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

Abstract

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.

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

“…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 et al, 2020;O'Neill et al, 2021).…”

“…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).…”

“…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 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.…”

Surgical Healthcare Interventions after Female Genital Mutilation/Cutting—A Review of the Evidence

“…Only one study investigated HCPs' perspectives on CR: In a qualitative study investigating gynecologists' attitudes towards CR, a negative attitude towards CR and consequently a reluctance to refer women to such surgery was demonstrated [50]. The gynecologists justified their reluctance by explaining that they did not regard the surgery as having functional benefits, and that potential symbolic, aesthetic, and mental justifications for seeking surgery were not considered sufficient for referral [50].…”

The benefits and disappointments following clitoral reconstruction after female genital cutting: A qualitative interview study from Sweden

“…Behar had to visit a couple of gynaecologists before finding someone willing to issue a referral for CR specialist care: 'I really fought for the referral, I went to two gynaecologists before I succeeded, they didn't want to send the referral.' Gynaecologists' reluctance to issue referrals for CR have been noted elsewhere [48], and seem to relate to a lack of knowledge about CR, but also to the limited evidence regarding the outcomes of CR surgery or to considering CR a scam. Villani [49] has noted that women requesting CR in France are required to display a certain image of 'maturity' in order to be considered eligible for surgery.…”