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Abstract

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”.
TYPE Original Research
PUBLISHED 12 August 2022
DOI 10.3389/fsoc.2022.943949
OPEN ACCESS
EDITED BY
Saron Karlsen,
University of Bristol, United Kingdom
REVIEWED BY
Hannelore Van Bavel,
University of Bristol, United Kingdom
Kath Woodward,
The Open University, United Kingdom
*CORRESPONDENCE
Malin Jordal
malin.jordal@hig.se
SPECIALTY SECTION
This article was submitted to
Gender, Sex and Sexualities,
a section of the journal
Frontiers in Sociology
RECEIVED 14 May 2022
ACCEPTED 18 July 2022
PUBLISHED 12 August 2022
CITATION
Jordal M, Påfs J, Wahlberg A and
Johansen REB (2022) “Damaged
genitals”—Cut women’s perceptions of
the eect of female genital cutting on
sexual function. A qualitative study
from Sweden. Front. Sociol. 7:943949.
doi: 10.3389/fsoc.2022.943949
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©2022 Jordal, Påfs, Wahlberg and
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author(s) and the copyright owner(s)
are credited and that the original
publication in this journal is cited, in
accordance with accepted academic
practice. No use, distribution or
reproduction is permitted which does
not comply with these terms.
“Damaged genitals”—Cut
women’s perceptions of the
eect of female genital cutting
on sexual function. A qualitative
study from Sweden
Malin Jordal1*, Jessica Påfs2, Anna Wahlberg3and
R. Elise B. Johansen4
1Department of Caring Sciences, University of Gävle, Gävle, Sweden, 2Department of Social Work,
University of Gothenburg, Gothenburg, Sweden, 3Department of Women’s and Children’s Health,
Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden, 4Norwegian Centre for Violence and
Traumatic Stress Studies, Department of Children and Adolescents, Oslo, Norway
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 eect 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-aected 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 aect 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 diculties as “real” and not merely “psychological blocks”.
KEYWORDS
clitorectomy, clitoral reconstruction, defibulation, excision, female genital cutting,
infibulation, sexual function
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Background
Female genital cutting (FGC) is the physical alteration of
women’s external genitalia, often involving cutting the clitoris
and/or labia, or narrowing the vaginal orifice (WHO, 2008).
The World Health Organization (WHO) typically divides FGC
into four types: Type I involves partial or total removal of
the clitoris and/or the prepuce (clitorectomy); Type II entails
partial or total removal of the clitoris and the labia minora,
with or without excision of the labia majora (excision); Type
III involves a narrowing of the vaginal orifice with the creation
of a covering seal, with or without excision of the external
parts of the clitoris (infibulation); and Type IV refers to all
other harmful procedures performed on the female genitalia
for non-medical purposes, such as pricking, piercing, incising,
and scraping (WHO, 2008). Around 200 million women and
girls worldwide have undergone some form of cutting (UNICEF,
2016). The practice is most prevalent in countries and regions
in Africa, the Middle East, and Asia, but has become a global
phenomenon due to migration (WHO, 2008). Despite years
of anti-FGC campaigns aimed at eradicating the practice, the
prevalence of FGC has declined only marginally; in fact, in actual
numbers it is believed to be increasing due to population growth
(UNICEF, 2016). An estimated half a million women and girls
with FGC live in Europe (Van Baelen et al., 2016), 38,000 of
them in Sweden (The National Board of Health and Welfare,
2015).
The cultural meaning of FGC varies between communities
and over time, but a common cultural underpinning is control
of women’s sexual libido (Berg and Denison, 2013). While
infibulation signifies an external “hymen” ensuring virginity
prior to marriage, some studies have found the rationale for
clitorectomy to be based on a perception of the clitoris as
the site of women’s sexual drive, which thus has to be cut to
ensure their sexual morality (Johansen, 2016). This rationale
has raised concern regarding the potential negative effects
of FGC, particularly clitorectomy, on female sexuality. While
negative health consequences after FGC—including obstetric,
psychological and sexual problems—are widely reported (Berg
et al., 2010, 2014; Berg and Denison, 2012; Villani, 2022),
studies investigating the effects of FGC on sexual function
have inconsistent or contradictory findings. 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 well-
used 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. Further,
the instrument has been critiqued for failing to explore the
socio-cultural factors involved in women’s experiences of sexual
function. Johnsdotter (2020, p. 13) writes about FSFI that it is
“is a blunt instrument for capturing sexual experiences—and it
completely overlooks social and cultural factors that affect how
we experience such elusive bodily sensations as sexual desire,
satisfaction and pain”. Thus, the FSFI is likely to be insufficient
in investigating women’s subjective perceptions and experiences
of a potential connection between FGC and sexual function.
Villani (2022) notes that questions of pleasure and desire
are largely embedded in social expectations and norms, which
should be considered when studying the sexual consequences
of FGC. It has been argued that cut women’s encounter with
Western values—which tend to assign higher significance to
women’s sexual rights to desire and pleasure, and to the
importance of the clitoris in securing these things –affects their
perceptions of their own sexuality and its relation to FGC
(Johnsdotter, 2013; Ziyada et al., 2020; O’Neill et al., 2021).
