Ultrasound-guided staging and reversal of female genital mutilation.

IMPORTANCE: FGM/C is common, effecting over 200 million women worldwide and has substantial associated morbidity. We seek improving the reversal procedure using ultrasound imaging. OBJECTIVE: The use of peri- and intraoperative ultrasound imaging for reconstructive surgery following FGM/C for staging and surgical planning, with focus on the clitoral structures and blood flow. STUDY DESIGN: This is a case series of patients with FGM/C who were evaluated and underwent reconstructive surgical management at a single institution between 2018 and 2022. Ultrasound examination with Doppler imaging was performed. The electronic medical record was queried for data regarding patient characteristics, examination and ultrasound findings, and surgical and postoperative course. RESULTS: Seven patients are described in this case series who sustained the FGM/C with classifications ranging from Ia to IIIb. The primary complaints were dyspareunia or apareunia. Six of seven (86%) reported anorgasmia. Four of seven (57%) had prior vaginal deliveries, and one of seven (14%) was delivered only by cesarean sections, two of seven (29%) have not been able to have intercourse. Ultrasound examination was utilized to facilitate recognition of the anatomic structures during the reconstruction, and Doppler was used to evaluate the clitoral blood flow. Doppler was useful to delineate clitoral tissues from a closely involved periclitoral inclusion cyst, aiding in surgical excision while minimizing clitoral vascular or nerve injury. Postoperative anatomical restoration, sexual function, and alleviation of dyspareunia were excellent. None of the patients reported decreased sexual pleasure postoperatively. CONCLUSIONS: Ultrasound imaging with Doppler can be utilized to facilitate personalized approaches to optimize both anatomical and functional results in cases of genital reconstruction.

Reconstructive surgery for women with female genital mutilation: A scoping review.

BACKGROUND: Female genital mutilation (FGM) is a global public health concern. However, reconstructive surgery remains unavailable in many countries. OBJECTIVES: This scoping review, guided by Joanna Briggs Institute (JBI) principles, explores indications, referral routes, eligibility, care pathways and clinical outcomes of reconstructive surgery for FGM. SEARCH STRATEGY: Medical Subject Headings (MeSH) terms and subject headings were searched in EMBASE, MEDLINE, SCOPUS, Web of Science and publicly available trial registers. SELECTION CRITERIA: Any primary experimental and quasi-experimental study addressing reconstructive surgery for FGM, and its impact on women, published before June 2023. DATA COLLECTION AND ANALYSIS: After removing duplicates from the search results, titles and abstracts were screened and data were extracted. Disagreements were resolved through panel discussion. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram depicts the search results and inclusion process. MAIN RESULTS: A total of 40 studies were included. Multidisciplinary teams were involved in 40% (16/40) of the studies, and psychosexual counselling was offered in 37.5% (15/40) of studies. Clitoral reconstruction using Foldes' technique was predominant (95%, 38/40). A total of 7274 women underwent some form of reconstruction. Post-surgery improvement was reported in 94% of the cases (6858/7274). The complication rate was 3% (207/7722 women with reconstruction). CONCLUSIONS: Further research and clinical trials are needed. Although the outcomes suggest improved sexual function and quality of life post-surgery, the evidence remains limited. Advocating surgical reconstruction for survivors of FGM is vital for addressing health disparities and potential cost-effectiveness.

Prognostic factors of poor surgical outcome after clitoral reconstruction in women with female genital mutilation/cutting.

