Abstract

Background: Clitoral restoration surgery also known as clitoroplasty, is a procedure aimed at re-exposing the clitoral remnant with or without defibulation to restore function for females who have undergone genital mutilation. The procedure remains controversial because of paucity of data for studies using validated outcome measures to document the efficacy and safety of clitoral restorative surgery. Objective: To assess sexual function and self-genital image after clitoral restorative surgery in women who had previously undergone female genital mutilation/cut. Design: A cross-sectional study. Setting: The Platinum surgery center in Nairobi, Kenya. Subjects/Participants: Ninety-six patients who underwent clitoral restorative surgery following female genital mutilation. Results: Majority of the study participants were aged below 35 years (54.5%), had college education (68.0%), married (53.3%), Christian (81.3%) and hailed from the Meru ethnic group (22.9%). Most study subjects had FGM/C type II (55.8%). A big proportion of the study participants were satisfied with their self-genital image (52.1%). The commonest indications for clitoral restorative surgery were low self-esteem (89.6%), failure to achieve orgasm (47.9%) followed by lack of self-identity (39.6%). The prevalence of Female Sexual Dysfunction (FSD) was 70.7% with majority of the women reporting moderate sexual desire (46.3%), poor arousal (46.3), inadequate lubrication (39%), lack of orgasm (39%), deficient satisfaction (51.2%) and moderate to high pain perception (36.6%) after clitoral restorative surgery. Conclusion: Clitoral reconstructive surgery enhances genital self-image but does not necessarily improve sexual function of women with FGM/C.

Keywords

Genital Mutilation, Clitoplasty, Genital Self-Image

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1. Introduction

The World Health Organization (WHO) defines female genital mutilation/cutting (FGM/C) as any operation involving partial or total removal of female external genitalia or other injury to female external genital organs for non-medical purposes [1]. While the precise number of women who have undergone female genital mutilation/cutting (FGM/C) globally remains unknown, UNICEF estimates that at least 200 million women and girls across 30 countries have undergone the practice, the majority of whom live in low-income countries [2]. The prevalence in Kenya is about 21.0%, as per the 2014 Kenya Demographic Health Survey [3]. FGM/C may include the clitoris (type I), labia minora or majora (type II), narrowing of the vaginal opening (type III) or any harmful genital procedure for non-medical reasons (type 4) [1]. The mutilation of the genitals destroys the neurovascular as well as muscular mechanisms responsible for normal sexual function [4]. The damage or cutting of the genital in female is done with an essence of reducing the desire of having sex in women. The excision of the inner clitoris influences the will of having sex and reaching orgasm [5]. Long-term sexual dysfunction owing to FGM/C was recorded, including dyspareunia, reduced sexual function, willingness and excitement, reduced lubrication, decreased orgasm and anorgasmia [1]. Since most erectile tissues are not excised, part of the cut clitoris recoils meaning healthy women with FGM/C may still attain orgasm and experience sexual interactions that satisfy them. Under the scar tissue, the palpable clitoral stump can be exposed, a neo-glans reconstructed and repositioned on the clitoral anatomical site; this is what clitoral restoration entails [6].

Reconstruction of the clitoris after mutilation in females is a novel medical procedure that has been conveyed as an efficient and viable approach for reducing clitoral pain, improving the excitement of sex and restoring the appearance of the vulvar comparable to females who are not gone through FGM/C [7]. Clitoral reconstructive surgery has been reported to enhance sexual function as it reduces clitoral pain by removing peri-clitoral fibrosis, making the clitoris more available to stimulation, which creates a new external clitoris and restores a more normal genital appearance^.[8].

For several thousand years, female genital mutilation/cut has been performed, yet scientific research has been restricted on the reasons why it continues today and the complete magnitude of the health harm it creates. Knowledge on measures to enhance health of women undergoing the operation is under documented.

2. Materials and Methods

2.1. Study Design

This was a cross-sectional study. The inclusion criteria comprised of women age 18 to 45 years who had undergone clitoral restorative surgery done following FGM/C in the months of January and February 2020. Women who did not consent were excluded from the study. The Female Sexual Function Index (FSFI) and female self-genital image (FGSIS) tool used to assess sexual function and genital image post-surgery. Female sexual dysfunction was defined as FSFI score of less than or equal to 26.55 while lack of genital self-image satisfaction was defined as FGSIS score of less than 22.

2.2. Study Setting

The study was done at the Platinum surgery center in Hurlingham area of Nairobi, Kenya. This center is a private facility dealing with aesthetic/plastic surgery.

2.3. Subjects and Participants

Ninety-six patients who underwent clitoral restorative surgery following FGM/C.

2.4. Sample Size Determination

The Fisher, 1981 formula was used to calculate the sample size using assumptions from Foldes et al. who reported an increased sexual desire in 81.0% of women who had undergone clitoral reconstructive surgery and 5% as the desired precision.

