Undoing the damage

Good results: Sisters Kadi (left) and Fatoumata have both undergone reconstructive surgery. Photo: Jonathan Cami

Each year more than 2 million girls worldwide are subjected to genital mutilation, but a pioneering technique is restoring hope to those affected.

It’s a crisp and sunny winter’s day in Barcelona and I have come to meet Fatou, an 18-year-old architecture student with a sweet smile who arrived in Spain from her native Senegal seven years ago. Like many African girls, Fatou was circumcised as a child, a procedure now known as female genital mutilation, and last year she underwent surgery to remove scar tissue and restore sensation. “Now when I have sex with my boyfriend, I feel something where I felt nothing before,” she tells me. “But also I am no longer different from the Spanish girls here. At school when they talked about sexual feelings, I didn’t understand. Now I am the same as them, and that is just as important.”

Fatou was cut at the age of five against the wishes of her mother, who had already emigrated to Spain. “I was living with my grandmother,” Fatou says. “She told me a lady would come to the house and I should be calm. There were four of us; we had to shower first, then our eyes were covered and women held our arms and legs. I was able to see the razor blade: there were four cuts. I bled a lot and cried and my grandmother was frightened, but she couldn’t take me to hospital because cutting was against the law.”

Healing hands: Pere Barri Soldevila performs reconstructive surgery in Spain. Photo: Jonathan Cami

The practice of female genital mutilation, or cutting (FGM/C), is concentrated in most African countries and the Middle East, as well as – covertly and illegally – among immigrant communities in Australia, Europe and the US. It can take several forms but usually involves excision of the clitoris and partial sealing of the vagina. It is done ostensibly to preserve a girl’s chastity and render her immune to sexual desire. When Fatou was 12 and reunited with her parents in Spain, her mother told her about the reconstructive surgery being offered free at Dexeus, a private women’s hospital in Barcelona.

“My sister and I said, ‘No, we didn’t want it’, ” she says. “But then some years later at school, I did an essay about FGM and I rang my grandmother in Senegal for help with the research. She told me she was no longer arranging cutting for her grandchildren, which made me happy. Then I decided to have the surgery.”

What was it like afterwards when she explored her newly exposed clitoris? Fatou laughs: “I thought it would be bigger. But now I know it is normal.”

Surgical choice: Pierre Foldes at the Paris hospital where he operates twice a week. Photo: AFP

Was she able to feel pleasure? “At first it was painful, but then after a few months it began to be exciting.”

Emboldened by her sister’s experience, 20-year-old Kadi, a trainee nurse, also had surgery in October last year, but there were complications. “I had inflammation and a urine infection,” she tells me. “I couldn’t walk for a month.” Now she has recovered, is sex with her boyfriend better? “It is certainly different,” she says. “The intensity of the pleasure has grown. But it is only four months since the surgery, so there is room for improvement.”

Two weeks after I meet the girls, Fatou and Kadi’s mother is due to have the surgery: she is apprehensive, they say. What does their father think? “He doesn’t understand it,” says Fatou. “But he says it is her decision.”

Tough decision: Khadija Gbla, from Sierra Leone, has decided against having reconstructive surgery. Photo: Randy Larcombe

The genital reconstruction program at Dexeus is headed by 37-year-old gynaecologist Pere Barri Soldevila, who worked for several years on humanitarian programs in Africa where almost all the women he saw had undergone FGM. “But I did not know reconstructive surgery existed until I did a residency in Paris and saw the technique there,” he tells me. “Then I thought, ‘Why don’t we do something for ladies in Spain?’ Everyone at Dexeus was very motivated; we knew from the beginning that we should not charge for treatment and our foundation agreed to fund it.”

He was confident there would be demand for reconstruction from migrant women. “But how to access them? It was very hard,” he says. “We held a press conference to launch the program in 2007 but it was a year before we had our first patient. It takes a lot of courage to go against the culture.”

Pierre Foldés is a urologist and a crusader for the rights of women to a pain-free, pleasurable sex life and safe childbirth. His technique of reconstructive surgery was pioneering work, initially developed when he worked as a volunteer with Médecins du Monde in African conflict zones. But others are picking up the baton: as well as Pere Barri Soldevila in Barcelona, reconstruction is now offered in San Francisco and, most recently, in Berlin at a clinic opened in September 2013 by Waris Dirie, the Somalian model whose Desert Flower Foundation campaigns to eradicate all forms of FGM.

