Female sexual dysfunction in female genital mutilation

Abstract

Female genital mutilation (FGM), otherwise known as female genital cutting (FGC), is currently very topical and has become a significant global political issue. The impact of FGM on the lives of women and girls is enormous, as it often affects both their psychology and physical being. Among the complications that are often under-reported and not always acknowledged is female sexual dysfunction (FSD). FSD presents with a complex of symptoms including lack of libido, arousability and orgasm. This often occurs in tandem with chronic urogenital pain and anatomical disruption due to perineal scarring.

To treat FSD in FGM each woman needs specifically directed holistic care, geared to her individual case. This may include psychological support, physiotherapy and, on occasion, reconstructive surgery. In many cases the situation is complicated by symptoms of chronic pelvic pain, which can make treatment increasingly difficult as this issue needs a defined multidisciplinary approach for its effective management in its own right.

The problems suffered by women with FGM are wholly preventable, as the practice need not happen. The current global momentum to address the social, cultural, economic and medical issues of FGM is being supported by communities, governments, non-governmental agencies (NGOs) and healthcare providers. It is only by working together that the practice can be abolished and women and girls may be free from this practice and its associated consequences.

Keywords

Female genital mutilation sexual dysfunction pain complications management

Introduction

The traditional practice of female genital mutilation (FGM), previously referred to as female circumcision, has attracted increasing international attention in the last two decades. The World Health Organization (WHO),^1–3 the United Nations^4,5 and UNICEF since 1997, the European Union^6,7 and NGOs such as the UK Foundation for Women’s Health Research and Development (FORWARD UK)⁸ have been instrumental in establishing strong global agreement against the continuance of this practice, by installing specific framework activities (Table 1). Understandably, this has proven not to be as easy as anticipated because of the complex nature of this problem and its wider ramifications within the society and culture of those who carry out this practice. Nonetheless 24 governments in 29 countries where FGM is most carried out have legislated concerning its practice.⁹

Table 1.

Framework activities in FGM (adapted from WHO 1998, 1999).

• Breaking the silence on FGM

• Raising awareness both nationally and internationally

• Providing information to all concerned

• Providing advocacy in politics, health and local communities

• Enhancing women’s view of themselves

• Involving policy makers

• Involving the community

History of FGM

Historical records suggest that the diverse practice of FGM may have originated in Egypt 5000 years ago,¹⁰ but it is not known whether it only started here or if it originated in different countries at the same time. With early records from a number of continents it seems unlikely that all forms of female circumcision originated among the Hamito-Semitic inhabitants of the shores of the Red Sea.^11,12 For example, excision might have come to the Kenyan peoples, notably the Maasai,¹³ from the Cushites who entered Kenya from Ethiopia.¹⁰ But the Kikuyu, although influenced by the Cushites, might have adopted excision as a result of Bantu influence. According to Sudanese folklore, FGM must have originated from Egypt, hence the term ‘pharaonic circumcision’, though there is no evidence of infibulation in the predynastic or in later Egyptian mummies.^12,14,15 However, there are many well-described reports among the Phoenicians, Hittites and Ethiopians from 23 BC.¹⁶ Excision and infibulation were certainly pre-Christian and pre-Islamic in these areas. The practice of FGM has continued throughout the Middle Ages into modern times, traversing all religions and many countries in the Middle East, Africa and Asia. FGM, notably clitoridectomy, was also practised in Europe and North America, by gynaecological surgeons in the second half of the 19th century for the treatment of epilepsy, ‘nymphomania’, catalepsy and other forms of insanity.¹⁷ This practice was widely condemned by most doctors. The specific origin of FGM is, therefore, obscured by time but the common historic reasons cited, such as the prevention of marital infidelity, remain the same as they did at its inception.

Current global situation

Presently, the practice appears to be predominantly based in Africa. Over 28 countries are affected.¹⁸ The numbers of women afflicted are thought to range from 30 million^1–3 to 130 million women (Table 1).^10,19 In the Middle East the numbers are considerably smaller but widely spread in Yemen, Qatar, United Arab Emirates, the borders of Saudi Arabia and parts of Israel.^20,21 The numbers are significantly lower in parts of Latin America (e.g. Columbia, Peru and Brazil), Mexico, India, Pakistan (among the Bohra people) and the Far East (e.g. Malaysia and Indonesia), though there are no accurate records.^1,2

