Sexuality is a complex process coordinated by the neurological, vascular, and endocrine systems 1,2. The importance of sexual health for quality of life and overall life satisfaction has been increasingly recognized 3.
Female sexual dysfunction is a complex and poorly understood condition that affects women of all ages. Sexual function has been reconceptualized as a cyclic (rather than a linear) process that is emphasized by social, psychological, hormonal, environmental, and biological factors 4.
In 2004, the Second International Consensus of Sexual Medicine accepted a revised definition for female sexual dysfunction: a disturbance in one or more of the female sexual functions that is persistent and causes personal distress and additional noncoital genital pain. Female sexual dysfunction may be further classified as lifelong (primary) or acquired (secondary) and as situational (occurs only under certain circumstances or with certain partners) or generalized (occurs in all situations and with all partners) 5,6.
Female genital cutting (FGC) is the collective name given to traditional practices that involve partial or total cutting of the female external genitalia, whether for cultural or for other nontherapeutic reasons. Recognition of its harmful physical, psychological, and human rights consequences has led to the use of the term ‘female genital mutilation’ (FGM). Many women who have undergone FGC do not consider themselves to be mutilated and become offended by the term ‘FGM’. Recently, other terms such as ‘FGC’ have increasingly been used 7.
FGM is classified into four major types: type I (clitoridectomy), partial or total removal of the clitoris or, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris); type II (excision), partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are ‘the lips’ that surround the vagina); type III (infibulations), narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris; and type IV (other), all other harmful procedures performed on the female genitalia for nonmedical purposes, for example, pricking, piercing, incising, scraping, and cauterizing the genital area 8.
Some studies have shown an increased likelihood of fear of sexual intercourse, post-traumatic stress disorder, anxiety, depression, and memory loss 9. FGM is associated with major psychosocial problems. From a group discussion involving some women who were genitally mutilated, it was observed that some feel physically incomplete and depressed. Recognized psychosocial complications include psychological trauma leading to lack of confidence, feeling of inadequacy, and phobia of having sex 10.
The aim of the current study is to assess the effect of FGM/C on the domains of the Female Sexual Function Index, namely lubrication, arousal, and orgasm.
Materials and methods
Between September 2009 and May 2010, a total of 300 sexually active women were included in the study: 200 had been subjected to FGM/C, whereas 100 had not and served as the control group. All women were married and below the age of 50 and had regular marital sexual relations with no reported male sexual troubles; women with unstable or interrupted sexual relations, sexual troubles because of their husbands, chronic illnesses affecting sexual function (complicated diabetes mellitus and chronic renal or hepatic insufficiency), major psychological troubles, and those involved in drug abuse were excluded from the study.
The study was conducted at the outpatient clinic of Kasr El Aini University Hospital, School of Medicine, Cairo University. Ethical approval was obtained from the board of the Research Ethical Committee at the Department of Andrology and Sexually Transmitted Diseases, Cairo University. Permission was obtained from the Department of Obstetrics and Gynecology, Cairo University.
To obtain informed consent from the participants, the women were first given a full explanation that the study was about the sexual health of a women, specifically about female sexual function. Second, they were informed about the aim of the study and their right to not participate or end their participation at any stage during the interview. All participants were assured of confidentiality. This interview took place in a separate partition within the outpatient clinic.
All patients were subjected to the following:
Demographic characteristics, including patient’s age, age at the time of marriage, current residence (urban/rural), original residence (urban/rural), educational level (illiterate, can read and write, high school graduate, or a holding university degree), and occupational status (working or housewife) were assessed for all women.
Our study also included data pertaining to the age at time of FGM/C, reasons provided to support the practice (custom, religion, cleanliness, chastity, or marriage), the person performing FGM/C (midwives, physicians, nurses, or barbers), the person who took the decision (mother, father, the family, or grandmothers), and their attitude toward FGM/C (agree/disagree).
Gynecological examination was carried out to detect local factors and the type of FGM/C performed.
Assessment of female sexual dysfunction: female sexuality was assessed in our study through an Arabic-translated version of the Female Sexual Function Index (FSFI) questionnaire, which is a brief, multidimensional, validated tool for assessment of female sexual function during sexual activity.
Only 11 questions were selected from the domains arousal, lubrication, and orgasm.
- Four questions assessed sexual arousal in terms of frequency, level, confidence, and satisfaction.
- Four questions assessed lubrication in terms of frequency, difficulty, frequency of maintenance, and difficulty in maintenance.
- Three questions assessed an orgasm in terms of frequency, difficulty, and satisfaction.
For each of the 11 questions, there were five possible answers. A full explanation of each question and its five possible answers was provided, and the patient’s answers were reported.
