ArticlePDF Available

Consequences of Female Genital Mutilation on Women’s Sexual Health – Systematic Review and Meta-Analysis

Authors:

Abstract and Figures

Background Female genital mutilation (FGM) can leave a lasting mark on the lives and minds of those affected. Aim To assess the consequences of FGM on women’s sexual function in women who have undergone FGM compared to women who have not undergone FGM. Methods A systematic review and meta-analysis were conducted from 3 databases; inclusion and exclusion criterions were determined. Studies included adult women having undergone FGM and presenting sexual disorders assessed by the Female Sexual Function Index (FSFI). Results Of 129 studies, 5 that met the criteria were selected. The sexual function of mutilated women, based on the FSFI total score and its different domains, was compared to the sexual function of non-mutilated women. There was a significant decrease in the total FSFI scores of mutilated women compared to non-mutilated women. However, the results obtained for the different domains were not the same for all authors. The meta-analysis highlighted a high heterogeneity with inconsistency and true variance in effect size between-studies. Conclusion Analysis of studies showed that there is a significant decrease in the total FSFI score, indicating that FGM of any type may cause impaired sexual functioning. But a firm conclusion on this topic is not yet achievable because the results of this analysis do not allow to conclude a cause and effect relationship of FGM on sexual function. Nzinga A-M, De Andrade Castanheira S, Herklmann J, et al. Consequences of Female Genital Mutilation on Women’s Sexual Health – Systematic Review and Meta-Analysis. J Sex Med 2021;XX:XXX–XXX.
Content may be subject to copyright.
ORIGINAL RESEARCH & REVIEWS
Consequences of Female Genital Mutilation on Womens Sexual
Health eSystematic Review and Meta-Analysis
Andy-Muller Nzinga, MASt PMR,
1
Stéphanie De Andrade Castanheira, BSc PT,
2
Jessica Hermann, BSc PT,
2
Véronique Feipel, PhD PT,
3,4
Augustin Joseph Kipula, PhD Sp Med & Reha,
1
and Jeanne Bertuit, PhD PT
2
ABSTRACT
Background: Female genital mutilation (FGM) can leave a lasting mark on the lives and minds of those affected.
Aim: To assess the consequences of FGM on womens sexual function in women who have undergone FGM
compared to women who have not undergone FGM.
Methods: A systematic review and meta-analysis were conducted from 3 databases; inclusion and exclusion
criterions were determined. Studies included adult women having undergone FGM and presenting sexual
disorders assessed by the Female Sexual Function Index (FSFI).
Results: Of 129 studies, 5 that met the criteria were selected. The sexual function of mutilated women, based on
the FSFI total score and its different domains, was compared to the sexual function of non-mutilated women.
There was a signicant decrease in the total FSFI scores of mutilated women compared to non-mutilated women.
However, the results obtained for the different domains were not the same for all authors. The meta-analysis
highlighted a high heterogeneity with inconsistency and true variance in effect size between-studies.
Conclusion: Analysis of studies showed that there is a signicant decrease in the total FSFI score, indicating that
FGM of any type may cause impaired sexual functioning. But a rm conclusion on this topic is not yet achievable
because the results of this analysis do not allow to conclude a cause and effect relationship of FGM on sexual
function. Nzinga A-M, De Andrade Castanheira S, Herklmann J, et al. Consequences of Female Genital
Mutilation on Womens Sexual Health eSystematic Review and Meta-Analysis. J Sex Med
2021;XX:XXXeXXX.
Copyright 2021, The Authors. Published by Elsevier Inc. on behalf of the International Society for Sexual Medicine.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Key Words: Female Genital mutilation; Sexual Dysfunction; Sexual health; Women
INTRODUCTION
Female genital mutilation (FGM) was dened by the World
Health Organization (WHO) as all procedures which intention-
ally alter or damage the external female genitalia organs for non-
medical reasons and which have no benet for the health of
young girls and women.
1
It is mainly classied into 4 types; Type
I: partial or total removal of the clitoris and/or the prepuce (clito-
ridectomy), Type II: partial or total removal of the clitoris and the
labia minora, with or without excision of the labia majora (exci-
sion), Type III: narrowing of the vaginal orice with covering by
cutting and appositioning the labia minora and/or the labia majora,
with or without excision of the clitoris (inbulation) and Type IV:
all other harmful procedures to the female genitalia organs for non-
therapeutic purposes, such as pricking, piercing, incision, scari-
cation, and cauterization. The identication of certain ambiguities
subsequently led to the creation of sub-divisions in order to make
this classication more complete and precise.
1
This practice is present in at least 30 countries, including some
European countries, as well as Australia and North America.
Although the exact number of girls and women who have
undergone FGM is unknown, it is estimated that at least 200
million girls and women have been subjected to this practice.
Among these, more than half live in just 3 countries: Indonesia,
Received August 14, 2020. Accepted January 4, 2021.
1
Pelvic oor Re-education Unit, Department of Physical Medicine and
Rehabilitation, University Clinics of Kinshasa, Faculty of Medicine, Univer-
sity of Kinshasa (UNIKIN), Kinshasa, Democratic Republic of Congo (DRC);
2
School of Health Sciences (HESAV), University of Applied Sciences and
Arts Western Switzerland (HES-SO), Lausanne, Switzerland;
3
Laboratory of Functional Anatomy, Faculty of Motor Sciences, Université
Libre de Bruxelles, Brussels, Belgium;
4
Laboratory of Anatomy, Biomechanics, and Organogenesis, Faculty of
Medicine, Université Libre de Bruxelles, Brussels, Belgium
Copyright ª2021, The Authors. Published by Elsevier Inc. on behalf of
the International Society for Sexual Medicine. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.jsxm.2021.01.173
J Sex Med 2021;-:1e11 1
Egypt, and Ethiopia, and 40 million girls are under the age of
15.
2,3
In Morocco and the Democratic Republic of Congo
(RDC), excision is found only in the border regions of countries
where it is performed (Mauritania for Morocco, and the Central
African Republic and Sudan for the DRC).
4
According to the WHO, the greater the intervention per-
formed, the greater the risks involved.
5
So, FGM can leave a lasting
mark on the lives and minds of those who have suffered from it,
and they are responsible for various complications in the short-
term and the long-term,
5
such as sexual dysfunction. Therefore,
a signicant lack in knowledge remains about FGM, as well as
about those consequences on womens sexual function.
6
Thus, this work aims to carry out a systematic review of the
literature and meta-analysis in order to assess the consequences of
FGM on womens sexual function in women who have under-
gone FGM compared to women who have not undergone FGM.
METHODS
Protocol
The ofcial PRISMA recommendations were used for carrying
out and writing the literature review.
7
Search Strategy
We conducted a systematic review of the scientic literature and
meta-analysis of the consequences of FGM on womens sexual
function who undergone it compared to those who had not un-
dergone it. This research was carried out in September 2019. 3
databases were used: CINHAL, PubMed, and Embase. The key-
words and descriptors were chosen in order to best respond to the
topic (Table 1). The descriptors were found using the Thesaurus of
the various databases. Subsequently, the use of the Boolean op-
erators OR and ANDallowed us to assemble the keywords and
descriptors in order to create the search equation that was then
developed and specied according to each database (Table 2).