2.5. Data Collection

Patients who underwent clitoral restorative surgery at Platinum Surgery Center were identified and serialized. The patients were recruited during their postoperative follow up visit at which point they were explained to the purpose of the study and consent sought. A pre-designed consent form outlining the study purpose, procedure, potential benefits and possible risks was used to obtain written informed consent. The qualified women were then called and phone interviews conducted using an interviewer-administered questionnaire to assess their Genital Self Image and Female Sexual Function 6 months after the surgery. Potential participants who declined to offer consent were replaced sequentially by the next eligible participant until a sample size of 96 was obtained.

2.6. Data Analysis

Statistical Package for Social Scientists (SPSS) version 21.0 was used to analyze data. The demographic characteristics of patients were analyzed, and presented as frequencies, ratios, and means with standard deviations. The association between patient characteristics and sexual function and genital image was analyzed using the chi square test and Logistic regression to identify risk factors and predictors. Statistical analysis was done at 95% confidence level, with a p < 0.05 considered to be statistically significant.

2.7. Ethical Consideration

The study was approved by the Kenyatta National Hospital/University of Nairobi Ethics Research Committee. Scientific content and compliance with applicable research and human subjects’ regulations was observed. The participants provided written consent for participation.

3. Results

Of the 127 women who underwent clitoral restoration surgery, 25 were not reachable via phone. Of the 102 who were reachable, 97 consented to participate in the study, 1 of whom was excluded due to incomplete data in their clinical file, as shown in Figure 1.

Figure 1. Study flow chart.

3.1. Demographic Characteristics

Majority of the study participants were aged below 35 years (54.5%), had college education (68.0%), married (53.3%), Christian (81.3%) and hailed from the Meru ethnic group (22.9%). Most study subjects had FGM/C type II (55.8%). The commonest indications for clitoral restorative surgery was low self-esteem (89.6%), failure to achieve orgasm (47.9%) followed by lack of self-identity (39.6%) as shown in Table 1.

Table 1. Demographic data of women who underwent clitoral restorative surgery in Kenya.

3.2. Genital Self-Image Following Clitoral Restorative Surgery

A big proportion of the study participants were satisfied with their self-genital image (52.1%), the appearance of their genitals (37.5%) felt comfortable allowing their sexual partners look at their genitals (64.6%), as depicted in Table 2.

Table 2. Genital self-image of women who underwent clitoral restorative surgery.

3.3. Correlation between Sociodemographic Characteristics and Genital Self-Image

After controlling for covariance between ethnic group and religion, a significant correlation was noted between religion and genital self-image in that Christian women were five times more likely to be satisfied with genital self-image than Muslim women following clitoral restoration (OR (95% CI) = 5.03 (1.52 - 16.7), p < 0.01). However, there was no association between genital self-image and age, education level, ethnic group or type of FGM/C as shown in Table 3.

3.4. Female Sexual Function of Women Who Underwent Clitoral Restorative Surgery

Of the 96 study subjects, 82 had resumed sexual intercourse after clitoral restorative surgery and were examined for female sexual function using the FSFI score. The prevalence of Female Sexual Dysfunction (FSD) was 70.7% with majority of the women reporting moderate sexual desire (46.3%), low arousal (46.3), low lubrication (39%), low orgasm (39%), low satisfaction (51.2%) and moderate to high pain perception (36.6%) after clitoral restorative surgery, as shown in Table 4.

3.5. Correlation between Sociodemographic Characteristics and Female Sexual Function

A positive correlation was observed between female sexual dysfunction and age more than or equal to 35 years (OR (95% CI) 3.04 (1.08 - 8.51), p = 0.03). Female sexual dysfunction was significantly more evident among those who had FGM/C type III (OR (95% CI) = 5.5 (0.95 - 31.6), p = 0.04). However, age, education level, marital status, ethnicity, religion and female genital self-image did not influence female sexual function among women who underwent clitoral reconstructive surgery as shown in Table 5.

Table 3. Correlation between sociodemographic characteristics and genital self-image based of the FGSIS score.

Table 4. Female Sexual Function of women who underwent post-clitoral restorative surgery.

Table 5. Female sexual function and demographic characteristics of women who underwent clitoral restorative surgery.

4. Discussion

The objective of this study was to determine genital self-image, female sexual function, and the factors associated with these sexual health parameters following clitoral restorative surgery among women with a history of female genital mutilation/cutting (FGM/C).

FGM/C is most prevalent in the North Eastern, Eastern, Nyanza, and Rift Valley regions of Kenya [8]-[12]. Consistent with this distribution, most women who sought clitoral restorative surgery in this study belonged to the Meru, Abagusii, Embu, and Somali communities. The majority were young, married, Christian, and had attained a secondary or tertiary level of education. The high educational status observed among participants may have facilitated greater awareness of reconstructive surgical options and improved access to specialized healthcare services.