A more thorough understanding of the complexity behind cut
women’s understanding and meaning-making of the potential
connection between FGC and sexual experiences, including the
socio-cultural-symbolic nexus (Esho, 2012), could inform care
providers, sex counselors, policy-makers, and others aiming to
provide healthcare for this group of women. To contribute to
this research gap, we aim to explore whether and how cut women
residing in Sweden perceive that FGC has affected their sexual
function and intimate relationships.
Methods
Design, recruitment, and data collection
The study has a qualitative design, which is useful
when endeavoring to explore a complex and underresearched
phenomenon (Kvale and Brinkmann, 2009) such as cut
women’s perceptions and experiences of sexual matters. The
inclusion criterion was having undergone FGC. All the
women were recruited at the Karolinska University Hospital
in Sweden upon requesting clitoral reconstructive surgery,
which is aimed at improving the anatomy and function of
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the clitoris (Foldès et al., 2012). The findings of this article
thus derive from a larger data set exploring motives and
expectations for, and experiences of, clitoral reconstructive
surgery. The women were asked by the surgeon or a
psychosexual counselor to consent to being contacted for
the study. If interested, they were contacted by the first
author and given an information letter stating the study’s
aim and purpose. Of the 27 women who replied to the
first author’s contact, 25 agreed to participate in the study.
Twenty-two of these women ultimately underwent clitoral
reconstruction, while three of them decided not to go through
with it.
Semi-structured interviews were used to collect the data.
The interviews were conducted during the period 2016–2019,
and lasted 23–80 min. They were carried out in the participants
home, in a private room on the hospital premises, or at a
library or a cafe, depending on practicalities and the woman’s
preferences. Eighteen of the participants were interviewed twice:
first upon requesting surgery and then about 1 year post-surgery.
The three women who declined surgery were interviewed for
the second time after having made this decision. In total, 44
interviews were conducted.
The interviews started with the interviewer obtaining
informed consent and informing the woman about measures for
ensuring confidentiality, that participation was voluntary, and
of her right to withdraw from the study at any point without
explanation as well as to decline to answer any questions if
she felt uncomfortable. The first interviews (upon requesting
clitoral reconstructive surgery) focused mainly on the motives
for requesting and expectations for the surgery. However, these
interviews also explored the women’s memories and perceptions
of their FGC, and their genital, mental, and sexual concerns,
particularly related to pain, sexual function, body (genital)
image, identity, and relational factors. The second interview
focused mainly on the after-effects of the surgery, particularly
related to pain, sexual function, body (genital) image, identity,
and relational factors; or, if they declined surgery, their reasons
for changing their mind. The findings around these questions
are reported elsewhere (see author and author); thus, the
present paper relies solely on data related to the women’s
perceptions and experiences of the potential effects of FGC on
sexual function, including their own. Three of the interviews
were conducted in English, two in Somali using an interpreter
(physically present or by telephone), and the remaining 39
in Swedish. Thirty-eight interviews were conducted face-to-
face and six over the telephone. Forty interviews were audio-
recorded and later transcribed, while in the remaining four
the interviewer took notes due to technical problems or the
woman not feeling comfortable being recorded. Here, more
detailed transcripts were written down immediately after the
interviews with help of the notes. The study was approved by the
Regional Ethical Review Board in Stockholm (2015/1188-31).
Descriptions of personal characteristics are kept to a minimum,
and pseudonyms are used for all participants to protect the
women’s confidentiality.
Reflection of the position as an
interviewer
The qualitative research interview is a co-creation between
interviewer and interviewee (Peeck, 2016). Asking cut women
about FGC and sexual difficulties may be uncomfortable for
both parties, but particularly for the interviewee. A first step for
minimizing such discomfort was to emphasize the voluntariness
of the study; if a woman did not respond to the first contact
attempted by the researcher, this was interpreted as a wish
to refrain from participating. If the woman agreed to be
interviewed, however, the interviewer paid significant attention
to establishing rapport and to making the interview situation
as comfortable as possible. This involved emphasizing the
conversational character of the interview. Also, the interviewer
sought to maintain an empathetic, non-judgmental attitude,
which involved being sensitive to signs of discomfort when
discussing sexual matters. While encouraging the women to
freely express their opinions, feelings, and experiences, efforts
were made not to push them to talk. Consequently, the
interviewed women’s accounts of sexual matters varied; while all
of them were asked how they viewed the connection between
FGC and sexual function, some avoided the topic or spoke about
it in very general terms, while others talked more openly and
included personal experiences. Further, the researchers position
as a white, uncut woman may have intimidated some of the
women as they positioned the researcher as belonging to a group
of women with “intact” genitals and thus distinguished from
themselves. This was sometimes indicated, for example by a
woman referring to the interviewer as being among “those of
you who have clitorises”. To balance out a potential sense of
difference between interviewer and interviewee (Liamputtong,
2010), the interviewer endeavored to avoid supporting the
narratives of “FGC damages sexual function” and “uncut women
have problem-free sex lives”. Instead, the interviewer attempted
to interrogate these matters openly and non-judgmentally,
sometimes also clarifying that sexual problems existed among
uncut women as well. While some women visibly found
it difficult to talk about certain sexual matters, which they
expressed through bodily manifestations such as embarrassed
laughter, looking down, or refraining from answering certain
questions, others conveyed a sense of relief at being able to
discuss such matters with a non-judgmental listener.
Data analysis
Thematic analysis was used to analyze the data (Braun
and Clarke, 2006). First, all interview transcripts were read
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thoroughly several times, looking for content related to
the study objectives, which was highlighted and extracted.
