Female genital mutilation/cutting (FGM/C) refers to all procedures involving the partial or the total removal of the external female genitalia or other damage to the female genital organs for nonmedical reasons 1. In 2007, WHO classified (FGM/C) into IV types: – type I: partial or total removal of the clitoris and/or the prepuce (clitoridectomy). Type II: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision). Type III: narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulations). Type IV: unclassified including all other harmful procedures to the female genitalia for nonmedical purposes (pricking, piercing, incising, scraping, and cauterization). In 2008, the WHO estimated that between 100 and 140 million women have undergone female genital mutilations worldwide and that every year about 3 million female children are mutilated in 28 African countries, with the highest prevalence in Somalia (97.9% of women) and Egypt (95.8%) 1,2.
FGM/C is still a problem in many developing countries, where sexual dysfunction adversely affects the quality of life, and it may often be responsible for psychopathological disturbances and other health problems. Also, it remains a taboo subject in many countries 3. FGM causes female sexual dysfunction disorders in terms of desire/libido, arousal, pain/discomfort, and inhibited orgasm 4,5. Laumann et al.6 have reported that 43% of women who have had FGM/C complain of at least one sexual problem, whereas 11–33% of them fall within a specific problem category.
Many factors may complicate the women’s chances of receiving help and consultation from health care institutes such as feelings of embarrassment, cultural and religious values, inadequate sex education, and restricted discussions with health professionals about sexual problems 7,8. This study aimed to examine the effects of FGM/C on psychosexual function of circumcised versus uncircumcised married women.
Materials and methods
This was a cross-sectional study carried out at Suez Canal University Hospital between June 2011 and February 2012 after obtaining Institutional ethical committee approval; 220 married women (married for up to 5 years) were recruited from among attendants or their relatives attending the Gynecology Clinic for various reasons after obtaining formal consent from each participant, to be included in the study, assuring them of the confidentiality of the results of the study. Women older than 50 years of age, married for more than 5 years, with minor scarring on the prepuce, not sexually active, with chronic medical diseases or neurological diseases, or those who refused to participate were excluded from the study. All participants completed a questionnaire through a structured interview and also underwent a gynecological examination. The questionnaire included information on age, age at the time of marriage, parity, educational level, and place of residence. Questions on circumcision included age at which the procedure was performed, the person who performed the circumcision (physician or others), the use of anesthesia or not, and reported complications. The women were also asked about the purpose of the circumcision, who made the decision to perform the circumcision, and whether they would wish their daughters to be circumcised or not.
Sexual dysfunction was assessed using the Female Sexual Function Index (FSFI): desire arousal, orgasm, satisfaction, and pain 9. The FSFI is a validated 19-item, self-administered, screening questionnaire that measures the aspects of sexual function in women (desire, arousal, orgasm lubrication, satisfaction, and pain). For this study, the Arabic translation was used. Responses to each question related to the previous month were reported and scored either from 0 (no sexual activity) or 1 (suggestive of dysfunction) to 5 (suggestive of normal sexual activity). Individual domain scores are obtained by adding the scores of the individual questions that comprise the domain and multiplying the sum by the domain factor provided in the FSFI for each domain. The full-scale score is obtained by adding the six domain scores (the minimum score possible is 2 and the maximum score is 36 10.
The symptoms check list 90 developed by Leonard and colleagues and translated by El Behery 11 was used for the identification of the incidence pattern of psychological illness, namely, depression, somatization, anxiety, hostility, and phobias.
Note: The score for the assessment of depression included 13 symptoms and ranged from 0 up to 52 points. The score for the assessment of somatization included 12 symptoms ranging from 0 up to 48 points. The score for the assessment of anxiety included 10 symptoms and ranged from 0 up to 40 points. The score for the assessment of hostility included six symptoms and ranged from 0 up to 24 points. The score for the assessment of phobia included seven symptoms and ranged from 0 up to 28 points.