For each of the three domains, a score of 0–5 was calculated. On the basis of the score obtained for each domain, the significance of each of them in comparison with the control group was determined.
In addition to administering the FSFI questionnaire, we also asked the women whether their partners had sexual problems (premature/delayed ejaculation or erectile dysfunction); if the participant reported any male sexual disorder, she was excluded from the study. In addition, we asked whether they engaged in enough foreplay and questioned them on the frequency of the sexual intercourse (daily, once/week, more than once/week, or monthly).
The collected data were transferred onto a computer and statistically analyzed using SPSS version 17.0 (SPSS Inc., Chicago, Illinois, USA).
Qualitative data are presented in the form of frequency and percentage and were statistically analyzed using the χ2-test.
Quantitative data were presented as mean and SD and were statistically analyzed using the independent t-test for comparing both the groups. The level of significance was considered when the P-value was less than 0.05.
There was no difference in the mean age between the two groups; however, genitally cut women were of a significantly younger age at the time of marriage, were of rural origin, had a low level of education (illiterate or could read and write only), and most were housewives and were unemployed (Table 1).
Data on female genital mutilation/cutting
The mean age at which the procedure of FGM/C was performed was 10.6±1.6 years (range 5–18 years). The most common form of FGC was type I (186 women, 93%), whereas 14 women had undergone type II FGC (7%). There were no cases of type III (infibulations) or type IV FGC. The results of the present study show that the family as a whole took the decision of performing the procedure of FGC in the case of 135 women (65%), whereas mothers took the decision in the case of 56 women (28%). Fathers and grandmothers played a minor role as the decision makers in the procedure [only in the case of five women (2.5%) and four (2%) women, respectively]. The majority of FGC procedures were carried out by traditional midwives called ‘dayas’ [136 women (68%)]. However, the number of procedures performed by medical practitioners showed an increase, such as that observed in our study: physicians performed 46 (23%) FGC procedures, whereas nurses performed 17 (8.5%). A barber performed the procedure only in the case of one woman (0.5%). All the uncircumcised (100%) as well as 80 (40%) circumcised participants disagreed with performing circumcision on their daughters and said that it is not important, is unnecessary for a woman, and is a painful procedure. However, 120 (60%) circumcised participants agree with performing it (Table 2).
There was no statistically significant difference in the frequency of sexual relation between the two groups, whereas women who had not undergone FGM/C reported experiencing statistically significantly satisfactory foreplay compared with those who had undergone mutilation (P<0.001).
Statistically significantly higher arousal and orgasm scores were reported among women who had not undergone FGM/C (14.76±2.99 and 11.9±1.977 vs. 12.68±3.87 and 10.07±2.91, respectively), whereas no statistically significant difference was reported with respect to the lubrication score between the two groups (P>0.415; Table 3).
A total of 168 women were under 30 years of age, 104 of them were circumcised and 64 were not. There were statistically significantly higher arousal and orgasm scores reported among women who had not undergone FGM/C (15.01±2.78 and 12.12±1.7 vs. 13.81±3.6 and 10.85±2.91, respectively), whereas no statistically significant difference was reported in the lubrication score between the two groups (P>0.322; Table 4).
The total number of women above 30 years of age was 132: 96 of them were circumcised and 36 were uncircumcised.
With respect to arousal and the orgasm scores, there was a statistically significant difference between the two groups, with women who had not undergone FGM/C scoring higher (14.3±3.31 and 11.5±2.36 vs. 11.44±3.8 and 9.22±2.69, respectively), whereas with respect to the lubrication score, there was no statistically significant difference observed between the two groups (P>0.111; Table 5).
We assessed the incidence of arousal, lubrication, and orgasmic disorders in women who had undergone FGM/C by analyzing a sample group of Egyptian women using a translated version of a validated study instrument (FSFI).
The results showed no significant difference between the circumcised and the uncircumcised participants with respect to their lubrication score, but statistically significant differences in arousal and orgasm scores were detected between the two groups, with higher scores among nongenitally cut women, which was more evident above the age of 30 years.
No difference with respect to age was found between the two groups; however, work status showed a definite significant difference among both the groups (P<0.001). In the present study, the majority of the circumcised respondents were housewives (66.5%), whereas the majority of the uncircumcised respondents were employed (76%). Gainful employment empowers women in various spheres of their lives, influencing sexual and reproductive health choices, education, and healthy behavior.