BACKGROUND: Complications of surgical clitoral reconstruction for female genital mutilation/cutting (FGM/C) are a rare occurrence, but there has been reports of patients experiencing chronic pain or clitoral burial. AIM: This study aims to assess which factors are predictive of the occurrence of surgical complications in women who had surgical reconstruction for FGM/C (type 1, 2, or 3). METHODS: This monocentric retrospective study was conducted among patients who underwent clitoral reconstruction after FGM/C from January 2016 to March 2020. Demographic and clinical data were abstracted from the medical records. OUTCOMES: The primary outcome was the occurrence of chronic pain (defined as occurrence or persistence of any clitoral pain >3 months after surgery), and the secondary outcome was the occurrence of clitoral burial. RESULTS: A total of 87 women were included in the analysis. Univariate analysis indicated significantly higher rates of a history of physical abuse in the group of women who experienced chronic pain after surgery (4 [100%] vs 2 [37.1%], P = .049). Patients with clitoral burial were significantly younger than the rest of the sample in univariate analysis (median [IQR], 29.6 years [24.6-30.2] vs 33.8 [28.2-37.9]; P = .049). CLINICAL IMPLICATIONS: Surgical treatment of women who underwent FGM/C should include the entire history of the patient and especially a record of experiencing physical abuse. STRENGTHS AND LIMITATIONS: The study stands out for its originality, the extensive sample size gathered over nearly 4 years, the surgical clitoral reconstructions conducted by an experienced surgeon, and the minimal amount of missing data. However, because the occurrence of these complications was rare, the number of patients in the subgroups was extremely low, preventing a valid multivariate analysis to be conducted. CONCLUSION: The study suggests that women with a history of physical abuse could be at greater risk for chronic pain after surgery and that younger women tend to experience more clitoral burial.

"Damaged genitals"-Cut women's perceptions of the effect of female genital cutting on sexual function. A qualitative study from Sweden.

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".

Surgical Treatments of Chronic Vulvar Pain After Female Genital Mutilation/Cutting.

BACKGROUND: Vulvar and in particular clitoral pain can affect women with Female Genital Mutilation/Cutting (FGM/C). To date, there is no comprehensive study on the different available treatments for vulvar pain after FGM/C. AIM: To study the outcome of surgical treatments of vulvar and/or clitoral pain among women living with FGM/C. METHODS: Retrospective review of the consecutive medical files of all 506 women who consulted at a specialized outpatient clinic for women with FGM/C between April 1, 2010 and December 31, 2017. OUTCOME: Subjective change in chronic vulvar pain after surgical treatment. RESULTS: In total, 36.1% of women (n = 183) experienced chronic pain, all types included, among which 2.8% (n = 14) experienced provoked or unprovoked chronic vulvar pain. Among the 14 women with provoked or unprovoked chronic vulvar pain, ten (71.4%) underwent surgical treatment: 7 underwent resection of vulvar scar complications (cysts, bridles, adhesions) with (n = 4) or without (n = 3) concomitant defibulation, 3 had clitoral reconstruction and one had labium reconstruction with removal of peri-clitoral adhesion. Nine out of ten (90%) experienced resolution of pain after surgery and the remaining woman (10%) was lost to follow-up. CLINICAL IMPLICATIONS: Safe and effective surgical treatments exist and patients with chronic vulvar pain post-FGM/C should be referred to specialists who would consider appropriate indications for surgery and support informed decision-making and treatment. STRENGTHS & LIMITATIONS: The strengths of this research are the big sample size of women from diverse cultural and religious backgrounds, as well as the availability of pre- and postsurgery iconographic material and histology. Limitations include a subjective reporting of pain without validated questionnaires. CONCLUSION: Effective surgical treatments for provoked or unprovoked chronic vulvar pain post-FGM/C are clitoral reconstruction, defibulation, cystectomy, and bridle removal. Surgical treatments should be combined with a culturally sensitive multidisciplinary care and follow-up. Bazzoun Y., Aerts L., Abdulcadir J. Surgical Treatments of Chronic Vulvar Pain After Female Genital Mutilation/Cutting. J Sex Med 2022;19:290-301.