Subsequently, these excerpts were coded and organized into
themes summarizing the essence of the data. The themes were
worked and reworked until they provided a sound and clear
demonstration of the interview content reflecting the study
objectives. Thus, the process was a dynamic and non-linear
movement involving reading and re-reading the whole data set,
excerpts, codes, and themes, until a sense of having captured the
core meaning of the data had been reached (Braun and Clarke,
2006).
Characteristics of participants
All the participants were first-generation immigrants in
Sweden. They had migrated from Eritrea (n=4), the Gambia
(n=2), Iraq (n=2), Senegal (n=1), Sierra Leone (n=2),
and Somalia (n=14) either along with their families, through
family reunification, or as sole migrants, many in childhood or
early adulthood. Nineteen of them had lived in Sweden for 10
years or longer. The participants were aged 19-56 years at the
first interview, with the majority in their 20s (n=6) or 30s
(n=14). Many (n=15) of them worked in the healthcare
sector, primarily as nurses or nurse assistants. Others worked
as engineers, personal assistants, or cleaners, or were studying.
Seven of the women were married, three were divorced, and 15
were unmarried. Several of the divorced and unmarried women
had a boyfriend. All women identified as heterosexual, and only
three of them said they had never had sex. Eleven of them had
children, and one had grandchildren.
Sixteen women reported having undergone FGC Type III,
seven Type II, and two Type I. The majority with Type III
(infibulation) had been defibulated prior to seeking clitoral
reconstructive surgery, when they had given birth or on other
occasions. The women had been cut at different ages: from
infancy up to 9–10 years of age. While those who had been cut
at a very young age could not remember the incident, others
remembered their cutting as traumatic. Some had been given
anesthesia and did not remember the actual cutting as traumatic
but more so the healing process, which they recalled as having
been painful.
Findings
Almost all the interviewed women perceived that FGC has
a negative effect on sexual function. They discussed learning
that the purpose of FGC is to reduce women’s sexual desire
and enjoyment, and reading literature on the importance of
the clitoris for women’s sexual pleasure and orgasm. This made
sense to them, as they themselves experienced FGC as having
negatively affected their sexual experiences. While the women
mainly believed that their impaired ability to enjoy sex had been
caused by the physical alteration to their genitalia, particularly
infibulation and the removal of genital tissue, they also regarded
the psychological aspects of FGC to have caused difficulties in
their sex lives and intimate relationships.
Coming to understand the connection
between FGC and sexuality
Many of the interviewed women said that in their
adolescence or early adulthood they had come to understand
that FGC was carried out to control women’s sexuality. Some
said that they had come to this understanding in the context
of origin, others after coming to Sweden. Behar, a 46-year-
old woman from Iraq, said she had come to realize this when
growing up: When I grew up, I understood that it [FGC] was to
reduce women’s sexuality. The women reasoned that the main
purpose of FGC was to diminish the woman’s sexual libido in
order to make her less promiscuous. Lola, a 32-year-old woman
from Eritrea, said: I guess it [FGC] is a way to hinder the woman
from feeling pleasure when she’s with a man; it must be due to that.
Or that she should stay with one man, I don’t know. But in some
way, one wants to deprive the woman of her capacity to feel sexual
pleasure, for her not to become sexually excessive.
Some of the interviewed women had read books by female
authors known for writing about their own experiences of
FGC, such as Nawal el Saadawi and Waris Dirie. While the
women largely perceived such literature as educative, they also
recounted that it made them anticipate problems in their own
sex lives.
As the women had migrated to Sweden or other Western
contexts with liberal sexual rights, often in their childhood or
early adulthood, many recounted how this exposure to Western
culture had formed their understanding of FGC as “wrong” and
“harmful” and as negatively affecting their capacity to enjoy sex.
Amina, a 46-year-old woman from Somalia, said: Because when
I was young, you know, I knew nothing about sex, but then once
you grow up and you read about sex in Cosmopolitan magazines
(laughs a little) and you realize there’s more to it than what you,
than what you feel or experience. . .
Being around female friends who openly discussed sexual
pleasure and women’s rights made the women reflect on their
own sexuality. Sara, a 32-year-old woman from Somalia who
had come to Sweden as a child, said: We grew up in the 90s
and there were so many girls’ bands, and then it was a lot about
owning your sexuality, eh, to feel pleasure during sex, and it
was important not to be doing something you didn’t enjoy. . . In
contrast to Sweden, where women were expected to enjoy sex
for their own sake, many women described how sex in their own
cultural background or upbringing was endorsed only within
marriage and as a means to produce children. The interviewed
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women had come to distance themselves from such an ideal,
which they considered old-fashioned and misogynistic. Instead,
they had come to value women’s right to sexual pleasure as an
essential human right, which they saw as natural once they had
been exposed to feminist and liberal thinking. Sara continued: I
also think this is natural, something that naturally comes when
one enters, when one is exposed to more liberal thoughts. . . I
think theres no woman who stands for women’s rights who doesn’t
think she should also have that right [to sexual pleasure]. For me
it’s more of a feminist idea existing all over the world, even if
the pressure comes, yes, it becomes more real because I live here
[in Sweden].
