Arguably one of the world’s most abhorrent surgical and/or ritualistic practices is the removal of the clitoris, i.e., a clitoridectomy (sometimes referred to as a clitorectomy). Apart from cases of medical necessity (e.g., the spreading of cancer to the clitoris), the vast majority of occurrences can really be best described as female genital mutilation and defined by the World Health Organisation (WHO) as “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons”. In societies where clitoridectomies are performed as part of tribal rituals (such as those by the Maasai in Kenya and Northern Tanzania), the main reason for them is by male societies trying to inhibit the act of female masturbation.
According to the World Health Organisation’s online report about female genital mutilation (FGM), clitoridectomies have no health benefits for females, that approximately 140 million girls and women worldwide (but mostly in Africa where about three million girls are at risk for FGM annually.) have been genitally mutilated (usually between infancy and 15 years old), and that FGM is mostly carried out by “traditional circumcisers” although there is a increasing trend for it to be carried out by health care providers (over 18% according to the WHO). They also note that FGM can be classified into four major types: (which I have reproduced verbatim from their report):
- Clitoridectomy: Partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
- Excision: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are “the lips” that surround the vagina).
- Infibulation: Narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris.
- Other: All other harmful procedures to the female genitalia for non-medical purposes (e.g. pricking, piercing, incising, scraping and cauterizing the genital area).
The WHO report also briefly examined the cultural, religious and social causes of FGM. The WHO noted:
“The causes of female genital mutilation include a mix of cultural, religious and social factors within families and communities. Where FGM is a social convention, the social pressure to conform to what others do and have been doing is a strong motivation to perpetuate the practice. FGM is often considered a necessary part of raising a girl properly, and a way to prepare her for adulthood and marriage. FGM is in many communities believed to reduce a woman’s libido and therefore believed to help her resist ‘illicit’ sexual acts….FGM is associated with cultural ideals of femininity and modesty, which include the notion that girls are ‘clean’ and ‘beautiful’ after removal of body parts that are considered ‘male’ or ‘unclean’. Local structures of power and authority, such as community leaders, religious leaders, circumcisers, and even some medical personnel can contribute to upholding the practice”
In a recent (2012) issue of medical journal The Lancet, Dr. Pierre Foldes and his colleagues assessed the immediate and long-term outcomes of reconstructive surgery following genital mutilation. They surveyed 2,938 females (consecutive cases between 1998 and 2009 with an average age of 29 years; 866 of them were re-surveyed at a one-year follow-up interview) that had received reconstructive surgery at the Poissy-St Germain Hospital (in France) following genital mutilation. Most of the women operated upon were from Africa (Senegal, Mali and the Ivory Coast) although Foldes and his colleagues reported that 564 of the women had been genitally mutilated while living in France. The authors reported:
“Expectations before surgery were identity recovery for 2933 patients (99%), improved sex life for 2378 patients (81%), and pain reduction for 847 patients (29%). At 1-year follow-up, 363 women (42%) had a hoodless glans, 239 (28%) had a normal clitoris, 210 (24%) had a visible projection, 51 (6%) had a palpable projection, and three (0·4%) had no change. Most patients reported an improvement, or at least no worsening, in pain (821 of 840 patients) and clitoral pleasure (815 of 834 patients). At 1 year, 430 (51%) of 841 women experienced orgasms. Immediate complications after surgery (haematoma, suture failure, moderate fever) were noted in 155 (5%) of the 2938 patients, and 108 (4%) were briefly re-admitted to hospital”.
On the basis of these findings, Dr. Foldes’ report concluded that the reconstructive surgeries that had been carried out following female genital mutilation appeared to be associated with both reduced pain and restored pleasure (including the ability to have clitoral orgasms).