Clinical and Patient-Reported Outcomes of 19 Patients Undergoing Clitoral and Labial Reconstruction After Female Genital Mutilation/Cutting.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is the intentional alteration, removal, or injury of female genitalia for non-medical reasons. Approximately 200 million females have been victims of FGM/C, and genital reconstructive procedures are increasing in demand. OBJECTIVES: The objectives of this study were to assess clinical and patient-reported outcomes after FGM/C reconstruction to help guide treatment practices. METHODS: Adult patients undergoing anatomic reconstruction after FGM/C were retrospectively identified. Outcomes included clitoral, labial, and donor site surgical site occurrences (SSO) and the need for revision operations. Patient-reported outcomes were assessed using an adapted version of the Female Sexual Function Index (FSFI), a validated outcomes instrument that assesses sexual function through 6 domains, with each domain having a maximum score of 6. RESULTS: Nineteen patients were identified in our review. Patients presented for reconstruction due to dyspareunia, inability to orgasm, chronic infections, to normalize appearance, and/or to "feel normal." There were no SSOs and two revision operations for adhesions. 74% of patients completed the FSFI postoperatively. Despite most patients seeking repair for inability to orgasm and/or dyspareunia, the median scores for these domains were 4.6 and 5.2. Patients' desire to engage in sexual activity scored lowest (3.9), and patients reported concerns over the appearance of their genitalia (50%) that affected self-confidence (85.7%). CONCLUSION: FGM/C reconstruction is safe and contributes to improvements in physical sexual health. Psychological trauma may contribute to lessened sexual desire and self-confidence even after reconstruction. Multidisciplinary treatment is important to address the long-term psychological effects of this practice. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Autologous Platelet-Rich Plasma for Clitoral Reconstruction: A Case Study.

Clitoral reconstruction after female genital mutilation/cutting (FGM/C) is associated with significant post-operative pain and months-long recovery. Autologous platelet-rich plasma (A-PRP) reduces the time of healing and pain in orthopedic and burn patients and could also do so in clitoral reconstruction. In the present case, a 35-year-old Guinean woman who had undergone FGM/C Type IIb presented to our clinic for clitoral reconstruction. Her request was motivated by low sexual satisfaction and body image. We surgically reconstructed the clitoris using the Foldès method and applied plasma and glue of A-PRP. The patient was highly satisfied with the procedure. Two months post-operatively, her pain had ceased entirely and re-epithelialization was complete. We conclude that A-PRP may improve pain and healing after clitoral reconstruction. Extensive studies investigating long-term outcomes are needed.

Postoperative pain after clitoral reconstruction in women with female genital mutilation: An evaluation of practices.

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 amongst 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 amongst 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.

Anatomical study of the clitoris and its implications on female genital mutilation and surgical repair.

BACKGROUND: Worldwide, 200 million girls and women have been subjected to female genital mutilation. To restore the clitoral function and vulvar anatomy, clitoral repair has been performed since the 2000s. Nevertheless, there is a lack of precise and comprehensive data on the clitoral anatomy during surgical repair. This study aimed to precisely describe the terminal anatomies of the dorsal nerve and artery of the clitoris, and the clitoral neurovascular flap advancement for reconstruction in patients with female genital mutilation. METHODS: This study was performed on seven fresh female cadavers. The site of origin, diameter, length, and trajectory of each nerve and artery were recorded. The clitoral neurovascular flap advancement was measured after a midline transection of the suspensory ligament was performed and after extensive liberation of the dorsal bundles at their emergence from the pubic rami. RESULTS: At the distal point of the clitoral body, the width of the dorsal nerve and artery was 1.9 ± 0.3 mm and 0.9 ± 0.2 mm, respectively. The total length of the dorsal bundles was 6.6 cm (± 0.4). The midpart of the suspensory ligament was sectioned, which allowed a mean anteroposterior mobility of 2.7 cm (± 0.2). Extensive dissection of the neurovascular bundles up to their point of emergence from the suspensory ligament allowed a mean mobility of 3.4 ± 0.2 cm. CONCLUSION: We described the anatomical characteristics of the dorsal nerve and artery of the clitoris and the mobility of the clitoral neurovascular flap for reconstruction post clitoridectomy. This was done to restore the anatomic position of the glans clitoris while preserving and potentially restoring clitoral function in patients with female genital mutilation.

Effects of clitoral reconstruction for female genital mutilation on perinatal outcomes: A retrospective case-control study.