Living in Sweden, many of the interviewed women
compared themselves to non-cut women, who they considered
to have a “normal” or “intact” sexuality. While not necessarily
believing that uncut women could not experience sexual
problems, they talked about these women’s sexual function as
contrasting with their own. Uncut women were perceived as
having a natural ability to feel sexual desire and pleasure and to
reach orgasm. Ruquia, a 37-year-old woman from Somalia, said:
Ruquia: Well, that women have this need [for sex], I think this
need, it’s like when you’re hungry, you need food. And when you
have sexual desire, then you need someone. Thats what I think.
Interviewer: But this isn’t something you feel that you have?
Ruquia: No. But I don’t think its strange that others have it. I
think it’s normal.
Complex causes of FGC on the body,
mind, and sexuality
When asked what they thought lay behind the potential
connection between FGC and women’s impaired sexual
function, the women mainly related it to the physical alteration
of the genitals caused by the cutting. Infibulation was said
to make penetrative sex directly painful, and most of the
interviewed women who had initially undergone infibulation
described sex when infibulated as “horrible”, especially in the
beginning. Ruquia said: In the beginning it [sex] hurt a lot. After
a while it became what it was, but it’s nothing I enjoy or long
for. Even if sexual intercourse had become more manageable
with time or after (partial) defibulation, many women described
experiencing continued pain and discomfort during sexual
intercourse. Aisha, a 56-year-old woman from Somalia, talked
about difficulty having penetrative sex due to scars and an
inelasticity of her genital tissue, even though she had been
defibulated: It’s easy to get tears. If you have penetrative sex, you
might have to stay away the whole week afterward so that it can
heal. Some said that even if they could initially experience sexual
desire and excitement, this would turn into anxiety when they
got closer to the actual sex as they anticipated that it would
be painful.
While infibulation was said to make penetrative sex painful,
the women also believed that the removal of clitoral tissue
reduced women’s capacity to feel sexual pleasure. Lola, a
32-year-old woman from Eritrea, referred to the scientific body
of literature highlighting the importance of the clitoris for
achieving orgasm when reasoning around cut women’s sexual
dysfunction: . . . There are studies saying that most women have
an orgasm after stimulating the clitoris. (. . . ) If most women
experience sexual enjoyment and have their orgasm through
stimulus of the clitoris, how is it for the woman who doesn’t
have a clitoris; what should she be stimulated from? Or get this
sexual pleasure?
Some said they had realized the importance of the clitoris
when they became sexually active. Fatou, a 30-year-old woman
from the Gambia, discussed coming to this realization when
she began having sex and experienced little pleasure: Before I
didn’t know, because I don’t know how, how it’s so important for
you to have your clitoris, I didn’t know it before, because I was
like, you know in my country they don’t talk about sex in public
(. . . ) So I didn’t know the impor tance of clitor is, until I started
having sex. . .
Several women reported limited genital or clitoral sensation
and associated this with being cut. Ami, a 37-year-old woman
from the Gambia, recounted the sensation of touching her
genitals: It feels like touching my elbows. Others said they
had “some sensation” in the clitoral area and had learned
to achieve orgasm through masturbation by “pressing a little
bit harder”. While most women complained about reduced
clitoral sensation, two women recounted the opposite problem,
describing an oversensitivity in the clitoral area. This was said
to cause pain and discomfort when walking, touching oneself,
or during sex. Zara, a 31-year-old woman from Iraq, said: I had
read that [cut] women are deprived of all the sensation, but I had
sensation, even so much that it hurt when I touched myself.
Thus, the women both assumed and experienced pain and
an absence of genital sensitivity, which they connected to
the physical alteration caused by FGC, which most of them
regarded as the main cause of cut women’s sexual problems. Yet,
they also acknowledged psychological aspects related to having
“damaged” genitals, which created shame and negatively affected
their self-confidence. The combination of feeling unable to enjoy
sex, having an inability to relax, and experiencing negative
anticipation was demonstrated in the conversation with Ami:
Interviewer: How do you think that what happened to you, the
FGC, affects your sexuality?
Ami: It affects everything.
Interviewer: You think so?
Ami: It does; I don’t “think”—it does.
Interviewer: Because you feel that it does? (Ami: mmhmm
[signifying agreement]) You feel it physically? (Ami: Mmhmm)
Do you think everybody who’s gone through it (FGC), that no one
experiences sexual enjoyment, that it doesn’t work, or. . . ?
Ami: For me it doesn’t work.
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Interviewer: It doesn’t? Can you, I don’t know if it’s possible,
but can you say something about what happens, why it doesn’t
work? Is it something physical, or is it something. . . ?
Ami: I’m afraid, so like I’m afraid, they can’t be down there, I
can’t relax, and then I don’t believe that.. . It doesn’t work.
For Ami, the physical became psychological, and these two
aspects in combination negatively affected her ability to enjoy
sex. While few women fully dismissed the physical aspect of
FGC as causing women’s sexual problems, Leila, a 32-year-old
woman from Somalia, was one who did. She had requested
surgery mainly to restore her genitals aesthetically, not because
she felt unable to enjoy sex, and rejected the assumption that
FGC removed women’s capacity to enjoy sex. Instead, she replied
It’s all in your head when asked about what she thought about cut
women’s complaints over sexual difficulties.
Others disagreed with such statements, and voiced
frustration at what they considered a tendency to reduce cut
women’s sexual problems to “psychological blocks”. Lola said:
It’s easy to say it’s a psychological block, like “you don’t have
your clitoris and now you’re psychologically blocked by that”.