Eligibility Criteria
In order to rene the search, inclusion and exclusion criteria
were determined (Table 3). Studies including adult women
having undergone FGM and presenting sexual dysfunction
assessed by the Female Sexual Function Index (FSFI) and its
different domains were selected. In view of the large number of
articles concerning the consequences of FGM, all articles pub-
lished before the year 2000 were excluded. Only descriptive and
epidemiological studies published in English, French, and Por-
tuguese were selected.
The FSFI is a multidimensional, reliable, and validated self-
assessment questionnaire consisting of 19 items and 6 domains
that assess the main dimensions of sexual function in women
over the past 4 weeks. The different domains assessed by the
FSFI are sexual arousal, lubrication, orgasm, desire, pain, and
satisfaction.
8
The19itemsoftheFSFIusea5-pointLikertscaleranging
from 1e5 with higher scores indicating greater levels of sexual
functioning on the respective item. For scoring the measure, the
sum of each domain score is rst multiplied by a domain factor
ratio (0.6 for desire; 0.3 for arousal; 0.3 for lubrication; 0.4 for
orgasm; 0.4 for satisfaction; and 0.4 for pain) in order to place
all domain totals on a more comparable scale, and then subse-
quently summed to derive a total FSFI score.
8
The total (overall) scores range from 2 to 36, and the lower
scores indicate more problematic sexual functions.
9
The FSFI clinical cutoff score of 26.55, established by Wiegel
et al in 2005 (English version), has been widely used as an index
to aid in distinguishing between women with and without
clinical sexual dysfunction.
10
Table 1. Keywords
Concept Keywords
female genital
mutilation
Circumcision, Female[Mesh] OR
female genital cuttingOR female
circumcision
sexual disorders Libido[Mesh] OR decreased libido
OR stenosis of the articial opening
to the vaginaOR sexual disorders
OR Sexual dysfunction
Table 2. Search equation
Database Search equation
CINHAL (MH Circumcision, Female)ORfemale
genital cuttingOR female genital
mutilation
AND
(MH Sexual Dysfunction, Female)OR
decreased libidoOR stenosis of the
articial opening to the vaginaOR sexual
disordersOR close vaginaOR (MH
Pelvic Pain)
Embase ('female genital mutilationOR female genital
cuttingOR 0female circumcision)
AND
female sexual dysfunctionOR sexual
disordersOR stenosis of the articial
opening to the vaginaOR Close vagina
OR libido disorderOR pelvis pain
syndrome
PubMed Circumcision, Female[Mesh] OR female
genital cuttingOR female circumcision
AND
decreased libidoOR stenosis of the articial
opening to the vaginaOR pelvic painOR
perineal painOR ruptured vulval scarOR
perineal tearsOR avulsion of the urethra
OR avulsion of the bladderOR sexual
disordersOR Sexual dysfunction
J Sex Med 2021;-:1e11
2Nzinga et al
In the English version of the FSFI scale, the contents are not
too sexually explicit, which may make it unsuitable for use in
many societies. So far, FSFI has been translated into more than
20 languages, and it has become the de facto gold standardin
the assessment of female sexual function and an indispensable
tool in clinical research of female sexual dysfunction.
11
This systematic review and meta-analysis used the FSFI trans-
lated into the Arabic language because all studies except that of
Esho et al
12
used the standardized and validated Arabic version of
the FSFI scale (ArFSFI). Thus the ArFSFI recommends 28.1 as the
cutoff.
13
The study by Esho et al had translated the English version by
themselves into their local tongue (Kipsigis) with 26.5 as the
cutoff.
12
This ArFSFI cutoff value is higher than that reported for the
original FSFI. This difference may be attributed to a variety of
cultural, sexual, educational, ethnic makeup, and age-related dif-
ferences between the study populations. Another source of differ-
ence may also be the use of different methods of determination and
the high prevalence of FGM in the Arabic (Egyptian) population.
13
Study Selection and Data Extraction
2 authors independently reviewed the titles and abstracts of
the studies obtained in the databases. Compliance with the
eligibility criteria was checked. Subsequently, the same authors
independently veried, by using a full reading of the studies, the
criteria dened in order to include or exclude them from the
review. In case of disagreement, another author helped to decide
between the situations.
Methodological Quality Assessment
For assessing the quality of the studies, the McMaster grid was
selected.
14
It allows the assessing of different types of studies, as
well as their internal and external validity. This grid consists of 9
items.
Data Analysis
2 data extraction tables were developed. The rst table
describes the population and its sociodemographic data such as
age, parity, level of education, and place of residence. The second
table offers a description of the results by grouping together
the scores by domain, as well as the total FSFI scores for each
study.
Meta-Analysis
A quantitative analysis was carried out on the results of FSFI.
A meta-analysis was also performed to assess the impact of FGM
on womens sexual function. The number of events in each
group was considered, and a random-effects model was used. The
size effect was calculated with a 95% condence interval with the
MetaEasy (A Meta-Analysis Add-In for Microsoft Excel). The
heterogeneity was assessed with Cochran Q tests. When the
Cochran Q test is signicant (P<.05), statistical heterogeneity is
present. I2 test was used for assessing inconsistency between
studies, with values of 25%, 50%, and 75% corresponding to
low, moderate, and high heterogeneity, respectively. If there is a
high level of heterogeneity, a random-effects model (DerSimo-
nian and Laird random-effects model ¼DL) is more appropriate,
and the DerSimonianand Lairds estimator for tau squared
(s
2
estimate DL) is the method most widely used to estimate the
between-study variance. Hence, if s
2
estimate is zero, the random
effect and xed effect model are the same.
RESULTS
Selection of the Studies
Figure 1 illustrates article selection. Among the 129 studies
identied in the 3 database searches, 5 met the eligibility criteria.
Quality of the Studies
The methodological quality of the studies was assessed using
the McMaster grid and is presented in Table 4. 3 studies
15e17
Table 3. Eligibility criteria
Inclusion criteria Exclusion criteria
Population Adult women with FGM
with sexual disorders
Nursling, children and teenager with FGM
With other than sexual disorders
Outcome FSFI- Questionnaire
Desire
Pain
Orgasm
Lubrication
Satisfaction
Arousal
Total FSFI score
Psychological disorders
Language English, French, and Portuguese Other language
Published date From 2000 till 2017 Before 2000
Design of study Descriptive
Epidemiological
Other design of study
FSFI ¼Female Sexual Function Index.
J Sex Med 2021;-:1e11
Female Genital Mutilation and Sexual Health 3
were considered of good methodological quality while the 2
others
12,18
presented poor methodological quality.
Data Extraction
Characteristics of the Studies
The characteristics of the 5 selected articles are illustrated in
Table 5.
The selected studies included participants from different
countries such as Saudi Arabia and neighboring countries,
18
Sudan,
17
Kenya
12
and Egypt.
15,16
The sample sizes varied be-
tween 107 and 650 participants. The average age of participants
ranged from 26 to 40 years for all studies except that of Esho
et al,
12
which reported age groups. In this study, 77 participants
were between the ages of 15e24, and 237 participants were aged
25 and over.
Concerning participant groups, all studies except that of Rouzi
et al
17
included a group of women with FGM (M) and a group
of women without FGM (N-M). 1 study divided the women
with FGM group into 2 subgroups, which included women cut
before marriage (MebM) and women cut after marriage
(MeaM).
12
The study by Rouzi et al
17
included only women
with FGM type I, II, and III, who were then compared with each
other.
In order to determine the type of mutilation, a physical
assessment was performed for the participants in 3 of the selected
studies,
15e17
while for the other 2 studies, the type of mutilation
was self-reported by the participants.