Women with FGM/C Types II and III comprised the largest proportion of those seeking clitoral restorative surgery. Given the greater extent of tissue excision and distortion of vulvar anatomy associated with these forms of FGM/C, they are more likely to result in sexual dysfunction, altered genital sensation, body image concerns, and other long-term psychosexual sequelae, thereby increasing the likelihood of seeking reconstructive intervention.

The primary reasons reported for pursuing clitoral restorative surgery were low self-esteem, inability to achieve orgasm, diminished genital sensation, loss of self-identity, and difficulties in intimate relationships. These findings highlight the profound physical, psychological, and psychosexual consequences of FGM/C and emphasize the multifaceted motivations underlying the decision to undergo reconstructive surgery. Similar findings have been reported by Jordal et al. in Sweden, where women cited symbolic restitution, reduction of visible stigma, restoration of bodily integrity, and improvements in intimacy, sexual function, and genital appearance as the principal motivations for undergoing clitoral restorative surgery [13].

Clitoral restorative surgery was associated with improved genital self-image, with more than half of the women reporting high levels of satisfaction with their genital appearance and feeling comfortable with their partners viewing their genitalia following surgery. These findings suggest that the procedure may contribute to enhanced self-acceptance and body image among women with a history of FGM/C. However, the lower uptake of surgery among Muslim women and older women in this cohort highlights the need for culturally sensitive awareness and educational initiatives to improve knowledge of available reconstructive options and facilitate equitable access to care for women who may benefit from the procedure. Our findings are consistent with previous studies evaluating the outcomes of clitoral restorative surgery. Seifeldin et al. reported that more than 90% of women who underwent surgical repair for FGM/C Types II and III at a women’s teaching hospital in Egypt experienced improved cosmetic satisfaction and psychological wellbeing [14]. Similarly, Goodman et al. demonstrated significant improvements in genital self-image and overall body esteem among 120 women who underwent clitoral restorative surgery in California, USA [15].

In this study, Christian women were five times more likely than Muslim women to report satisfaction with their genital self-image following clitoral restorative surgery. This disparity may reflect differences in cultural perceptions of FGM/C and reconstructive surgery, as well as variations in the availability of social support. These findings underscore the importance of culturally sensitive awareness and educational initiatives to improve understanding and acceptance of reconstructive options among affected communities. However, further research is warranted to elucidate the underlying factors contributing to this observed disparity.

Traditionally, genital surgical restoration is done to improve both the genital self-image and female sexual function. While an improvement in the genital self-image was observed, surgical restoration did not translate to a significant improvement in female sexual function in this study. More than 70% of participants met the criteria for female sexual dysfunction, with genital pain, inadequate lubrication, impaired orgasm, reduced sexual satisfaction, and diminished sexual desire identified as the predominant contributing. Post-operative dyspareunia has been identified as a strong predictor for sexual dysfunction with women exhibiting the symptom reported to have a higher risk of female sexual dysfunction [16]. Similar findings were reported by Esho et al. in Kenya, where women described persistent challenges related to sexual desire, arousal, and satisfaction following genital reconstructive surgery [17]. Likewise, Goodman et al. reported a decline in physical and sexual functioning after surgery [15].

The identifiable factors associated with female sexual dysfunction following clitoral restorative surgery in this study were age equal to or above 35 years and type III FGM/C. The factors associated with female sexual dysfunction following clitoral restorative surgery in this study were age ≥ 35 years and Type III FGM/C. The association between increasing age and female sexual dysfunction is consistent with previous evidence demonstrating an age-related decline in sexual function, which has been attributed to hormonal changes, comorbidities, and psychosocial factors that adversely affect sexual desire, arousal, lubrication, and orgasm [18]. Similarly, women with Type III FGM/C may be at greater risk of persistent sexual dysfunction because of the more extensive anatomical disruption, scarring, and chronic pain associated with infibulation [1], all of which may influence postoperative sexual outcomes and potentially confound the relationship between clitoral restorative surgery and sexual function.

5. Study Strengths and Limitations

Genital self-image and female sexual function were not evaluated prior to clitoral restorative surgery, limiting the study’s ability to establish a causal relationship between clitoral restorative surgery and the observed outcomes. Nevertheless, the primary outcomes were evaluated using internationally validated instruments enhancing the reliability, reproducibility, and comparability of our findings with other studies. To the best of current knowledge, this is among the first studies from sub-Saharan Africa evaluating genital self-image and sexual function after clitoral restorative surgery. The study provides locally relevant evidence from a high prevalence FGM/C setting, thereby addressing an important gap in the literature.

6. Conclusion

Clitoral restorative surgery is associated with improved genital self-image among women with a history of female genital mutilation/cutting (FGM/C). However, female sexual dysfunction remains high, particularly among women aged ≥ 35 years and those with Type III FGM/C. These findings highlight the need for comprehensive care, including psychosexual counseling, pain management, and appropriate preoperative counseling to optimize postoperative outcomes.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References