Of course, but it’s still related to the physical; I really want to
emphasize that. It’s related to the physical: You don’t feel it,
you get no stimulus there. (. . . ) And you think about it and the
physical becomes psychological. And that, of course, becomes
a block.
While all the women had initially requested clitoral
reconstruction surgery, some had come to reconsider their
initial assumption that cut women’s sexual problems were
merely related to physical aspects. Sara had changed her mind
after taking part in the sexual counseling offered in connection
with the clitoral reconstruction, and had come to question her
previous assumption that her sexual problems were related to
the physical aspects of FGC. She said: Starting to talk about it,
accepting yourself, can make you feel less shame. Having difficulty
having an orgasm may not only have to do with that [the physical
consequences of FGC].
FGC and its negative aect on intimate
relationships
The interviewed women believed that difficulties
experiencing sexual pleasure caused struggles in their intimate
relationships. While some said they had largely stayed away
from men, mainly due to shame or a fear of engaging in sexual
relations, others said they endured sex for the sake of their
partner. The women perceived their inability to enjoy sex
as creating feelings of sadness, shame, and distrust. In turn,
they felt these feelings negatively affected their ability to relax
during sex with their intimate partner. Some said that their
lack of interest in sex might push their partner to be unfaithful,
which created a fear of abandonment and rejection. Amina, a
46-year-old married woman from Somalia, said:
Interviewer: How would you.. . evaluate that relationship
with him [your husband]?
Amina: Ehm. . . I think it’s, I think we could look at it two
ways, because we have children, we, the relationship is strong
because of that. But I think if it were only based on sexuality
[laughs a little], I think he would’ve left me a long time ago because
he’s, I feel he hasn’t, I’ve denied him. Because I.. Yeah. I don’t, ehm,
it’s, I’m not always easily.. sexually. . . [silence]
Interviewer: Yeah, I understand. Has he complained
about that?
Amina: He has complained, he has and, you know, it’s also
interfered a little with our relationship because hes then had to
look elsewhere. It hasn’t been easy. . .
Even if the women did engage in sex with their partner, they
believed that the partner was able to tell that they did not enjoy
the sex, which again made them feel guilty as they believed that
this made the men enjoy it less. Ami said: I feel ashamed. And
then I feel bad, I feel sorry for the guy because, I, it’s this also, that
both have to enjoy it for it to be good, and yes.. .
Swedish men were thought to be more liberal than men from
cultures where FGC is performed, and thus likely to engage in
sexual practices other than vaginal sex, such as oral sex. Fear of
being exposed as cut and of being unable to enjoy oral sex made
some women avoid dating Swedish men. Lola said: Swedes are a
bit more liberal and much more about oral sex and stuff like that,
which is my absolute fear. If you’re doing oral sex its to stimulate
the clitoris and I don’t have that. I don’t know if I consciously or
unconsciously avoid them [Swedish men]. . .
The women also believed that men with cultural
backgrounds similar to their own would prefer non-cut
women. Some recounted having been asked about their FGC
status by new partners, with the underlying message that the
man would end the relationship if FGC was confirmed. Yet, the
men’s disapproval of FGC was mostly related to infibulation;
some of the women who had been defibulated and undergone
clitoral reconstruction said they had told their new partner
that they had “only been cut a little” (i.e., undergone less
extensive forms of FGC), which seemed to be more accepted.
However, while some women talked about being rejected based
on their FGC, others talked about supporting, loving, and
caring partners who expressed concern and empathy for their
girlfriend or wife, including a wish for her to enjoy sex.
Discussion
Almost all the interviewed women regarded the physical
aspects of infibulation and clitorectomy as having harmed
their sexual function, although they also acknowledged that
psychological aspects of FGC affected their ability to enjoy sex.
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Jordal et al. 10.3389/fsoc.2022.943949
Sexual difficulties were perceived to cause struggles in their
intimate relationships.
Clitorectomy and its damage to sexual
function
The women highlighted the physical aspects of clitorectomy
as causing problems with sexual desire and sensation. This
may not be surprising, as there is a growing body of literature
supporting the importance of the clitoris for women’s sexual
function and orgasm (Levin, 2020; Limoncin et al., 2020;
Mahar et al., 2020). Even in contexts where FGC is common,
such as Somalia, the clitoris is commonly perceived as the
physical site for women’s sexual desire and pleasure, which
is why it is seen as being in need of removal (Talle, 2007).
