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Dossier: Réparer les corps et les sexes

The Growing Demand in Europe for Reconstructive Clitoral Surgery after Female Genital Cutting: A Looping Effect of the Dominant Discourse?

L’essor de la reconstruction clitoridienne après l’excision en Europe : effet de loupe ou discours dominant ?
Sara Johnsdotter
p. 141-166

Résumés

Quand les activistes combattent « l’excision » dans les années 1980, un fossé discursif s’est créé et persiste aujourd’hui. Les militants, les ONG, les gouvernements et certains chercheurs considèrent ces pratiques comme des mutilations, tandis que d’autres chercheurs n’ont pas adopté le nouveau terme de « mutilations génitales féminines » ou MGF et n’adhéraient pas à la perspective que ces pratiques devaient être décrites à l’intérieur d’un contexte plus large comprenant une multitude de variations. Partant de ce décalage, cet article discute la « chirurgie reconstructive clitoridienne » ou « la reconstruction clitoridienne » comme un phénomène culturel en plein essor. Utilisant le concept de « loupe grossissante » de Ian Hacking, nous montrons que la demande croissante pour la chirurgie reconstructive clitoridienne dans les pays européens doit être comprise en relation au discours dominant contre les mutilations génitales féminines. Alors que beaucoup d’équipes interdisciplinaires en Europe essayent de fournir un encadrement holistique et respectueux pour les femmes qui ont recours à la chirurgie, nous observons que ce discours hégémonique anti-FGM a des effets négatifs pour les femmes qui choisissent ou non la chirurgie.

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Texte intégral

Introduction

1In an increasing number of countries in Europe, the healthcare system offers circumcised women a surgery that is intended to «repair» early-life ritual cutting of the clitoral tip. As knowledge about the operation spreads, demand grows among women in affected immigrant groups. Granted, many women who go through the surgery feel better afterwards: restored, and fully feminine. But I would like to suggest that, despite its aura of benevolence, this surgery is embedded in a wider political context that deserves attention, and it comes with some negative social effects that ought to be critically discussed.

  • 1 Ian Hacking, «The looping effects of human kinds», in Dan Sperber, David Premack and Ann James Pr (...)

2In this article, I start with a brief historical look at dominant discourses on female genital cutting in Europe. After that, I present the surgery, which is known as «reconstructive clitoral surgery», or «clitoris repair», and I describe the motivations as well as the outcomes according to current research. I introduce the concepts of «interactive kinds» in research and related «looping effects»1 and argue that we ought to understand the growing demand for clitoris repair as an effect of a certain discourse rather than as a response to medical needs. After that, I present some concerns about the negative social effects of promotion of a surgery that is so strongly associated with a morally charged and ideological discourse. Finally, I make an attempt to draw out some of the implications of the current state of affairs.

3Regarding terminology: I will say «female genital mutilation» (FGM) when referring to activist or public discourse, since this is the established term. When I refer to the traditional practices as such, I prefer the more emic term «female circumcision» or the politically neutral term «female genital cutting» (FGC). Thus, these terms, with all their different connotations, will appear side by side.

From circumcision of girls to «female genital mutilation»

  • 2 Sara Johnsdotter, «Girls and boys as victims: Asymmetries and dynamics in European public discour (...)

4In the 1970s, the activism to put an end to what is now often called «female genital mutilation» (FGM) had not yet started. In the then scarce literature on the subject, the ritual practices involving «modifications of girls» genitalia were often described as equal to ritual practices «modifying boys» genitalia. This perspective of juxtaposing circumcision of girls and boys was in line with most local understandings of genital modifications of girls genitalia, according to which these procedures symbolically mirror each other – reflected in many languages where the same local term is used irrespective of gender, and generally with an added word specifying whether the «circumcision» concerns boys or girls2.

  • 3 Peter Andreas and Ethan Nadelmann, Policing the globe: Criminalization and crime control in inter (...)
  • 4 Sara Johnsdotter and Ruth Mestre i Mestre, «“Female genital mutilation” in Europe: Public discour (...)

5Activism that eventually resulted in the current global campaign to eradicate FGM, which we are all familiar with today, started in the late 1970s, and the process can be described as in line with what Peter Andreas and Ethan Nadermann (2006) have called the emergence of a «global prohibition regime»3. This is a model that describes the stages involved when a certain practice, at one point in time widely accepted, becomes object for repudiation, suppression, and criminalisation. At the first stage, a certain behaviour is widely accepted. At the second stage, influential social groups state that the behaviour should be banned; and at the third suppression and criminalisation take place. During the fourth stage, criminal laws and police action on the international level are established, and international institutions and conventions play a coordinating role. The fifth stage is characterised by powerful pressures to conform with the dictates of the regime. These stages are all identifiable in the process in which «circumcision of girls» – for a long time seen as no more problematic than circumcision of boys – turned into «female genital mutilation», which became object for global campaigns and strategies of eradication at the global level4.

The result: Divided perspectives of female genital cutting (FGC)

  • 5 Ellen Gruenbaum, «Sociocultural dynamics of female genital cutting», in Peter J Brown and Svea Cl (...)

6While activism to combat «female genital mutilation» (FGM) started in the late 1970s and flourished in the 1980s, social science scholars did not so readily abide by the new perspective5. This division of perspectives persists until today. Often it is possible to identify with which camp experts associate themselves through the terminology they use: FGM is used by most activists and medical scholars, while many social scientists prefer «female circumcision» or «female genital cutting» (FGC). Additionally, there are those who try to merge the perspectives by using the acronym FGM/C.

  • 6 E.G., Richard A. Shweder, «What about “female genital mutilation”? And why understanding culture (...)
  • 7 See, for example, the following authors who are all American scholars of African heritage, and th (...)

7Among some scholars, there is a more pronounced critique of what has been called «the global anti-FGM discourse»6. At a discursive level, the key positions of the two camps – in a simplified version; in reality positions are more scattered – can be described thus: According to most «FGM» researchers, activists, and policy makers, FGM is a violation of the human rights of women and girls, and their right to bodily integrity; FGM is performed in attempts to control women’s sexuality, and there is a strong focus on medical and sexual consequences. In contrast, scholars critical to the anti-FGM discourse argue that the global anti-FGM discourse is neo-colonialist and/or anti-feminist; that advocates of this discourse avoid discussing genital modifications accepted in the West, such as circumcision of boys and surgery in intersexed infants; and they claim that descriptions of medical and sexual consequences are often exaggerated7. Few of the critics defend circumcision of girls per se, but they do highlight questions that can be summarised into something like: «who has the power to define these practices and how they are contextualised?», «who has the right to put this issue at the top of the agenda of things that need to change in order to improve women’s lives ?», and «how can we have a serious discussion about this, when there are so many misconceptions and unfounded statements floating around?».

  • 8 Among them all, we find for example: Janice Boddy, Wombs and alien spirits: Women, men, and the Z (...)
  • 9 Jon-Håkon Schultz and Inger-Lise Lien, «Meaning-making of female genital cutting: Children’s perc (...)
  • 10 Wairimu Ngaruiya Njambi, «Irua Ria Atumia and anti-colonial struggles among the Gikuyu of Kenya: (...)
  • 11 Fuambai Ahmadu, «Rites and wrongs», op. cit.
  • 12 Claudia Merli, «Negotiating female genital cutting (sunat) in southern Thailand», in Chitra Ragha (...)
  • 13 One attempt to address this gap was made by fifteen researchers – including medical scientists as (...)

8Numerous anthropologists from various countries have contributed – during decades – with a more nuanced contextualisation of the practices, and discussed such aspects as how rituals are performed in order to prepare the child for a life in religious community, to accentuate gender difference and to perfect gendered bodies, for beautification, for cleanliness, to improve the social status of the girl through ritual, and so on8. They have strived to convey the complexity of the issue, and have described circumcision of girls as it appears as a reality in people’s lives. In such renderings, there are few traits that are common if one compares an infibulation of 6-year old girl in Somalia9 or an excision of a Gikuyu adolescent who opted for it10, with an excision during the Bondo initiation rite in Sierra Leone11 or a pricking of an eight-month old toddler in Thailand12. There is so much more complexity and variation involved here than the hegemonic global anti-FGM discourse allows for. The gap between what is said about female circumcision among anthropologists and other social science researchers on the one hand, and activists and policy makers on the other hand, does not seem to be narrowing with time13.

9This background about divided perspectives is relevant to the issue of how we understand the reconstructive clitoral surgery now increasingly available to circumcised women in Europe. The surgery is firmly established within the first anti-FGM perspective. The starting point of the critical discussion in this paper is in line with the latter perspective, originating in anthropology.

