HEALTH

A Controversial Procedure To Restore The Clitoris After FGM

It’s helping thousands of victims of genital cutting, but not all experts think it should be the go-to treatment

HEALTH
Photo Illustration: Diana Quach
Aug 23, 2016 at 3:00 PM ET

When Kiki was nine years old, in Guinea, she thought she was being taken to buy some Play-Doh. Instead, she was taken to a stranger’s house and forced to undergo a procedure known as female genital mutilation (FGM), sometimes referred to as female genital cutting. Over 200 million women around the world have undergone FGM, but Kiki is one of only a few thousand who have attempted to surgically reverse its effects, electing to have a so-called clitoral restoration surgery.

The restorative surgery is seemingly a godsend for women who unwittingly underwent FGM as children — offering the chance to both physically restore sensation and also the opportunity to reclaim their own sexuality. But the procedure is not without controversy. Because the surgery is relatively new, and therapy can help with psychological issues, not all experts are convinced that surgery is the best option for FGM victims in the long-term. Further complicating the conversation around the procedure is the fact that one of its largest proponents is a new religion that believes extraterrestrials engineered life on Earth. (More on that later.)

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In Kiki’s home country of Guinea, FGM is traditional—70 percent of women in the country aged 20 to 24 were cut before age 10. And although her mother’s family, devoutly Muslim, didn’t approve of the practice, the women on her father’s side encouraged it.

On the day of her FGM, her aunt took her to a stranger’s house. “The next thing I knew, I was jumped on,” Kiki, whose name has been changed for this story, recalls to Vocativ. “When you feel like someone is about to harm you, you want to run. I tried to take off, they circled me, next thing I knew I was on the ground.” Kiki was taken to the backyard. One woman sat on her chest, making it hard to breathe, while another two women pulled her legs apart. Kiki recalls being overcome by pain and fear; at some point during the procedure, she says, she lost consciousness.

In the immediate aftermath of cutting, women can feel severe pain, bleeding or have infections; in the long term, they might have pain during urination, menstruation, or intercourse; buildup of scar tissue; and psychological problems like depression or post-traumatic stress disorder.

Now Kiki lives in Indiana, having graduated not long ago from university there. When she first tried to have sex in college, it was painful. She could have an orgasm, but “it was a struggle…it would take a while,” she says. Her friends would talk about their great sex lives, and she would just listen, nodding. “‘Why are you so quiet?’ they would ask me. And I would say, ‘Well, what do you want me to say?’”

A few years ago, she heard about clitoral restoration and set out on a path that would ultimately change her relationship to sex and to her own identity.

On a physical level, the goal of clitoral restoration is to reduce pain and restore lost sensation to women’s genitals. On an abstract level, it can help victims of FGM take ownership of their identity and sexuality.

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FGM is a catch-all term that refers to a range of procedures, from the entire removal of the external part of the clitoris (clitorectomy) to “nicking” the clitoris but leaving it intact. There are lots of reasons why cultures continue to perform FGM, but it’s no coincidence that it involves the organ that is the nexus of much of a woman’s sexual pleasure. “In some cultures, women are told that if they don’t cut the clitoris, it will be big or make a woman hypersexual so that she will not be marriageable,” says Jasmine Abdulcadir, a gynecologist at Geneva University Hospitals in Switzerland, where she runs a clinic for victims of FGM.

But, much like an iceberg, only a small percentage of the clitoris is visible outside the body. So even if the visible part has been nicked or removed, as is the case among women who fit into the first two classes of FGM, there’s more tissue inside the body. To perform a clitoral restoration procedure, the surgeon slices open the area around where the clitoral tissue would typically exit the body, and simply pulls down the existing tissue, fastening it to the surrounding tissues to keep it in place.

“When I go to reconstruct clitorises where there has been cutting, the clitoris is always there 100 percent of the time. There’s no question it’s still there,” says Marci Bowers, an OBGYN who has performed more than 200 clitoral restoration procedures. “In fact, in one third of cases where I operate, the clitoris is completely intact. There’s nothing missing. It’s just covered in a web of scar tissue.”

The surgery itself takes less than an hour and is done under anesthesia. The recovery usually takes a few months.

First performed in Egypt 2006, clitoral restoration procedures truly started to gain traction in 2012, when French surgeon Pierre Foldes published a study for which he performed the procedure on nearly 3,000 women. A year after the operation, Foldes followed up with about 30 percent of the patients, and found that most of them had reduced pain and increased sensation in the clitoris. Half had even experienced an orgasm.

The results were a sensation, sparking interest among other surgeons and patients alike, plus kicking off a flurry of stories in the popular press.

Today there are a handful of surgeons running clinics scattered across the world—Geneva, Burkina Faso, San Francisco—who know how to perform the clitoral restorations. One of the biggest orchestrators is a Las Vegas-nonprofit called Clitoraid. The organization was founded in the philosophy of the Raelian Movement, a religion with followers that believe that human extraterrestrials engineered and synthesized DNA to create all life on Earth. Rael, the founder of the religion, reportedly saw first-hand what effects FGM can have on women during a visit to West Africa in 2003, according to a Clitoraid press officer.