A general examination was performed to examine the external genitalia to identify the type of circumcision performed and to exclude any medical disorders, followed by a vaginal examination to elicit vagenismus pain or abnormal vaginal discharge or infection.
Microsoft Excel 2003 (Microsoft Corporation New York, New York, USA) and SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, Illinois, USA) version 15 for Microsoft Windows were used to analyze data. Data were statistically described in terms of mean, SD, frequencies (number of cases), and percentages. For quantitative variables, the Student t-test and analysis of variance were used to test the significance of difference; for categorical data, the χ2-test was performed. A probability value (P-value) of less than 0.05 was considered statistically significant.
Among the women studied, circumcision was not identified in 56 women (25.45%). There were no statistically significant differences between the circumcised and the uncircumcised women in terms of age and number of children. Circumcised women were younger at the time of marriage and were mostly from rural areas. Also, circumcised women were found to have a lower level of education (Table 1).
The mean age at circumcision was 10.5±1.3 years. It was found that a midwife, 49.4%, followed by a nurse, 20.1%, had performed the circumcision. Pain was the main complication. Although tradition was the most prevalent reason for FGM/C, in 53.7% of cases doctors were behind the decision to circumcise (Table 2).
The total FSFI score was 18.6±3.9 in the circumcised groups compared with 21.5±3.5 in the uncircumcised group (P=0.001). Comparison of FSFI scores in circumcised women according to the type of circumcision performed indicated that the type II group had significantly lower scores of desire, lubrication, orgasm, pain, and satisfaction domains as well as the total score. Uncircumcised women had statistically significantly higher scores in all domains compared with circumcised women, except for the score of arousal (Table 3).
Comparison of type I and type II circumcised women showed a significant difference in terms of postoperative pain, which was reported to be the main complication in both groups. Postoperative hemorrhage was significantly more prevalent among women who underwent a type II circumcision. The other reported complication was difficulty in lubrication; urinary problems were reported to be higher in women who underwent type II circumcision compared with type I circumcision, with no statistically significant difference (Table 4).
There was no statistically significant difference between the different types of circumcision in terms of different psychological health problems assessed using symptoms check list 90. Type II circumcised women were found to have higher scores in the domains of somatization, depression, anxiety, and phobia. Type I circumcised women were not significantly different from uncircumcised women (Table 5).
FGM/C, officially referred to as female circumcision and at the community level as Tahara (cleanliness), is still prevalent in Egypt. Ninety one percent of women of reproductive age have undergone FGM/C 12, down from 97% in 2000 13. The procedure is usually performed in girls before or at the time of puberty. The WHO has classified circumcision into four types 1.
In 1996, type I and II circumcisions accounted for 84% of all cases; 9% of cases had type III circumcision, whereas 7% had not undergone the procedure 14. This was in agreement with the present study, in which as type I circumcision was identified in 85.9% of the cases and type II circumcision in 14.1% of the cases, with no type III circumcision. However, according to the Demographic and Health Survey conducted in 2008, doctors in Egypt perform a large majority (72%) of circumcisions in girls younger than 17 years of age and ‘Dayas’ (traditional birth attendants) perform 21% of circumcisions as reported by girls’ mothers 1. The present study showed that the mean age of the women at the time of circumcision was (10.5±1.3). The circumcision was mainly performed by a midwife (49.4%), followed by a nurse (20.1%).
In the present study, the circumcised group was younger at the time of marriage, had lower education, and mostly lived in rural areas, where they were more likely to be circumcised than urban women. These findings were in agreement with those of Nicoletti 15 and Sundby 16.