Reconstructive Clitoral Surgery

  • 14 Michela Villani, «From the “maturity” of a woman to surgery: Conditions for clitoris repair», Sex (...)
  • 15 Leye, E. (2018). «Multidisciplinary care for women affected by female genital mutilation/cutting (...)
  • 16 Jasmine Abdulcadir, «Psychosexual health after female genital mutilation/cutting and clitoral rec (...)
  • 17 Mallika Anand, Todd J. Stanhope and John A. Occhino, «Female genital mutilation reversal: A gener (...)
  • 18 Pierre Foldès, Béatrice Cuzin, and Armelle Andro, «Reconstructive surgery after female genital mu (...)
  • 19 Pierre Foldès et al., «Reconstructive surgery». Jasmine Abdulcadir, Michel Boulvain and Patrick P (...)

10Reconstructive clitoral surgery, or «clitoris repair»14, «clitoral reconstruction»15, «clitoral re-exposition»16, or «female genital mutilation reversal»17, was introduced in Europe in the 1990s by the French urologist Pierre Foldès18. There are now several techniques used by different surgeons, but also different ways of «reconstructing» or «repairing» depending on the individual woman and the type of circumcision. The basic idea, however, is to uncover clitoral tissue in order to obtain a protruding clitoris, often through a loosening of ligaments that allows for a repositioning of the clitoris19.

  • 20 Armelle Andro and Marie Lesclingand, «Female genital mutilation», op. cit.
  • 21 Pierre Foldès, «The pseudo-clitoris, a particular female genital mutilation: case series». Confer (...)
  • 22 Sophie Alexander, Jasmine Abdulcadir, Dina Bader, and Elise Dubuc, «Variations in availability an (...)
  • 23 Sophie Alexander, et al., «Variations in availability», op. cit.
  • 24 Refaat B. Karim and Judith J. Dekker, «From female genital mutilation»
  • 25 UEFMG (United to End Female Genital Mutilation), Country Focus Spain, 2016, available from https: (...)
  • 26 Royal College of Obstetricians and Gynaecologists, Green-top Guideline No. 53. Female Genital Mut (...)
  • 27 www.theguardian.com/society/2013/aug/25/surgery-for-female-genital-mutilation.

11In France, the surgery is widely available and reimbursed by the national health insurance system since 200420. There are now more than 5 500 women who have undergone the surgery according to Pierre Foldès’ technique21. Also in Germany, the surgery is paid for by the social security system. In, for example, Belgium, Switzerland, and Sweden, women can access special units22. In Austria23 and the Netherlands24, the surgery can be obtained through private practitioners. Women in Spain and Italy have access to the reconstructive surgery through specific clinics25. In the UK, it seems that gynaecologists argue against the surgery26, but it has been performed by at least one British surgeon27.

  • 28 Pierre Foldès et al., «Reconstructive surgery», op. cit. Armelle Andro and Marie Lesclingand, «Fe (...)
  • 29 Pierre Foldès et al., «Reconstructive surgery», op. cit., p. 137.

12There are a few commonly cited motivations behind requests for reconstructive clitoral surgery. The most prominent one is «recovery of identity» or aspirations to become «a complete woman»28. Other motivations are hopes for pain relief and improved quality of sex. In the first survey of outcomes of the surgery (2 938 women) that was published by Pierre Foldès et al. (2012), «identity recovery» was expected by 99% of the women, «improved sex life» by 81%, and «pain reduction» by 29%. Only 861 women (29%) attended the 1-year follow-up and everyone was not asked about pain or clitoral pleasure. Among them, 821 out of 844 experienced improvement or no worsening regarding pain, while nine women with no pain before surgery had either discomfort or pain afterwards. Among the 368 who had never experienced orgasm before surgery, 129 (35%) were now able to orgasm. Concurrently, 12 (23%) of 53 patients who had regularly had orgasms before the operation reported reduced orgasm afterwards. Twenty patients, the survey shows, «were worsened for clitoral pleasure»29.

  • 30 Pierre Foldès et al., «Reconstructive surgery», op. cit. ; Rigmor C. Berg, Sølvi Taraldsen, Marya (...)
  • 31 Jasmine Abdulcadir, Maria I. Rodriguez, and Lale Say, «A systematic review of the evidence on cli (...)
  • 32 Royal College of Obstetricians and Gynaecologists, Green-top Guideline No. 53, p. 4.
  • 33 Jasmine Abdulcadir, «Psychosexual health after female genital mutilation», op. cit., p. 31.

13Most women do feel better after surgery30. Yet, the evidence is weak as regards the benefits of the surgery in relation to possible harm and negative consequences, systematic overviews show31. The Royal College of Obstetrics and Gynaecology in the UK advise against the surgery: «Clitoral reconstruction should not be performed because current medical evidence suggests that such surgery may result in further damage to the clitoral nerves and blood vessels without conclusive evidence of benefit»32. The complication rate in different studies varies from 5,3 % to 40%33.

  • 34 See, e.g., Lucrezia Catania, Omar Abdulcadir, Vincenzo Puppo, Jole Baldaro Verde, Jasmine Abdulca (...)
  • 35 H. M. Merckelbagh, M. N. Nicolas, M. P. Piketty, and J. L. Benifla, «Assessment of a multidiscipl (...)
  • 36 Els Leye, «Multidisciplinary care». Lotte De Schrijver et al., «A multidisciplinary approach».

14There is an increasing demand for a holistic and sensitive care of women who seek reconstructive clitoral surgery, and many practitioners and scholars urge that the operation should be seen as only one tool among many in a repertoire of care options. Other care paths that are suggested include sexual counselling, psychosexual therapy, and correct education about the actual anatomical structure of the clitoris34. A study from France35 reports that counselling that is multidisciplinary and wider in scope may result in a majority declining surgery – in this case 82% out of 169 of the women who sought the operation were content with counselling. Only 27%, that is, 29 out of 107 women, who received information or came with a request about surgery, underwent the operation in the end, it is reported from three years of practice at the Brussels clinic. Also in Belgium, multidisciplinary teams work in a holistic manner to offer women other kinds of treatment beside surgery36.

Interactive kinds and the looping effect

  • 37 Ian Hacking, «The looping effects».
  • 38 Ian Hacking, «Between Michel Foucault and Erving Goffman».
  • 39 Ian Hacking, «The sociology of knowledge about child abuse», Noûs, 22(11), 1988, p. 53-63.
  • 40 Ian Hacking, «The looping effects», op. cit., p. 55.
  • 41 Ibid.

15In contrast to atoms and rocks, people are affected by what is said about them. Canadian philosopher of science Ian Hacking has discussed this in terms of «interactive kinds», found only in the human domain37. The «human kinds» are categories constructed through our attempts to organise knowledge about people, and – in contrast to «natural kinds» – the «human kinds» categories are laden with values38 (one of his examples is «child abuse»). The act of classification and labelling may deeply affect those who are classified and labelled, and there is a «looping effect» of interactive kinds among the people who are labelled or classified. As described by Hacking39: «Classification of people and their actions affects the people and their actions, which in turn affects our knowledge about them and classification of them»40. A «looping effect», cycles of changes, may be the result when people begin interacting with these classifications and see themselves in a new light41.

  • 42 For example, headlines such as «Female genital mutilation denies sexual pleasure to millions of w (...)

16European countries with substantial groups of immigrants from FGC-practising communities, mainly Africans, are deeply influenced by state campaigning against «female genital mutilation», and they all have programs to combat the practice in order to protect second-generation girls from FGM. The immense anti-FGM apparatus that is a result of the global prohibition regime can be found at all levels in many European countries: at community, municipality, region and state levels as well as that of the European Union. This discourse is often harsh, not to say offensive: the word «mutilation» is the only authorised label in this hegemonic discourse. Consequently, the key label of «mutilation» communicates to circumcised women that they are incomplete, maimed, disfigured. The notion that «FGM» is detrimental to the ability to enjoy sex is widespread: the public discourse in most Western countries, which in its eradication efforts highlights all the possible negative consequences of FGC, keeps asserting that FGC leads to destruction of sexual function42. Hence, European women and girls in in once-practising FGC communities are now in public labelled «mutilated» and sexually deprived.