12,18
FSFI Results
The FSFI outcomes of the 5 selected studies are reported in
Table 6. Only signicant results are reported.
Desire
Anis et al
15
and Ismail et al
16
described that women without
FGM experienced more sexual desire than women with FGM.
According to the types of mutilation, the study by Ismail et al
16
reported that women without FGM experienced more
sexual desire than women with FGM type II. Rouzi et al,
17
revealed that sexual desire was felt more in types I and II than
type III.
Table 4. McMaster grid outcome
Articles
Ismail et al,
2017 Esho et al, 2017
Rouzi et al,
2017 Anis et al, 2012
Alsibiani et al,
2010
Purpose (2 points)
Stated clearly (1 point) Yes yes yes yes yes
Relevant background
literature reviewed (1 point)
Yes yes yes yes yes
Design case-control
study
comparative cross-
sectional study
cross-sectional
study
cross-sectional
study
case-control
prospective
study
Sample (2 points)
Described in detail Yes yes yes yes yes
Size justied Yes no no yes no
Outcomes (2 points)
Reliable Yes no Yes yes yes
Valid Yes no Yes yes yes
Intervention (3 points)
Described in detail N/A N/A N/A N/A N/A
Contamination avoided N/A N/A N/A N/A N/A
Co intervention avoided N/A N/A N/A N/A N/A
Results (4 points)
Reported in terms of
statistical signicance
Yes yes yes yes yes
Analysis method(s)
appropriate
Yes yes yes yes not addressed
Clinical importance reported not
addressed
not
addressed
not addressed not addressed not addressed
Drop-outs reported No no no no no
Conclusions and implications (1 point)
Appropriate given study
methods and results
Yes Yes yes yes no
Total points/14 9 6 8 9 6
J Sex Med 2021;-:1e11
4Nzinga et al
Table 5. Characteristics of the included studies
Sample and
its division
(n) Age (years) Level of education Place of residence Parity
Ismail et al, 2017 n ¼394 High education Rural
M (197) 32.6 ±10.3 110 (55.6) 115 (58.6) 2.0 ±1.4
N-M (197) 31.7 ±8.5 115 (58.5) 101 (51.4) 1.7 ±1.3
Esho et al,
2017
n¼314 Kindergarden
to primary
secondary
school
0e34
MebM
(140)
15e24 : 12
(15.6)
124 (50.4) 16 (23.5) 28 (22.4) 112 (59.3)
25 : 128
(54.0)
MeaM
(29)
15e24 : 10
(13.0)
25 (10.2) 4 (5.9) 11 (8.8) 18 (9.5)
25 : 19 (8.0)
N-M þM
(145)
15e24 : 55
(71.4)
97 (39.4) 48 (70.6) 86 (68.8) 59 (31.2)
25 : 90
(38.0)
Rouzi et al,
2017
n¼107 Primary
school
High/preparatory
school
Secondary
high
school
University
degree
Type I (42) 31.2 ±4.7 0 (0) 0 (0) 5 (12.0) 37 (88.0) 2.4 ±1.3
Type II (27) 37.3 ±5.6 0 (0) 0 (0) 15 (56.0) 12 (44.0) 2.9 ±1.4
Type III (38) 40.1 ±5.7 11 (29) 15 (39) 12 (32.0) 0 (0) 3.5 ±1.0
Anis et al,
2012
n¼650 Elementary Middle University Rural Urban Nulliparous 1e2>2
M (333) 29.3 ±7.3 82 (26.6) 188 (56.4) 63 (18.9) 180 (54.1) 21 (6.3) 11 (3.3) 301
(90.3)
N-M (317) 26.2 ±6.8 73 (23.0) 108 (34.1) 136 (42.9) 271 (85.4) 23 (7.26) 16 (5.1) 278
(87.7)
Alsibiani et al,
2010
n¼260 High school Saudi Neighboring
countries
Nulliparous Multiparous
M (130) 30 ±7.8 117 (90.0) 108 (41.5) 152 (58.5) 13 (10) 117 (90.0)
N-M (130) 31 ±8.2 120 (92.0) 16 (12.3) 114 (87.3)
M¼women with FGM; MeaM ¼women with FGM after Marriage; MebM ¼women with FGM before Marriage; N-M ¼women without FGM; N-M þM¼married women without FGM.
Data are provided as mean ±SD or number (percentage).
J Sex Med 2021;-:1e11
Female Genital Mutilation and Sexual Health 5
Table 6. FSFI results
Studies
Sample
and its
division
(n) Desire Pvalues Arousal Pvalues Lubrication Pvalues Orgasm Pvalues Satisfaction Pvalues Pain Pvalues
Total
score Pvalues
Ismail
et al,
2017
Type I (145) 3.5 ±1.4 Inter-group:
.038
Type I vs Type
II: .229
Type I vs N-M:
.141
Type II vs N-M:
.020
3.1 ±1.6 Inter-group: .005
Type I vs Type II:
.628
Type I vs N-M: .005
Type II vs N-M: .021
3.6 ±1.5 Inter-group:
.002
Type I vs Type
II: .247
Type I vs N-M:
.006
Type II vs N-M:
.002
3.3 ±1.5 Inter-group: <
.001
Type I vs Type
II: .166
Type I vs N-M:
.002
Type II vs N-M:
<.001
3.6 ±1.4 Inter-group:
.008
Type I vs Type
II: .458
Type I vs N-M:
.011
Type II vs N-M:
.012
3.1 ±1.5 Inter-group: <
.001
type I vs Type
II: .024
type I vs N-M:
<.001
type II vs N-M:
<.001
20.2 ±6.9 Inter-group: <
.001
type I vs Type II:
.177
type I vs N-M: <
.001
type II vs N-M: <
.001
Type II (52) 3.2 ±1.3 3.0 ±1.7 3.3 ±1.6 2.9 ±1.5 3.4 ±1.4 2.6 ±1.3 18.6 ±7. 5
N-M (197) 3.7 ±1.1 3.6 ±1.7 4.1 ±1.7 3.9 ±1.7 4.0 ±1.5 3.8 ±1.6 23.3 ±8.1
Esho et al,
2017
MebM (140) 3.3 ±1.3 .402 3.8 ±1.4 .472 3.7 ±1.4 .008 4.1 ±1.4 .019 4.7 ±1.2 .042 4.1 ±1.5 .142 23.9 ±6.6 .019
MeaM (29) 3.3 ±1.1 3.7 ±0.9 3.6 ±0.9 3.8 ±1.3 4.2 ±1.1 4.7 ±1.4 22.8 ±4.8
N-M þM
(145)
3.5 ±1.1 3.9 ±0.9 4.1 ±0.8 4.4 ±0.9 4.7 ±1.1 4.4 ±1.1 25.3 ±3.5
Rouzi et al,
2017
Type I (42) 4.0 ±0.4 Type I vs Type
III
<.001
Type II vs Type
III
<.001
4.1 ±0.3 Type I vs Type III
<.001
Type II vs Type III
<.001
4.6 ±0.5 Type I vs Type
III
<.001
Type II vs Type
III
<.001
4.8 ±0.3 Type I vs Type
III
<.001
Type II vs Type
III
<.001
4.8 ±0.7 Type I vs Type
III
<.001
Type II vs Type
III
<.001
4.5 ±0.5 Type I vs Type
III
<.001
Type II vs Type
III
<.001
26.8 ±1.9 Type I vs Type III
<.001
Type II vs Type III
<.001
Type II (27) 3.3 ±0.4 3.3 ±0.4 3.8 ±0.5 3.8 ±0.5 4.0 ±1.0 3.5 ±0.8 21.6 ±2.8
Type III (38) 2.2 ±0.5 1.9 ±0.8 2.6 ±1.2 2.7 ±1.3 3.4 ±0.9 2.2 ±1.2 14.9 ±5.5
Anis et al,
2012
M(333) 3.3 ±0.8 Inter- group:
<.05
4.1 ±0.7 Inter- group: <.05 4.1 ±0.8 Inter- group:
<.05
4.5 ±0.7 Inter- group:
<.05
4.6 ±0.9 Inter- group:
<.05
3.1 ±1.2 NS 23.9 ±2.2 Inter- group: <
.05
N-M (317) 4.0 ±0.7 4.8 ±0.7 4.8 ±0.7 4.8 ±0.6 5.0 ±0.7 3.2 ±0.7 26.8 ±2.2
Alsibiani
et al,
2010
M (130) 3.6 ±1.1 NS 3.6 ±1.2 Inter- group: .007 3.4 ±1 Inter- group:
.01
3.7 ±1.2 Inter- group:
.03
4.5 ±1.2 Inter- group:
.03
3.5 ±1 NS 21.4 ±4.4 Inter- group: .009
N-M (130) 3.7 ±1.2 4.2 ±1.4 3.9 ±1.3 4.2 ±1.4 5 ±1.4 3.8 ±1.1 23.5 ±5
NS ¼no signicant.
