Female genital mutilation/cutting (FGM/C) is defined by the World Health Organization as including all procedures involving partial or total removal of the external female genitalia or other injuries to the female genital organs for non‐medical reasons [1]. FGM has a tribal origin. It is a widespread cultural ritual, mostly in sub‐Saharan Africa, and to some extent in the Middle East and Far East, and among immigrant communities in Europe [2,3]. FGM/C is customarily carried out domestically and without anaesthesia by a traditional circumciser using a knife or razor. About 200 million girls in Africa and the Middle East have undergone FGM/C, from toddlers to pubertal girls [1].

Types of Female Genital Mutilation/Cutting (FGM/C)

FGM/C involves one or more procedures that vary according to geographical region and local practices (Figure 46.1) and may be categorised into four major types [2,4].

• Type I, in which all or part of the external clitoris and the clitoral hood is removed.
  
• Type II, in which Type I is combined with removal of all or a part of the labia minora.
  
• Type III (infibulation), in which all or part of the labia minora and labia majora are removed, and the resulting wound is sutured. A small cutaneous fistula is left for the passage of urine and menstrual blood, and the wound is opened only for intercourse and childbirth.
  
• Type IV includes all other harmful procedure to the female genitalia for non‐medical purposes.

In Western countries, the demand for reconstruction of scarred female genitalia is increasing due to the empowerment of immigrant women from Africa [2,3,5]. Although the harmful effects on health depend on the type of FGM/C, all types include removal of all or part of the external clitoris and clitoral hood [1,4]. Therefore, correction of the mutilated clitoris is usually required to remedy the state of FGM/C for these women.

Current recommendations regarding the healthcare of woman after FGM/C differ among the European countries. Whereas clitoral reconstruction is reimbursed in some countries, other countries are still debating the potential psychophysical harm of FGM /C and considering questions such as whether reconstruction after FGM/C is advisable or not and whether it should, or should not, be part of the primary healthcare reimbursement system [2,6]. Healthcare professionals often view the surgical correction of FMG/C only as a way to support gender identity and promote female completeness, which, in their view, can easily be alternatively achieved by sexual counselling and anatomy lessons [2,7,8].

The surgical technique for clitoral reconstruction after FGM/C has been well established by Pierre Foldès [9–11], and other surgeons have reproduced his surgical results [12–15]. However, the first article on reconstruction was published by Thabet [16]. It should be noted that the outcome of external genital reconstructive surgery in this group of women has to date not been fully established and recognised in the mainstream scientific medical literature [2].

Human rights and FGM/C

FGM/C is recognised internationally as a violation of the human rights of girls and women [1,17]. FGM/C is also a violation of the right to the highest attainable standard of health, as FGM/C interferes with healthy genital tissue in the absence of medical necessity. FGM/C can also violate the right to life, as in the most extreme cases a girl dies when undergoing the procedure. Because FGM/C is commonly carried out on young girls, it is a violation of the rights of children [18]. The practice also violates a person’s right to security and physical integrity, including freedom from violence. The international community also considers FGM/C a form of torture, a cruel, inhuman, and degrading process. The European Court of Human Rights has repeatedly emphasised that subjecting a girl or woman to FGM/C amounts to ill‐treatment: “It is not in dispute that subjecting a woman to female genital mutilation amounts to ill‐treatment contrary to Article 3 of the Convention” and therefore the risk of undergoing FGM/C is even a ground to apply for asylum [19].

Acknowledging that FGM/C is a violation of the human rights of girls and women that needs to be eliminated worldwide implies that women ought to be offered treatment to optimally undo the injury to their genital organs, whenever possible. Therefore, any well‐informed and competent adult woman should be free to choose reconstructive surgery of the clitoris after FGM/C.

Impact of FGM/C

FGM/C is commonly performed by traditional practitioners using non‐sterile equipment. The practice is carried out on young females less than 15 years of age, without any analgesia. To this day, FGM/C has no proven health benefits and can lead to life‐threatening complications, and significant psychological harm and permanent physical debilitation.

The procedure of FGM/C involves (partly) excising healthy genitalia and is intended to disrupt natural tissue functioning. The immediate effects of FGM/C are pain, bleeding, and psychological distress. Notable complications include haemorrhage, injury to the adjacent tissues, acute urinary retention, infection and abscesses, and failure to heal, which can be fatal. After complete healing, the long‐term consequences include recurrent urinary tract infections, menstrual difficulties, chronic pelvic infections, increased risk of obstetric complications, and keloid scar formation [4,17]. In addition to this, physical and emotional dysfunction can be persistent throughout life if left untreated [19].

Sexuality and FGM/C

In communities where it is practised, FGM/C is supported as a traditional rite. Family honour within a community may also be dependent on the daughter’s virginity, and FGM/C is used as a tool to maintain this [3]. Although the driving force of FGM/C is to facilitate sexual restraint, victims of this practice are still able to experience a fulfilling sexual life [20].

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