17In London in November 2018, I met a British African young woman who wore a T-shirt with a print on it: «Circumcised Not Mutilated». Displaying her self-categorisation in public, she resisted how she was classified in her society: refusing to accept a label from the dominant discourse that she found degrading and oppressive. Not all women of similar background explicitly position themselves in relation to how they are classified in public discourse. If they internalise what is being said about them – that they are «mutilated», «disfigured», and not fully feminine – we have reason to describe this situation as one of a looping effect. This looping effect can be described as a situation in which women identify with the discursive classification of them, and act as a result of this classification, and then reappear in studies mapping new knowledge about what characterises the category «women who seek clitoris repair surgery after FGM». The interactive kind of the category «mutilated woman» has evolved and, through the looping effect, turned into a category with slightly new knowledge about it.

The motives in context

  • 43 Pierre Foldès et al., «Reconstructive surgery».

18In the Lancet article, written by Pierre Foldès and colleagues, it is stated that the surgery is offered «to reduce pain», «to help women to improve their sex lives» and «to recover their identity», and these are also the stated motives on the part of the women43. Below, I will briefly say something about these motives in relation to outcomes of the surgery. In addition, I will comment on these motives in relation to research about these aspects when comparisons have been made between circumcised women and women without circumcision. Finally, a few remarks regard the wider cultural context.

Pain

  • 44 Gillian Einstein, «From body to brain: Considering the neurobiological effects of female genital (...)
  • 45 Jasmine Abdulcadir, Diomidis Botsikas, Mylène Bolmont, Aline Bilancioni, Dahila Amal Djema, Franc (...)
  • 46 Sharifa A. Alsibiani, and Abdulrahim A. Rouzi, «Sexual function in women with female genital muti (...)

19There is nothing strange about pain as a result of FGC: damaged tissue may give rise to not only local pain where the trauma to the body took place, but also to neuropathic pain44. Yet, and perhaps counterintuitively, it is difficult to demonstrate a higher rate of pain among women with FGC as compared to women without it. Some studies show some difference in the pain domain between circumcised women and a control group of uncircumcised. For example, in one study the women with FGC scored 4,29 in the pain domain of FSFI [Female Sexual Function Index], while women without FGC scored 5,47 (which is a sign of a lower level or prevalence of pain)45. In contrast, in other studies, no statistically significant difference has been found between the study group of circumcised women and the control group of uncircumcised46.

  • 47 Pierre Foldès et al., «Reconstructive surgery», op. cit.

20The relatively small or non-existent differences in FSFI pain scores between women with and without FGC raises the issue of whether or not it is the cutting that has caused the pain – if that was always the case, we would expect a greater difference between these two groups (that is, genitally cut women would have the pain after the cutting in addition to pain caused by other factors that cause pain also in uncircumcised women). Most women who seek the surgery do not state «pain» as a motive for surgery – only 29% offered reduced pain as an expectation before surgery in Pierre Foldès’study. As many as 67% of the women reported «no pain» pre-operatively; nevertheless, some women experienced pain in that bodily area, and most of them were helped by this surgery47.

  • 48 Miznah Al-Abbadey, Christina Liossi, Natasha Curran, Daniel E. Schoth, and Cynthia A. Graham, «Tr (...)
  • 49 Pierre Foldès et al., «Reconstructive surgery». Mathilde Vital, Sophie de Visme, Matthieu Hanf, H (...)

21Surgery to relieve pain is not common although it does take place; for instance, it has been shown that vestibulectomy can reduce vulvar pain significantly48. In follow-ups after reconstructive clitoral surgery, many women report that they have improved or experience no worsening pain, and sometimes radical improvement in the FSFI pain domain after surgery can be demonstrated49. On the other hand, a drawback of surgery is that new scarred tissue is created, which can lead to pain where preoperatively there was none. In Pierre Foldès’study, nine women with no pain before surgery had either discomfort or pain afterwards.

  • 50 Danielle Jacobson et al., «The lived experience», op. cit., p. 18.

22Pain is difficult to measure and also an elusive phenomenon to study. As pointed out by Jacobsen and colleagues: «Culture is a significant factor in how an individual reacts to pain […]. In general, there is little knowledge of cultural beliefs and preferences on the experience of pain»50. They suggest that, possibly, the wider cultural context – there are societies in which FGC is validated in contrast to other societies in which all forms are condemned – may have an effect on how pain after FGC is experienced.

Sex

  • 51 For a discussion about ideological bias at the WHO and among some researchers, see for example, S (...)
  • 52 Kate Miller, Waris Dirie, and Corrie James, Desert flower: The extraordinary journey of a desert (...)
  • 53 https://www.desertflowerfoundation.org/en/waris-dirie.html.

23Activists – and here I include the WHO, because when it comes to FGM, activist interests are given priority over scientific values51have tried for many years to prove how detrimental FGM is to sexuality. Mass media coverage of FGM highlights the loss of sexual pleasure, and a great deal of the general public think about sex after FGC in line with how it is described by Waris Dirie and co-authors in the bestseller Desert Flower: «The most minimal damage is cutting away the hood of the clitoris, which will prohibit the girl from enjoying sex for the rest of her life»52. According to the Desert Flower Foundation, there are 11 million copies in print of this book and it has been translated into numerous languages53. So, this is what people in general know about sex after female circumcision.

  • 54 For example, regarding pain in Abdulcadir et al., «Sexual anatomy and function».
  • 55 For example, regarding arousal in Tracy Chu and Adeyinka M. Akinsulure-Smith, «Health outcomes an (...)

24But this is not what research shows. FSFI is a blunt instrument for capturing sexual experiences – and it completely overlooks social and cultural factors that affect how we experience such elusive bodily sensations as sexual desire, satisfaction and pain. Yet, something can be said about the data resulting from FSFI studies and the attempts to use them to account for negative effects on sexuality as a result of FGC. Similar to studies on pain, one finds none or little difference between women with FGC compared to those without, when it comes to sexual function. While one study finds significant differences between circumcised and uncircumcised women in one domain and not in any other domain54 – in another study, it is another domain that stands out55. Apart from telling us that FSFI has its limitations as an instrument to measure sexual function, the results – albeit sprawling – demonstrate that FGC does not seem to be as detrimental to sexual function as is often alleged. If it were, we should not find so many studies with little or virtually no difference between women with and without circumcision in the six domains of the questionnaire.

  • 56 Pierre Foldès et al., «Reconstructive surgery», op. cit.

25Yet «improved sex life» is one of the most important expectations among women who seek the surgery. In Pierre Foldès’study, 81% of the women expected it from the surgery. 129 (35%) of the 368 women who had never had an orgasm before the procedure started to experience restricted or regular orgasms. Half the women who presented with restricted orgasm before the procedure reported a regular orgasm after it56.

  • 57 Pierre Foldès et al., «Reconstructive surgery», op. cit., p. 137.

26On the other hand, for some women the surgery did not improve their sex life but rather the opposite: «12 (23%) of 53 patients who had regularly had orgasms before reported reduced orgasm afterwards»57. No less than twenty patients worsened in terms of clitoral pleasure. In conclusion, when the surgery is promoted, greater attention should be given to the risk of impaired sensitivity when new scars are produced in the clitoral area.

Identity

  • 58 E.g., Aud Talle, «From “complete” to “impaired” body: female circumcision in Somalia and London», (...)

27Anthropologists all know that circumcision of girls is extremely painful and may have serious medical consequences. But we also know that it often has positive connotations in local groups that practice it: among the alleged benefits, a common motive is to make girls ready for womanhood, and the state of being circumcised is often seen as a mark of perfect femininity. One could say that circumcision of girls is done to instill a sense of identity as being a perfected woman58.

  • 59 Michela Villani, «From the “maturity” of a woman to surgery: conditions for clitoris repair», Sex (...)

28So, when women seek the reconstructive operation in Europe with the main motive being «to recover femininity» or to become «fully feminine», we must assume that the demand for surgery is a response to a discourse labelling women as «imperfect» and «not fully feminine (any longer)». Sociologist Michela Villani conducted an original study in France in the 2000s, in which she analysed medical records and interviews with the professionals in the multidisciplinary team responsible for the clitoris repair surgery. In her article, she demonstrates how the reconstructive clitoral surgery is intertwined with culture-specific ideas of what a perfect woman is, what desirable sexuality is, and how a circumcised woman is expected to think of herself and her body in order to fit into the ideal womanhood in Europe59.

  • 60 Rigmor C Berg et al., «Reasons for and experiences with», op. cit.

29The negative effect of the public discourse about «mutilation» in Europe is salient in some research about the reconstructive operations. In a review of outcomes after surgical interventions after FGC, the authors found differences in motivations for clitoral reconstruction when comparing women residing in Western countries to those in African countries: women in Western countries more often stated «restoration of identity» as a motivation for surgery60.

