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ORIGINAL RESEARCH |
From the 1Department of 2Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts; and 3Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: The medical records of 40 consecutive women with a history of type III female genital cutting who underwent defibulation between 1995 and 2003 were reviewed. Data collected included demographics, indications for the procedure, closure type, intraoperative and postoperative complications. Telephone surveys were conducted between 6 months and 2 years postprocedure to evaluate the long-term health and sexual satisfaction outcomes.
RESULTS: Of 40 women identified as having undergone defibulation, 95% were Somali, 65% were married, and 73% were between the ages of 19 and 30. Primary indications for defibulation were being pregnant (30%), dysmenorrhea (30%), apareunia (20%), and dyspareunia (15%). Secondary indications were apareunia (20%), difficulty urinating (12.5%), and dyspareunia (10%). Sixty-five percent had a subcuticular repair. Forty-eight percent had an intact clitoris buried beneath the scar. None had intraoperative or postoperative complications. Of the 32 patients reached by telephone, 94% stated they would highly recommend it to others. One hundred percent of patients and their husbands were satisfied with the results, felt their appearance had improved, and were sexually satisfied.
CONCLUSION: Defibulation is recommended for all infibulated women who suffer long-term complications. The complication rates are minimal, with high satisfaction rates among patients and their husbands.
LEVEL OF EVIDENCE: II-3
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Women who have undergone female genital cutting can suffer immediate and long-term complications. Bleeding, hemorrhage, infections, tetanus, oliguria, sepsis, and death are some of the immediate complications that have been documented. Long-term complications for women who have undergone type III procedures include dysmenorrhea, dyspareunia, apareunia (no coitus due to the inability to achieve penetration), urinary retention, infertility, chronic vaginal and urinary tract infections, urinary calculi, and neuromas.4,7–12
It is recommended that women with type III female genital cutting who are pregnant or who suffer long-term complications undergo defibulation (also known as deinfibulation), or opening of the scar. Defibulation is a surgical procedure wherein a vertical incision is made on the scar to expose the introitus and create new labia majora. Few data are available with which to assess the operative complication rates, the patient and husband satisfaction rates, and the physical and sexual outcomes. The purpose of this study was to assess the effect of defibulation on symptoms and sexual function. It also evaluated the effect of the procedure on the woman’s partner.
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MATERIALS AND METHODS |
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Patients who underwent defibulation received either general or regional anesthesia. The procedure entailed grasping the infibulated scar with Allis clamps bilaterally and making a vertical incision anteriorly with Mayo scissors, exposing both the introitus and urethra (Fig. 2). Hemostasis was assured on each side using either a subcuticular or interrupted sutures (routinely poliglecaprone 25 [Monocryl, Ethicon Endo-Surgery, Inc., Cincinnati, OH] or polyglactin [Vicryl, Ethicon Endo-Surgery]). This also prevented the two exposed edges from rehealing together (Fig. 3). Long-acting local anesthesia was subsequently injected to ease postoperative pain. Upon discharge, women were given topical and oral analgesics, instructed to perform sitz baths, and advised to expect a change in their voiding stream.
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A 30-minute telephone survey was conducted (by an independent interviewer) between 6 months and 2 years after the procedure to collect demographic data and responses to inquiries about patients’ surgical experience. The interviewer read the questionnaire instructions and notified the responders that the information gathered would be strictly confidential. The questionnaire was used to update the patients’ demographics and marital status, to correlate their indications for surgery with the medical records, to document whether symptoms had resolved postdefibulation, to assess ongoing problems as well as patient and husband satisfaction with the outcome, and to determine whether patients discussed the procedure with members of their family and whether they would recommend the procedure to others. In cases where language was an issue, the questionnaire was conducted through an out-of-state interpreter participating in a teleconference. Once the patient was interviewed, we obtained verbal permission from her to interview her husband. A separate telephone call was made to interview the husband.
The measurement of satisfaction was divided into three categories: whether the patient and husband were happy overall with her decision to defibulate (yes or no), whether the patient and husband were happy with her new appearance (yes or no), and whether their sexual life had improved (yes or no). We used proportions to quantify results. We calculated 95% confidence intervals (95% CI) around the proportions based on binomial probabilities.16
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RESULTS |
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Of the women identified, 32 were reached by telephone (80%); the remaining 20% had been evaluated at their outpatient postoperative visit but could not be located by telephone. One hundred percent (95% CI 89.1–100) of the patients interviewed were satisfied with the procedure, felt it had corrected the problem, were happy with the new appearance, and were sexually satisfied. Ninety-four percent (95% CI 79.2–99.2) stated that they found the procedure and postoperative course to be less painful and traumatic than anticipated (Table 3).
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Eighty-one percent (95% CI 63.6–92.8) stated they recovered more easily than they expected, and unsolicited comments revealed that patients were "amazed" at how fast they healed. Twelve percent (4 patients) stated that they had ongoing problems. Those four patients complained of occasional dyspareunia. Of the four patients, two had primarily suffered from apareunia, one from dyspareunia, and one from dysmenorrhea. One hundred percent (95% CI 89.1–100) stated that coitus had improved significantly.
In a follow-up telephone call 28 husbands were interviewed, one declined the interview, one was deceased, and two were out of the country. The husbands’ nationalities were the same as their wives. One hundred percent (95% CI 87.7–100) of the husbands stated they were satisfied with the surgical outcome and their wives’ new appearance and that their sexual life had improved. Although only 53% (95% CI 34.7–70.9) of the patients discussed their surgery with others (primarily husband and close family member), 94% (95% CI 79.2–99.2) stated they would highly recommend it to others (Table 3). Reasons for not discussing it with others (even their husbands) included privacy, shame, fear of being rebuked, of not getting married, not wanting to disappoint parents, feeling that others would not understand, and protecting their husband’s position in society (by maintaining the image that he defibulated her on their wedding night or in the months that followed).