The place of residence is another variable that can be expected to be associated with the prevalence of FGC. In our study, it does not affect the observed levels of FGC; this may be because the study was conducted in the capital city. Of the circumcised and uncircumcised women, 84 and 91%, respectively, were living in urban areas. Furthermore, 16 and 9% of circumcised and uncircumcised women were living in rural areas, respectively. This finding contradicts that of Tag El Din et al. 11, who reported that 46.2% of respondents lived in urban areas, whereas 61.7% lived in rural areas. However, this finding is in agreement with that reported by The United Nations Children’s Fund (UNICEF) 12, as there are some countries in which the place of residence does not affect the observed number of FGC cases (e.g. Egypt, Guinea, Mali, Ethiopia, Sudan(north), Eritrea, and Chad). Moreover, Al-Hussaini 13 reported that 44.9% of circumcised women in his study were living in urban areas and 55.1% were living in rural areas, which contradicts our results but agrees with those of Tag El Din and colleagues.
The educational level was correlated with sexual problems and FGM/C, wherein a negative correlation between the level of education of the woman and the practice of FGM/C was observed. In our study, only 3.5% of circumcised women held a university degree, whereas 58% of uncircumcised women held the same. Moreover, UNICEF (2005) reports that prevalence levels of FGM/C are generally lower among women with higher levels of education, indicating that circumcised girls are likely to have lower levels of education.
Establishing a relationship between a woman’s FGM/C status and her educational level can often be misleading, as FGM/C is usually performed before the completion of education and often before it commences. Therefore, the level of education of the mother appears to be a more significant determinant of the FGM/C status of the daughters. It is generally observed that women with higher levels of education are less likely to have circumcised daughters compared with women with lower or no formal education 12.
In the current study, the mean age at which the procedure of FGM/C was performed was 10.6±1.6 years. This finding largely corresponds with the findings of Tag El Din et al. 11, who reported that the average age was 10.1±2.3 years. Moreover, it is also in accordance with UNICEF’s data stating that girls in Egypt generally undergo FGM/C between the ages of 7 and 11 12. In addition, Al-Hussaini 13 also reported that the mean age at which FGM/C was performed was 7.25±2.09 years.
The most common forms of FGM/C still widely practiced throughout Egypt are type I (commonly referred to as clitoridectomy) and type II (commonly referred to as excision). Type I was the most common type of FGM/C in our study, found in 93% of respondents, and type II was found in 7%. Similarly, Al-Hussaini 13 reported that 51% of the respondents in his study had undergone type I FGM/C and 49% had undergone type II.
The results of this study showed that the family as a whole takes the decision of performing the procedure of FGM/C (65%), whereas mothers took the decision in 28% of our respondents. At this point, we disagree with the results of Tag El Din et al. 11, who reported that the main decision maker was the mother (65.2%), whereas the entire family took the decision in 24.2% of cases. As for the fathers, both studies agree with their role being minor; in this study, they only represent 2.5% of cases, and in the study by Tag El Din et al. 11, they represent 9.4% of the cases.
In Egypt, in the past, the majority of FGM/C procedures were performed by traditional midwives called dayas. However, according to the Demographic and Health Survey (1995), the number of procedures performed by medical practitioners (doctors, nurses, or trained midwives) tripled to 55%, with a concomitant drop in the number of procedures performed by dayas. In the present study, physicians performed 23% of FGM/C procedures, whereas nurses performed only 8.5%. Dayas and midwives performed 68% of FGM/C procedures. This corroborates the report by UNICEF 12, which states that, in the majority of countries, FGM/C is performed by traditional practitioners, including midwives and barbers. Moreover, the results of Al-Hussaini 13 showed that the traditional midwives performed the FGM/C procedure in 79.1% of cases, whereas 10.6% of cases were performed by physicians and 4% by nurses. Our results are in agreement with those of Tag El Din et al.11, who showed that 57.3% of FGM/C procedures were performed by physicians and 29.3 and 10.4% were performed by midwives and nurses, respectively. Similar to that observed in Egypt, in Benin, the Demographic and Health Survey data found that over 90% of circumcisions in girls were performed by traditional practitioners. In developed countries, immigrants asked doctors who were originally from their own community to circumcise their girls illegally. This raises the question on why doctors perform such procedures in the absence of medical indications such as clitoromegally or redundant labia. This may either be because of common beliefs among people belonging to the same community or a means of money making. More frequently, in countries where FGM/C is not allowed, traditional practitioners are brought into the country or girls are sent abroad to be circumcised by immigrants who strongly believe in this practice 14.
