Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Sexuality and genital cutting

Jean L Fourcroy

Almighty God created sexual desire in ten parts; then he gave nine parts to women and one to men.

-Attributed to Ali ihn Abu Taleb, husband of Muhammeds daughter1

Does female genital cutting or female genital circumcision/ female genital mutilation affect female sexuality? To understand the impact of a cultural custom on a woman’s sexuality, one must first understand the origin, perpetuation, and prevalence of the custom as well as understand the procedure itself.

The question of a woman’s sexuality must also be understood within the culture where female genital cutting/female genital mutilation is practiced. Cultural and social mores play an important role in the acceptance and achievement of normal sexual function for both men and women. These mores limit a woman’s freedom during her entire life, including menses, marriage, pregnancy, and postpartum. Cultural mores also identify specific customs that should or must be followed. Thus, tradition, law, education, and the status of women are important indicators of sexual health.

Sexual health is an assumed right for every individual.Sexual health is a state of physical, emotional, mental, and social well-being related to sexuality; it is not merely the absence of disease, dysfunction, or infirmity.3 Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences. A sexual experience must be free of coercion, discrimination, and violence. For many women, discrimination and violence are part of their lives. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled.2 Sexual rights embrace human rights that are already recognized in international human rights documents, national laws, and other consensus documents. Education of women may be the most important socioeconomic piece of the puzzle of how to preserve the sexual health of women.4-6

Sexual health assumes that each individual:

 receive the highest attainable standard of health in relation to sexuality, including access to sexual and reproductive health-care services

 be able to seek, receive, and impart information in relation to sexuality

 have sexuality education

 have respect for bodily integrity

 have a choice of partner

 be able to decide whether to be sexually active or not

 be able to have consensual sexual relations and/or marriage

 be able to decide whether or not, and when, to have children

 be able to pursue a satisfying, safe, and pleasurable sexual life.

The responsible exercise of human rights requires that all persons respect the rights of others.7

History and prevalence of female genital cutting/female genital mutilation

The current preferred term for our subject is female genital cutting (FGC), but female genital mutilation (FGM) and cutting (FGC) are used interchangeably.

The origin of female cutting rituals cannot be traced but appears to have been practiced as early as the time of the Pharaohs. Even though female genital cutting/female genital mutilation is practiced mostly in Islamic countries, it is not an Islamic practice, and there does not appear to be a religious connection. The “circumcision” of girls, in any form, predated Islam by many centuries. It was practiced in some parts of Arabia at the time of the Prophet Muhammad and was evidently a custom of the time that may have been a practice of some, but not all, of the local tribes. Female genital cutting/female genital mutilation is practiced by Muslims and non-Muslims alike residing in sub-Saharan African in countries that include, but are not limited to, Egypt, Sudan, Somalia, Ethiopia, Kenya, and Chad (Fig. 16.8.1). A minor form of the procedure is also performed in some parts of the Middle East and south Asia.8 In Africa and the Middle East, it is performed by Muslims, Coptic Christians, members of various indigenous groups, Protestants, and Catholics. The procedure is also found among some ethnic groups in Oman, the United Arab Emirates, and Yemen, as well as in parts of India, Indonesia, and Malaysia. It is important to remember that, within a country, tribes or cultures may vary in the practice or the type of cutting employed.9 Country-specific “Demographic and Health Surveys”, listing the prevalence rates of female genital cutting/female genital mutilation, are maintained by the US State Department.10

Patterns of immigration have spread this practice worldwide. Estimates of the prevalence of female genital cutting/ female genital mutilation in the USA are based on the numbers of such immigrant families throughout the country. In 1990, it was estimated that nearly 168 000 immigrant women and girls in the USA had either undergone female genital cutting/female genital mutilation or were at risk of it.12,13

The Qur’an refers to the sexual relationship in marriage as one of mutual satisfaction that is considered a mercy from Allah. “It is lawful for you to go in unto your wives during the night preceding the [day’s] fast; they are as a garment for you and you are as a garment for them (2:187) ... and he has put love and mercy between you” (30:21).8

Figure 16.8.1. Map of African continent. Main areas where female genital cutting (FGC)/female genital mutilation (FGM) is practiced." Sub-Saharan African countries practicing some form of FGC include Egypt, Sudan, Somalia, Ethiopia, Kenya, and Chad.