At the same time, Somali women and men generally perceive
types of FGC that remove all or parts of the external clitoris,
commonly referred to as Sunna circumcision, as having few
negative consequences for women’s health and sexuality, at
least compared to infibulation (Johansen, 2022). A disregard of
the possible harm of clitorectomy on sexual function has also
been demonstrated among researchers and healthcare workers
(Dellenborg, 2004; Ahmadu, 2007; Ahmadu and Shweder, 2009;
Jordal et al., 2020). Swedish gynecologists refuting the negative
effect of the clitorectomy on women’s sexual function (Jordal
et al., 2020) highlight the internal structures of the clitoris, and
thus perceive it impossible to “cut” the clitoris in any substantial
way, as most of the clitoral organ will remain under the surface
and be accessible to stimulation through the vagina (O’Connell
et al., 1998). Healthcare providers and FGC scholars instead
warn that an overemphasis of the physical consequences of
FGC may become a self-fulfilling prophecy, causing women
to anticipate their sexual function as “damaged” (Johnsdotter,
2018; Jordal and Griffin, 2018; Jordal et al., 2020; O’Neill et al.,
2021). In contrast, cut women living in societies where FGC is
highly regarded may perceive their sexual function positively, as
suggested by Esho (2012) who studied FGC and sexual function
among the Maasai people in Kenya. However, the women in
our study opposed the construction of cut women’s sexual
problems as merely “psychological blocks”. Einstein (2008)
discusses the possible biological effects of FGC on the brain
and nervous system. She suggests that clitorectomy may involve
a neurological rewiring in some women, which may explain
why accounts of sexual function after FGC vary. Individual
factors, as well as the extensive nature of the cutting (the clitoris
glans, hood, bulb, etc.) and the fact that clitoral erectile tissue
extends internally to a considerable degree, suggest that some
cut women achieve orgasm through vaginal stimulation. On
the other hand, as cutting the clitoris glans is likely to affect
sensation both directly (by removing highly sensitive tissue) and
indirectly (by cutting nerves connected to the inner portions of
the clitoris and further altering sensation), other women may
experience that their ability to feel sexual sensation and orgasm
are reduced (Einstein, 2008). While it is difficult to distinguish
between the physical and psychological factors involved with
cut women’s experiences of sex, future studies should aim to
distinguish between various sexual practices as well as types
and anatomical extents of FGC, and reconsider the possible
biological consequences of clitorectomy.
Sexual diculties cause struggles in
intimate relationships
The women in this study grieved their limited or excessive
genital sensation, which they perceived as harming their ability
to enjoy sexual activities and as causing struggles in their
intimate relationships, which were all described as heterosexual.
Some perceived an expectation to participate in penetrative
sex to fulfill the man’s needs and expectations in an intimate
relationship, even if they themselves experienced a lack of desire
or even discomfort and pain. Yet, an inability to enjoy sex
was perceived to limit their partner’s pleasure, which created
shame and guilt. As the coital imperative is dominant within
the heterosexual sexual script, with its implicit focus on child
production (Levin, 2020; Limoncin and Nimbi, 2020; Mahar
et al., 2020), penetrative sex is also often the focus in studies
on the effects of FGC on sexual function (Obermeyer, 2005;
Nour, 2006; Catania et al., 2007; Krause et al., 2011; Rouzi et al.,
2017; Villani, 2022). However, due to criticism of the coital
imperative, which has been shown to create an orgasm gap in
heterosexual couples (Mahar et al., 2020; Andrejek et al., 2022),
a new sexual script with increased focus on pleasure for both
parties is likely to be on the rise. This is also illustrated in the
narratives of the women in the present study on their perception
of Swedish men being “more about oral sex”. Thus, expectations
that they should enjoy sexual practices focusing on enhancing
female pleasure, such as oral sex, seemed to pose additional stress
for the interviewed women; not only because they felt they were
“missing out” on desirable sexual experiences, but also due to
a fear of failing to live up to gendered expectations of sexual
enjoyment. Men from backgrounds similar to the women’s own
were also thought to value the woman’s ability to enjoy sex,
although they did not talk about them as being particularly
concerned with oral sex. This could indicate a shift in perspective
regarding women’s sexuality even within cutting communities,
which could be a driving force toward the eradication of FGC.
However, the apparent contradiction between norms promoting
Sunna circumcision to at least to some degree reduce women’s
sexual libido (Johansen, 2022) and men’s desire for women to
enjoy sex needs to be explored further. Nevertheless, a fear of
failing to live up to expectations that they should enjoy sex made
some women avoid intimate relationships, particularly with
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Jordal et al. 10.3389/fsoc.2022.943949
Swedish men. These findings suggest that cut women perceive
themselves not to be “real women” in terms of contemporary
ideals regarding female sexuality and gendered expectations and
norms. Thus, new sexual scripts highlighting women’s sexual
pleasure may not be liberating for cut women, but may instead
cause them to remain in the penetrative sexual script, as their
FGC is less pronounced or noticed in such practices. Thus, we
agree with Villani (2022) that future studies on FGC and sexual
function need to include a broader spectrum of sexual practices
than the heterosexual vaginal intercourse and the significance
attributed to these practices.
The importance of institutional
recognition
While the interviewed women did not want to be recognized
as “cut” by their partners and peers, they did want recognition
by healthcare institutions and had all sought to undergo clitoral
reconstruction. Gender scholar Ovesen (2020), who investigated
help-seeking among lesbian victims of intimate partner violence
(IPV), writes about the importance of institutional recognition.
She suggests that there is an existing inequality in who receives
institutional recognition (for example as a “victim of IPV”) and
thus in who is considered worthy of protection and care and who
is not. This renders some individuals’ bodily needs unrecognized
and unsupported, and thus more bioprecarious, than others’
(Griffin and Leibetseder, 2020; Ovesen, 2020). Recognition,
Ovesen argues, is not only about who is counted as a victim;
it also concerns individuals’ sense of belonging within a certain
context. In the present study, institutional recognition could be
translated into the offering of clitoral reconstruction. Clitoral
reconstruction, while growing in popularity, is still not available
in most countries (Jordal and Griffin, 2018; Villani, 2022). While
there are currently no recommendations supporting clitoral
reconstructive surgery from mainstream medical bodies such
as the WHO and the RCOG in the UK (Royal College of
Obstetricians and Gynaecologists, 2015; WHO, 2016; Villani,
2022), which could be related to a fear of exposing cut women
to unnecessary surgical risks and pain (Bah et al., 2021), many
women who have undergone clitoral reconstruction claim it has
helped them gain a newfound ability to enjoy sex (including oral
sex) or to now no longer feel “cut” and thus less ashamed and
distressed in intimate relationships (author).