  • 61 Michela Villani, «Reparative approaches in medicine and the different meanings of “reparation” fo (...)

30This situation is aptly captured by Michela Villani, who conducted qualitative interviews with women who have asked for or undergone clitoris repair in France and Switzerland: «In the context of diaspora, women are doubly penalised: the practice being performed during childhood is only interpreted by discourses and values condemning the FGM/C as a form of violence»61.

Mass media renderings and «the white man’s burden»

  • 62 «Female genital mutilation» is situated at «the limits of tolerance». For a discussion about «FGM (...)
  • 63 The Public Policy Advisory Network on Female Genital Surgeries in Africa, «Seven Things to Know». (...)
  • 64 To mention just a few: Fuambai Sia Ahmadu, «Between rites and rights: Excision in women»s experie (...)

31Another discursive stream – the one found in the bulk of the mass media representations of FGM – is of interest here, because it provides yet another layer surrounding the clitoris repair surgeries in Europe. While many European societies are characterised by multicultural policies, favoring norms that dictate that we all should show tolerance when we face other cultural practices, FGM constitutes an exception62. When it comes to representations in the media of circumcision of girls, there is a virtual wallowing in horror stories in which the worst case scenario is presented as «the typical FGM»63. In fact, these representations – as pointed out by many American scholars of African origin – are deeply neocolonial in their tone64.

  • 65 An often-cited description of FGM can be found in Desert Flower: «They use no anesthetic. They’ll (...)
  • 66 Christina Julios, Female genital mutilation and social media, London, Routledge, 2018. Jules Morg (...)
  • 67 E.G., Soheir A. Morsy, «Safeguarding women’s bodies: The white man’s burden medicalized», Medical (...)
  • 68 Sharmila Lodhia, «Beyond rescue: Rethinking advocacy and intervention in the Women’s and Gender S (...)
  • 69 This was before the number of estimated circumcised girls and women in the world was adjusted to (...)

32The Desert Flower Foundation is a key actor, not only in setting the tone for how FGM is represented in the public discourse65, but also as an agent for the establishment of clinics providing clitoris repair in Europe66. In Copenhagen in 2015, at a Nordic conference for researchers on female genital cutting, a plastic surgeon presented his data on the so far performed operations in his country. He concluded with a slide showing the cutest little Somali toddler girl and the headline Save a Little Desert Flower. Then the audience was offered a deal including «Protection from FGM», «Protection from forced marriage», «Checked regularly by a medical doctor», and «Education» for a cost of «30 Euros». Why this was relevant in relation to his presentation on reconstructive clitoral surgery in adult women remains obscure, but it shows how the clitoris repair phenomenon at times is embedded in a wider political context, that of the anti-FGM discourse which at times displays neocolonial overtones. There was no discussion, for example, about under which conditions the girls» families were to be asked about consent or if they were expected to just willingly hand over their girl children for medical checks. Indeed, this was an example of political symbolism: the real living girls (who are, generally speaking, part of wider families who care for them) were reduced to symbols of potential victimhood, represented as future victims that need to be rescued by outsiders. This attitude is sometimes described as «the white man’s burden»67 or «the white saviour industrial complex»68 and it clearly builds on neocolonialist discourses. Some of the same complacence was expressed during the 2015 Paris conference Management of women with FGM/C: 1st International consultation, when an opening speaker in his welcome talk chuckled when he announced that there were now about 130 million clitoris repairs to be performed in the future69.

Clitoris repair: beside medical intervention, heroism, wizardry, business?

  • 70 Hubert Prolongeau, Undoing FGM: Pierre Foldès, the surgeon who restores the clitoris, translated (...)

33At this conference in Paris, in January 2015, Pierre Foldès was present and was celebrated as a hero. The enthusiasm surrounding this avantgarde surgeon and his surgical technique was rather overwhelming: when he stood up and said something, he immediately received strong applause from the audience. The blurb on a book about him and his surgery may give an idea of the basis of the hero-worship: «One hundred and thirty million excised women inhabit the globe. These massive statistics mask human realities: torment breaks these victims one by one. Pierre Foldès took their hurt in both hands, nesting their stammered complaints in his heart»70.

  • 71 Jasmine Abdulcadir et al., «Sexual anatomy and function». Rachel N. Pauls, «Anatomy of the clitor (...)

34Pierre Foldès and other surgeons are not only heroes against the backdrop of the anti-FGM discourse that paints FGC as a meaningless, maiming, and cruel practice. They also stand out as something of wizards. This has to do with the WHO standard definition and classification of FGM, the one cited in practically all texts that cover the issue. In the WHO typology, the description of two of the types (I and II) is phrased «the partial or total removal of the clitoris», while type III is said to be performed «with or without removal of the clitoris». What the WHO refer to here is the external visible tip of the clitoris, which is only a fraction of the entire organ. One might call it a «folk version» of the clitoris, since many lay people think that the visible tip is all there is to the clitoris. Even though knowledge seems to spread quickly these days, not everyone knows that clitoris is an organ that stretches into the body: the external glans and hood in addition to the internal body, root, crura, and bulbs can have an overall size of nine to eleven centimetres71.

35Presumably, the experts at the WHO are reluctant to rephrase their definition, in which it is claimed that there can be a «total removal of the clitoris», since such a change would possibly be construed in terms of their downplaying the seriousness of FGM. This current definition, which is at the core of practically all descriptions of FGM and which reverberates in the mass media all over the world, is part of the discourse that many circumcised women internalise in their views of themselves and their own bodies.

  • 72 How female genital mutilation blights life - Interview with French urologist, Pierre Foldès. http (...)

36To young women, who grow up being told that they completely lack a clitoris, it must sound like magic that there are surgeons who can rebuild it from nothing. There is an interview with Pierre Foldés – this interview is even used in Swedish governmental anti-FGM campaigning – in which he says that «circumcised women often have a significant loss of capacity to experience orgasm», but that «it is fairly easy to reconstruct a clitoris with its nerves and vessels… so it is functional because it is not aesthetic surgery»72. In light of the WHO definition, such an utterance must be understood as medical wizardry. The WHO definition of FGM is misleading, and surgeons in this field do of course not construct a clitoris, they do not build a new organ. Yet, at the discursive level, this is what seems to go on. First: there is no clitoris. Then: a surgeon creates one.

37Furthermore, future research needs to look into how these surgeries are related to different forms of capital (in Bourdieu’s terms). No one can doubt that these surgeries generate some kind of symbolic capital since they are embedded in a well-established understanding of FGM as the ultimate evil and, in this worldview, the surgeons are there to «reverse» the evil through clitoral surgery. But there might be reason to look into also other forms of capital generated in this area. While the clitoris repair surgery is reimbursed by the national health insurance system in some countries, in other places the surgeries may be entangled in the wider market of cosmetic plastic surgery. This beautification industry is a market that is partly tainted for its intrinsic business motives, generating profit while it is feeding from the positive connotations of white coat professions. To the best of my knowledge, these developments regarding commercial aspects of clitoris repair in Europe have not been researched thus far.

When the surgery is coupled with the anti-FGM discourse

  • 73 Jasmine Abdulcadir et al., «A systematic review», op. cit.
  • 74 Royal College of Obstetricians and Gynaecologists, Green-top Guideline.

38Indeed, in most cases, the clitoris repair surgery works to make women feel better about themselves. So why is it important to critically discuss this phenomenon? First, there are some medical considerations to take into account before more healthcare systems introduce the surgery in their arsenal of care options. The operation is not yet evidence-based73, and consequently, there are some concerns regarding to what extent the benefits of surgery can be expected to exceed the potential harm and complications. That is why gynaecologists in the UK, among others, advise against it74.

39As has been pointed out by surgeons who at times do perform the operation, and also other professionals who work in multidisciplinary clinics that circumcised women turn to for access to the clitoris repair surgery: Some women are not helped by surgery. Some feel worse after surgery. Some lose their previous capacity to experience orgasm, and some experience pain or discomfort afterwards. These risks are doubtlessly communicated to presumptive clitoris-repair patients when they turn to the multidisciplinary clinics that exist today in many European countries. And that kind of information, in combination with access to other care options, is probably the explanation for why clinics report that many women who initially ask for surgery end up without it.

  • 75 A few examples from the last ten years: «Pioneering op gives female circumcision victims hope», C (...)