In the current study, when asked what they believed the main reason justifying the continuation of FGM/C was, the majority of women (41%) cited ‘custom and tradition’ or it being a ‘good tradition’ as a reason for their support. This result was similar to that observed among 46.5% of respondents in the study by Al-Hussaini 13 but was different from the findings of Tag El Din et al.11, who reported similar results in 17.9% of respondents. Of note, religious beliefs was cited as a reason by 19.5% of respondents in the current study. In contrast, the study by Tag El Din et al.11 and Al-Hussaini 13 had 33.4 and 0.8% of respondents citing similar religious beliefs a reason, respectively. These variations in results may be related to the location of the study, as the cultural beliefs of Egyptians differ from one governorate to another; 31% of women in Egypt believe FGM/C is required by their religion 12.
Other frequently mentioned reasons include ‘hygiene and cleanliness’ (which refers to esthetic judgments on physical appearance, rather than the concept of actually being dirty) and the belief that FGM/C brings greater pleasure to husbands. These reasons were cited by 14.5% of our participants, 18.9% of participants in the study by Tag El Din et al.11, and by only 2.4% of participants in the study by Al-Hussaini 13. A total of 16.5% of respondents in this study cited chastity protection and inhibition of lustful cravings and therefore preservation of a girl’s virginity, protecting her from becoming promiscuous and preventing her from engaging in immoral behavior, as a reason; this is similar to the findings of Tag El Din et al.11, who reported that 15.9% of respondents held similar views, whereas in Al-Hussaini’s 13 study, 10.2% of respondents held similar views. Another reason that women cited to justify their support for FGM/C is the belief that a girl cannot get married unless she is circumcised. The belief that FGM/C is necessary to ensure better marriage prospects for a daughter was cited by 8.5% of our respondents.
Our results showed that most respondents in both groups engaged in sexual intercourse within the normal range, mostly once/week (48% in the FGM/C group and 48.5% in the control group) or more than once/week (38.5% in the FGM/C group and 43% in the control group). This was also reported by El-Nashar et al. 15 as being 12.2 and 58.5%, respectively. Further, Hassanin et al. 16 reported that 46.76% of respondents engaged in intercourse 1–2 times/week. This is consistent with the findings of Al-Sibiani and Rouzi 17, who reported that 90% of women who had undergone FGM/C engaged in sexual intercourse more than once/week compared with 92% of women who had not undergone FGM/C. In our study, the frequency of sexual intercourse showed no significant differences between those who had undergone FGM/C and those who had not (P=0.254).
In the present study, 42% of the respondents in the FGC group engaged in sufficient foreplay, and 62% of respondents who had not undergone FGC reported foreplay to be almost sufficient. In contrast, Witting et al. 18 reported that the main complaints of the women were ‘too little foreplay’ (42%) and ‘partner is more interested’ (35%).
The mean scores of both arousal and orgasm showed significantly higher levels among women who had not undergone FGM/C (P<0.0001), whereas the lubrication score showed a nonsignificant difference (P>0.415). These results are in accordance with those of Catania 19, who reported significantly higher scores for arousal and orgasm among women who had not undergone FGM/C (arousal: 18.07±3.22 versus 15.12±3.38 in the circumcised group, P<0.001; orgasm: 13.22±3.72 versus 11.91±2.99 in the circumcised group, P=0.04). However, nonsignificant scores were obtained for the lubrication domain (P=0.12); and the mean score was 18.22±3.83 for the control group versus 17.24±2.86 for the FGM/C group.
In addition, Al-Sibiani and Rouzi 17 reported similar findings with significantly higher arousal and orgasm scores among nongenitally cut women, with a P-value of 0.007 and 0.003, respectively; however, they also reported a significantly higher lubrication score among nongenitally cut women.
Many of the women in this study reported that they engaged in sexual activity because of marital commitment, financial reasons, to avoid the sense of guilt, for religious reasons, and also to reduce the risk of their husbands engaging in extramarital sexual relationships. The husbands’ choice of an unsuitable time for sexual intercourse and unfavorable socioeconomic circumstances such as lack of adequate privacy at home and low income were the most common aggravating factors. Similarly, Leiblum and Rosen 20 reported that conflicts in a relationship (specifically lack of trust and intimacy), conflicts over power and control, and loss of physical attraction toward the partner are important causative factors for hypoactive sexual desire.
From this study, it was concluded that FGM/C may have a negative impact on female arousal and orgasm in genitally cut women, and this effect is more noticeable with advancement in age, whereas no significant effect was noticed on desire and lubrication. FGM/C is a deeply rooted multifactorial social practice that is more common among groups that are less educated and of low socioeconomic status. It is recommended that any action against FGM/C should take into account the many reasons that support and motivate this practice. It is an issue that demands a collaborative approach involving health professionals, religious leaders, educationalists, and nongovernmental organizations. Community development and raising educational and socioeconomic levels seem to be the best way to combat its practice.
Conflicts of interest
There are no conflicts of interest.