Sexuality is embedded in power relations, many of which are
gendered (Villani, 2022). The interviewed women’s request for
clitoral reconstruction could be seen as a desire to transgress
the boundaries of the coital imperative, which is increasingly
portrayed as insufficient for achieving the full possibility to
experience sexual pleasure. It can also be seen as a desire to
balance out existing power differences whereby cut women are
regarded as inferior, in being judged not only as “cut in a
context in which FGC is considered “barbaric and backwards”
(Pred, 2000; Pedwell, 2010) but also as incapable of the full
possible experience of sexual enjoyment (Jordal et al., 2018;
Villani, 2018). In a Norwegian study, the authors demonstrated
that women with more liberal attitudes regarding gender and
sexual equality were also more positive to seeking out FGC-
related healthcare (Ziyada et al., 2020). This could indicate
that cut women seeking help for sexually related problems in
Sweden are also those who have taken up the host country’s
ideals of gender equality and sexual rights, an indication of
societal and ideological integration. At the same time, choosing
reconstructive clitoral surgery to integrate in the host society
may involve new concerns for the women involved.
Methodological considerations
All the interviewed women in this study had sought to
undergo clitoral reconstruction. Many women requesting this
surgery in Sweden hope to, at least partly, improve their sexual
function (author). Thus, the choice of recruitment may cause
selection bias as this group of women may attribute greater
importance to the clitorectomy for their self-experienced sexual
problems than women who do not seek clitoral reconstruction.
Thus, more research investigating perceptions and experiences
of FGC and sexual function among cut women who do not
seek out clitoral reconstruction is needed. At the same time,
one cannot assume that women who do not request surgery
have different perceptions and experiences. As suggested by
Ziyada et al. (2020), variations in healthcare seeking are not
necessarily due to differences in experiences; instead, they
may reflect differences in the perceived need to improve their
sexual function or willingness to break with social norms.
That many of the interviewed women worked in healthcare
(as nurses, nurse assistants, or midwives) might also indicate
that the interviewed women were aware of available healthcare
interventions to a higher degree than those not working in
this field.
Disentangling the physical and psychological aspects of the
connection between FGC and sexual function is difficult, if
not impossible. Therefore, this was not the objective of the
present study; rather, we wanted to explore the multifaceted
ways in which women reason around the potential connection
between FGC and sexual function. While the women were
asked about why they had requested clitoral reconstruction, the
connection they perceived between FGC and sexual function was
not a major theme during the interviews. Rather, the interviews’
primary purpose was to understand the women’s motives and
expectations for the surgery and their experiences of its after-
effects. One could therefore assume that more profound answers
would have emerged if the interviews had been dedicated to
exploring interlinkages between FGC and sexual experiences.
Nevertheless, our choice to let the women recount sexual
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Jordal et al. 10.3389/fsoc.2022.943949
aspects when examining their motives for surgery, as well as
its after-effects, resulted in a wide diversity of reflections on
the matter. We chose this approach to avoid causing the study
participants any discomfort, even though it may have prevented
us from uncovering detailed information, particularly on self-
experienced sexual problems. Yet, the fact that the interviewer
did not push the women to talk in detail about their sexual
experiences also means that the accounts of sexual difficulties
were largely self-derived. We believe that this was a sound
compromise, not only because the data still contains valuable
accounts on both general matters and personal experiences,
but more so because we find that the woman’s well-being
and integrity in the interview situation are more important
than pushing her to speak about difficult matters. Also, that
the women were not pushed likely means that the issues that
came up were something they had reflected on beforehand
and were not merely a reality created in interaction with
the interviewer.
Conclusion
The women interviewed for this study understood
clitorectomy as having damaged their sexual function, which
they felt had negatively affected their intimate relationships.
While not rejecting the notion that psychological aspects
of FGC were also reducing their ability to enjoy sex, they
wanted the physical consequences of FGC on their sexual
function to be recognized as “real” and not be dismissed or
explained away as “psychological blocks”. Future studies on
FGC and sexual function need to consider the complexity of
the psychological, physiological, and socio-cultural-symbolic
aspects of FGC and include a broader spectrum of sexual
practices than heterosexual intercourse and the significance
attributed to them.
Data availability statement
The datasets presented in this article are not readily
available because the data is considered of sensitive
nature. Requests to access the datasets should be directed
to MJ, malin.jordal@hig.se.
Ethics statement
The studies involving human participants were reviewed
and approved by Regional Ethical Review Board in Stockholm.
Written informed consent for participation was not required for
this study in accordance with the national legislation and the
institutional requirements. The patients/participants provided
their oral informed consent to participate in this study.
Author contributions
All authors listed have made a substantial, direct,
and intellectual contribution to the work and approved it
for publication.
Funding
The University of Gävle covered the costs for open access
and English proof reading of the manuscript.
Acknowledgments
We wish to thank all the interviewed women who
contributed with their valuable perspectives.