Foldés operates two days a week at the Clinique St Germain, a modern building tucked discreetly away in an outer suburb of Paris. It is a place full of secrets: the women who assemble in the waiting room mostly come alone, saying nothing to husbands or family. They are silenced by shame and the distant memory of pain and fear in their childhood past. One woman sits quietly, her hands folded in her lap. Her daughter sits beside her. Soon two more women arrive: they are around 30-ish and solidly built, with a defiant, slightly aggressive air, and I think they are probably very nervous. The patients are all here in the hope that Foldés can restore their womanhood.

As I wait, leafing through copies of Paris Match, Foldés strides out of his office, a tall man running his hand through rumpled white hair, evidently harassed. He has been in theatre all morning and now faces a clinic rapidly filling up with prospective patients. Seconds later he is back: “Come, we can have a few minutes,” he says. On his laptop he plays me a slide show: gruesome examples of the damage inflicted by FGM. “The women who come here are victims of this grotesque practice.” He insists he does not push them towards surgery. “They may have a period of reflection, some come back again and again. They are afraid of disapproval, even threats, from their community or family members. They are walled up in their own silence and our aim is to give them back their voice.”

I discover the two younger women in the waiting room are sisters, born in Paris to parents from Mali, west Africa, and they were cut when they were six and seven years old. Later they tell me about the woman who did it, a kind of procuress. “She did all the Mali girls,” they say. “She would call on the mothers in our community offering to cut their daughters. We had to go to her flat to have it done. She is in prison now.”

When Foldés first thought of restoring the clitoris 15 years ago, he was shocked by the dearth of information. “There was nothing, absolutely nothing on this organ, although there are hundreds of books on the penis and several surgical techniques to lengthen it, enlarge it or repair it,” he says. “Nobody was studying the clitoris: it was as if it didn’t exist.”

Foldés explains that though the tip of the clitoris has been excised in the original cutting, several centimetres of the stump remain, complete with nerve endings. He holds up a small ultrasound device: “A very expensive bit of kit,” he says, “but useful. I can show the woman the body of her clitoris on the screen.

“Scar tissue surrounds the clitoris as if it is en croute; we remove the scarring, snip the ligaments to pull up and expose a new tip and then, fibre by fibre, stitch the three layers around it to prevent it retracting.”

A report by Foldés published in The Lancet journal last year was challenged by three British gynaecology consultants. His claims that neurovascular sensitivity could be preserved in a newly excavated clitoris were not anatomically possible, they said: creation of a cosmetic clitoris could not revive lost or damaged nerves.

“They are totally wrong,” insists Foldés, bringing up a colourful diagram of female genitalia on his screen. “Here is the nerve running all along the trunk and these little red dots are pleasure zones – see, there are more of them in the main body than on the tip.”

But he admits it is not clear how successfully sexual pleasure can be achieved with reconstruction: “Women tell me they have sexual feelings they didn’t have before, but if you’ve never had an orgasm how do you know what it feels like?”

The elegant woman from the waiting room, who we’ll call Aminata, is looking forward to finding out. When I catch up with her after her consultation, she tells me she was cut at the age of nine in her home city of Dakar in Senegal. She is now in her mid-40s but remembers the episode with terrifying clarity: “It was very early in the morning, there was no anaesthetic and the pain was unbelievable. It stays with me today – I can still conjure it up.”

Aminata is a financial administrator and lives in Washington with her husband. “He was from a neighbouring country in west Africa, so he was not surprised that I had been cut. Even so, you can’t understand what it does to your psyche: you don’t feel like a real woman. It has an impact on your sexual relationship but you are ashamed to discuss it.” She had not told her 21-year-old daughter, Kenza, that she had been cut until today: she never found the right moment. Kenza admits she was surprised: “I knew of the practice but I’d placed it in a different context – rural villages and ignorance. It was shocking to discover it had been done to my mother in the capital city.”

Foldés has told Aminata that he can restore her clitoris. Has she ever achieved orgasm? “I believe I have,” she says cautiously. But she is hoping for something better? “Yes! I’m feeling optimistic.”

In France, reconstructive surgery for victims of FGM is funded by the government and Foldés has carried out the procedure on thousands of women. In Barcelona, since Pere Barri Soldevila launched his charitable program seven years ago, word has spread: women tell mothers who tell their daughters and numbers are slowly increasing. There have been 52 reconstructions since the first patient in 2008, 13 of those in 2013 and four already this year. Each patient has medical and psychological follow-ups after six months. “Most are happy,” says Barri. “Some are extremely happy and for some it did not work – there was no difference in sensation. This could be because nerves were damaged during the procedure or because of previous damage, or for psychological reasons.”