Afifi 17 study in Egypt, showed an association between women’s empowerment and education and the intention to discontinue the practice of FGM/C for daughters, with young age being cited as the reason for discontinuing the practice. This was in agreement with the present study, in which 57.1% of uncircumcised women had a higher education level versus 17.1% of the circumcised group. Community-maintained practices of FGM/C are followed, for which a variety of reasons are given by families. Some ethnic groups believe that the clitoris can make men impotent or can even kill them during sexual intercourse. Others believe that the clitoris neutralizes the erection and hence prevents conception. It is also believed that the clitoris can kill a baby during birth and in Sudan, it is believed that FGM can cure certain infant diseases 18. Circumcision is believed to reduce a women’s sexual desire and lessen the temptations of extramarital sex, thus also reducing the chances of children being born outside the patriarchal lineage and preserving a girl’s virginity 18,19. In the present study, tradition was the main reason given for undergoing the procedure in the circumcised group, followed by religion, in agreement with the findings of several studies 20,21.
There was a significant difference between the uncircumcised and the circumcised groups in the total score and in the scores in the domains of desire, lubrication, orgasm, pain, and satisfaction. However, the score on arousal was not statistically significant. This was in agreement with El-Defrawi et al.20 who have suggested that circumcision has a negative impact on a woman’s psychosexual life, resulting in problems such as vaginal dryness during intercourse (48.5%), lack of sexual desire (45%), less pleasure (49%), fewer orgasms, and difficulty in achieving an orgasm (60.5%). Elnashar and Abdelhady 21 reported that dyspareunia, loss of libido, failure to achieve an orgasm, and husband’s dissatisfaction were commonly encountered problems among circumcised women 21. In agreement with these findings, Hassanin et al.22 reported a high prevalence of sexual dysfunction in circumcised women; however, the Thabet and Thabet 23 study found that women with type 1 FGM/C experienced no reduction in sexual desire, whereas those who had undergone type II and type III circumcision had several sexual problems. Also, the Abd El-Naser et al.24 study showed that the scores of sexual desire, arousal, orgasm, satisfaction, and pain were comparable between circumcised and uncircumcised groups, whereas the score of lubrication was significantly higher in the uncircumcised group. The total FSFI score showed no significant difference between the circumcised and the uncircumcised groups.
In Egypt, Elnashar and Abdelhady 21 found that circumcised women had significantly higher rates of psychological problems than women who were not circumcised. Others have also found a higher prevalence of post-traumatic stress disorder 25 and sexual health problems among circumcised women 1,26. Psychological problems such as post-traumatic stress disorder, behavioral disturbances, psychosomatic illnesses, anxiety, nightmares, depression, psychosis, neurosis, and suicide because of painful FGM procedures may occur. This result was in agreement with that of the present study. Also, subsequent painful menstruation, painful intercourse, recurring episodes of frigidity, occurrence of dermoid cysts, and urine incontinence might also cause psychological problems 3,27–29. A study carried out on 651 circumcised Egyptian women showed that their sexual desire was not affected by the procedures, but the ability to achieve an orgasm was dependent on the severity of the operation and the extent to which social messages inhibiting sexual expression were internalized 30; coital difficulty or inability to have vaginal intercourse at all because of stenosis of the vagina may affect up to 35% of infibulated women 31.
A positive relationship was found between the type of cut a woman has undergone and the likelihood that she will have a visible long-term complication, although no major differences were found between the type of complication and the type of cut, in that all types of complications were more prevalent among women with type II and type III cuts than among those with a type I cut 32,33. This was in agreement with the present study as pain and postoperative hemorrhage were significantly higher in the type II circumcised group than in the type I circumcised group.
Pelvic inflammatory disease, severe pain, 32 acute urinary retention, and urinary tract infections 32,34,35 have been shown to be three times more common in women who have undergone infibulations than in those who have had a clitoridectomy 36–39. This complication was not evident in the present study as none of the women had undergone type III cuts.
Limitation of this study
In the present study, participants were recruited from among women or their relatives attending the gynecologic clinic for health problems and not from among the general population. Sociodemographic variations might affect the self-assessment of psychosexual problems encountered.
We concluded that FGM/C may be a contributing factor to psychosexual dysfunction, especially if type II or more circumcision has been performed, before considering psychosexual dysfunction as type dependent. A large population study should be carried out.
Conflicts of interest
There are no conflicts of interest.
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