGM/C. Still, there are several areas in need for improvement, particularly monitoring and evaluation.
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Affiliation(s)
- R. Elise B. Johansen
- Norwegian Centre for Violence and Traumatic Stress Studies, PB: 181 Nydalen, 0409 Oslo, Norway
| | - Mai Mahgoub Ziyada
- Norwegian Centre for Violence and Traumatic Stress Studies, PB: 181 Nydalen, 0409 Oslo, Norway
| | - Bettina Shell-Duncan
- Department of Anthropology, University of Washington, M230 Denny Hall, Box 353100, Seattle, WA 98195-3100 USA
| | - Adriana Marcusàn Kaplan
- Wassu-UAB Foundation, Universitat Autònoma de Barcelona, Módul de Recerca A - Campus Bellaterra, 08193 Barcelona, Spain
| | - Els Leye
- International Centre for Reproductive Health, Ghent University, De Pintelaan 185 UZP114, 9000 Ghent, Belgium
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Abdulcadir J, Marras S, Catania L, Abdulcadir O, Petignat P. Defibulation: A Visual Reference and Learning Tool. J Sex Med 2018; 15:601-611. [PMID: 29463476 DOI: 10.1016/j.jsxm.2018.01.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 01/16/2018] [Indexed: 11/29/2022]
Abstract
Female genital mutilation type III (infibulation) is achieved by narrowing the vaginal orifice by creating a covering seal, accomplished by cutting and appositioning the labia minora and/or labia majora, with or without clitoral excision. Infibulation is responsible for significant urogynecological, obstetrical, and psychosexual consequences that can be treated with defibulation (or de-infibulation), an operation that opens the infibulation scar, exposing the vulvar vestibule, vaginal orifice, external urethral meatus, and eventually the clitoris. This article provides a practical comprehensive, up-to-date visual learning tool on defibulation, with information on pre-operative, post-operative, and follow-up information. Abdulcadir J, Marras S, Catania L, et al. Defibulation: a visual reference and learning tool. J Sex Med 2018;15:601-611.
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Affiliation(s)
- Jasmine Abdulcadir
- Department of Obstetrics and Gynecology, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Sandra Marras
- Department of Obstetrics and Gynecology, Geneva University Hospitals, Geneva, Switzerland
| | - Lucrezia Catania
- Regional Referral Center for the Treatment and Prevention of Female Genital Mutilation, Health Promotion of Immigrant Women, Department of Maternal and Child Integrated Activity, University of Florence, Viale della Maternità, Florence, Italy
| | - Omar Abdulcadir
- Regional Referral Center for the Treatment and Prevention of Female Genital Mutilation, Health Promotion of Immigrant Women, Department of Maternal and Child Integrated Activity, University of Florence, Viale della Maternità, Florence, Italy
| | - Patrick Petignat
- Department of Obstetrics and Gynecology, Geneva University Hospitals, Geneva, Switzerland
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Prise en charge sexologique des femmes excisées : expérience nantaise, France. Étude préliminaire. SEXOLOGIES 2017. [DOI: 10.1016/j.sexol.2017.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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15
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Dugast S, Winer N, Wylomanski S. Sexological care of circumcised women: Experience in Nantes, France. Preliminary study. SEXOLOGIES 2017. [DOI: 10.1016/j.sexol.2017.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abdulcadir J, Tille JC, Petignat P. Management of painful clitoral neuroma after female genital mutilation/cutting. Reprod Health 2017; 14:22. [PMID: 28178983 PMCID: PMC5299774 DOI: 10.1186/s12978-017-0288-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 01/20/2017] [Indexed: 12/02/2022] Open
Abstract
Background Traumatic neuromas are the result of regenerative disorganized proliferation of the proximal portion of lesioned nerves. They can exist in any anatomical site and are responsible for neuropathic pain. Post-traumatic neuromas of the clitoris have been described as an uncommon consequence of female genital mutilation/cutting (FGM/C). FGM/C involves partial or total removal of the female genital organs for non-therapeutic reasons. It can involve cutting of the clitoris and can cause psychological, sexual, and physical complications. We aimed to evaluate the symptoms and management of women presenting with a clitoral neuroma after female genital mutilation/cutting (FGM/C). Methods We identified women who attended our specialized clinic for women with FGM/C who were diagnosed with a traumatic neuroma of the clitoris between April 1, 2010 and June 30, 2016. We reviewed their medical files and collected socio-demographic, clinical, surgical, and histopathological information. Results Seven women were diagnosed with clitoral neuroma. Six attended our clinic to undergo clitoral reconstruction, and three of these suffered from clitoral pain. The peri-clitoral fibrosis was removed during clitoral reconstruction, which revealed neuroma of the clitoris in all six subjects. Pain was ameliorated after surgery. The seventh woman presented with a visible and palpable painful clitoral mass diagnosed as a neuroma. Excision of the mass ameliorated the pain. Sexual function improved in five women. One was not sexually active, and one had not yet resumed sex. Conclusion Post-traumatic clitoral neuroma can be a consequence of FGM/C. It can cause clitoral pain or be asymptomatic. In the case of pain symptoms, effective treatment is neuroma surgical excision, which can be performed during clitoral reconstruction. Surgery should be considered as part of multidisciplinary care. The efficacy of neuroma excision alone or during clitoral reconstruction to treat clitoral pain should be further assessed among symptomatic women.