M: women with FGM/N-M: women without FGM; MebM: women with FGM before Marriage/MeaM: women with FGM after Marriage/N-M þM: married women without FGM.
Data are provided as mean ±SD.
The FSFI score is ranges from 2 to 36 and the lower scores indicate more problematic sexual function. The cutoff used is 28.1.
J Sex Med 2021;-:1e11
6Nzinga et al
Arousal
According to the studies by Anis et al,
15
Ismail et al,
16
and
Alsibiani et al,
18
women without FGM experienced more sexual
arousal than women with FGM. Women without FGM are
more sexually aroused than those with FGM types I and II.
16
Sexual arousal was felt more in types I and II than type III.
17
Lubrication - OrgasmeSatisfaction
Esho et al,
12
Anis et al,
15
Ismail et al,
16
and Alsibiani et al
18
revealed that women without FGM had more lubrication,
orgasm, and sexual satisfaction than women with FGM.
According to Ismail et al,
16
women without FGM had more
lubrication, orgasm, and sexual satisfaction than women with
FGM types I and II. The lubrication, orgasm, and sexual
satisfaction were present more in types I and II than type III.
17
Pain
According to the study by Ismail et al,
16
women without
FGM experienced less pain during sexual intercourse than
women with FGM. Ismail et al
16
described that women without
FGM experienced less pain during intercourse than women with
FGM types I and II, and women with FGM type I experienced
less pain than those of type II. According to the study by Rouzi
et al,
17
pain during intercourse was less felt in women with FGM
types I and II than those of type III.
Total Score
3 studies demonstrated that women with FGM had more
sexual dysfunction than women without FGM.
15,16,18
Ismail et al
16
illustrated that the women without FGM had
less sexual dysfunction than women with FGM types I and II.
According to the study by Rouzi et al,
17
women with FGM types
I and II had less sexual dysfunction than those of type III. The
study by Esho et al
12
found that married women without FGM
had less sexual dysfunction than women with FGM cut before
and after marriage.
Meta-Analysis
In order to facilitate the understanding of these results, 2
graphs were created (Figure 2). About the comparison between
FSFI results scores obtained by women with and without FGM,
in the study by Ismail et al,
16
the comparison was made between
women with FGM type I and women without FGM, and in the
study by Esho et al,
12
it was done between mutilated women
after marriage and married women without FGM. Since the
Figure 2. Forests -plots of FSFI total scores. Figure 1 is available in color online at www.jsm.jsexmed.org.
Articles in duplicate – removed
n=2
Articles excluded by title
n=109
Articles excluded by abstract
n=12
Articles excluded because they
did not meet the criteria
n=1
Embrase
0 Articles
Pub Med
109 Articles
5 Included studies
Total of articles
n=129
127 Selected articles
18 Selected articles
6 Selected articles
Figure 1. Flow-chart.
J Sex Med 2021;-:1e11
Female Genital Mutilation and Sexual Health 7
study by Rouzi et al
17
did not contain a group of women with
FGM, the results obtained by these authors were not displayed
on this graph.
With condence level of 95% (t-test) the Pvalue was smaller
than 0.05; It means that this meta-analysis have shown statisti-
cally signicant negative effects of FGM on womens sexual
function. Several studies had reported the same outcomes and
were sufciently similar to warrant pooling the negative effect of
FGM in womens sexual health. However, this meta-analysis
found the high heterogeneity (I
2
¼94.5%) with inconsistency
between studies. So, a random-effects model was used
and found a true variance in effect size (s
2
estimate ¼0.23)
between-studies.
DISCUSSION
All studies included a large number of participants (107
participants). Concerning the recruitment context, 3 studies
recruited participants during a routine consultation in the
gynecology department of the regional hospital.
16e18
In the
study by Anis et al,
15
participants were also recruited during a
hospital visit, but the context of this visit is not specied. Finally,
Esho et al
12
stated that the participants in their study were
identied from the sample of a similar study.
In order to determine or conrm the type of FGM included in
the studies, a physical assessment was carried out in 3 of the
selected studies.
15e17
In the other 2 studies, the type of muti-
lation was self-reported.
12,18
Conrming the type of mutilation
by a genital assessment is a strong point since self-declaration of
the type of mutilation is not reliable, and it is possible that it
inuences the accuracy of the results obtained by the authors.
19
The eligibility criteria for women in the studies are only specied
by 2 out of 5 authors.
15,17
On the other hand, all studies except
that of Esho et al
12
included only sexually active women.
All studies except that of Rouzi et al
17
compared the results
obtained by the FSFI of women with FGM with those obtained
in women without FGM to determine whether or not there was
more sexual dysfunction in women who have undergone it.
While Rouzi et al
17
compared the results of the different groups
of women who undergone FGM to determine the inuence of
type on sexual dysfunction.
Given those studies used both the FSFI questionnaire in
Arabic (ArFSFI) and Kipsigis version with different cut off of the
total FSFI score, respectively, of 28.1 and 26.55 to aid in
distinguishing between women with and without clinical sexual
dysfunction, for the interpretation of this score, we considered
that the lower scores indicated more problematic sexual function.
All authors found a signicant decrease in the total FSFI score
obtained by women who experienced FGM as compared with
women who did not have FGM. According to them, FGM may
cause impaired sexual functioning. Rouzi et al
17
suggested that 9
out of 10 women who have undergone type I to III FGM suffer
from sexual dysfunction. The authors showed that the average
FSFI scores obtained by women with FGM, whatever the type,
were below the recommended threshold of 28.1. However, the
authors pointed out that the scores obtained in type III FGM
were signicantly lower than those obtained in types I and II
FGM. This means that the more extensive is the FGM, the
greater is the sexual dysfunction.