How many report achieving orgasm? “Some 75 per cent say there’s been an increase in sensitivity,” he says. “Between 30 and 35 per cent can have an orgasm whenever they want. But I think the reconstruction is important to them for other reasons: they can feel like European women.”

There have been a few women who have come to him for a reconstruction but when he examines them he finds they are not mutilated. “This is starting to happen,” he says. “In her native country the girl has experienced the ritual that attends FGM – the party, so to speak – but she has not been cut. She was told it was done and grows up thinking she is different from European girls. Then I tell her, ‘You are lucky, you don’t have FGM.’ In such cases, the women are referred to a psychologist.”

Marci Bowers works as a gender reassignment specialist and began offering genital reconstruction at her clinic in San Mateo, California four years ago. Her patients came via Clitoraid, a charity funded by the Raelian sect, which promotes sexual pleasure as a human right. But the majority of women who seek Bowers’ help are, she says, principally interested in the restoration of their feminine identity. At first Bowers was “wildly excited” at the prospect of transforming the lives of circumcised women. “But the results are not what I expected. The procedure is much more subtle than I realised and the clitoris has a tendency to retreat back under the skin of the perineum.”

Like Barri, Marci Bowers studied with Foldés in Paris but admits that the disappointment may be due to her own technical limitations. “The other things we battle with,” she says, “are that patients are psychologically traumatised, lack sexual confidence and may not easily access orgasm. I try not to set the bar too high and am now more guarded in what I promise.”

When Khadija Gbla came to Australia from Sierra Leone, she soon realised that she was different from other girls. “The idea of reversing the procedure was the first thing I went looking for,” she tells me, “but that was 12 years ago and there was nothing anywhere that I could find.” Recently Gbla, now 25, read about the work of Foldés in Paris. “My first reaction was one of hope,” she says, “but I am an intelligent woman – I said to myself, ‘Let’s think about biology.’ Apparently some nerve endings remain after clitoridectomy and some women retain sensation. If you have surgery you might end up losing what little you had in the first place. Then there is the emotional and psychological toll. We are already traumatised by the original procedure – do we want to be traumatised all over again for not necessarily any gain? I don’t think this is exciting news, just potential for more damage. I’m waiting for something better to come along.”

Meanwhile, more than 2 million girls worldwide are subjected to FGM/C every year. Although the practice has dropped by half in a handful of countries where education has penetrated, it is still prevalent in others – up to 98 per cent of girls are cut in Somalia, according to UNICEF.

In Australia, as in the rest of the developed world, the emphasis is on prevention. At Monash Health, health worker Faduma Musse has spent 10 years working with African migrant communities to stop FGM/C happening. “It is against the law here,” she says. “But girls are taken out of the country to have it done. People say, ‘She is my child’, then I tell them they could lose the child if they break the law. They are not happy with us but slowly people are learning. It takes a long time.”

THE PAIN OF CIRCUMCISION 

The crude and cruel tradition of circumcising young girls takes different forms depending on local practice. In some cases, only the clitoris is excised (clitoridectomy); in others the inner lips or labia minora are also removed. Infibulation is the sealing of the vaginal opening by cutting and repositioning the inner or outer labia, leaving only a small opening for urination and menstruation. Often all three forms are practised: clitoridectomy, total excision and infibulation.

Opening up the entrance to the vagina for intercourse and delivery is known as de-infibulation and is offered by specialist clinics in the developed world, including, since 2010, the Royal Women’s Hospital in Melbourne. This is a relatively simple procedure compared to the reconstructive work offered by Pierre Foldés and his acolytes elsewhere. “Routine de-infibulation leaves the vulva with two scars,” Pierre Foldés tells me at his Paris clinic. “Whereas reconstruction of the lips is precise surgery.”

Female genital mutilation, or cutting (FGM/C) often causes problems in childbirth. “The vulva has sometimes become attached to the pubic bone, so is not mobile and independent as it should be,” Foldés explains. “This may cause both pain and a pseudo infibulation: that is to say scar tissue has partially sealed the vaginal opening, blocking the exit of the baby. In addition, intercourse and delivery can cause lacerations of the perineum with subsequent bleeding.”

In some cases the vagina is left so obstructed that urine and menstrual blood cannot pass easily, cysts build up with fluid, and urinary tract and kidney infections are common. One of the more degrading consequences of FGM is a fistula, where a hole is created between the vagina and the bladder or the anus, often after prolonged labour due to the obstructed birth passage.