40However, this more pragmatic and nuanced approach is not yet part of the public discourse that surrounds the surgery, which in mass media publications generally is glorified and painted as the panacea that will save countless FGM victims75. Consequently, until the public discourse about the surgery becomes more nuanced and grounded in facts, the discourse per se may have serious negative effects for circumcised women in Europe. At a more abstract level, the surgery comes with strong symbolic messages, fortifying the already widespread simplistic messages from the anti-FGM campaigning: «You are mutilated. Your genitals are devastated. You have lost your ability to (fully) enjoy sex. Your identity was cut away with circumcision. You need surgery to be truly feminine».

  • 76 Jasmine Abdulcadir et al., «Reconstructive surgery», op. cit., p. 91.

41The gynaecologist Jasmine Abdulcadir and colleagues warned against this situation already in 2012, in a commentary following the Lancet publication by Pierre Foldès and colleagues (2012) on reconstructive clitoral surgery. In an attempt to explain why younger women in this study seemed to experience more sexual problems than older, they pointed out that «violent messages against FGM/C can cause a negative perception of genital self-image and negative expectations regarding social acceptance and sexuality. Young women can imagine that their genitalia have been cut away without any possibility of sexual pleasure or, when sexual pleasure is present, assume that they have a less satisfying sexual life than do uncut women»76.

  • 77 Sexual activities can be pleasurable and lead to orgasm also in women with no sensations in the e (...)
  • 78 Christopher Quinn-Nilas, Lindsay Benson, Robin R. Milhausen, Andrea C. Buchholz, and Melissa Gonc (...)

42Hence, we need to think thoroughly about the public messages we offer to already circumcised young African women and girls in western countries. For the sake of their sexual wellbeing: instead of feeding them with unsubstantiated claims about erased possibilities to enjoy sex after FGC, they need to know that they have good chances to experience sexual pleasure, although they have undergone circumcision during childhood77. Psychological expectations are crucial for how we experience sex, and self-esteem and body image are at the core of how we see ourselves as sexual beings. Body shame and body concerns undermine possibilities to enjoy sex and a negative view of genital appearance is devastating to sexual well-being78.

43These negative messages are entirely in line with the most popular statements in the global anti-FGM discourse, well illustrated by the Desert Flower bestseller. In an interview with a Somali woman in Sweden, that book came up in our conversation:

A year ago, there was an interview with Waris, about her book, and how she was circumcised, and why, and her views. And during the interview she said that the girl can not be happy, that all their enjoyment has been cut away. And all the girls were extremely shocked. So… that book, and that interview, honestly crushed the mentality of young Somali women here. Hundred percent. From that day and till today, it has been crushed. You are being told by a Somalian person that your enjoyments have gone. Now the Westerners have been telling you, and now a Somali has been telling you… so your mentality… your self-esteem, and confidence, has really been crushed. [Interview with 26-year-old Somalian unmarried woman in Sweden; my translation.]

  • 79 Pierre Foldès et al., «Reconstructive surgery», op. cit., p. 140.

44While clitoris repair surgeries may be experienced as fulfilling to some women, promotion statements such as «[the operation] allows mutilated women to recover their identity»79 is a forceful message to circumcised young women about their identity as mutilated and sexually disfigured. Some of these women might not have the wish or the means to go through surgery – yet they have to carry the weight of the disparaging «mutilation» and «lost femininity» classification.

  • 80 To give one example out of many possible, the multidisciplinary team at the Brussels clinic seems (...)

45What we see here is the looping effect of the interactive kind of «the mutilated woman»: the more the surgery is promoted within an anti-FGM discourse, the more women will demand it, and the more the ideas of mutilation and identity loss will be fortified. The loop is a continuous process that involves advocates of the surgery, public discourse and the women who are classified by it. This loop is currently not benign – although the multidisciplinary teams in clitoris repair clinics in Europe seem to do an admirable work in providing a holistic care to women who seek surgery80. In a wider perspective, something needs to be done in order to take the more malign versions of the anti-FGM discourse in another direction.

Concluding remarks

46With this discussion, I do not intend to throw out the baby with the bathwater. There is nothing inherently «good» or «evil» about the surgery itself, and it is clear that many women feel helped by it. I also have no intention to criticise individual professionals who work with this surgery, and who are most certainly very good at what they do. My criticism concerns the discourse in which the surgery is embedded, which contributes to pathologising circumcised women and heightens the risk of worsened wellbeing and sexual health among them.

47If the discursive looping effect is allowed to thrive, we can expect that the numbers of women seeking a surgical solution will keep increasing. Although some of these immigrant women felt like full women in their countries of origin (since one of the main motives for circumcision in many groups is to create perfect women), they may request surgery when they learn from the dominant discourse that they are «mutilated» and sexually deprived, and lack the means to be fully female without surgery. Furthermore, also those who do not opt for surgery will be negatively affected by the discourse.

  • 81 Moderators: Sarah O’Neill and Sophie Alexander.

48Judging from conference presentations and discussions at «3d International expert meeting on management and prevention of female genital mutilation/ cutting», which took place in Brussels in May 2019, the time has come for serious efforts to get down to the problem with the current dominant anti-FGM discourse. The theme was recurrently brought up during the conference, and an entire workshop was dedicated to «Decreasing stigma»81. Even though the multidisciplinary teams that encounter the women who request the surgery are very aware of the role of a malign discourse and the negative effects of stigma that comes with that discourse, changes are needed at a more general level. There is something deeply disturbing about societies telling women that they are mutilated and not fully feminine, and then offering them a solution that involves a knife.

49The clitoris repair surgery is here, as a great tool for individual women who are not helped by other care options. But today, this surgery is about so much more than a medical service offered to women with medical needs. The emergence of this surgery is a cultural phenomenon on an ideological battlefield, and needs to be openly discussed as such.

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VILLANI (Michela), «Reparative approaches in medicine and the different meanings of “reparation” for women with FGM/C in a migratory context», Diversity and Equality in Health and Care, n°14, 2017/5, p. 264-267.

VITAL (Mathilde), DE VISME (Sophie), HANF (Matthieu), PHILIPPE (Henri-Jean), WINER (Norbert), and WYLOMANSKI (Sophie), «Using the Female Sexual Function Index (FSFI) to evaluate sexual function in women with genital mutilation undergoing surgical reconstruction: A pilot prospective study», European Journal of Obstetrics and Gynecology and Reproductive Biology, n°202, 2016, p. 71-74.

WHO (World Health Organization), WHO guidelines on the management of health complications from female genital mutilation, Geneva, WHO, 2016.

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Notes

1 Ian Hacking, «The looping effects of human kinds», in Dan Sperber, David Premack and Ann James Premack (eds), Causal cognition: An interdisciplinary approach, Oxford, Oxford University Press, 1995, p. 351-383. Ian Hacking, «Between Michel Foucault and Erving Goffman: Between discourse in the abstract and face-to-face interaction», Economy and Society, 33(3), 2004, p. 277-302.

2 Sara Johnsdotter, «Girls and boys as victims: Asymmetries and dynamics in European public discourses on genital modifications in children» in Michela Fusaschi M and Giovanna Cavatorta (eds) FGM/C: From Medicine to Critical Anthropology, Torino, Meti Edizioni, 2018, p. 33-49.

3 Peter Andreas and Ethan Nadelmann, Policing the globe: Criminalization and crime control in international relations, Oxford University Press, New York, 2006.

4 Sara Johnsdotter and Ruth Mestre i Mestre, «“Female genital mutilation” in Europe: Public discourse versus empirical evidence», International Journal of Law, Crime and Justice, 51, 2017, p. 14-23.

5 Ellen Gruenbaum, «Sociocultural dynamics of female genital cutting», in Peter J Brown and Svea Closser (eds), Understanding and applying medical anthropology, London, Routledge, 2016, p. 418-427.

6 E.G., Richard A. Shweder, «What about “female genital mutilation”? And why understanding culture matters in the first place», Daedalus, 129(4), 2000, p. 209-232. Sara Johnsdotter and Ruth Mestre i Mestre, «“Female genital mutilation” in Europe».