However, the domains affected by this sexual dysfunction
were not the same for all the authors. Indeed, Esho et al
12
demonstrated a signicant difference between married women
without FGM and those with FGM in only 3 out of 6 domains
(lubrication, orgasm, and satisfaction), compared to 4 out of 6
domains (lubrication, arousal, orgasm and satisfaction) for
Alsibiani et al
18
between without FGM and with FGM
women, and 5 domains out of 6 (desire, lubrication, arousal,
orgasm and satisfaction) for Anis et al
15
concerning the same
groups.
Ismail et al
16
were the only ones to demonstrate that all
domain scores were lower in women who have undergone FGM
compared to women without FGM, with the exception of the
sexual desire domain, which did not differ between women
without FGM and those with FGM type I. Finally, Rouzi et al
17
showed that although all types of mutilation were associated with
scores below the recommended threshold of 28.1, all scores (6 of
6 domains) obtained by women with FGM type III were
signicantly lower than the scores obtained by women with
FGM types I and II.
According to the literature, there is a higher risk of dyspar-
eunia with type III FGM relative to types I and II,
20
and FGM
decrease sexual satisfaction, reduce sexual desire and arousal,
decrease lubrication during sexual intercourse and reduce the
frequency of orgasm or anorgasmia.
20e22
This can be justied by the fact that in women with FGM,
parts of the erogenous genital zones and sexually responsive
vascular tissue are excised.
22
The removal of womens genital
parts may lead to damaged nerve endings, as well as to the
development of inelastic scar tissue and adhesions surrounding
the excised areas, and for this reason, FGM may cause impaired
sexual functioning.
23
Given that some types of FGM involve the removal of sexually
sensitive structures, including the clitoral glans and part of the
labia minora, some women report the reduction of sexual
response and diminished sexual satisfaction. In addition, scarring
of the vulvar area may result in pain, including during sexual
intercourse.
20e22
Nevertheless, although not all women with FGM show
sexual issues, it seems that they may be physiologically less
capable of becoming sexually stimulated than women without
FGM,
22
due to the essential role of the integrity of the clitoris
and labia minora for the achievement of sexual response.
23
It is
important to specify that in women with FGM, some essential
structures involved in the achievement of orgasm have not been
removed.
24
J Sex Med 2021;-:1e11
8Nzinga et al
Let us highlight that the mean scores of FSFI found in women
who did not experience FGM were also below the recommended
threshold of 28.1. Although they had the intact structures
involved in the achievement of sexual response, this can be
justied in the fact that some psychological or physiological
factors are also involved in this decrease, which is the reason why
those women without FGM had a low score, but this score
remained above the mutilated womens score.
According to WHO guidelines, womens sexuality is
multifactorial and depends, among other things, on the inter-
action of anatomic, cognitive, and relational factors.
21
In addition, another possible compensatory mechanism to
overcome the “‘anatomical barrier”’ is the ability of women to
enhance stimulus originating from other sensory or erotic areas
or through the ideation of emotions and fantasy.
22,25,26
So, some authors underline that women with FGM identify
their breasts, tongue, or vagina as their most sensitive parts of the
body.
27e29
According to the WHO guidelines, although there is evidence
showing that these adverse health outcomes are associated with
FGM and that many communities have started to acknowledge
this association, in reality, health care providers are still
often unaware of the many negative health consequences and
remain inadequately trained to recognize and treat them
properly.
21
So, clitoral reconstruction represents the principal but not the
only reconstructive option for women with FGM. Other
possibilities include reconstruction of the clitoris and labia,
deinbulation, removal of cysts, neuromas, and scar tissue.
30
In
addition, these approaches can be combined with novel recon-
structive techniques.
24
Clitoral reconstruction is the procedure that involves the
resection of the skin that covers the stump with the aim of
revealing the clitoris; the suspensory ligament is subsequently
sectioned to mobilize the stump. The scar tissue is then removed,
and the glans is placed into a physiological position.
31
The aim of
surgery is to restore both clitoral anatomy and function, improve
the patients self-esteem, body image, sexual function, and reduce
pain during sexual intercourse.
32
Deinbulation is a minor surgical procedure carried out to re-
open the vaginal introitus in women living with type III FGM.
This procedure is performed to improve health and well-being, as
well as to allow intercourse and/or to facilitate childbirth.
21
A recent systematic review evaluated the effects of recon-
structive surgery. The results indicate that about 3 women out of
4 regain a visible clitoris; self-reported ameliorations in pain
during sex, clitoral function/pleasure, orgasm, and desire are in
the 43e63% range, but up to 22% reported a worsening in
sexual outcomes. As underlined by the authors, it is difcult to
ascertain the real impact of reconstructive surgery due to
methodological limitations and insufcient study similarity.
24,33
So prospective studies of the impact of reconstructive surgery
on the sexual function of women with FGM are
limited.
23,31,34,35
That is the reason why, the GDG (Guideline Development
Group) underlined that surgery alone, in particular clitoral
reconstruction, does not treat all aspects of sexual dysfunction
that may occur among women living with FGM (57), and other
medical interventions such as the use of genital lubricants have
not been extensively studied.
21,36
As suggested by WHO guidelines, sexual counselling is rec-
ommended for preventing or treating female sexual dysfunction
among women living with FGM (conditional recommendation;
no direct evidence). This is conditional because there is a general
lack of direct evidence regarding the use of sexual counseling,
specically among women living with FGM, and it is anticipated
that this topic will be highly sensitive.
21
A systematic review investigating the effects of sexual counselling
for treating or preventing sexual dysfunction in women living with
FGM was conducted to help inform this recommendation. The
authors found no studies that met the inclusion criteria, and
therefore, direct evidence could not be used.
21,37
Given that womens sexuality is multifactorial, the GDG
noted that offering treatment alternatives for sexual dysfunction,
in this case sexual counselling, to this population should be seen
as a priority.
21
After surgery, WHO offers to provide treatment and post-
traumatic re-education for girls and women victims of mutila-
tion.
38
This pelvic oor re-education and other explanations are
needed to help women become familiar with their newgeni-
talia image.
39
Abdulcadir et al proposed further studies that could evaluate
the effectiveness of treatments, such as perineal re-education (eg,
biofeedback or Kegel exercises) in women with FGM. Because
perineal re-education could improve not only lower urinary tract
symptoms and dyspareunia but could also increase the womans
self-knowledge of anatomy and physiology, which may improve
satisfaction with genitalia image.
6
Overall, careful counseling and a multidisciplinary approach
are essential to identify those women who would most benet
from a surgical and/or psychological approach or pelvic oor re-
education.
24
In short, all authors demonstrated a signicant difference
between the total FSFI scores obtained by women with and
without FGM. Indeed, women with FGM had signicantly
lower scores than women without FGM, indicating that they had
more sexual dysfunction.
However, the domains affected by this dysfunction differed
slightly from 1 study to another. Despite the differences found
among studies concerning the various domains, the results
collected in this review demonstrate that FGM may cause sexual
dysfunction in affected women, and the more FGM is extended,
J Sex Med 2021;-:1e11
Female Genital Mutilation and Sexual Health 9
the greater is the dysfunction. Based on these ndings, a
rm conclusion on this topic is not yet achievable because this
meta-analysis found the high heterogeneity with inconsistency
and true variance in effect size between-studies.