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Affiliation(s)
- Jasmine Abdulcadir
- Department of Obstetrics and Gynecology, Geneva University Hospitals, 30 Bld de la Cluse, 30 Bld de la Cluse, 1211, Geneva, Switzerland. .,Faculty of Medicine, University of Geneva, Rue Michel Servet 1, 1205, Geneva, Switzerland.
| | - Jean-Christophe Tille
- Division of Clinical Pathology, Geneva University Hospitals, Rue Michel Servet 1, 1205, Geneva, Switzerland
| | - Patrick Petignat
- Department of Obstetrics and Gynecology, Geneva University Hospitals, 30 Bld de la Cluse, 30 Bld de la Cluse, 1211, Geneva, Switzerland
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17
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Interventions to Address Sexual Function in Women Affected by Female Genital Cutting: a Scoping Review. CURRENT SEXUAL HEALTH REPORTS 2017. [DOI: 10.1007/s11930-017-0099-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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18
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Aimen FM, Monneins F, Majed G, Amine B. A rare cause of infertility: A late complication of female genital mutilation. ASIAN PACIFIC JOURNAL OF REPRODUCTION 2016. [DOI: 10.1016/j.apjr.2016.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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19
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De Schrijver L, Leye E, Merckx M. A multidisciplinary approach to clitoral reconstruction after female genital mutilation: the crucial role of counselling. EUR J CONTRACEP REPR 2016; 21:269-75. [DOI: 10.3109/13625187.2016.1172063] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Lotte De Schrijver
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | - Els Leye
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
- RHEA, Centre of Expertise on Gender, Diversity and Intersectionality, Vrije Universiteit Brussel, Brussels, Belgium
| | - Mireille Merckx
- Faculty of Medicine and Health Sciences, Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium
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20
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Sexual Anatomy and Function in Women With and Without Genital Mutilation: A Cross-Sectional Study. J Sex Med 2016; 13:226-37. [PMID: 26827253 DOI: 10.1016/j.jsxm.2015.12.023] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 11/24/2015] [Accepted: 12/06/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Female genital mutilation (FGM), the partial or total removal of the external genitalia for non-medical reasons, can affect female sexuality. However, only few studies are available, and these have significant methodologic limitations. AIM To understand the impact of FGM on the anatomy of the clitoris and bulbs using magnetic resonance imaging and on sexuality using psychometric instruments and to study whether differences in anatomy after FGM correlate with differences in sexual function, desire, and body image. METHODS A cross-sectional study on sexual function and sexual anatomy was performed in women with and without FGM. Fifteen women with FGM involving cutting of the clitoris and 15 uncut women as a control group matched by age and parity were prospectively recruited. Participants underwent pelvic magnetic resonance imaging with vaginal opacification by ultrasound gel and completed validated questionnaires on desire (Sexual Desire Inventory), body image (Questionnaire d'Image Corporelle [Body Image Satisfaction Scale]), and sexual function (Female Sexual Function Index). MAIN OUTCOME MEASURES Primary outcomes were clitoral and bulbar measurements on magnetic resonance images. Secondary outcomes were sexual function, desire, and body image scores. RESULTS Women with FGM did not have significantly decreased clitoral glans width and body length but did have significantly smaller volume of the clitoris plus bulbs. They scored significantly lower on sexual function and desire than women without FGM. They did not score lower on Female Sexual Function Index sub-scores for orgasm, desire, and satisfaction and on the Questionnaire d'Image Corporelle but did report significantly more dyspareunia. A larger total volume of clitoris and bulbs did not correlate with higher Female Sexual Function Index and Sexual Desire Inventory scores in women with FGM compared with uncut women who had larger total volume that correlated with higher scores. CONCLUSION Women with FGM have sexual erectile tissues for sexual arousal, orgasm, and pleasure. Women with sexual dysfunction should be appropriately counseled and treated.
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Andro A, Lesclingand M. Les mutilations génitales féminines. État des lieux et des connaissances. POPULATION 2016. [DOI: 10.3917/popu.1602.0224] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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