OBJECTIVES: To investigate the perinatal outcomes of women with a history of female genital mutilation (FGM) who underwent clitoral reconstruction (CR) compared with women with FGM who did not undergo CR. MATERIAL AND METHODS: Retrospective case-control study at Angers University Hospital, between 2005 and 2017. INCLUSION CRITERIA: pregnant women >18 years who underwent CR after FGM. Only the first subsequent delivery after CR was included. Each woman with CR was matched for age, ethnicity, FGM type, parity, and gestational age at the time of delivery with two women with FGM who did not undergo CR during the same period of time. At birth, the main outcomes were the need for episiotomy and having an intact perineum after delivery. RESULTS: 84 women were included (28 in the CR group; 56 in the control group). In the CR group, patients required significantly fewer episiotomies (5/17[29.4 %]) compared to the control group (28/44[63.6 %], p = 0.02), even after excluding operative vaginal deliveries (2/13[15.4 %] vs 21/36[58.3], p < 0.01). CR reduces the risk of episiotomy (aOR = 0.15, 95 %CI [0.04-0.56]; p < 0.01) after adjusting on the infant weight and the need for instrumental delivery. In the CR group, 47 % of the patients had an intact perineum after delivery, compared to 20.4 % in the control group (p = 0.04). CR increases the odds of having an intact perineum at birth by 3.46 times (CI95 %[1.04-11.49]; p = 0.04). CONCLUSION: CR after FGM increases the chances of having an intact perineum after delivery by 3.46 times and reduces the risk of episiotomy by 0.15 times compared to women with FGM who did not underwent CR.

Swedish Gynecologists' Positioning in Relation to Clitoral Reconstruction After Female Genital Cutting. A Qualitative Interview Study.

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.

In Vivo Imaging-Based 3-Dimensional Pelvic Prototype Models to Improve Education Regarding Sexual Anatomy and Physiology.

BACKGROUND: Myths, misconceptions, and taboos about sexual anatomy and physiology are common and can affect sexual health and maintain harmful practices and beliefs. AIM: To construct a female and a preliminary male 3-dimensional (3D) pelvic model on the basis of in vivo imaging, which could be studied in sex education and clinical practice. METHODS: We retrospectively studied the images of 200 female pelvic magnetic resonance examinations and reviewed the literature to choose the optimum magnetic resonance imaging (MRI) protocol for the study of the clitoris and surrounding organs. We also conducted a cross-sectional study of 30 women who were undergoing a pelvic MRI. 15 women had undergone female genital mutilation/cutting involving the clitoris and 15 had not. The best-quality MRI images of 3 uncut and 1 cut clitoris, together with the principal surrounding pelvic organs, were selected to generate 3D reconstructions using dedicated software. The same software was used to reconstruct the anatomy of the penis and the principal surrounding pelvic organs, based on contrast-enhanced computer tomography images. Images of both models were exported in .stl format and cleaned to obtain single manifold objects in free, open source software. Each organ model was sliced and 3D printed. A preliminary feedback was collected from 13 potential users working in urology, gynaecology, sexual medicine, physiotherapy, and education. OUTCOMES: The main outcomes of this study are a kit of 3D pelvic models, 2-dimensional figures of female and male sexual anatomy, and files for 3D printing. RESULTS: We present a kit containing 3D models and 2-dimensional figures of female and male sexual anatomy, based on in vivo imaging and, feedbacks and suggestions received from potential users. CLINICAL TRANSLATION: Our kit can be used in anatomy and sex education among and by health professionals, teachers, sex educators, students, and the general population. STRENGTHS & LIMITATIONS: The strengths are that the models were based on in vivo imaging, can be dismantled/reassembled, and show analogous anatomic structures of the clitoris and the penis. The female models represent diversity, including women with female genital mutilation/cutting. The limitations are that the male model is preliminary and can be improved if based on an MRI; that imaging-based anatomic representations can differ from anatomic dissections; and that the models represent the sexual organs at rest or during an unknown state of arousal only. CONCLUSION: Our kit can be studied in anatomy, biology, and sex education, as well as in clinical practice. Abdulcadir J, Dewaele R, Firmenich N, et al. In Vivo Imaging-Based 3-Dimensional Pelvic Prototype Models to Improve Education Regarding Sexual Anatomy and Physiology. J Sex Med 2020;17:1590-1602.

Clinical Features Associated with Female Genital Mutilation/Cutting: A Pilot Longitudinal Study.