This review has some limitations. First, this article focusses on
only 1 of the various domains affected by FGM. Other com-
plications linked to FGM were not analyzed in view. Second, the
language and publication bias may have led to a lack of studies on
sexual function on women with FGM with negative results
found, and no funnel plot or other assessment of publication bias
was included. Third, often the lack of appropriate standardized
sexual function questionnaires and appropriate control groups
was observed. Finally, we could not generalize the results of
negative effect of FGM on womens sexual function because
conclusions about cause and effect can only be drawn in the case
of randomized controlled trials.
For the future, it would therefore be interesting to carry out a
review concerning other types of short-term and long-term
complications due to FGM and to propose management
options for each of these complications. This would provide a
broader understanding of this topic, as well as a holistic idea of
the management that can be used by different health care
professionals, including physiotherapists.
CONCLUSION
The analysis of these 5 selected studies showed that there is a
signicant decrease in the total FSFI score, meaning that FGM of
any type may cause impaired sexual functioning; however, the
results obtained for the different domains were not the same for
all authors. The meta-analysis highlighted a high heterogeneity
with inconsistency between the different studies. Therefore, a
rm conclusion on this topic is not yet achievable because the
results of this analysis do not allow to conclude a cause and effect
relationship of FGM on sexual function.
Corresponding Author: Jeanne Bertuit, PhD PT, School of
Health Sciences (HESAV), University of Applied Sciences and
Arts Western Switzerland (HES-SO), Av de Beaumont 21
-1011, Lausanne, Switzerland. Tel: þ4121 316 81 33; E-mail:
jeanne.bertuit@hesav.ch
Conict of interest: The authors report no conicts of interest..
Funding: None.
STATEMENT OF AUTHORSHIP
Andy-Muller Nzinga, Writing review and editing Software;
Stéphanie De Andrade Castanheira, Writing original
Draft Investigation Data Curation; Jessica Herklmann, Writing
original Draft Investigation Data Curation; Véronique Feipel,
Conceptualization Methodology; Augustin Joseph Kipula,
Conceptualization; Jeanne Bertuit, Funding Supervision
Conceptualization.
REFERENCES
1. World Health Organization. Classication of female genital
mutilation. WHO. Available at: https://www.who.int/
reproductivehealth/topics/fgm/overview/en/.; Accessed
November 1, 2020.
2. United Nations Childrens Fund. Female Genital Mutilation/
Cutting: A global concern. Available at: https://www.unicef.
org/media/les/FGMC_2016_brochure_nal_UN UNICEF_
SPREAD.pdf.; Accessed November 1, 2020.
3. Land of Women Switzerland. Female genital mutilation in
Switzerland: State of place of prevention, care and protection
measures in relation to female genital mutilation (FGM) in
Switzerland: Summary. Bern. Available at: https://www.terre-
des-femmes.ch/images/docs/2014_EtatsdesLieux_MGF.pdf.;
Accessed November 1, 2020.
4. FPS Public Health, Safety of the Food Chain and Environment
and GAMS Belgium. Female Genital Mutilation: guide for the
use of the professions concerned. Brussels. Available at:
http://gams.be/wp-content/uploads/2016/05/guide-mgf-fr_G
AMS-Belgique.pdf.; Accessed November 1, 2020.
5. World Health Organization. Female genital mutilation and
other harmful practices. Geneva (n.d.). Available at: https://
www.who.int/reproductivehealth/topics/fgm/overview_fgm_re
search/en/; Accessed November 1, 2020.
6. Abdulcadir J, Rodriguez MI, Say L. Research gaps in the care
of women with female genital mutilation: An analysis. BJOG
2015;122:294-303.
7. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement
for reporting systematic reviews and meta-analyzes of studies
that evaluate health care interventions: explanation and
elaboration. Plos Med 2009;6:e1000100.
8. Rosen C, Brown J, Heiman S, et al. The Female Sexual Func-
tion Index (FSFI): A Multidimensional Self-Report Instrument
for the Assessment of Female Sexual Function. J Sex Marital
Ther 2000;26:191-208.
9. Female sexual function index. Available at: https://www.
fsquestionnaire.com; Accessed November 1, 2020.
10. Wiegel M, Meston C, Rosen R. The Female Sexual Function
Index (FSFI): Cross-validation and development of clinical
cutoff scores. J Sex Marital Ther 2005;31:1-20.
11. Sun X, Li C, Jin L, et al. Development and validation of Chinese
version of Female Sexual Function Index in a Chinese
population-A pilot study. J Sex Med 2011;8:1101-1111.
12. Esho T, Kimani S, Nyamongo I, et al. The heatgoes away:
Sexual disorders of married women with female genital
mutilation/cutting in Kenya. Reprod Health 2017;14:164.
13. Anis TH, Aboul Gheit S, Saied HS, et al. Arabic translation of
female sexual function index and validation in an Egyptian
population. J Sex Med 2011;8:3370-3378.
14. Law M, Stewart D, Pollock N, et al. Critical Review Form
Quantitative Studies. Available at: https://srs-mcmaster.ca/
wp-content/uploads/2015/04/Critical-Review-Form-Quantitat
ive-Studies-English.pdf.; Accessed November 1, 2020.
15. Anis TH, Aboul Gheit S, Awad HH, et al. Effects of Female
Genital Cutting on the Sexual Function of Egyptian Women. A
Cross - Sectional Study. J Sex Med 2012;9:2682-2692.
J Sex Med 2021;-:1e11
10 Nzinga et al
16. Ismail SA, Abbas AM, Habib D, et al. Effect of female
genital mutilation/cutting; types I and II on sexual function:
Case-controlled study. Reprod Health 2017;14:108.
17. Rouzi AA, Berg RC, Sahly N, et al. Effects of female genital
mutilation/cutting on the sexual function of Sudanese women:
A cross-sectional study. Am J Obstet Gynecol 2017;217:62.
e1-62.e6.
18. Alsibiani SA, Rouzi AA. Sexual function in women with female
genital mutilation. The Egypt J Fertil Steril 2010;12:3-8.
19. Elmusharaf S, Elhadi N, Almroth L. Reliability of self reported
form of female genital mutilation and WHO classication:
Cross sectional study. BMJ 2006;333:124.
20. Berg RC, Underland V, Odgaard-Jensen J, et al. Effects of
female genital cutting on physical health outcomes: a
systematic review and meta-analysis. BMJ Open 2014;
4:e006316.
21. World Health Organization. Guidelines on the management
of health complications from female genital mutilation.
Geneva: WHO. Available at: https://www.who.int/
reproductivehealth/topics/fgm/management-health-compli
cations-fgm/en.; Accessed November 1, 2020.
22. Berg RC, Denison E, Fretheim A. Psychological, social and
sexual consequences of female genital mutilation/cutting
(FGM/C): a systematic review on quantitative studies. Report
from Kunnskapssenteret nr 13-2010. Oslo: Nasjonalt kunn-
skapssenter for helsetjenesten; 2010.
23. Thabet SMA, Thabet ASMA. Defective sexuality and female
circumcision: the cause and the possible management.
J Obstet Gynaecol Res 2003;29:12-19.
24. Buggio L, Facchin F, Chiappa L, et al. Psychosexual Conse-
quences of Female Genital Mutilation and the Impact of
Reconstructive Surgery: A Narrative Review. Health Equity
2019;3:36-46.
25. Abdulcadir J, Botsikas D, Bolmont M, et al. Sexual Anatomy
and Function in Women With and Without Genital Mutilation:
A Cross-Sectional Study. J Sex Med 2016;13:226-237.
26. Nour NM, Michels KB, Bryant AE. Debulation to treat female
genital cutting: effect on symptoms and sexual function.