Female genital cutting/female genital mutilation is thought to preserve a family’s honor and prevent promiscuity and immorality. The virginity of the girl-child is economically important, and the value placed upon this virginity probably dates back to the days of nomadic existence. However, it is claimed that the custom of genital mutilation is perpetuated because a circumcised woman provides more sexual pleasure for her husband. In a community when the majority of women have been circumcised, those who are not are considered abnormal by themselves or their families. It is a mark of cultural identity. Within a culture, female genital cutting/female genital mutilation is a powerful marker of belonging and affirms a woman’s identity. To be circumcised is to be normal. Belonging to the culture has tremendous significance in terms of the desirability of a young woman as a wife; a daughter’s marriageability is a major means for her family to achieve economic advancement and independence. Thus, a woman’s being unsuitable for marriage affects the ability of her family to prosper. The procedure is believed to ensure cleanliness and chastity and to minimize the sexual appetite of women, thus reducing the likelihood that they will bring shame on themselves or their families through sexual indiscretion. These guarantees of a young woman’s purity further enhance her attractiveness to potential suitors.8,14-16

In summary, the proponents of female genital cutting/ female genital mutilation believe that:

 The practice reinforces a woman’s place in her society.

 It establishes eligibility for marriage.

 It initiates a girl into womanhood.

 Female genitals are unhygienic and in need of cleaning.

 Female genitals are ugly and will grow unwieldy if not cut back.

 The practice safeguards virginity.

 It prevents maternal and infant mortality.

 It improves fertility.

 It enhances a husband’s sexual pleasure.

Cultural issues and social mores play an important role in the acceptance and achievement of normal sexual function for both men and women. Tradition, law, education, and the status of women are important indicators of the reproductive function of and freedom of women.17-19 Cultural mores limit women’s freedom during her entire life.

Female genital cutting has been considered one of the “three feminine sorrows”: that is, the sorrow on the day of the mutilation, that of the wedding night, and that of childbirth, reflecting the pain associated with these crucial points of a woman’s life.20

The cutting is usually done in infancy or just before puberty, but practice varies from tribe to tribe. It is a rite of passage, but also the physical sign of a woman’s marriageability, the assurance of virginity, and the formation of a chastity belt of her own tissue. The perpetuation of this custom is difficult to understand, since the risks to the health of women are so great, but harm is not the intention.

The term “female circumcision” is clearly inaccurate, as “circumcision” denotes the removal of part of the male prepuce. The World Health Organization has defined female genital cut- ting/female genital mutilation as all procedures that involve the partial or total removal of the female external genitalia and/or injury to the female genital organs for cultural or any other nontherapeutic reasons.2 Although the term “female genital mutilation” was previously used to describe this practice, it is now more widely known as “female genital cutting” to avoid the stigma previously associated with female genital mutilation.

Female genital cutting/female genital mutilation refers to a spectrum of surgical excisions from partial to complete clitoridectomy, including the removal of the labia minora and/or majora, scarifying the remnants, and even inserting a matchstick to maintain a sufficient opening for urination. The procedure can be classified according to the extent of the excision. Type I, often referred to as “sunna circumcision”, involves the removal of the clitoral prepuce (also called the clitoral hood), but it can also include either partial or total removal of the clitoris (clitoridectomy). Removal of the hood is similar to male circumcision but would be very difficult in a small, prepubertal girl. Types II, III, and IV are more traditional surgical excisions, and are all more damaging to the female urogenital system. Extensive genital excisions may require that the girl remain with her legs bound together from hip to ankle for 1 month or longer to ensure the adequate formation of scar tissue around the raw edges of the labia3,15,16,2CW9,32,33 (Table 16.8.1 and Fig. 16.8.2a-c).

Associated complications can be either immediate or delayed. At the time of the procedure, hemorrhage, shock, infection, and even septicemia and death are possible; severe pain because of the lack of anesthesia can contribute to shock and death. Urinary retention is often the immediate result of the procedure.

Table 16.8.1. Female genital cutting/female genital mutilation classifications

Type I Also known as “sunna" and involves the excision of the prepuce and/or partial or total clitoridectomy

Type II Procedure involves removal of the clitoris and partial or total excision of the labia minora

Type III This is also known as “Pharaonic" and involves clitoridectomy, and excision of the labia minora and majora; infibulation is the reapproximation of the cut ends

Type IV Refers to any other form of genital manipulation, e.g., burning, pricking, or piercing

Figure 16.8.2a. Type I - excision of prepuce, partial clitoridectomy, or total clitoridectomy. Type 1 is also known as “sunna", an Islamic term that refers to a traditional practice, or a customary procedure or action. The image on the left has red highlighting the area cut, and the healed area on the right.

