Mike Bebernes investigates the new surgery that helps reverse female genital mutilation.

Campaigns have a hard fight against a deeply rooted cultural practice. Photo: Nichol Brumm/Flickr

For centuries, modesty and chastity have been seen as the paradigms of womanhood; of “good” women.

And of course sexual pleasure had no place in this picture of purity, in fact, it was something only “harlots” and “loose women” felt. Today, this is ensured in some cultures through the agonising ritual of Female Genital Mutilation (FGM), which prevents women from being able to experience sexual pleasure alongside other serious side effects.

Millions of women have had this natural right torn from them when they’re young but now it can be returned with a new surgery that restores genital function. And now this opportunity has come to Australia.

What is FGM?

Female genital mutilation (FGM) has roots throughout Northern Africa. Though no religion demands outright for FGM, practitioners often have religious support. In many cases, the call for FGM stems from social pressures. Some cultures consider the practice as part of raising a girl properly. Others believe it promotes modesty, fidelity and chastity.

According to the World Health Organization (WHO) there are no medical benefits to FGM, but the negative effects of the surgery are wide-ranging and significant. Any surgery carries risk of infection and bleeding, but these concerns and the potential contraction of HIV are compounded by the conditions in which FGM often takes place. For the most part, these nations lack sophisticated medical resources and knowledge. Even without these risks, the long-lasting effects of FGM include increased menstrual pain, trouble urinating, painful sex, substantially higher risk of pregnancy complications and increased infant and maternal mortality rates.

But the physical damage doesn’t begin to quantify the psychological wounds or sexual power dynamic created by FGM. The WHO estimates there are between 100 and 140 million women living with the consequences of FGM worldwide. And in some countries, like Somalia, Guinea and Egypt, a reported 95 percent or more of girls over 10 years old have experienced some form of FGM.

Activism against FGM is widespread and it is banned in most western countries. FGM has been illegal in Australia since 1996 and certain professional groups are mandated to report circumstances in which they believe a child may be at risk of FGM. Many nations, including Australia also have laws forbidding taking a girl out of the country for the purposes of FGM.

An Answer

Long relegated solely to raising awareness and counseling those already hurt by the practice, activists now have a new weapon in the fight against FGM. Over the last decade, doctors have developed a pair of relatively simple procedures that can restore full functionality, including renewal of sexual pleasure to most victims of female genital mutilation.

Reversal of FGM first started where it began, in Africa, and has since spread to individual clinics in the UK, France and USA. The surgery became available in Australia for the first time when the Royal Women’s Hospital in Melbourne opened a reversal clinic in September.

Pierre Foldes, a French surgeon, developed the reversal surgery for the most common types of FGM (called Type I and Type II FGM). The breakthrough came from a basic understanding of female anatomy.

“It was shocking for me to discover in my research that there was nothing, absolutely nothing on this organ, although there are hundreds of books on the penis, and several surgical techniques to lengthen it, enlarge it or repair it. Nobody was studying the clitoris because it is associated with female pleasure. There was very little anatomical detail on it. It was as if it didn’t exist. I had to start from scratch,” he told the Scottish newspaper The Scotsman.

Contrary to popular belief, the clitoris is a region, not an isolated spot. The exposed section of the clitoris is merely part of a larger area beneath the surface that harbors the same level of sensitivity. The Types I and II FGM procedures cut off or completely remove the exposed section of the clitoris, a process typically referred to as a clitoridectomy. The cut area grows over with scar tissue, blocking the sensitivity of the region.

Foldes discovered that this scar tissue can be easily removed, exposing the remaining sensitive areas of the clitoris.  He believes it took so long to discover such an elementary procedure because the male-dominated medical field in Africa were largely ignorant about women’s issues.

The third, most severe, form of FGM involves slightly more work to reverse. In Type III FGM, medically referred to as infibulation, large portions of the labia are removed along with the clitoris. The vaginal canal is then sewn up, leaving behind only a small hole for urination and menstruation.  The reversal procedure for Type III, simply reopens the canal and removes scar tissue to expose the remaining labia and clitoral tissue.  For medical purposes, reversal surgeries for all types I, II and III fall under the umbrella term deinfibulation.