(1) Background: Female genital mutilation/cutting (FGM/C) is associated with physical and psychological complications. However, there is scarce literature on how women with FGM/C respond to treatment interventions. (2) Methods: In the present pilot longitudinal study, we assessed changes in general psychopathology (Symptom Check List-90-R), sexual functioning and distress (Female Sexual Function Index, Female Sexual Distress Scale-Revised, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) female sexual dysfunction criteria), body image (Body Shape Questionnaire), and sexual body image (Female Genital Self-Image Scale) in a sample of n = 15 women with FGM/C before and after reconstructive surgery. (3) Results: Sexual distress was significantly improved following surgery. We also observed an improvement in general psychopathology and genital self-image. However, sexual function was not improved. (4) Conclusions: These results provide evidence for the benefits of reconstructive surgery on sexual distress in women with FGM/C. The impact of surgery on sexual function cannot be conclusively evaluated.

Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate.

INTRODUCTION: Clitoral reconstruction (CR) is a controversial surgical procedure performed for women who have undergone medically unnecessary, often ritualistic genital cutting involving the clitoris. Such cutting is known by several terms; we will use female genital mutilation/cutting (FGM/C). Treatments offered to women affected by complications of FGM/C include defibulation (releasing the scar of infibulation to allow penetrative intercourse, urinary flow, physiological delivery, and menstruation) and CR to decrease pain, improve sexual response, and create a pre-FGM/C genital appearance. AIM: In this study, our aim is to summarize the medical literature regarding CR techniques and outcomes, and stimulate ethical discussion surrounding potential adverse impacts on women who undergo the procedure. METHODS: A broad literature review was carried out to search any previous peer-reviewed publications regarding the techniques and ethical considerations for CR. MAIN OUTCOME MEASURE: The main outcome measure includes benefits, risks, and ethical analysis of CR. RESULTS: While we discuss the limited evidence regarding the risks and efficacy of CR, we did not find any peer-reviewed reports focused on ethical implications to date. CLINICAL IMPLICATIONS: CR can be indicated as a treatment for pain and potential improvement of associated sexual dysfunction when these have not responded to more conservative measures. Women must be appropriately informed about the risks of CR and the lack of strong evidence regarding potential benefits. They must be educated about their genital anatomy and disabused of any myths surrounding female sexual function as well as assessed and treated in accordance with the current scientific evidence and best clinical practices. STRENGTH & LIMITATIONS: This is the first formal ethical discussion surrounding CR. This is not a systematic review, and the ethical discussion of CR has only just begun. CONCLUSION: We present a preliminary ethical analysis of the procedure and its potential impact on women with FGM/C. Sharif Mohamed F, Wild V, Earp BD, et al. Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate. J Sex Med 2020;17:531-542.

Clinical, Sexual and Psychopathological Changes after Clitoral Reconstruction in a Type II Female Genital Mutilation/Cutting: A Case Report.

Female genital mutilation/cutting (FGM/C) is a health issue associated with serious negative psychological and health consequences. However, there is little literature on the impact of FGM/C on female sexuality, mental health and genital self- image after clitoral reconstructive surgery. Our aim was to assess sexual function, psychopathology and genital self-image in a type II FGM/C patient. The patient was assessed prior to FGM/C reconstructive surgery and at a 6-month follow-up. At follow- up, she reported an improvement in sexual function and a clear improvement of the psychopathological state. However, a worsening in genital self-image was also endorsed after the surgery. Our findings uphold that FGM/C reconstructive surgery can lessen psychopathological and sexual distress, although more research is needed in order to increase awareness of the potential benefits of genital reconstruction and to perfect the surgery procedures. These results have repercussions for health practitioners and psychologists alike in terms of developing prevention strategies and treatment protocols for FGM/C women.

Psychosexual Consequences of Female Genital Mutilation and the Impact of Reconstructive Surgery: A Narrative Review.

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.

'I want what every other woman has': reasons for wanting clitoral reconstructive surgery after female genital cutting - a qualitative study from Sweden.