The vast majority of FGM occurs as a result of third party intervention. However, there are a few isolated cases of clitoral/labial self-mutilation in the clinical and medical literature. (I also examined more general female genital self-mutilation in a previous blog particularly in relation to internal vaginal self-mutilation). A recent paper by Dr. David Veale and Joe Daniels published in a 2012 issue of the Archives of Sexual Behavior examined what they believe is the only case of a women who wanted a clitoridectomy for cosmetic reasons. Prior to this case, they noted that there had been only two previous reports in the literature of self-mutilation of the clitoris/labia (one by Dr. Krasucki and colleagues in a 1995 issue of the British Journal of Medical Psychology and Dr. Wise and colleagues in a 1989 issue of the Journal of Sex and Marital Therapy). Both of the women in these cases of clitoral/labial self-mutilation were associated with severe psychosis/schizophrenia. Veale and Daniels reported that:
“The patient was a 33-year-old married woman with two children who lived with her husband. She was not from a culture that conducted FGM but she believes she was taught about it at school…She can remember starting to dislike her genitalia and pubic hair very gradually since about the age of 13. As she was at boarding school, it was not possible to shave her pubic hair until she left at the age of 18…Her motivation for shaving was a desire for ‘’simplicity and bareness’. She had continued to wax and shave her pubic hair for the past 14 years and was in the process of permanent hair removal, feeling it was more hygienic as well as preferred by her husband. Her dislike of her genitalia continued to increase gradually during adolescence with the growth of secondary sexual characteristics, including the labia minora. The changes in the labia minora became more pronounced with pregnancy and birth of two children born vaginally…She had tried piercing her inner labia and clitoral hood as a form of distraction. However, she found the piercings uncomfortable, which drew further attention to her dislike, so she removed them. Cosmetic labiaplasty had been performed about 1 year prior to assessment. She reported this as much improving the cosmetic appearance of her genitalia and reducing her self-consciousness.
She had become aware that she could do something surgically about her genitalia from her late teens. She had no concerns about the rest of her body and had had no other cosmetic procedures in her lifetime. When assessed, she knew that the appearance of her genitalia looked normal, but she felt they were ugly and hated the look of them. However, her concerns did not amount to a preoccupation (one of criteria for a diagnosis of body dysmorphic disorder…She felt self-conscious in a swimsuit and would not use public changing rooms. She denied that she was being coerced towards surgery or that any sadomasochism was involved…She understood that a clitoridectomy could lead to anorgasmia. However, she believed that the orgasms she experienced during intercourse or by masturbation were mainly vaginal and not clitoral. Improving the aesthetics of the genitalia was more important to her than achieving orgasm and would reduce her anxiety in sexual intimacy…In summary, she had a longstanding aversion to her genitalia associated with an extreme desire for a cosmetic procedure. Such a request, in the absence of any cultural beliefs, would suggest to most clinicians that a patient was very disturbed. However…she had no evidence of any psychiatric disorder or personality disorder”.
Following a full psychiatric check and interviews with the woman’s husband, a clitoridectomy was performed. Veale and Daniels were fully aware that the request for a voluntary clitoridectomy was extremely rare and unusual. However, the post-operative, the woman was extremely grateful and satisfied with the results (even at follow-up nearly two years later). She reported that her sex life had improved and there was no desire to modify any other part of her body. They concluded that although cases of wanting voluntary clitoridectomy are exceedingly rare, there is always the possibility that in the future others may seek such a procedure on cosmetic grounds but that those wanting such a radical operation will require very careful assessment before any operation took place.
Foldes, P., Cuzin, B. & Andro, A. Reconstructive surgery after female genital mutilation: a prospective cohort study. The Lancet, 380, 134-141.
Krasucki, C., Kemp, R., & David, A. (1995). A case of female genital self- mutilation in schizophrenia. British Journal of Medical Psychology, 68, 179–186.
Veale, D. & Daniels, J. (2012). Cosmetic clitoridectomy in a 33-year-old woman. Archives of Sex Behavior, 41, 725-730.
Wikipedia (2012), Clitoridectomy. Located at: http://en.wikipedia.org/wiki/Clitoridectomy
Wise, T. N., Dietricha, M., & Segalle, E. (1989). Female genital self- mutilation: Case reports and literature review. Journal of Sex and Marital Therapy, 15, 269–274.
World Health Organisation (2012). Female genital mutilation (Fact Sheet 241), February. Located at: http://www.who.int/mediacentre/factsheets/fs241/en/