A recent increase in immigration to Europe, Australia,^22,23 Canada and North America^24–26 of women from countries where FGM is performed (Jones et al., 1997),¹¹⁹ has meant that modern Western gynaecological practice must include knowledge of the consequences of FGM. Most of the women seen are from Africa. The WHO estimates that there are over 27,000 women and girls with FGM in France²⁷ and 87,000 in Australia.²² (Department of Health, 1992). In the UK, the numbers are estimated to be around 100,000 women and girls (FORWARD UK, 2014).¹²⁰ Moreover in these countries, despite legal constraints, many women and girls are at risk of undergoing FGM,^28–30 because their community demands it. Thus there is a great need to understand the traditions behind FGM and to raise awareness within the health services of adoptive countries that FGM is a problem they must also face. FGM is no longer a local issue, but a global one, even though its major impact is still mainly low- and middle-income countries (Table 1).

While it is very difficult for people outside the cultures affected by FGM to understand why this wilful mutilation of girls and women occurs, within those cultures no uniform agreement of benefit exists. Many reasons are given, including good tradition, social acceptance, religious cleanliness, prevention of promiscuity and adultery,²⁰ enhancement of male sexual pleasure and preservation of virginity.³¹ Good tradition by far outweighs all the other reasons, particularly in the pursuit of matrimony, where FGM is seen as a practice necessary to improve a woman’s chances for marriage.

The role of religion in female circumcision is important, as many people believe that it determines the perpetuity, and indeed the necessity, of this practice.³² Religions which practice FGM include Christianity and the Russian Coptic Sect,³³ the Israeli Bedouins³⁴ and the Ethiopian Jewish Fallasha,³⁵ but it is most commonly linked to Islam.^36,37 However, the Koran does not condone the practice and indeed the prophet Mohamed’s wives and daughters were not so treated.^14,38 Indeed, FGM is not carried out in all Islamic states, and the evidence is that FGM is a cultural, rather than a religious, practice.

Classification of female genital mutilation

The WHO Technical Working Group (1998) has classified FGM into four categories:

Type I: Removal of the prepuce with or without part or the entire clitoris (Sunna or traditional ‘female circumcision’);

Type II: Clitoridectomy with removal of the prepuce and the clitoris, together with partial or total excision of the labia minora;

Type III: Infibulation with removal of part or all of external genitalia and stitching/narrowing of the vaginal opening leaving a small aperture for passing urine and menstrual blood. (‘Clasp circumcision’);

Type IV: Unclassified, including piercing, tattooing and cosmetic labiaplasty.

The practice of FGM

The age of girls on whom this procedure is carried out ranges from birth to adulthood (Table 2).³⁹ The age groups are rough guides to when FGM occurs but girls may be younger or older according to individual circumstance, if, for example, a certain ‘operator’ is not available. Increasingly, in some areas, the operation is delayed because the conviction that FGM is essential is being challenged.⁴⁰

Table 2.

Prevalence of FGM in eight African countries (adapted from WHO data, 1998).

Country	Female population	Prevalence	Number
Benin	2,730,000	50%	1,365,000
Egypt	28,769,000	97%	27,905,930
Ethiopia	2,087,000	85%	24,723,950
Kenya	13,935,000	50%	6,967,500
Mali	5,485,000	94%	5,155,900
Nigeria	64,003,000	40%	25,601,200
Sudan	14,400,000	89%	12,816,000
Tanzania	15,520,000	10%	1,552,000
Total of 28 African countries 136,797,440

The instruments commonly used vary and include razors, blades, scissors and knives. No anaesthesia is usually given but in some rural communities traditional brews which induce deep sleep are administered before the procedure is carried out. Once the surgery is done, the wound may be dressed with bandages and traditional paste with the legs kept apart. But in some cases the legs are bound together, with thorns or sutures holding the skin, leaving the ‘operation site’ to heal in a tight airless environment.¹⁸

The outcome of such practices depends on the age of the child, the type of intervention and the conditions under which it is performed, the general standard of health of the girl and the skill of the operator. The physical and psychological consequences are variable but can be devastating, ranging from little discomfort to problems, which persist throughout life. Some 80% of women and girls who have undergone this procedure subsequently need medical intervention, but because of the taboo regarding this practice many do not present to medical practitioners.^41–44

Evidence recorded extensively by practitioners worldwide show that ill effects and complications of FGM are most commonly related to infibulation (FGM III), than to other practices. The author’s own experience suggests that these reports derive predominantly from hospitals and clinics situated in large towns and cities. The need for medical attention after FGM in the rural community remains under-reported. This may be as a result of minimal or non-existent medical facilities, or because people are afraid to report harmful practices.

