Mar 21 / Dr Priyesh Patel

FGM Clitoral Reconstruction Surgery: Restoration & Recovery

Clitoral reconstruction, or FGM Reconstructive Surgery, is a hot topic in Female Genital Mutilation (FGM). It's important to understand that many forms of FGM result in clitoral damage. While defibulation, a minor surgical procedure, offers relief to some by opening up Type 3 FGM, it's essential to recognise that it doesn't fully restore lost or damaged clitoral anatomy. It is not always the solution it is made out to be. For the 200 million girls and women who have undergone FGM, many suffer from severe health problems, including painful periods, painful intercourse and other issues that require attention. The way their genitals look can cause significant psychological issues for them.

So, what options do survivors have? How do we treat FGM? What FGM surgery options are there? What do Doctors know about this? Is FGM reconstruction something we need to consider?
  1. What is Clitoral Reconstruction Surgery?
  2. Where is it practised?
  3. Why do women want Clitoral Reconstruction?
  4. What is Clitoraid?
  5. How is the Surgery done and by whom?
  6. Is it available to every women?
  7. Is it a Quick Fix?
  8. What is the Evidence & Outcomes?
  9. What are the Concerns?
  10. Should Professionals offer it?
  11. What do we tell Survivors?
  12. What now...

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What is Clitoral Reconstruction Surgery?

Clitoral reconstruction surgery is gaining increasing recognition, acceptance and popularity worldwide as a viable treatment option for survivors of FGM. It is being sought after by women who desire to reduce chronic clitoral pain, improve their sexual function, and restore the way their genitals appearance to before they had FGM.

Often, portions of the clitoris remain obscured by scar tissue resulting from FGM. Reconstructive surgery aims to uncover the clitoris and restore and reconstruct its affected anatomy. It aims to improve the appearance and functionality of  a women's genital area.
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Where is it practised?

Clitoral reconstructive surgery is practiced in several European countries, including France, Belgium, Switzerland, the Netherlands, and Sweden. It is also practiced in certain African countries. Additionally, there are doctors offering the procedure privately in the USA through online platforms.

Insurance coverage for this procedure varies by country and jurisdiction.

Why do women want Clitoral Reconstruction?

Here are the five key motivations that are interconnected and drive women to consider having the surgery: These factors represent not just desires, but urgent needs — a desperate quest to reclaim what was taken from them, to alleviate their suffering, and to restore a sense of wholeness and dignity.

  1. Symbolic Restitution: Undoing the harm caused by FGM.
  2. Repairing Visible Stigma: Addressing the physical consequences of FGM.
  3. Improving Sex and Intimacy: Aiming for physical and symbolic recovery.
  4. Alleviating Physical Pain: Seeking relief from discomfort.
  5. Reconstructive Surgery as Personal Hope: Viewing it as a pathway to empowerment.

What is Clitoriaid?

Clitoraid, a US based NGO, launched an ‘Adopt a clitoris’ fundraising campaign in 2022 to sponsor 150 women to have CR performed by US surgeons on a humanitarian mission in Kenya.
Each procedure is estimated to cost $600. However their fully equipped centre in Burkina Faso, called the Pleasure Hospital, remains unopened due to religious discrimination.

Presenting Clitoral Reconstructive Surgery as a cure for presumed sexual dysfunction caused by an injustice raises ethical considerations.

How is the Surgery done and by whom?

The way the surgery is performed varies around the world in many ways including the pre-operative and post-operative counselling for women. There is also differences in the criteria needed for surgery and the established pathways for the procedure.

Clitoral Reconstructive Surgery is performed by specialists in different fields, including urologists, gynaecologists, and plastic surgeons. However, there seems to be limited interdisciplinary communication among these specialists.

The goals of reconstructive clitoral surgery vary based on the individual and their specific needs. Due to the natural variation in clitoral anatomy, the surgical methods and techniques for clitoral reconstruction need to be highly individualised and tailored to each patient.

Further information on the different methods and techniques used in Clitoral Reconstructive Surgery
There are various methods and techniques used in Clitoral Reconstructive Surgery, which may involve the following steps:

  1. Freeing the stump from adhesions
  2. Making a buttonhole incision over the stump
  3. Cutting the suspensory ligaments
  4. Preserving the dorsal neurovascular bundle
  5. Suturing a neoclitoral shaft to a nearby structure such as adjacent skin, labia, pubic periosteum, or Bulbocavernosus muscles

Here are two articles reviewing the known methods of Clitoral Reconstructive Surgery...

Is it available to every women?

Clitoral Reconstructive Surgery is not widely available in most countries where FGM is practised, resulting in limited accessibility and equitable implementation. There is a limited number of specialists worldwide who are trained to perform Clitoral Reconstructive Surgery. Women often choose to travel to other countries to undergo the surgery, often paying for it themselves.

What is the Evidence & Outcomes

Evidence suggests that reconstruction surgery can achieve the desired benefits of reducing chronic clitoral pain and improving sexual function. However there are ricks and complications to be aware of.

A 2017 systematic review of 62 studies found that after Clitoral Reconstructive Surgery, 77% of women had a visible clitoris, indicating a successful outcome in terms of anatomical restoration. Most women self-reported improvements in their sexual life following the procedure. However, it is important to note that 22% of women experienced a worsening in sexuality-related outcomes. Success of the procedure depends on various factors such as the extent of previous damage and individual genital anatomy.

There is limited evidence on the effectiveness of Reconstructive Surgery in achieving desired outcomes such as improving genital appearance and benefiting women's lives. Findings on the risks and benefits of are mixed. There are genuinely valid concerns about the potential negative physical and psychological consequences because the surgery may not fully restore normal pelvic and sexual functioning.

