Clitoral reconstructive surgery in women and girls living with female genital mutilation: A systematic review

Abstract

BACKGROUND: Female genital mutilation (FGM) is recognized as a violation of human rights, with global prevalence affecting million girls and women. FGM varies in type and severity, and poses physical, emotional, and social risks, with a significant impact on female sexual function leading to mental health issues and reduced quality of life. Surgical techniques, such as clitoral reconstructive surgery, are practiced to restore clitoral function. OBJECTIVES: To assess the effectiveness of clitoral reconstructive surgery in mitigating sexual dysfunction, vulvodynia, clitoral pain, low self-esteem, and negative body image among women living with any type of FGM. SEARCH STRATEGY: The following major databases were searched for published and gray literature, without language restrictions, from inception to May 2023: CINAHL Plus, IRIS, MEDLINE (Ovid), PsycINFO (EBSCOhost), SCOPUS, and Web of Science. SELECTION CRITERIA: Controlled studies, cohort studies, and quasi-experimental studies with assessment before and after the intervention were included if they involved women seeking clitoral reconstruction to address the selected outcomes measured (sexual dysfunction, vulvodynia, clitoral pain, low self-esteem, and negative body image). DATA COLLECTION AND ANALYSIS: Studies were independently assessed for inclusion, data extraction, and risk of bias. Data were extracted for meta-analyses and the evidence assessed using the GRADE (Grade of Recommendation, Assessment, Development and Evaluation) approach. MAIN RESULTS: We identified 13 studies. All but one used the same "Foldès technique". The other study used a vaginal mucosal graft. Meta-analysis of vulval pain, clitoral pain, or pain during intercourse before and after clitoral reconstruction showed a significant reduction in pain (odds ratio 79.67, 95% confidence interval 41.67-152.33). The studies also reported an improvement in body image and self-esteem, as well as in clitoral sexual function. Adverse events included hematoma, infection, suture failure, edema, prolonged postoperative pain, mild inflammation, and necrosis. The certainty of evidence was very low on all outcomes. CONCLUSIONS: Although clitoral reconstructive surgery for FGM seems safe and effective, preoperative sexual health counseling should be offered. Women should be clearly informed about the risks and the limited evidence of possible benefits of clitoral reconstructive surgery, and their assessment and treatment should follow current scientific evidence and best clinical practice.