Complications of FGM

The complications following FGM are many^45–47 and have been outlined below in Table 3. The most common acute complications include shock, severe pain, haemorrhage and infection. Shock, as an immediate result of the procedure, due to haemorrhage, is a major problem.^48–51 Pain may be so great that the patient has great difficulty in recovering from the experience, leaving long-term psychological sequlae.^43,53

Table 3.

Age at which FGM is performed within various races and cultures.

Age at circumcision	Race/Culture	References
At birth	Some Igbo people in Nigeria	Basden, 1966;¹⁰⁹ Megafu, 1983¹¹¹
Neonatal period	Parts of Ethiopia	Meskal et al., 1990¹¹⁰
Infancy	Parts of the Middle East and Nigeria	WHO, 1998;¹¹² Diejomaoh and Faal, 1981¹¹³
Childhood	Most African societies, e.g. Sudan, Egypt, Somalia	El-Saadawi, 1980¹¹⁴; Sayed, 1996¹¹⁵
Teenagers	Some Bantu tribe and Australian Aborigines	WHO, 1998
Before or at marriage	Masai tribe, Yako tribe of Nigeria	Forde, 1941¹¹⁶
After birth of first child	Swahili speaking communities	Forde, 1941

Table 4.

Some complications of FGM.

Immediate complications	Death Shock and Pain* Haemorrhage* Infection including septicaemia* Adjacent organ damage* Acute urinary retention Fracture/Dislocation of the femur, humerus or clavicle
Long-term complications	Failure of healing Recurrent UTI and renal/bladder calculus formation urethral obstruction and difficulty in passing urine* Pelvic infections and abscess formation menstrual abnormalities and associated infertility* Sexual dysfunction* Fistulae AIDS, HIV and other blood-borne diseases Problems with pregnancy and childbirth* Psychological or psychiatric problems*

Common complications.

Adapted from Dirie and Lindmark, 1991b, 1992;¹¹⁷ Rushwan, 2000;¹¹⁸ WHO, 1998.

Continuing haemorrhage and infection are perhaps the most common intermediate complications seen and may result in worsening chronic anaemia, sepsis and abscess formation. Another potentially fatal consequence is tetanus.^11,50,51,54 However, the commonest long-term problems remain recurrent and persistent urinary tract infections⁵⁵ and chronic pelvic inflammatory disease, both of which impact on menstrual function and fertility.⁵⁶

The structures adjacent to where FGM is sited are the most liable to traumatic damage. These include the urethra, vagina, perineum and anus. The consequences of FGM observed include permanent incontinence, chronic urinary retention,^57,58 closure of the vaginal aperture and vulval/clitoral swellings.^59–61

The long-term consequences of FGM are usually determined by the original ‘acute’ complication. FGM sites may fail to heal. Where sites heal, they may result in keloid formation and contracture. In the urethra, a poor urinary stream and incomplete emptying of the bladder results, with accompanying recurrent urinary tract infections⁵⁵ and calculus formation. In the vagina, adhesions and haematocolpos may ensue.⁶²

The major problem for most young women begins with marriage. In many cases the vaginal orifice is so small that sexual intercourse is impossible.³⁹ This may result in attempts by the new husband to ‘open up’ the wife. Often this entails the use of razor blades or other sharp implements. In some cases the traditional midwife or female elder of the village may try and intervene. They frequently use unsterile instruments to achieve their aim. By carrying out these procedures on stenosed vaginas, severe haemorrhage, further trauma to the urogenital organs (including vesico-vaginal fistulae), extensive bruising and chronic pelvic pain may result.^63–65 Sometimes anal intercourse may take place as a result of apareunia. This may lead to distortions of the anus, anal fissures, anal sphincter incompetence and in some cases a recto-vaginal fistula.^55,66,67 Clearly, female sexual dysfunction (FSD) is a significant problem in this group of women. It is often essential that corrective reconstructive plastic procedures of the vulva, vagina, perineum and anus are carried out timeously.