Obstet Gynecol 2006;108:55-60.
27. Megafu U. Female ritual circumcision in Africa an investigation
of the presumed benets among Ibos of Nigeria. East Afr
Med J 1983;60:793-800.
28. Nwajei SD, Otiono AI. Female Genital Mutilation: implications
for Female Sexuality. Womens Stud Int Forum 2003;
26:575-580.
29. Okonofu FE, Larsen U, Oronsaye F, et al. The association
between female genital cutting and correlates of sexual and
gynaecological morbidity in Edo State, Nigeria. BJOG 2002;
109:1089-1096.
30. Sigurjonsson H, Jordal M. Addressing Female Genital Mutila-
tion/Cutting (FGM/C) in the Era of Clitoral Reconstruction:
plastic Surgery. Curr Sex Health Rep 2018;10:50-56.
31. Folde`s P, Cuzin B, Andro A. Reconstructive surgery after
female genital mutilation: a prospective cohort study. Lancet
2012;380:134-141.
32. Paterson LQP, Davis SN, Binik YM. Female genital mutilation/
cutting and orgasm before and after surgical repair. Sexology
2012;21:3-8.
33. Berg RC, Taraldsen S, Said MA, et al. The effectiveness of
surgical interventions for women with FGM/C: a systematic
review. BJOG 2018;125:278-287.
34. Ouédraogo CM, Madzou S, Touré B, et al. Practice of
reconstructive plastic surgery of the clitoris after genital
mutilation in Burkina Faso. Report of 94 cases. Ann Chir Plast
Esthet 2013;58:208-215.
35. Vital M, de Visme S, Hanf M, et al. Using the Female Sexual
Function Index (FSFI) to evaluate sexual function in women
with genital mutilation undergoing surgical reconstruction: a
pilot prospective study. Eur J Obstet Gynecol Reprod Biol
2016;202:71-74.
36. Abdulcadir J, Rodriguez MI, Say L. A systematic review of the
evidence on clitoral reconstruction after female genital
mutilation/cutting. Int J Gynaecol Obstet 2015;129:93-97.
37. Okomo U, Ogugbue M, Inyang E, et al. Sexual counselling for
treating or preventing sexual dysfunction in women living with
female genital mutilation: A systematic review. Int J Gynaecol
Obstet 2017;136(Suppl 1):38-42.
38. World Health Organization. Female genital mutilation: an
overview. Geneva : WHO. Available at: https://apps.who.int/
iris/handle/10665/42150.; Accessed November 1, 2020.
39. Adyam Y. Management of female genital mutilation: health,
socio-cultural, psychosocial, ethical, and legal dimensions.
[Thesis] Geneva: Geneva University of Health; 2013. Available
at: https://apps.who.int/iris/bitstream/handle/10665/206437/
9789241549646_eng.pdf. Accessed November 1, 2020.
J Sex Med 2021;-:1e11
Female Genital Mutilation and Sexual Health 11
... This is largely due to difficulties involved in measuring sexuality in finding an appropriate comparison group as well as the complex interplay between physical, psychological and sociocultural aspects of sexuality (Esho, 2012;Johnson-Agbakwu and Warren, 2017). Thus, some studies find increased risk of impaired sexual function among women who have undergone FGC (Esho et al., 2017;Rouzi et al., 2017;Buggio et al., 2019;Pérez-López et al., 2020;Nzinga et al., 2021) while others do not (Obermeyer, 2005;Catania et al., 2007;Abdulcadir, 2016). Many of these studies, however, do not distinguish between the different types of FGC or variations in the anatomical extent of the cutting. ...
... Impaired sexual function is characterized by difficulty moving through the stages of sexual desire, arousal, and orgasm, but also involves the subjective experience of sexual satisfaction (Rosen et al., 2000). Many of the existing studies investigating the effects of FGC on sexual function have used predefined questionnaires such as the Female Sexual Function Index (FSFI) (Catania et al., 2007;Ismail et al., 2017;Rouzi et al., 2017;Pérez-López et al., 2020;Nzinga et al., 2021). The FSFI is a wellused tool for measuring desire, subjective arousal, lubrication, orgasm, and pain (Rosen et al., 2000), but is not adapted to or validated for use among women with FGC or for many of the various cultural settings women with FGC belong to. ...
Article
Full-text available
Female genital cutting (FGC) is a traditional practice, commonly underpinned by cultural values regarding female sexuality, that involves the cutting of women's external genitalia, often entailing the removal of clitoral tissue and/or closing the vaginal orifice. As control of female sexual libido is a common rationale for FGC, international concern has been raised regarding its potential negative effect on female sexuality. Most studies attempting to measure the impact of FGC on women's sexual function are quantitative and employ predefined questionnaires such as the Female Sexual Function Index (FSFI). However, these have not been validated for cut women, or for all FGC-practicing countries or communities; nor do they capture cut women's perceptions and experiences of their sexuality. We propose that the subjective nature of sexuality calls for a qualitative approach in which cut women's own voices and reflections are investigated. In this paper, we seek to unravel how FGC-affected women themselves reflect upon and perceive the possible connection between FGC and their sexual function and intimate relationships. The study has a qualitative design and is based on 44 individual interviews with 25 women seeking clitoral reconstruction in Sweden. Its findings demonstrate that the women largely perceived the physical aspects of FGC, including the removal of clitoral tissue, to affect women's (including their own) sexual function negatively. They also recognized the psychological aspects of FGC as further challenging their sex lives and intimate relationships. The women desired acknowledgment of the physical consequences of FGC and of their sexual difficulties as “real” and not merely “psychological blocks”.
Article
Full-text available
Purpose: We aim to provide a comprehensive overview of the health consequences of female genital mutilation/cutting (FGM/C), with a particular focus on the psychosexual implications of this practice and the overall impact of reconstructive plastic surgery. Methods: A MEDLINE search through PubMed was performed to identify the best quality evidence published studies in English language on long-term health consequences of FGM/C. Results: Women with FGM/C are more likely to develop psychological disorders, such as post-traumatic stress disorder, anxiety, somatization, phobia, and low self-esteem, than those without FGM/C. Most studies showed impaired sexual function in women with FGM/C. In particular, women with FGM/C may be physiologically less capable of becoming sexually stimulated than uncut women. Reconstructive surgery could be beneficial, in terms of both enhanced sexual function and body image. However, prospective studies on the impact of reconstructive surgery are limited, and safety issues should be addressed. Conclusion: Although it is clear that FGM/C can cause devastating immediate and long-term health consequences for girls and women, high-quality data on these issues are limited. Psychosexual complications need to be further analyzed to provide evidence-based guidelines and to improve the health care of women and girls with FGM/C. The best treatment approach involves a multidisciplinary team to deal with the multifaceted FGM/C repercussions.
Article
Full-text available
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.
