Sensitivity after Clitoral Reconstruction in Patients with Female Genital Mutilation.

Background: In the past decades, reconstructive choices after female genital mutilation extended beyond de-infibulation and scar release. The current trend to expand techniques addressing sexual and aesthetic aspects by reconstructing the clitoris and prepuce, and dissecting the clitoral nerves raises concern, as there is a paucity of evidence on the functional outcomes and suspected iatrogenic lacerations. Methods: A total of 128 female genital mutilation patients were included in the study. To evaluate clitoral sensitivity after elevation, the Semmes-Weinstein-monofilament test was performed before and after genital reconstruction. Results: Preoperatively, patients with a visually intact clitoris showed significantly better sensitivity compared with patients with a mutilated clitoris or infibulation (P < 0.0001). Surgery was performed in 84 patients. After clitoral reconstruction (CR), 70 of 73 patients were able to perceive 2.83 monofilaments (95.9%), whereas three perceived 3.61. Patients with a visually intact clitoris served as control, and 95.0% perceived 2.83 monofilaments. We showed a significant improvement of clitoral sensitivity (P = 0.0020) in the subgroup consisting of patients with a mutilated clitoris in whom the test was performed before and after reconstruction. Conclusions: Clitoral sensitivity improves significantly after CR. Seventy of 73 patients attained the same sensitivity as unharmed women. No patient showed a decreased sensitivity compared with their preoperative findings. Therefore, our study supports the argument that CR offers sufficient improvement of objective clitoral sensitivity without additionally addressing clitoral nerves.

Postoperative Course of Reconstructive Procedures in FGM Type III-Proposal for a Modified Classification of Type III Female Genital Mutilation.

BACKGROUND: Reconstruction after female genital mutilation (FGM) has developed from being merely a therapy for complications to addressing body perception and sexuality. However, evidence regarding a direct correlation between FGM and sexual dysfunction is scarce. The present WHO classification provides an imprecise grading system, which makes it difficult to compare present studies with treatment outcomes. The aim of this study was to develop a new grading system based on a retrospective study of Type III FGM, evaluating operative time and postoperative results. METHODS: The extent of clitoral involvement, operative time of prepuce reconstruction and lack of prepuce reconstruction, and postoperative complications of 85 patients with FGM-Type III were retrospectively analyzed at the Desert Flower Center (Waldfriede Hospital, Berlin). RESULTS: Even though universally graded by the WHO, large differences in the degree of damage were found after deinfibulation. In only 42% of patients, a partly resected clitoral glans was found after deinfibulation. There was no significant difference in operative time when comparing patients who required prepuce reconstruction and patients who did not (p = 0.1693). However, we found significantly longer operative time in patients who presented with a completely or partly resected clitoral glans when compared to patients with an intact clitoral glans underneath the infibulating scar (p < 0.0001). Two of the 34 patients (5.9%) who had a partly resected clitoris required revision surgery, while none of the patients in whom an intact clitoris was discovered under the infibulation required revision. However, these differences in the complication rates between patients with and without a partly resected clitoris were not statistically significant (p = 0.1571). CONCLUSIONS: A significantly longer operative time was found in patients who presented with a completely or partly resected clitoral glans when compared with patients with an intact clitoral glans underneath the infibulating scar. Furthermore, we found a higher, though not significantly significant, complication rate in patients with a mutilated clitoral glans. In contrast to Type I and II mutilations, the presence of an intact or mutilated clitoral glans underneath the infibulation scar is not addressed in the present WHO classification. We have developed a more precise classification, which may serve as a useful tool when conducting and comparing research studies.

Cognitive-Emotional Aspects of Post-Traumatic Stress Disorder in the Context of Female Genital Mutilation.

Around 200 million women and girls worldwide are affected by female genital mutilation/cutting (FGM/C). FGM/C is a procedure that harms or alters the external female genitals for non-medical reasons, and is usually performed on children. Often, this procedure leads to severe consequences for the women's physical and mental health. In a cross-sectional sample of 112 women seeking medical counseling, physical and mental health characteristics associated with FGM/C were examined and possible predictors for the development of post-traumatic stress disorder (PTSD) in women affected by FGM/C were identified. A total of 55.4% (n = 66) of the women reported symptom levels of probable PTSD. Predictors for higher PTSD symptomology were an older age at the time of the FGM/C procedure, feelings of guilt and the centrality of the event in the woman's life. Thus, cognitive-emotional processing was found to play an important role in the emergence of PTSD in women suffering from FGM/C. However, interventions taking into consideration these characteristics are mostly lacking and need to be investigated further in the context of FGM/C.

[Psychological Strain due to Female Genital Mutilation: An Explorative Analysis in the Context of Medical Counselling]. / Psychische Belastung durch weibliche Genitalverstümmelung: Eine explorative Untersuchung im Rahmen einer medizinischen Sprechstunde.

Female genital mutilation (FGM) is a procedure that injures or removes parts of the external female genitals for nonmedical reasons and without the consent of the affected girls. Often this procedure leads to severe consequences for the women's physical and mental health. Reconstructive surgery can reduce these symptoms. In an exploratory study of 97 women seeking medical counselling, characteristics of the sample were analysed descriptively, reasons for reconstructive surgery were examined and agreement between the women's knowledge with the results of the medical examination was assessed. 56.7% (n=55) of the women examined were suspected to suffer from PTSD. Relief of pain was the reason most frequently mentioned for reconstructive surgery (45.4%; n=44). Accordance between women's knowledge of anatomic structures and the degree of mutilation with the results of the medical examination was low (κ=0.09). In addition to surgical measures, women suffering from FGM should be offered psychotherapeutic assistance. To improve the understanding on the effect of psychotherapy after FGM, sound longitudinal studies are indispensable.