In a meta-analysis of 44 primary studies involving 3 million participants on obstetric consequences of FGM, it was evident that prolonged labour, obstetric lacerations, instrumental delivery, obstetric haemorrhage and difficult delivery were markedly associated with FGM. This indicates that FGM is a factor in their occurrence and significantly increases the risk of delivery complications. There was no significant difference in risk found, however, with respect to Caesarean section and episiotomy.⁶⁸

Female sexual dysfunction in FGM

Female sexual dysfunction is classified as either hypoactive sexual desire or disorders of sexual desire, sexual arousal, orgasm or sexual pain.⁶⁹ The prevalence of FSD after FGM has been estimated at between 25% and 63% depending on the definition used and population studied.^70,71 It is often as a cause of pelvic floor dysfunction, commonly caused by childbirth in younger women and by the menopause in older women.^72–74 Patients with neurological disease have a higher prevalence of all types of sexual functional disorder,^75,76 though precise figures are not known. In women with FGM, there is no defined prevalence and much of what is known comes from anecdotal information provided by health workers in the field. It is known, from the literature, that many women suffer trouble with desire, arousability, satisfaction and ability to achieve orgasm in the general population. Thus it is not surprising that in women with FGM, especially when complications outlined above have ensued, would tend to have problems with sexual intercourse. They thus avoid sexual contact as it exacerbates all these difficulties.^77,78

As FSD is a multi-factorial problem that may be exacerbated by external factors, such as chronic pain,⁷⁹ it is not surprising that in women with FGM the situation is considerably more complex owing to anatomical distortion. There is a paucity of literature in this field, but drawing on knowledge of FSD in chronic urogenital pain, a hint of the severity of the suffering of women with FGM may be surmised. Clearly chronic urogenital pain and FGM co-exist, and thus its impact on FSD cannot be underestimated.^32,80,81

Importantly, it has been found that women were more likely to report antecedent stressful events, such as frequent physical and sexual abuse and post-traumatic stress disorder, when they were diagnosed with both major depression and chronic pain syndromes.⁸² They also reported symptoms of dyspareunia, dysmenorrhea and vulvar pain. The site and severity of pain, when compounded by depression and physical disability, impacted greatly on sexual dysfunction.^83,84 Patients were depressed in relation to their pain, irrespective of its site: higher pain scores being associated with greater depression. Likewise a study from the Netherlands showed one in six women who had undergone FGM suffered from post-traumatic stress disorder and one-third reported symptoms related to depression or anxiety. The negative feelings caused by FGM became more prominent during childbirth or when suffering from other physical problems, when they were more likely to report FGM. Migration to the Netherlands led to a shift in how women perceived FGM, making them more aware of the negative consequences of this practice. Indeed, many women felt ashamed to be examined by clinical practitioners and avoided visiting doctors.⁸⁴

Despite the lack of published data, the experience of clinics treating complex urogynaecological issues is that many women suffering from the effects of FGM will admit to avoiding sexual intercourse on account of anatomical derangement as outlined above, or because of pain and inability to achieve physical coitus owing to scarring.⁸⁵ Among such women, the importance of sexual avoidance is medically significant as it impacts greatly on their relationship with their husbands or partners. These women also avoid seeking new relationships so that they do not have to face, among other things, the embarrassment of having to discuss the problem.⁸⁶ Established relationships can also break down as a consequence of the complexities of their condition. Unsurprisingly, sexual dysfunction heightens anger, frustration and depression; all of which will place a strain upon any relationship.^87–90

According to some authors, among women where sexual function has commenced, dyspareunia is commonly superficial in nature and tends to improve with time as the vaginal skin naturally softens with use and physiotherapy.⁹¹ However, in a significant proportion, superficial dyspareunia may persist when the scarring does not soften and thus reconstructive surgery may be required. Deep dyspareunia may also occur as this is often associated with chronic pelvic inflammatory disease, as a result of the initial FGM procedure. This is more difficult to treat and may require long-term pharmacological and possibly surgical treatment.⁹² Many women may complain of lack of sexual enjoyment.⁹³ This may be as a direct result of the clitoroidectomy or because of the anxiety associated with the sexual act. In the case of the former, some women claim sensitivity returns following the birth of their first child. It is not entirely understood as to why this happens, unless a partial rather than a total clitoroidectomy may have been performed. This may mean that a few rudimentary nerve fibres may be contained within the scar tissue.

It is evident therefore that sexual problems encountered with FGM may therefore be not only physical, but also psychological.⁴³

The gamut of psychological complications of women from FGM communities are manifold.^43,64,94 Common manifestations include low self-esteem, disturbed self-identity, psychosexual dysfunction and psychopathology, which is often under-reported.^85,86,95,96 Its impact in FSD has not been quantified nor qualified, except in small numbers of patients.