Although the age of circumcision ranges from newborn to adult years, it is primarily a prepubertal custom done while the child is held down by a family member. When one considers the anatomy of the underdeveloped prepubertal female external genitalia, one can begin to understand the associated adverse events. It is a procedure done without anesthesia, sterile instruments, or visual accuracy. Miscalculations are disastrous. The clitoris, like the penis, is rich in vascular, lymphatic, and neural supply; and extensive bleeding is common.

Delayed gynecologic complications include hematocolpos, menstrual disorders, vaginal stenosis, and future infertility or sterility (see Chapters 9.2-9.5 of this book). An uncommon occurrence can be hematocolpos secondary to imperforate hymen unrelated to female genital cutting. When a young a girl presents with an enlarging abdominal mass and apparent amenorrhea, she may be killed for the honor of the family if they assume that she is pregnant and fail to realize that her menstrual flow is obstructed. The urologic complications relate to the extent of the adnexal damage from infection, bleeding, or the wideness of the excision of the clitoris and adnexal labia. Either incontinence, because of loss of sphincter function, or urethral stenosis and inability to void appropriately can result. The latter is associated with increased urinary infections because of the relative or complete obstruction. Obstetric complications include prolonged labor and fistula formation between the vagina and the bladder or urethra because of the prolonged labor secondary to the altered birth canal4,30,33-35 (see Chapter 7.5).

Late-appearing scars include dermoid inclusions, neuromas, vulvar cysts and abscesses, and keloid formation.36,37 All of these are especially troublesome and painful when nerve endings become entrapped. Sexual “scars” also include the pain and fear that may accompany intercourse and lead to marital problems. Depression and other psychiatric complications may be secondary to a system built on distrust. The person holding the child at the time of the procedure is usually a trusted family member such as the mother; this breach of trust has long-term effects on child and parent.

Each of these complications can obviously affect a woman’s sexuality. However, there has been little research on the effects of these procedures on women’s sexuality. Women with extensive female genital cutting/female genital mutilation may find vaginal intercourse impossible or impeded, although they may be fertile. Childbirth in such women also requires appropriate care, including anesthesia and a midlongitudinal cut, to avoid extensive tearing and obstetric delay.29,38 Nour notes that the two main causes of infertility are anatomic and psychologic barriers. Women with type III have infertility rates as high as 25-30%. Dyspareunia and the inability to achieve penetration can create stress and frustration in a couple’s sexual life (see Chapters 12.1-12.6).

Figure 16.8.2b. Type II involves the removal of the clitoris accompanied by partial or total excision of the labia minora. It is thought that this is the most common form of circumcision practiced throughout central and western Africa. No stitching takes place, but deep cutting of the labia minora may result in raw surfaces that fuse together during healing, creating a false infibulation or pseudo-infibulation. The image on the left has red highlighting the area cut, and the healed area on the right.

The sexual complications of female genital cutting/female genital mutilation have not been well researched, and there are conflicting reports. The removal of a woman’s external sexual organs (such as the clitoris) and infibulation may leave the woman with little sexually sensitive genital tissue. Although female genital cutting/female genital mutilation does not affect the hormones that contribute to sexual arousal, the missing structures and tissue can have a negative effect on sexual desire, arousal, pleasure, and satisfaction. Other sexually sensitive parts of the body, such as the breasts, nipples, lips, neck, and earlobes, may become increasingly sensitive in women who have undergone female genital cutting to make up for the lack of clitoral stimulation.31 The type and depth of the genital cut also affect sexual responsiveness. Each of these factors plays an important role in the sexual life of women with female genital cutting/female genital mutilation.21 Although type I may be practiced in one culture, the cutter may have missed his aim with a screaming child. It has been reported that women with type I were unaffected, while those with type III were significantly affected.39 A report and curriculum developed by Dr Morris at San Diego State University confirmed some of the problems.14,46 One woman reported to the investigators: “When I make love with my husband, I can’t handle it. I don’t want to see him because I have a lot of pain.”

Lightfoot-Klein24-26 reported that “close to 90% of Sudanese women interviewed claimed to achieve, or had at some time in their lives achieved, orgasm”. It should be observed that orgasmic responses may vary according to the amount of tissue removed, and there is variation in erogenous stimulation as well as cultural expectations.

Figure 16.8.2c. Type III involves the most extensive alteration and constitutes approximately 15% of all procedures. This is referred to as “Pharaonic" circumcision or infibulation. It involves the removal of the clitoris, labia minora, and labia majora with reapproximation of the raw surfaces. A small opening is preserved to ensure passage for urine and menstrual blood. The image on the left has red highlighting the area cut, and the healed area is shown on the right.