Article
Full-text available
Background Female genital mutilation/cutting (FGM/C) has been implicated in sexual complications among women, although there is paucity of research evidence on sexual experiences among married women who have undergone this cultural practice. The aim of this study was to investigate the sexual experiences among married women in Mauche Ward, Nakuru County. Methods Quantitative and qualitative data collection methods were used. Quantitative data were obtained from 318 married women selected through multistage sampling. The women were categorized into: cut before marriage, cut after marriage and the uncut. A questionnaire was used to collect demographic information while psychometric data were obtained using a female sexual functioning index (FSFI) tool. The resulting quantitative data were analyzed using SPSS® Version 22. Qualitative data were obtained from five FGDs and two case narratives. The data were organized into themes, analyzed and interpreted. Ethical approval for the study was granted by Kenyatta National Hospital-University of Nairobi Ethics and Research Committee. Results The mean age of the respondents was 30.59 ± 7.36 years. The majority (74.2%) had primary education and 76.1% were farmers. Age (p = 0.008), number of children (p = 0.035) and education (p = 0.038) were found to be associated with sexual functioning. The cut women reported lower sexual functioning compared to the uncut. ANOVA results show the reported overall sexual functioning to be significantly (p = 0.019) different across the three groups. Women cut after marriage (mean = 22.81 ± 4.87) scored significantly lower (p = 0.056) than the uncut (mean = 25.35 ± 3.56). However, in comparison to the cut before marriage there was no significant difference (mean = 23.99 ± 6.63). Among the sexual functioning domains, lubrication (p = 0.008), orgasm (p = 0.019) and satisfaction (p = 0.042) were significantly different across the three groups. However, desire, arousal and pain were not statistically different. Conclusion Generally, cut women had negative sexual experiences and specifically adverse changes in desire, arousal and satisfaction were experienced among cut after marriage. FGM/C mitigating strategies need to routinely provide sexual complications management to safeguard women’s sexual right to pleasure subsequently improving their general well-being.
Article
Full-text available
Background: The existing literature is contradictory regarding effects of female genital mutilation/cutting (FGM/C) on sexual functions. The aim of this study was to explore the impact of type I and II FGM/C on sexual function of Egyptian women. Methods: We recruited 197 cut women and 197 control women from those visiting Assiut University hospitals for different reasons. We asked each woman to fill the Arabic female sexual function index (FSFI) (a self reported 19-item questionnaire assessing the main domains of female sexual function). Genital Examination was done to confirm the type of FGM. Results: Female sexual dysfunction (FSD) was found in 83.8% of FGM/C cases in contrast to 64.5% of the control. The total FSFI score in the FGM/C group (19.82 ± 7.1) was significantly lower than in the control group (23.34 ± 8.1). Concerning the types of FGM/C, type 73.6% of cases had type I and 26.4% had type II. Type I FGM/C was performed mainly by physicians (62.1%) while type II was performed mainly by midwives (44.4%). FSD was found in 83.4% of FGM/C I cases and in 84.6% of FGM/C II cases. There was no statistically significant difference between the two types of FGM/C as regards total and individual domain scores except for the pain domain. There were significantly lower total and individual domain scores in both FGM/C types except for the desire domain compared to control. Conclusion: In this study, FGM/C was associated with reduced scores of FSFI on all domains scores, and among both types I and II, both were associated with sexual dysfunction.
Article
Background: Female genital mutilation/cutting (FGM/C) changes normal genital functionality and can cause complications. There is an increasing demand for treatment of FGM/C-related complications. Objectives: We conducted a systematic review of empirical quantitative research on the outcomes of interventions for women with FGM/C-related complications. Search strategy: A search specialist searched 16 electronic databases. Selection criteria: Selection was independent by two researchers. We accepted quantitative studies that examined the outcome of an intervention for a FGM/C-related concern. Data collection and analysis: We extracted data onto a pre-designed form, calculated effect estimates, and performed meta-analyses. Main results: We included 62 studies (5829 women), which investigated the effect of defibulation, excision of cysts, and clitoral reconstruction. Meta-analyses of defibulation versus no defibulation showed a significantly lower risk of cesarean section (RR=0.33, 95% CI 0.25, 0.45) and perineal tears with defibulation: 2nd degree tear (RR=0.44, 95% CI 0.24, 0.79), 3rd degree tear (RR=0.21, 95% CI 0.05, 0.94), 4th degree tear (RR=0.06, 95% CI 0.01, 0.41). The meta-analyses detected no significant differences in obstetric outcomes of antenatal versus intrapartum defibulation. Except for one, none of the studies on excision of cysts indicated complications, rather, resolution of problems were favorable. Reconstructive surgery resulted in a visible clitoris in about 77% of women. Most women self-reported improvements in their sexual life, but up to 22% experienced a worsening in sexuality-related outcomes after reconstruction. Conclusions: Women with FGM/C who seek therapeutic surgery should be informed about the scarcity of evidence on benefits and harms of available procedures. This article is protected by copyright. All rights reserved.
Article
Background: Female Genital Mutilation/Cutting (FGM/C) is a cultural practice that involves several types of removal or other injury to the external female genitalia for non-medical reasons. While much international research has focused on the health consequences of the practice, little is known about sexual functioning among women with various types of FGM/C. Objective(s): To assess the impact of FGM/C on the sexual functioning of Sudanese women. Study design: This is a cross-sectional study conducted at Doctor Erfan and Bagedo Hospital, Jeddah, Saudi Arabia. Eligible women completed a survey and a clinical examination, which documented and verified women's type of FGM/C. The main outcome measure was female sexual function, as assessed by the Arabic Female Sexual Function Index (ArFSFI). Results: 107 eligible women completed the survey and the gynecological exam, which revealed that 39% of the women had FGM/C type I, 25% had type II, and 36% had type III. Reliability of self-report of the type of FGM/C was low, with underreporting of the extent of the procedure. The results showed that 92.5% of the women scored lower than the ArFSFI cut-off point for sexual dysfunction. The multivariable regression analyses showed that sexual dysfunction was significantly greater with more extensive type of FGM/C, across all sexual function domains (desire, arousal, lubrication, orgasm, satisfaction, and pain) and overall. Conclusion(s): The study documents that a substantial proportion of women subjected to FGM/C experience sexual dysfunction. It shows that the anatomical extent of FGM/C is related to the severity of sexual dysfunction.
Article
Objectives: Few prospective studies have evaluated sexual function in women with female genital mutilation by cutting (FGM/C) before and after clitoral reconstructive surgery, and none used a validated questionnaire. A validated questionnaire, the Female Sexual Function Index (FSFI) was used for the first time, to assess the impact of reconstructive surgery on sexual function in women with female genital mutilation/cutting (FGM/C) before and after clitoral reconstructive surgery. Study design: Women with FGM/C consulting at the Nantes University Hospital for clitoral reconstruction between 2013 and 2014 were prospectively included. All patients completed a questionnaire at inclusion, describing their social, demographic, and FGM/C characteristics. They were also asked to complete the FSFI as well as a questionnaire about clitoral sensations, symptoms of depression or anxiety, and self-esteem before and 3 and 6 months after the surgery. Paired Wilcoxon and McNemar tests were used to compare data. Results: Of the 12 women included, 9 (75%) had type II mutilations. Results showed a global sexual dysfunction (median FSFI summary score=17) before surgery. Clitoral sensations were absent in 8 women (67%). Six months after surgery, all FSFI dimensions except lubrication had improved significantly (median FSFI summary score=29, P=0.009). Ten women had clitoral sensations, and 11 (92%) were satisfied with their surgery. Conclusion: This study shows that 6 months after clitoral reconstructive surgery, women reported a multidimensional positive improvement in their sexual function. The FSFI is a promising tool for routine standardized assessment of the sexual function of women with FGM/C for determining appropriate management and assessing it. Larger studies with validated questionnaires assessing self-esteem, depression, and body image are also needed to develop an integrative approach and to provide evidence-based recommendations about management of these women.
Article
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.