Management of FSD in FGM

In the UK, women with FGM (and other vulnerable women) find it very difficult to gain access to specialist gynaecology services such as urogynaecology, where complications such as incontinence, voiding dysfunction, chronic urogenital pain and sexual dysfunction are usually investigated and treated. This may not only be due to their FGM condition but also to other associated factors which act as barriers to access to healthcare such as low income, linguistic difficulties and legal status. These barriers are the same for many women, and not just those with FGM. Most women with FGM in the Western world who present to gynaecologists do so because of problems with sexual intercourse, micturition or postpartum complications. In the case of the latter two conditions, they can usually access reasonable care in a general setting, but in the case of FSD a dedicated clinic with a sympathetic and knowledgeable environment is essential.

The treatment of FSD in women with FGM needs to be individually tailored. The definitive cause needs to be determined and treated. Treatment should include pelvic floor exercises and training, psychology, cognitive therapy, pharmacotherapy and reconstructive or restorative surgery.^97–99

Physiotherapy

Pelvic floor physiotherapy is performed using the core muscles as a whole, especially when pain is a contributory feature as seen in FGM, as they often have a musculoskeletal component related to the pelvic floor.¹⁰⁰

Musculoskeletal pain that is not essentially genitally based often interferes with sex as well, yet is not considered an adjunct to distinct sexual dysfunction. Musculoskeletal pain is generally addressed by physiotherapists, orthopaedists and rheumatologists who are not traditionally trained in sexual medicine, and therefore, the sexual concerns of women with musculoskeletal pain often go unaddressed. Review of the peer-reviewed literature cites fatigue, medication and relationship adjustment as affecting sexuality much as chronic illness does. While musculoskeletal contributors to genital sexual response and pain are considered relevant to sexual function, little is understood about how musculoskeletal syndromes specifically affect sexual activity. Lack of mobility can restrict intercourse and limit sexual activity. Physical therapists are uniquely qualified to provide treatment to address functional activities of daily living, including sexual intercourse, and offer advice for modifications in positioning.

Psychology and counselling

Many women are affected by FGM and though cultural acceptance is high, personal acceptance is not. The psychological impact on the woman’s life and on FSD cannot be underestimated. But, the access to specialised post-traumatic psychology services is very limited and it is therefore the duty of all health providers to ensure such care is available. The women from these societies are, therefore, fighting many health problems, as well as socioeconomic strife. The need for empowerment remains very strong.

Sexual and relationship counselling should be offered as a component of rehabilitative treatment, but FSD is difficult to treat, especially where pain is a significant component, and thus it is advocated that all couples are evaluated within the context of a multidisciplinary clinic setting.¹⁰¹ Culturally for women from FGM communities, these discussions take place without the husband being present. Thus, the situation may be complicated further, as the husband may not ‘accept the advice of a third party’. Thus, the women are encouraged to bring their husbands to the consultation.⁸⁶ Failing that, some women will bring close members of their family with them, such as a sister, a sister-in-law and/or a mother who could then ‘clarify the situation to the husband’, thus avoiding conflict.

A population of 2106 sexually active women with FGM, assessed using the Female Sexual Function Index (FSFI) questionnaire,⁹⁶ showed that tradition, cleanliness and virginity were the most common motives empowering the continuation of FGM (100%), followed by men’s wish, aesthetic factors, marriage and religious factors (45–100%). There was only negative correlation between type II FGM and sexual satisfaction. No statistically significant difference between type I FGM and women who had not had FGM was found. However, this survey was carried out on sexually active women who, ipso facto, had managed to overcome their difficulties at least in part.

In conclusion, it is apparent that a variety of sociocultural myths, religious misbeliefs, and hygienic and aesthetic concerns are behind the continuation of the practice of FGM. But more worryingly, a large proportion of the participants appear to support the continuation of FGM in spite of its acknowledged adverse effects and the sexual dysfunction associated.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is not commonly used in FGM. Evidence, however, from a recent cross-sectional study and a small randomised controlled trial provides preliminary support for the CBT treatment model in restoring sexual function in congenital abnormality of the female genital tract, characterised by the non-formation of the vagina and the uterus (Mayer-Rokitansky-Kuster-Hauser Syndrome or MRKH).¹⁰² It is thought to be applicable to a number of other congenital or acquired gynaecological conditions.