Female genital cutting (FGC) involves the removal of women's external genitalia for non-therapeutic reasons. An estimated 38,000 women living in Sweden have undergone some form of the procedure. These women often belong to marginalised minorities of immigrant women from countries where FGC is widespread. Clitoral reconstructive surgery following FGC has recently been introduced in Sweden. This study investigates women's perceptions of FGC and clitoral reconstructive surgery with a particular focus on: (1) reasons for requesting reconstructive surgery, and (2) FGC-affected women's expectations of the surgery. Seventeen women referred for clitoral reconstructive surgery at the Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, Stockholm, participated in the study. Findings revealed five factors motivating women's request for clitoral reconstruction (CR): (1) symbolic restitution - undoing the harm of FGC; (2) repairing the visible stigma of FGC; (3) improving sex and intimacy through physical, aesthetic and symbolic recovery; (4) eliminating physical pain; (5) and CR as a personal project offering hope. These factors were highly interconnected, suggesting that the reasons for seeking surgery were often multiple and complex.

Addressing Female Genital Mutilation/Cutting (FGM/C) in the Era of Clitoral Reconstruction: Plastic Surgery.

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.

[Complex vulvar reconstruction following female genital mutilation/cutting]. / Die komplexe Rekonstruktion der Vulva nach weiblicher Genitalverstümmelung/Genitalbeschneidung.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is a worldwide problem affecting millions of women and is especially common in Africa and Arabia. Women suffer from serious physical and psychological problems. Anatomic reconstruction, therefore, is an important and life-changing option for many affected women. OBJECTIVES: This work gives a short overview of specialized techniques invented by the author for functional and aesthetic vulvar reconstruction following FGM/C. This work does not intend to provide anatomic or surgical details. MATERIALS AND METHODS: The anterior obturator artery perforator flap (aOAP flap), the omega domed flap (OD flap), and a microsurgical procedure called neurotizing and molding of the clitoral stump (NMCS procedure) are described. RESULTS: The aOAP-flap for vulvar reconstruction, the OD-flap for clitoral prepuce reconstruction, and the NMCS-procedure for reconstruction of the clitoral tip provided natural, reliable, and long-lasting results, all of which normalize the anatomy of the mutilated outer female genitalia. CONCLUSIONS: The reconstructive options presented contribute to re-establish normal anatomy and, thus, support women's health and relieve the burden forced upon them by FGM/C.

Management of painful clitoral neuroma after female genital mutilation/cutting.

BACKGROUND: Traumatic neuromas are the result of regenerative disorganized proliferation of the proximal portion of lesioned nerves. They can exist in any anatomical site and are responsible for neuropathic pain. Post-traumatic neuromas of the clitoris have been described as an uncommon consequence of female genital mutilation/cutting (FGM/C). FGM/C involves partial or total removal of the female genital organs for non-therapeutic reasons. It can involve cutting of the clitoris and can cause psychological, sexual, and physical complications. We aimed to evaluate the symptoms and management of women presenting with a clitoral neuroma after female genital mutilation/cutting (FGM/C). METHODS: We identified women who attended our specialized clinic for women with FGM/C who were diagnosed with a traumatic neuroma of the clitoris between April 1, 2010 and June 30, 2016. We reviewed their medical files and collected socio-demographic, clinical, surgical, and histopathological information. RESULTS: Seven women were diagnosed with clitoral neuroma. Six attended our clinic to undergo clitoral reconstruction, and three of these suffered from clitoral pain. The peri-clitoral fibrosis was removed during clitoral reconstruction, which revealed neuroma of the clitoris in all six subjects. Pain was ameliorated after surgery. The seventh woman presented with a visible and palpable painful clitoral mass diagnosed as a neuroma. Excision of the mass ameliorated the pain. Sexual function improved in five women. One was not sexually active, and one had not yet resumed sex. CONCLUSION: Post-traumatic clitoral neuroma can be a consequence of FGM/C. It can cause clitoral pain or be asymptomatic. In the case of pain symptoms, effective treatment is neuroma surgical excision, which can be performed during clitoral reconstruction. Surgery should be considered as part of multidisciplinary care. The efficacy of neuroma excision alone or during clitoral reconstruction to treat clitoral pain should be further assessed among symptomatic women.