7 See, for example, the following authors who are all American scholars of African heritage, and they all have feminist views: Rogaia Mustafa Abusharaf (ed.) Female circumcision: Multicultural perspectives, Philadelphia, University of Pennsylvania Press, 2006. Leslye Amede Obiora, «Bridges and barricades: Rethinking polemics and intransigence in the campaign against female circumcision», Case Western Reserve Law Review 47(2), 1997, p. 275-379. Leslye Amede Obiora, «The little foxes that spoil the vine: Revising the feminist critique of female circumcision», Canadian Journal of Women and Law 9(1), 1997, p. 46-73. Obioma Nnaemeka, «If female circumcision did not exist, western feminism would invent it», in Susan Perry and Celeste Schenck (eds), Eye to eye: Women practicing development across cultures, London, Zed, 2001, p. 171-189. Obioma Nnaemeka, «The challenges of border-crossing: African women and transnational feminisms», in Obioma Nnaemeka (ed.), Female circumcision and the politics of knowledge: African women in imperialist discourses, Westport, CT, Praeger Publishers, 2005, p. 3-18. Fuambai Ahmadu, «Rites and wrongs: An insider/outsider reflects on power and excision», in Bettina Shell-Duncan and Ylva Hernlund (eds) Female “circumcision” in Africa: Culture, controversy, and change, London: Lynne Rienner Publishers, 2000, p. 283-312. Naomi Onsongo, «Female genital cutting (FGC): Who defines whose culture as unethical?», International Journal of Feminist Approaches to Bioethics, 10(2), 2017, p. 105-123.

8 Among them all, we find for example: Janice Boddy, Wombs and alien spirits: Women, men, and the Zār cult in northern Sudan, Madison: University of Wisconsin Press, 1989. Ylva Hernlund, Winnowing culture: Negotiating female «circumcision» in the Gambia, Doctoral dissertation, University of Washington, 2003. Fuambai Ahmadu, Cutting the anthill: the symbolic foundations of female and male circumcision rituals among the Mandinka of Brikama, the Gambia, Doctoral dissertation, London School of Economics and Political Science, 2005. Lisen Dellenborg, Multiple meanings of female initiation: Circumcision» among Jola women in Lower Casamance, Senegal, Doctoral dissertation, University of Göteborg, 2007. Maria Malmström, Just like couscous: Gender, agency and the politics of female circumcision in Cairo, Doctoral dissertation, Göteborg University, 2009.

9 Jon-Håkon Schultz and Inger-Lise Lien, «Meaning-making of female genital cutting: Children’s perception and acquired knowledge of the ritual», International Journal of Women’s Health, 5, 2013, p. 165-175.

10 Wairimu Ngaruiya Njambi, «Irua Ria Atumia and anti-colonial struggles among the Gikuyu of Kenya: a counter narrative on “female genital mutilation”», Critical Sociology, 33, 2007, p. 689-708.

11 Fuambai Ahmadu, «Rites and wrongs», op. cit.

12 Claudia Merli, «Negotiating female genital cutting (sunat) in southern Thailand», in Chitra Raghavan and James P. Levine (eds) Self-determination and women’s rights in Muslim societies, Waltham, Brandeis University Press, 2012, p. 169-187.

13 One attempt to address this gap was made by fifteen researchers – including medical scientists as well as scholars in the humanities and social science – in 2012: The Public Policy Advisory Network on Female Genital Surgeries in Africa, «Seven things to know about female genital surgeries in Africa», Hastings Center Report, 42(6), 2012, p. 19-27.

14 Michela Villani, «From the “maturity” of a woman to surgery: Conditions for clitoris repair», Sexologies, 18(4), 2009, p. 259-61. Armelle Andro and Marie Lesclingand, «Female genital mutilation: Overview and current knowledge», Population, 71(2), 2016, p. 217-296.

15 Leye, E. (2018). «Multidisciplinary care for women affected by female genital mutilation/cutting «, in Gabriele Griffin and Malin Jordal (eds.) Body, migration, re/constructive surgeries: Making the gendered body in a globalized world, London, Routledge, 2018, p. 63-77.

16 Jasmine Abdulcadir, «Psychosexual health after female genital mutilation/cutting and clitoral reconstruction», in Gabriele Griffin and Malin Jordal (eds.) Body, migration, re/constructive surgeries: Making the gendered body in a globalized world, London, Routledge, 2018, p. 19-38.

17 Mallika Anand, Todd J. Stanhope and John A. Occhino, «Female genital mutilation reversal: A general approach» , International Urogynecology Journal, 25 (7), 2014, p. 985-986.

18 Pierre Foldès, Béatrice Cuzin, and Armelle Andro, «Reconstructive surgery after female genital mutilation: A prospective cohort study», The Lancet, 380 (9837), 2012, p. 134-141. Armelle Andro and Marie Lesclingand, «Female genital mutilation», op. cit.

19 Pierre Foldès et al., «Reconstructive surgery». Jasmine Abdulcadir, Michel Boulvain and Patrick Petignat, «Reconstructive surgery for female genital mutilation», The Lancet, 380(9837), 2012, p. 90-92. Jasmine Abdulcadir, «Psychosexual health ». Refaat B. Karim and Judith J. Dekker, «From female genital mutilation to female genital reconstruction», The PMFA Journal 1(4), 2016, p. 1-3. Hannes Sigurjonsson and Malin Jordal, «Addressing female genital mutilation/cutting (FGM/C) in the era of clitoral reconstruction: Plastic surgery», Current Sexual Health Reports, 10, 2018, p. 50-56. D. M. O’Dey, «Anatomic reconstruction following female genital mutilation/cutting», Journal Für Asthetische Chirurgie, 11 (4), 2018, p. 180-184.

20 Armelle Andro and Marie Lesclingand, «Female genital mutilation», op. cit.

21 Pierre Foldès, «The pseudo-clitoris, a particular female genital mutilation: case series». Conference abstract, Female genital mutilation/cutting: sharing data and experiences to accelerate eradication and improve care: part 2. Reproductive Health, 14:2, 115, 2017.

22 Sophie Alexander, Jasmine Abdulcadir, Dina Bader, and Elise Dubuc, «Variations in availability and approach to clitoral surgery for female genital mutilation/cutting in receiving (and source) countries», European Journal of Public Health, 28, Supplement 1, 2018, p.170.

23 Sophie Alexander, et al., «Variations in availability», op. cit.

24 Refaat B. Karim and Judith J. Dekker, «From female genital mutilation»

25 UEFMG (United to End Female Genital Mutilation), Country Focus Spain, 2016, available from https://uefgm.org/index.php/country-context-es/. UEFMG, Country Focus Italy, 2017, available from https://uefgm.org/index.php/country-context-it/.

26 Royal College of Obstetricians and Gynaecologists, Green-top Guideline No. 53. Female Genital Mutilation and its Management, London, RCOG, 2015.

27 www.theguardian.com/society/2013/aug/25/surgery-for-female-genital-mutilation.

28 Pierre Foldès et al., «Reconstructive surgery», op. cit. Armelle Andro and Marie Lesclingand, «Female genital mutilation», op. cit.

29 Pierre Foldès et al., «Reconstructive surgery», op. cit., p. 137.

30 Pierre Foldès et al., «Reconstructive surgery», op. cit. ; Rigmor C. Berg, Sølvi Taraldsen, Maryan Said, Ingvil Krarup Sørbye, and Siri Vangen, «Reasons for and experiences with surgical interventions for female genital mutilation/cutting (FGM/C): A systematic review», The Journal of Sexual Medicine, 14(8), 2017, p. 977-990. Jasmine Abdulcadir, Maria I Rodriguez, Patrick Petignat, and Lale Say, «Clitoral reconstruction after female genital mutilation/cutting: case studies», The Journal of Sexual Medicine, 12(1), 2015, p. 274-281.

31 Jasmine Abdulcadir, Maria I. Rodriguez, and Lale Say, «A systematic review of the evidence on clitoral reconstruction after female genital mutilation/cutting», International Journal of Gynecology and Obstetrics, 129(2), 2015, p. 93-97. Sophie Alexander, et al., «Variations in availability».