In Raelism, pleasure is an important way to connect to the extraterrestrial creators, and FGM works counter to that mission. “When barbaric traditions cut off the clitoris of little girls, not only do they violate their right to body integrity as children, but they also violate their very right to feel mentally and emotionally balanced and harmonious throughout their lives,” the press officer told Vocativ in an email.

Clitoraid now mostly serves to raise awareness for FGM and to foster connections for clitoral restoration procedures—between surgeons so that they can be trained to perform them, between victims of FGM and doctors to do the surgery.

More A Controversial Alternative To Banning Female Genital Cutting

That’s how Kiki found out about the clitoral restoration procedure. When she came to the U.S. for college, she was evaluated by a doctor who suggested that Kiki look into it. “Since I’m a curious person, I started doing research online,” Kiki says. She contacted Clitoraid and, in early 2015, she hopped on a plane to meet Harold Henning, one of the two surgeons in the country performing the procedure at the time (and the only one who is also Raelian). Kiki didn’t pay anything for the surgery itself, she says—just her plane ticket and the $500 hospital fee. She knew about the organization’s connection to Raelism, but it wasn’t pushed on her; she doesn’t remember ever talking about it with Henning.

Kiki’s recovery went quickly and within a few months she was totally healed. Now, more than a year later, she says you can’t even tell she had surgery. And It’s been a game-changer for her sex life: “I was not feeling much pleasure. Now it’s completely different,” she says.

If the effects of FGM were only physical — or if all cases were as straightforward as Kiki’s — experts would likely recommend the procedure unequivocally. But FGM is much more complex than that. The surgery comes with risks, things like infection and complications. And, even if it goes according to plan, it might not address the psychological issues like fear of intimacy.

Abdulcadir, who runs the clinic in Geneva, has the training to perform the surgery, but she considers it a last resort. Of the approximately 15 women who come to her clinic every month, only about 20 percent ask for the surgery (the rest are seeking help due to pregnancy or complications from FGM). Those that do want the surgery spend three months meeting with psychiatrists and sex therapists, and receiving education about their own anatomy, before the surgery is a possibility. “Once they start to know how their bodies work, how their anatomy and clitoris are, the majority of them do not go for surgery—their needs are met by counseling and education,” Abdulcadir says.

Part of the reason for this is that Abdulcadir has reservations about the long-term effects of the procedure. Foldes, in his seminal study, followed up with less than a third of the patients, and only after a year. “What happens after five years? After 10? When a woman changes partners or when she has kids? We’ve had studies about clitoral restoration procedures,” Abdulcadir says, “But now we need good, quality studies with long-term follow-ups.”

This lack of long-term data is part of the reason that the World Health Organization, in the recently-published guidelines about FGM (of which Abdulcadir was one of the collaborators), stated that there’s not yet enough evidence to wholeheartedly recommend the procedure.

Mariya Karimjee, a freelance writer based in Karachi, Pakistan who has publicly discussed her experience of being cut and its effects on her as an adult, says she thought about the surgery when she first heard about Foldes’ study. She brought it up with her doctor, but he didn’t sound totally convinced by the science, Karimjee recalls, in part because there wasn’t enough long-term follow-up.

Eventually, she gave up on the idea of the surgery. “I wanted an easy fix, to undo the damage,” Karimjee says. “It sounds appealing. But at this point in my life I don’t know that it really is a quick fix.” It would take months for the skin to regrow, and it would be painful. “I don’t need any more pain.”

Bowers and Henning, both of whom perform the surgery primarily on patients from Clitoriad, agree that counseling is important, but believe the surgery is as well. The procedure is medically sound, Bowers says, but “the question is, psychologically, is it worthwhile? You don’t want to re-traumatize someone.” She recommends sex therapy to many of her patients after the surgery.

Henning believes that all people could benefit from sex therapy, “but that’s not criteria for surgery,” he says. “Most of these women have lived with this for many years. They have already had all the experiences they’re going to have with sexuality beforehand.”

For her part, Bowers is disappointed by WHO’s cautionary approach in recommending the restoration procedure. “It does need to be evidence-based, there’s a healthy reason for that. But what they’ve said, that’s really misinformation. All it takes is to hear one personal account of someone having the first orgasm in their life to say there’s no more evidence needed. This works.”

There’s certainly no one-size-fits-all solution for how women deal with the effects of FGM. Karimjee plans to find a sex therapist—“I would rather figure out if there’s a psychological trauma, and do that hard work. Even if I had surgery I would probably need that,” she says.

But for Kiki, who has never seen a therapist and has no plans to do so in the near future, the procedure was enough to restore her sexual function.

More importantly, the surgery make her feel like whole self. “Someone took something away from me that they were not entitled to. They did it just for the sake of it, out of cruelty,” Kiki says. “Now I got that back.”