Both procedures are relatively simple and can often be performed using only local anesthetic. The RWH Clinical Practice Guide states “preparation for deinfibulation should be that of a minor surgical procedure.”  Women usually only need two or three days of rest at home and basic anti-infection care after the surgery, though it can take months for sexual pleasure to be fully restored. The RWH reports that benefits of the surgery include improved urinary function, decreased menstrual complications and pain and a dramatic increase in sexual pleasure.

In recent decades FGM has been confined to countries in North Africa and the Middle East, but growing immigration from the region makes the issue increasingly relevant in Australia. Census data reports more than 72,000 people born North Africa or the Middle East living in Victoria in 2006, up from 60, 000 in 2001.

White said each of the “half dozen or so” deinfibulations at the RWH so far have been performed on women who experienced FGM in North Africa and have since come to Australia.

Gentle Hands

Of course the physical results are just a portion of the lasting ramifications of the deinfibulation procedures.  The practice of FGM dates back for millennia. The mental toll FGM takes- including depression, shame and horrific flashbacks- are well documented. The reversal surgery, on the other hand, has only a few years of precedent and a small sample size to establish what the long-term psychological effects are. Even so, doctors know that providing support for the surgery’s mental and cultural results must be equally delicate to the surgeon’s hand.

“It is the early days yet, but we have received great feedback who have attended the clinic so far,” said Rosemary Burrell, Clinical Director of Women’s Health Services at the Royal Woman’s Hospital.

Of primary concern is how a woman who has undergone deinfibulation will be accepted in her community.  FGM is the established norm in many societies and the reversal of FGM can be perceived as a subversion, and therefore, rejection of that culture.

“It’s very culturally sensitive, “ said Sarah White, Director of Communications for the Royal Women’s Hospital. “There’s a generational discomfort. The communities involved are worried about being judged.”

The staff at the RWH understands the cultural dissonance between Australian doctors and their African patients. The clinic offers multi-layered support before and after the procedure to help ease this divide and provide an open dialogue for concerns.

“Providing women with high-quality care involves expertise in the legal, clinical, social and cultural aspects of FGM,” said Burrell. “The clinic is multidisciplinary and the women have access to [support workers], in addition they can be referred to social workers or any of specialist gynecology units including the sexual counseling clinic.”

“We offer on-the-spot counseling and address their direct circumstances,” said White.

At times the effort goes more toward reassuring those closest to the patient rather than the woman herself.   According the White, the women are “frequently accompanied by family members” who are suspicious of the process.

Certain circumstances can compound the issues surrounding the reversal. In the majority of cases, deinfibulation is an elective procedure. The woman undergoing surgery has made the choice herself.  Some cases of Type III FGM, though, necessitate deinfibulation because the small vaginal hole left in Type III frequently makes the normal functions of conception and birth impossible. This means some women are forced to make a decision they might not have made otherwise.

“We know that [some] women will need deinfibulation before they can have sex with their husband or give birth vaginally,” said Burrell

In these cases, doctors must open up the vaginal canal in order to prevent life-threatening consequences for both the mother and child. In Africa, the woman’s vagina would be re-sewn after childbirth. Australian law prohibits reclosing the hole.

Starting to Live

The major hurdle RWH faces is building awareness of the surgery but the cultural divides between doctors and African communities in Australia create further difficulties.

“Many of the women won’t read English,” said White. The RWH offers information pamphlets in Arabic, Amharic, Somali and Tigrigna to bridge this gap.

“[Surgery information is spread] through the network of workers across the state, through GP’s and other regional networks particularly those who deal with refugee and migrant populations, Women’s Health Services and media… We also expect that once women have been to the clinic, word of mouth in the communities may be the most effective way of raising awareness,” said Burrell.

“There’s a slow trickle,” said White, “[but] word is spreading.”

Massah, a woman born in Sierra Leone now living in Australia, said: “[The surgery] is like giving us a second life.  Actually, it’s starting to live.”