32 Royal College of Obstetricians and Gynaecologists, Green-top Guideline No. 53, p. 4.

33 Jasmine Abdulcadir, «Psychosexual health after female genital mutilation», op. cit., p. 31.

34 See, e.g., Lucrezia Catania, Omar Abdulcadir, Vincenzo Puppo, Jole Baldaro Verde, Jasmine Abdulcadir and Dalmar Abdulcadir, «Pleasure and orgasm in women with female genital mutilation/cutting (FGM/C)», The Journal of Sexual Medicine, 4(6), 2007, p. 1666-1678. Abdulcadir et al., «Clitoral reconstruction». Abdulcadir et al.., «A systematic review». Jasmine Abdulcadir, Omar Abdulcadir, Martin Caillet, Lucrezia Catania, Béatrize Cuzin, Birgitta Essén, Pierre Foldès, Sara Johnsdotter, Christa Johnson-Agbakwu, Nawal Nour, Charlemagne Ouedraogo, Nicole Warren, and Sophie Wylomanski. «Clitoral surgery after female genital mutilation/cutting» Aesthetic Surgery Journal, 37(9), 2017, p. 113-115. Jasmine Abdulcadir, «Psychosexual health after female genital mutilation». Rigmor C Berg et al., «Reasons for and experiences with». Laura Buggio, Federica Facchin, Laura Chiappa, Giussy Barbara, Massimiliano Brambilla, and Paolo Vercellini, «Psychosexual consequences of female genital mutilation and the impact of reconstructive surgery: A narrative review», Health Equity, 3(1), 2019, p. 36-46. Martin Caillet and Fabienne Richard, «A Belgian multi-disciplinary female genital mutilation medical reference center: A descriptive report of three years of practice», Conference abstract, Female genital mutilation/cutting: sharing data and experiences to accelerate eradication and improve care: part 2. Reproductive Health, 14:2, 115. Lotte De Schrijver, Els Leye, and Mireille Merckx. «A multidisciplinary approach to clitoral reconstruction after female genital mutilation: the crucial role of counselling», The European Journal of Contraception and Reproductive Health Care, 21(4), 2016, p. 269-75. Christa Johnson-Agbakwu and Nicole Warren, «Interventions to address sexual function in women affected by female genital cutting: A scoping review”, Current Sexual Health Reports, 9(1), 2017, p. 20-31. Uduak Okomo, Miriam Ogugbue, Elizabeth Inyang, and Martin M. Meremikwu, «Sexual counselling for treating or preventing sexual dysfunction in women living with female genital mutilation: A systematic review», International Journal of Gynecology and Obstetrics, 136, 2017, p. 38-42. World Health Organization, WHO guidelines on the management of health complications from female genital mutilation, Geneva, WHO, 2016.

35 H. M. Merckelbagh, M. N. Nicolas, M. P. Piketty, and J. L. Benifla, «Assessment of a multidisciplinary care for 169 excised women with an initial reconstructive surgery project» [in French], Gynecologie, Obstetrique and Fertilite, 43, 2015, p. 633-639.

36 Els Leye, «Multidisciplinary care». Lotte De Schrijver et al., «A multidisciplinary approach».

37 Ian Hacking, «The looping effects».

38 Ian Hacking, «Between Michel Foucault and Erving Goffman».

39 Ian Hacking, «The sociology of knowledge about child abuse», Noûs, 22(11), 1988, p. 53-63.

40 Ian Hacking, «The looping effects», op. cit., p. 55.

41 Ibid.

42 For example, headlines such as «Female genital mutilation denies sexual pleasure to millions of women», The Guardian, 13 Nov. 2008. In another Guardian article, it is claimed that «Unlike male circumcision, female genital mutilation also inhibits sexual pleasure», in «What is female genital mutilation?», The Guardian, 17 May 2014. The description in the Miller, Dirie and James book, Desert Flower, of lost ability to feel sexual pleasure after any form of FGM, is probably one of the most impactful sources of this discourse. For a critical discussion of such statements, see Sara Johnsdotter, «Discourses on sexual pleasure after genital modifications: the fallacy of genital determinism», Global Discourse, 3(2), 2013, p. 256-265.

43 Pierre Foldès et al., «Reconstructive surgery».

44 Gillian Einstein, «From body to brain: Considering the neurobiological effects of female genital cutting», Perspectives in Biology and Medicine, 51(1), 2008, p. 84-97. Danielle Jacobson, Emily Glazer, Robin Mason, Deanna Duplessis, Kimberly Blom, Janice Du Mont, Navmeet Jassal, and Gillian Einstein, «The lived experience of female genital cutting (FGC) in Somali-Canadian women’s daily lives», PLOS One, 13(11), 2018, e0206886.

45 Jasmine Abdulcadir, Diomidis Botsikas, Mylène Bolmont, Aline Bilancioni, Dahila Amal Djema, Francesco Bianchi Demicheli, Michal Yaron, and Patrick Petignat, «Sexual anatomy and function in women with and without genital mutilation: A cross-sectional study”, The Journal of Sexual Medicine, 13(2), 2016, p. 226-237.

46 Sharifa A. Alsibiani, and Abdulrahim A. Rouzi, «Sexual function in women with female genital mutilation», Fertility and Sterility, 93(3), 2010, p. 722-724. Sahar A. Ismail, Ahmad M. Abbas, Dina Habib, Hanan Morsy, Mustafa Bahloul, and Medhat A. Saleh, «Effect of female genital mutilation/ cutting; Types I and II on sexual function: Case-controlled study «, Reproductive Health, 2017, 14:108.

47 Pierre Foldès et al., «Reconstructive surgery», op. cit.

48 Miznah Al-Abbadey, Christina Liossi, Natasha Curran, Daniel E. Schoth, and Cynthia A. Graham, «Treatment of female sexual pain disorders: A systematic review», Journal of Sex and Marital Therapy, 42(2), 2016, p. 99-142.

49 Pierre Foldès et al., «Reconstructive surgery». Mathilde Vital, Sophie de Visme, Matthieu Hanf, Henri-Jean Philippe, Norbert Winer, and Sophie Wylomanski, «Using the Female Sexual Function Index (FSFI) to evaluate sexual function in women with genital mutilation undergoing surgical reconstruction: A pilot prospective study», European Journal of Obstetrics and Gynecology and Reproductive Biology, 202, 2016, p. 71-74. Ivan Mañero and Trinidad Labanca, «Clitoral reconstruction using a vaginal graft after female genital mutilation» Obstetrics and Gynecology, 131(4), 2018, p. 701-706.

50 Danielle Jacobson et al., «The lived experience», op. cit., p. 18.

51 For a discussion about ideological bias at the WHO and among some researchers, see for example, Sara Johnsdotter and Birgitta Essén, «The hazards of politically correct research», The Tierney Lab [The New York Times» research blog], 23 Feb 2008, available from https://tierneylab.blogs.nytimes.com/ 2008/02/23/the-hazards-of-politically-correct-research/, and other posts in the debate, in which also the WHO posted: https://tierneylab.blogs.nytimes.com/2008/01/25/who-responds-on-fgm/

52 Kate Miller, Waris Dirie, and Corrie James, Desert flower: The extraordinary journey of a desert nomad, New York, Virago, 1998, p. 218.

53 https://www.desertflowerfoundation.org/en/waris-dirie.html.

54 For example, regarding pain in Abdulcadir et al., «Sexual anatomy and function».

55 For example, regarding arousal in Tracy Chu and Adeyinka M. Akinsulure-Smith, «Health outcomes and attitudes toward female genital cutting in a community-based sample of West African immigrant women from high-prevalence countries in New York City», Journal of Aggression, Maltreatment and Trauma, 25(1), 2016, p. 63-83.

56 Pierre Foldès et al., «Reconstructive surgery», op. cit.

57 Pierre Foldès et al., «Reconstructive surgery», op. cit., p. 137.

58 E.g., Aud Talle, «From “complete” to “impaired” body: female circumcision in Somalia and London», Benedicte Ingstad and Susan R Whyte (eds.) Disability in Local and Global Worlds, Berkeley, University of California Press, 2007, p. 56-77. Fuambai Ahmadu, «Ain’t I a woman too? Challenging myths of sexual dysfunction in circumcised women», Ylva Hernlund and Bettina Shell-Duncan (eds) Transcultural bodies: Female genital cutting in global context, New Brunnswick, Rutgers, 2007, 278-310.

59 Michela Villani, «From the “maturity” of a woman to surgery: conditions for clitoris repair», Sexologies, 18(4), 2009, p. 259-261.

60 Rigmor C Berg et al., «Reasons for and experiences with», op. cit.

61 Michela Villani, «Reparative approaches in medicine and the different meanings of “reparation” for women with FGM/C in a migratory context», Diversity and Equality in Health and Care, 14(5), 2017, p. 264-267, quote on p. 266.

62 «Female genital mutilation» is situated at «the limits of tolerance». For a discussion about «FGM» as a challenge to multiculturalism, see Richard A. Shweder, «What about “female genital mutilation?”», op. cit.

63 The Public Policy Advisory Network on Female Genital Surgeries in Africa, «Seven Things to Know». Leslye Amede Obiora, «The little foxes». Dina Bader, «Picturing female circumcision and female genital cosmetic surgery: a visual framing analysis of Swiss newspapers, 1983-2015», Feminist Media Studies, 2018, p. 1-19.