Genital pain resulting from complications of Reconstructive Surgery can evoke memories of the traumatic experience of FGM and contribute to symptoms of Post-traumatic stress disorder (PTSD). It can also worsen existing mental health conditions or trigger negative psychological effects.

What are the known Risks and complications of Clitoral Reconstructive Surgery?
  • Risks associated with anaesthesia
  • Post-operative complications
  • Wound complications including haemorrhage, wound dehiscence and wound infections, new keloid scars
  • Hospital readmissions
  • Need for revision surgery
  • Necrosis of vaginal grafts
  • New chronic vulval pain
  • Clitoris hyperaesthesia
  • Changes to orgasm
  • No change to sexual functions
  • Detrimental worsening of mental health conditions or triggering of conditions such as PTSD, depression and anxiety.

Is it a Quick Fix?

No, it is not a quick fix or a miracle cure. Clitoral Reconstructive Surgery may not be ideal for every survivor. It cannot restore clitoral or labial tissue that has been removed in the past.

What are the Concerns?

Decisions to have surgery should follow Evidence-Based Medicine where possible. The World Health Organisation, (WHO) advises caution when interpreting the safety and clinical outcomes of Clitoral Reconstructive Surgery for several reasons including:

  1. Concerns about potential damage to genitalia including vulval structures like the urethra and clitoral nerves and blood vasculature.
  2. High rates of post-operative complications, such as readmission and reoperation, as well as reduced clitoral response in sexual activity.
  3. Methodological limitations in the research studies.
  4. Large or unknown loss to follow-up of cases.
  5. Use of non-validated scales and a lack of standardised methods to assess outcomes, including clitoral function and sexual function.

Should Professionals offer it?

There is a lack of universally recognised standards for Clitoral Reconstructive Surgery in terms of procedural techniques, follow-up protocols, monitoring, and evaluation. On top of that, recent evidence analysis suggests that it should not be indicated solely based on physical or anatomical grounds. Instead, Clitoral Reconstructive Surgery should only be considered when women have not responded to more conservative measures.

“Unless a clear direct cause for pain (e.g. scar tissue, clitoral neuroma, abscess, cyst) is identifiable, surgical procedures should be avoided.” - WHO, 2018.

The WHO express reservations about performing invasive surgery on asymptomatic women with FGM who request reconstructive surgery. If surgical is necessary, it is recommended to choose the least invasive procedure available. The Royal College of Obstetricians and Gynaecologists (RCOG), who's main role is providing training and continuing professional development for obstetricians and gynaecologists in the UK, advises against the use of Clitoral Reconstructive Surgery in girls and women with FGM. RCOG state that clinical trials are needed to assess its safety and effectiveness over a long-term period.

Therefore, Clitoral Reconstructive Surgery has not be a readily available option for survivors of FGM around the world. 

What do we tell Survivors?

People seeking therapeutic surgery should be fully informed about the limited evidence for potential benefits and the potential risks associated with the procedure. Honesty is key in avoiding unrealistic expectations. We must also be wary that this expectation among survivors can lead to exploitation of them.

Some survivors of FGM and activists argue that Clitoral Reconstructive Surgery should be more readily available for girls and women and that by not offering it we are failing them.

What now?

There is a recognised need for ethical and academic discussions surrounding the implementation of Clitoral Reconstructive Surgery in the context of FGM. These discussions should encompass various aspects, including sociocultural factors, bodily functions, sexuality, and gender roles within society.

These discussions are complex and have only recently started to take place...

Relevant Sources
Mohamed FS, Wild V, Earp BD, Johnson-Agbakwu C, Abdulcadir J. Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate. J Sex Med. 2020 Mar;17(3):531–42. 

WHO. Guidelines on the management of health complications from female genital mutilation [Internet]. 2016 [cited 2023 Sep 3]. Available from: https://www.who.int/publications-detail-redirect/9789241549646

Jordal M, Griffin G, Sigurjonsson H. ‘I want what every other woman has’: reasons for wanting clitoral reconstructive surgery after female genital cutting - a qualitative study from Sweden. Cult Health Sex. 2019 Jun;21(6):701–16. 

Clitoraid. Clitoraid.org. 2022 [cited 2023 Sep 14]. Clitoraid launches its 2022 ‘Adopt a Clitoris’ fundraising campaign to help FGM victims in Kenya. Available from: https://www.clitoraid.org/news.php?extend.199

Penn Medicine. Female Genital Mutilation Reconstructive Surgery. [Internet]. [cited 2023 Sep 14]. Available from: https://www.pennmedicine.org/for-patients-and-visitors/find-a-program-or-service/plastic-surgery/reconstructive-surgery/female-genital-mutilation-reconstructive-surgery

Verma M, Khoiwal K, Chaturvedi J. Clitoral Reconstruction Techniques for Female Genital Mutilation: Recent Advances. Aesthet Surg J. 2022 Jun 20;42(7):NP510–1. 

Abdulcadir J, Bianchi Demicheli F, Willame A, Recordon N, Petignat P. Posttraumatic Stress Disorder Relapse and Clitoral Reconstruction After Female Genital Mutilation. Obstetrics & Gynecology. 2017 Feb;129(2):371. 

Berg R, Taraldsen S, Said M, Sørbye I, Vangen S. The effectiveness of surgical interventions for women with FGM/C: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology. 2018;125(3):278–87. 

RCOG. RCOG. 07/15 [cited 2023 Sep 9]. Female Genital Mutilation and its Management (Green-top Guideline No. 53). Available from: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/female-genital-mutilation-and-its-management-green-top-guideline-no-53/

Buggio L, Facchin F, Chiappa L, Barbara G, Brambilla M, Vercellini P. Psychosexual Consequences of Female Genital Mutilation and the Impact of Reconstructive Surgery: A Narrative Review. Health Equity. 2019;3(1):36–46. 

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