Pharmacotherapy

Pharmacotherapy may have a limited role in FSD in FGM where it is dependent on co-morbid states such as chronic pelvic pain, menopausal symptoms or recurrent urinary tract infections. All of these respond to medical therapy such as neuropathic analgesics, hormone replacement therapy and low dose antibiotic therapy, respectively. Their importance lies in their being treated before specifically addressing FSD in FGM. This is important in order to appraise, evaluate and treat the condition further using other therapies, once the co-morbidities have been adequately managed.

Reconstructive or restorative surgery

In cases where the above interventions are not helpful, or not possible to institute, it is often because the anatomy is so distorted that non-invasive measures will fail unless the anatomy is corrected.

The commonest procedure used is de-infibulation, which needs to be performed under a general anaesthetic in most instances.^103,104 To perform this procedure under local anaesthesia may simply remind the patient of the trauma suffered at the initial FGM procedure. In FGM III, where the occluded vagina is covered with skin, leaving a little hole just above the posterior fourchette for the passage of urine, the skin is divided in the mid-line working from the free lower edge to the apex just above the root of the clitoris. The edges of the two flaps created are freshened and sutured to recreate the labia minora. Sometimes the tissue is sewn back onto itself in order to achieve a good anatomical result. In severe cases, extensive reconstructive pelvic floor surgery may also be required. In all cases good analgesia is imperative. The aim of surgery is to recreate a functional and accessible vagina and to be able to visualise the urethra. Patients often make a rapid recovery as long as the area is kept clean and dry. The patients are then encouraged within 3 months to return to or indeed commence sexual intercourse, if it is culturally acceptable.

In pregnant women with FGM, where de-infibulation has not taken place before delivery, the procedure may be performed in labour. An anterior or upward episiotomy is carried out.¹⁰⁵ However, skilled hands are required for this type of surgery and it should not be undertaken by untrained personnel, as damage to adjacent organs, particularly the urethra, can readily occur.⁴⁵ Most of these women will deliver normally. However, in cases where an anterior episiotomy is not performed, obstructed labour can result in the formation of tears, lacerations, avulsion of the urethra and subsequently fistulae.^106,107 Each one of these complications often requires further reconstructive surgery.

A study of birth outcomes of patients who had undergone FGM, carried out in Switzerland, showed that 6% wished to have their FGM de-infibulated antenatally, 43% requested a de-infibulation during labour, 34% requested de-infibulation during labour only if considered necessary by the medical team and 17% were unable to express their expectations.¹⁰⁸

Restorative or reconstructive surgery can thus be controversial as some practitioners do not believe it is required. However, women with FGM often have a very clear idea of what they want: they wish to’look normal’, ‘feel comfortable’, ‘pass urine without obstruction’ and ‘have sexual intercourse without fear’. In order to help them fulfil these aims, surgery becomes a significant component of their care. But, this surgery must be done by specialists in reconstructive vaginal and vulval surgery, using plastic surgery techniques when required, and not left in the hands of generalists.

The role for surgical management in FGM and its complications is well documented and well understood. What is more difficult to approach and treat is the psychological problem associated with FGM, and indeed some question this role as it needs to be culturally sensitive and can therefore not be left within the remits of a general psychology service. This poses a significant problem for healthcare providers.

Conclusion

FGM is no longer just in the domain of the nations who practise it but it is now part of global politics. FGM remains a highly emotive issue and laws alone cannot enforce its abolishment. In some cases it may serve to drive the practice underground. The whole management of FGM and the complications suffered, such as sexual dysfunction, requires careful discussion, understanding and temperance of the issues involved.

Female sexual dysfunction in women with FGM has been an under-reported condition for decades, and often overlooked in the face of managing a defined ‘clinical’ situation such as anterior labial scarring or inclusion clitoral cysts, without thought for the impact it has had or may have. It is only in the last few years that this issue is starting to be addressed. Treating FSD requires a multitude of approaches including conservative and surgical treatment. But, to combat the problems faced by these women, it needs to be understood that FGM is not a simple cultural practice, but a significant cause of pelvic floor dysfunction in all its ramifications. The problems suffered by these women are complex, but they will only disappear when the practice becomes obsolete. The momentum created within the last few years needs to be harnessed to continue to raise greater awareness in the world about FGM, engage communities and work together towards its global eradication as a practice. However, even then, the sequelae for many women will live on.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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