Gruenbaum23 concluded that “the effect of female circumcision on sexuality is not uniform or sufficiently well understood. It would appear that the various forms of female circumcisions are not equally devastating to female sexuality. There can be no doubt that many of the circumcision practices can alter physical well-being, including sexual responsiveness. Psychologic aspects of sexuality must also impact on sexual responses. The trauma of circumcision may always influence a woman’s sex life.”

Measures of female sexual function often use coital frequency as a surrogate marker of normal sexual function. Unfortunately, there is no way to identify in these studies who initiated the sex act. In a study evaluating Nigerian women attending family planning and antenatal clinics, a structured questionnaire was used which asked about the frequency of orgasm achieved during sexual intercourse and symptoms of reproductive tract infections.4 Forty-five percent of the women were circumcised, including 71% with type I and 24% with type II. The researchers found no significant differences between cut and uncut women in the frequency of reports of sexual intercourse, the frequency of reports of early arousal during intercourse, and the proportions reporting experience of orgasm during intercourse. Uncut women were significantly more likely to report that the clitoris is the most sexually sensitive part of their body, while cut women were more likely to report that their breasts are their most sexually sensitive body parts. Cut women were significantly more likely than uncut women to report having lower abdominal pain and vaginal discharge. Female genital cutting in this group of women did not attenuate sexual feelings. However, female genital cutting may predispose women to adverse sexuality outcomes, including early pregnancy and reproductive tract infections.

Depression and other psychologic disorders may be important sequelae of female genital cutting/female genital mutilation and would also be important markers of the perception of women’s sexuality. No research has been done to determine the effect of depression or possible anxiety on sexuality in these women.

Do male expectations determine the prevalence of female genital cutting/female genital mutilation and the sexual response of women? “If men say they don’t want the external genitalia, then women won’t want to have it.”23 An important aspect of assumed male sexual pleasure is the culturally defined anatomic appearance. Male preference is for smoothness of the vulva in cultures practicing female circumcision; a husband may find a woman’s body distasteful if the vulva is not smooth. Female sexual desires may reflect the cultural norm set by men. In many of these cultures, the fidelity of the partners will be an important aspect of a woman’s sexuality. Does the presence of the husband’s multiple partners outside the home affect a woman’s sexual response? Partner reduction and fidelity have been important concepts in the reduction of human immunodeficiency virus.41 There are few jobs in rural areas, and most men in rural areas must travel far for migrant work. The acceptance and availability of prostitutes in a particular country will also be important determinants in the spread of disease.

In many of the cultures practicing female genital cutting/female genital mutilation, a dry vagina is also deemed important. The role of agents thought to dry and tighten a woman’s vagina and serve as love potions to attract sexual partners and ensure their faithfulness is unclear. It is presumed that these agents draw out moisture, but such astringent agents may be important to reduce secretions from the high prevalence of vaginal infections.42-45

Does female genital cutting/female genital mutilation allow women to have a normal and fulfilling sexual relationship? The ability to engage in a mutually fulfilling sexual relationship is an important element in reproductive health. The role of female genital cutting/female genital mutilation in the normal cycle of sexuality is unclear. It is also difficult to understand if we look through Western eyes. Although female genital cutting/female genital mutilation is supposed to control sexuality before marriage, these same women are expected to be sexually responsive to their husbands in marriage. Coital difficulty or inability to have vaginal intercourse at all because of stenosis of the vagina may affect up to 35% of “Pharaonically” circumcised women, and dyspareunia may be common. It is probable that sexual pain disorders may play a role and have an indirect effect on desire, arousal, and orgasmic sexual responses. Sexual dysfunction is highly associated with negative experiences in sexual relationships and reduction of overall well-being. Sexual complications include the pain and fear that may accompany sexual intercourse and can lead to marital problems.

Cultural sensitivity in addressing these problems with a circumcised woman is critical. Most immigrant women do not feel comfortable discussing intimate problems with health-care workers they view as strangers. Toubia31 cautions health workers to assume that satisfactory sexual and emotional relationships exist in couples regardless of the degree of the women’s genital cutting. In interviews with genitally cut women, it was found they had experienced orgasm at some time. Their statements were “qualified by the fact that they were not always sexually satisfied, and it was the nature of the relationship and the sensitivity of the partner that made the difference”. Many couples can have a fulfilling relationship because of the deep emotional bond, camaraderie, and social compatibility even if the sexual aspect is missing.

Although both US and Canadian law, as well as many state laws and international laws,44,45 prohibit the circumcision of any woman under the age of 18 years, there are still many women in the USA who have undergone this procedure. Changes in reproductive rights and information must challenge the culture of silence that has been associated with sex education and contraceptive understanding. Education for women and their daughters will be key to improving their sexuality.

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