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DISCUSSION |
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We found two major studies on defibulation in the published literature. One study documented performing defibulation in five women and recommended defibulation before pregnancy.27 Another study, in which 25 women were defibulated using carbon dioxide laser surgery under local anesthesia, concluded that the procedure had minimal complications and is an alternative treatment for type III female genital cutting. This study stated that some of the patients were in mild to moderate discomfort during the placement of the anesthesia.28
In this surgical case series, there were no intraoperative or major postoperative complications. The majority of patients were surprised at how painless the procedure was and how quickly they recovered. Of the patients who had postoperative complaints, all had been defibulated with interrupted suture. The knots or stitches that were exposed appeared to cause a moderate amount of irritation. Although these symptoms resolved, those who had been repaired with a subcuticular closure had no complaints. We would therefore recommend using a subcuticular closure to reduce if not prevent perioperative discomfort.
Defibulation resolved most of the preoperative complaints. Patients who had dysmenorrhea had described their menses as being severe (lasting more than ten days with vomiting despite nonsteroidal anti-inflammatory medications). These symptoms completely resolved for all but one, which suggests that partial obstruction of menstrual flow was the primary reason for the dysmenorrhea. Defibulation resolved 11 of 14 cases in which dyspareunia was the primary complaint. Of the three unresolved cases, one patient had specifically said she did not want to be "opened too much" at her initial procedure; she subsequently returned to be defibulated further. The other two said their pain resolved when using lubricants. But all said their sexual life had significantly improved. Although asking to be "opened just a bit" is a common request, we would not recommend this, because patients may continue having dyspareunia. Given these findings, we would recommend defibulating past the urethra.
All patients were satisfied with their surgery immediately postoperatively as documented in the medical records and in the follow-up telephone surveys. One hundred percent of the husbands reported that they were satisfied with their wife’s decision to defibulate. They were also satisfied with the appearance of the reconstructed genitalia and their improved sexual life. In this study, husbands were supportive and instrumental in persuading their wives to undergo this procedure. We believe that by being involved, husbands become better informed about female genital cutting, learn what tissue is removed, the health consequences of the practice, and the subsequent risks and benefits of defibulation. Also, the husbands’ reported satisfaction with the surgery calls into question the traditional beliefs that men want their wives closed tightly to enhance their own sexual pleasure and that the very appearance of infibulated genitalia is esthetically more pleasing to men.14,23–26 Introducing couples to this type of discussion breaks the centuries-old barrier designating female genital cutting as the exclusive domain of women.
Defibulation also helped restore the external genitalia of women with an intact clitoris. Although all the patients were believed to have undergone type III female genital cutting, almost 50% of them had an intact clitoris buried under the scar, which was discovered during surgical dissection. This may have been a deliberate decision by the African circumciser or may have simply been an error. Given that most girls are cut without anesthesia, the reflexive movement of the child during the procedure may make it difficult for the circumciser to determine whether the clitoris has been successfully removed. As a result, the girl is sewn up with the clitoris buried beneath the scar. This finding reaffirms the importance of palpating the clitoral region before making the anterior incision so as not to harm an intact clitoris.
Given the various types of infibulation seen in this study, the World Health Organization may want to consider defining type III more specifically into subtypes that describe in detail what tissue has been removed. It would more accurately portray the degree of damage done to the external genitalia.
This study population may not have been a random sample of circumcised women. Forty percent of the patients presented to the physician requesting defibulation, which creates selection bias. Another limitation is that, although patients during the interview were informed that confidentiality would be protected, members of this community may have tried to answer questions in a way that they believed would please the physician. An independent interviewer and an out-of-state interpreter were used to minimize these tendencies. Nevertheless, the overly positive responses may reflect the patients’ lack of confidence in their privacy despite reassurance. Another challenge was eliciting accurate responses regarding sexual satisfaction. Instruments such as the female sexual function index or the sexual function questionnaire have not been validated on infibulated women and may not be culturally appropriate. As a result, a decision was made to simply ask, without further specifics whether both husband and wife each felt that their sexual life had improved. The presumption is that coitus with defibulation is easier and less painful, and therefore better than with an infibulated woman. But we needed to test that presumption.
The strength of this study lies in the fact that so many women and husbands were willing to participate and to divulge information not routinely discussed in public. Issues of female genital cutting and sexuality are typically taboo in these cultures and are rarely disclosed. Eliciting such sensitive information from African women—and more so, from African men— is unusual; the study thus provides a rare insight into the sexuality of these couples. This insight, in turn, can aid health providers in counseling couples about the health and sexual benefits of defibulation.
In conclusion, defibulation is recommended for all infibulated women who experience long-term complications such as dysmenorrhea, dyspareunia, apareunia, or chronic vaginal and urinary infections. Complication rates are low, and patient and husband satisfaction rates are high. The American College of Obstetricians and Gynecologists has designed a slide-lecture kit that explains this procedure using photographs and detailed instructions.14 Patients who require defibulation should be referred to an experienced gynecologist or speak with experts in the field to provide optimal health care (https://www.acog.org/from%5fhome/proxy/ and http://www.brighamandwomens.org/africanwomenscenter).
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Footnotes |
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doi:10.1097/01.AOG.0000224613.72892.77
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REFERENCES |
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