Conflict of interest
The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed
or endorsed by the publisher.
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Somali and Sudanese transnational discourses on female genital cutting (FGC) center on a shift from infibulation to sunna circumcision, a change perceived to reduce health risks and accommodate religious teaching, yet this shift is far less extensive and substantial than its typical portrayal suggests. Based on data from interviews and focus group discussions with 95 migrants of Somali and Sudanese origin, in this paper, I explore these migrants’ discourses of change and how and why they seem blurred and contradictory. Most participants described the ongoing abandonment of infibulation and uptake of sunna circumcision in terms of civilization, modernization and transition toward a more correct Islam; however, their perceptions of the anatomical extents and religious and cultural meanings of sunna circumcision appeared blurred and contradictory. We suggest that these blurred and contradictory perceptions of sunna circumcision enable the study’s participants to maneuver in a context of opposing and changing social norms regarding FGC.
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Clitoral reconstruction (CR) has been the subject of several studies in recent years, mainly in the medical field. Women with female genital mutilation or cutting (FGM/C) seek clitoral reconstructive surgery to improve their sexual well-being, but also because they are affected by poor self- and body image. CR is supposed to help women with FGM/C reconstruct their sense of self, but the benefits and risks of this surgery have not been sufficiently explored. There are currently no recommendations supporting CR from mainstream medical bodies, and there have been very few ethical studies of the procedure. This article critically discusses the principal studies produced in the medical field and available reflections produced in the social sciences. Through the theoretical frameworks of postcolonial and feminist studies, the article discusses sexuality and pleasure, gender and identity, and race and positionality, with the aim of promoting collaborative work on CR between researchers and social and health professionals.
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Gender scholars have addressed a variety of gender gaps between men and women, including a gender gap in orgasms. In this mixed-methods study of heterosexual Canadians, we examine how men and women engage in gender labor that limits women’s orgasms relative to men. With representative survey data, we test existing hypotheses that sexual behaviors and relationship contexts contribute to the gender gap in orgasms. We confirm previous research that sexual practices focusing on clitoral stimulation are associated with women’s orgasms. With in-depth interview data from a subsample of 40 survey participants, we extend this research to show that both men and women engage in gender labor to explain and justify the gender gap in orgasms. Relying on an essentialist view of gender, a narrow understanding of what counts as sex, and moralistic language that recalls the sexual double standard, our participants craft a narrative of women’s orgasms as work and men’s orgasms as natural. The work to produce this gendered narrative of sexuality mirrors the gender labor that takes place in the bedroom, where both women and men engage in sexual behaviors that emphasize men’s pleasure to a greater extent than women’s.
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Background: Clitoral reconstruction (CR) is surgical reparation of the clitoris cut as part of the practice of female genital cutting (FGC) available in a handful of countries, including Sweden. The surgery aims at restoring the clitoris esthetically and functionally, thus has implications for sexual health. Gynaecological examinations can be an opportunity for dialogue regarding women’s sexual health. Gynecologist play a role in referring patients experiencing FGC-related problems, including sexual, to specialist services such as CR. Aim: The aim of this study was to explore how gynecologists position themselves in relation to CR. Method: Eight gynecologists were interviewed using semi-structured interviews. The interviews were tape-recorded, transcribed and analyzed using thematic analysis. Results: The gynecologists positioned themselves in three different ways in relation CR; outright negative, uncertain or positive toward the surgery. Those positioning themselves as negative thought CR was a harmful fraud and denied any possible benefits, at least sufficient for referral for CR. Those positioning themselves as uncertain did not deny possible benefits, but were skeptical toward CR improving cut women’s sexual health and function. Those positioning themselves positive considered the potential physical, psychological/emotional, esthetic, or symbolic aspects of CR as important for general well-being and sexual health. Conclusion: There was a great variety in how the gynecologists positioned themselves toward CR, and many were skeptical toward the functional benefits in relation to sexual health. This is likely to diverge cut women’s access to CR surgery.
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Introduction: More than 200 million women and girls have undergone genital mutilation. Clitoral reconstruction (CR) can improve the quality of life of some of them, but is accompanied by significant postoperative pain. Objective: Assess and describe the management of postoperative pain after CR, and the practices among specialists in different countries. Methods: Between March and June 2020, 32 surgeons in 14 countries (Germany, Austria, Belgium, Burkina Faso, Canada, Ivory Coast, Egypt, Spain, United States of America, France, the Netherlands, Senegal, Switzerland, Sweden) responded to an online questionnaire on care and analgesic protocols for CR surgery. Results: At day 7 post CR, 97% of the surgeons observed pain among their patients, which persisted up to 1 month for half of them. 22% of the participants reported feeling powerless in the management of such pain. The analgesic treatments offered are mainly step II and anti-inflammatory drugs (61%). Screening for neuropathic pain is rare (3%), as is the use of pudendal nerve block, used by 8% of the care providers and only for a small percentage of women. Conclusion: Pain after CR is frequent, long-lasting, and potentially an obstacle for the women who are willing to undergo clitoral surgery and also their surgeons. Most surgeons from different countries follow analgesic protocols that do not use the full available therapeutic possibilities. Early treatment of neuropathic pain, optimisation of dosing of standard analgesics, addition of opioids, use of acupuncture, and routine intraoperative use of pudendal nerve block might improve the management of pain after CR.
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