64 To mention just a few: Fuambai Sia Ahmadu, «Between rites and rights: Excision in women»s experiential texts and human contexts», The International Journal of African Historical Studies, 42(2), 2009, p. 283-284. Obioma Nnaemeka, «African women, colonial discourses, and imperialist interventions: Female circumcision as impetus», in Obioma Nnaemeka (ed.) Female circumcision and the politics of knowledge: African women in imperialist discourses, Westport, CT, Praeger Publishers, 2005, p. 27-45. Rogaia Mustafa Abusharaf, «Revisiting feminist discourses on infibulation: Responses from Sudanese feminists», in Ylva Hernlund and Bettina Shell-Duncan (eds.) Female «circumcision» in Africa: Culture, controversy, and change, London, Lynne Rienner Publishers, 2000, p. 151-67. Dina Bader, «Picturing female circumcision».

65 An often-cited description of FGM can be found in Desert Flower: «They use no anesthetic. They’ll cut the girl using whatever they can lay their hands on: razor blades, knives, scissors, broken glass, sharp stones – and in some regions – their teeth» (p. 218). In their website (www.desertflowerfoundation.org), they frequently use words such as «crime», «victims», «survivors», and «torture».

66 Christina Julios, Female genital mutilation and social media, London, Routledge, 2018. Jules Morgan, «Working towards an end to FGM», The Lancet, 385 (9971), 2015, p. 843-844. Refaat B. Karim and Judith J. Dekker, «From female genital mutilation», op. cit. I will not delve too deeply into a similar key actor based in North America, the organization Clitoraid (at www.clitoraid.org). They share with The Desert Flower Foundation the strong language: «These women, like millions of others in sub-Saharan Africa and other parts of the world, endured the horrific practice of genital cutting when they were little girls […]. For most of their lives, they lived with a mutilated vulva and multiple health consequences, plus the inability to feel sexual pleasure. They were thankful to be free from this brutal past and to be given back their human dignity, in which sexual pleasure and integrity plays a central role» (http://clitoraid.org/print.php?news.174). This organization also shares the zeal to spread the clitoris repair surgery, in North America and in Burkina Faso. For their work in North America, see Petra M. Boynton, «Challenging Clitoraid», in A. Cornwall, S. Jolly, and K. Hawkins (eds.) Women, sexuality and the political power of pleasure, London, Zed Books, 2013. For their work in Burkina Faso, see Margaret Nyarango, Fluid identities: Contextualising genital reconstructive surgery after female circumcision in Burkina Faso, Doctoral dissertation, Massey University, Auckland, New Zealand, 2016.

67 E.G., Soheir A. Morsy, «Safeguarding women’s bodies: The white man’s burden medicalized», Medical Anthropology Quarterly 5(1), 1991, p. 19-23.

68 Sharmila Lodhia, «Beyond rescue: Rethinking advocacy and intervention in the Women’s and Gender Studies classroom», Feminist Teacher, 27(1), 2016, p. 1-23.

69 This was before the number of estimated circumcised girls and women in the world was adjusted to the current figure of 200 million. UNICEF, Press release: New statistical report on female genital mutilation shows harmful practice is a global concern, 2016, available from https://www.unicef.org/media/media_ 90033.html.

70 Hubert Prolongeau, Undoing FGM: Pierre Foldès, the surgeon who restores the clitoris, translated by Tobe Levin, Frankfurt am Main, UnCUT/VOICES Press, 2011.

71 Jasmine Abdulcadir et al., «Sexual anatomy and function». Rachel N. Pauls, «Anatomy of the clitoris and the female sexual response», Clinical Anatomy 28(3), 2015, p. 376-384.

72 How female genital mutilation blights life - Interview with French urologist, Pierre Foldès. https://www.youtube. com/watch?v=ob3wsi30ZlQ.

73 Jasmine Abdulcadir et al., «A systematic review», op. cit.

74 Royal College of Obstetricians and Gynaecologists, Green-top Guideline.

75 A few examples from the last ten years: «Pioneering op gives female circumcision victims hope», CNN, 2 Sept 2009; «Reconstructive surgery brings hope to survivors of genital cutting», Africa Renewal [UN Africa news], 31 Jan 2013; «Little-known surgery restores sexual pleasure to female genital mutilation victims», HuffPost, 6 Feb 2015; «Reconstructive surgery gives hope to FGM survivors», Al Jazeera, 6 Dec 2016; «Doctors around the world rally for new surgery to counter female genital mutilation», TIME, 21 March 2017; «Survivors and doctors fight back against FGM», New Internationalist, 8 March 2018; «The Melbourne surgeon giving FGM survivors their orgasms back through clitoris restoration», ABC Australia, 4 April 2019. A rare example of a more balanced report is «4 women with lives scarred by genital cutting: could a surgeon heal them?», The New York Times, 24 May 2019.

76 Jasmine Abdulcadir et al., «Reconstructive surgery», op. cit., p. 91.

77 Sexual activities can be pleasurable and lead to orgasm also in women with no sensations in the external genital area, since signals can be transmitted through other pathways than the usual one. Barry Komisaruk, Carlos Beyer-Flores, and Beverly Whipple, The science of orgasm, Baltimore, John Hopkins University Press, 2006.

78 Christopher Quinn-Nilas, Lindsay Benson, Robin R. Milhausen, Andrea C. Buchholz, and Melissa Goncalves, «The relationship between body image and domains of sexual functioning among heterosexual, emerging adult women», Sexual Medicine, 4(3), 2016, p. 182-189. Maria F. Malmström, «The production of sexual mutilation among Muslim women in Cairo», Global Discourse, 3(2), 2013, p. 306-21. Christa Johnson-Agbakwu and Nicole Warren, «Interventions to address sexual function». The importance of attitude to own circumcision for body image and sexual functioning was also demonstrated in this study regarding men: Jennifer A. Bossio and Caroline F. Pukall, «Attitude toward one’s circumcision status is more important than actual circumcision status for men»s body image and sexual functioning», Archives of Sexual Behavior, 47(3), 2018, p. 771-781.

79 Pierre Foldès et al., «Reconstructive surgery», op. cit., p. 140.

80 To give one example out of many possible, the multidisciplinary team at the Brussels clinic seems to work with a profound understanding of the role of discourse for their patients» self-understanding. Sarah O’Neill, Cendrine Vanderhoeven, and Fabienne Richard: «Reconstructing selves: Therapeutic journeys after “female genital mutilation” in Belgium», paper presentation at the panel «Understanding “FGM” and sexual violence in diaspora: women’s journeys through re-creations of identity and discourses on trauma”, EASA conference Staying, Moving, Settling, Stockholm, 14-17 August 2018. Sarah O’Neill, «I have changed my mind, I don’t want the operation anymore”: Therapeutic pathways of women who request reconstructive surgeries after FGM/C in Belgium», paper presentation at the conference 3d International expert meeting on management and prevention of female genital mutilation/cutting, Brussels, May 20-21 2019.

81 Moderators: Sarah O’Neill and Sophie Alexander.

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Sara Johnsdotter, « The Growing Demand in Europe for Reconstructive Clitoral Surgery after Female Genital Cutting: A Looping Effect of the Dominant Discourse? »Droit et cultures, 79 | 2020, 141-166.

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Sara Johnsdotter, « The Growing Demand in Europe for Reconstructive Clitoral Surgery after Female Genital Cutting: A Looping Effect of the Dominant Discourse? »Droit et cultures [En ligne], 79 | 2020/1, mis en ligne le 27 octobre 2020, consulté le 26 janvier 2021. URL : http://journals.openedition.org/droitcultures/6153

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Sara Johnsdotter

Sara Johnsdotter est professeure en Anthropologie médicale à l’Université de santé et société de Malmö en Suède. Sa recherche est principalement focalisée sur les Somaliens en Suède, notamment sur les questions d’excision, de reproduction et de santé sexuelle. Elle a représenté la Suède dans plusieurs recherches de l’Europe sur les « mutilations génitales féminines », dont la plus récente avec la professeure Ruth Mestre i Mestre, de l’Université de Valence, portant sur les procédures pénales en Europe (Johnsdotter & Mestre i Mestre, 2015 : Female Genital Mutilation in Europe: An Analysis of Court Cases, Brussels: European Commission). Parmi ses autres publications on peut citer : «Projected cultural histories of the cutting of female genitalia: A poor reflection as in a mirror», History and Anthropology, n°23, 2012/1, «Discourses on sexual pleasure after genital modifications: The fallacy of genital determinism», Global Discourse, n°3, 2013/2, et «Meaning well while doing harm: compulsory genital examinations in Swedish African girls», Sexual and Reproductive Health Matters, n°27, 2019/2.

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