Clitoral reconstruction: procedure, recovery and results
In brief
Clitoral reconstruction is a reconstructive surgical procedure offered to women who have undergone female genital mutilation (FGM, excision); it involves freeing the part of the clitoris that remains under the scar and repositioning it on the outside; its results develop over several months. In the largest published series (2,938 women operated on in France, The Lancet, 2012), the great majority of patients seen again at one year described stable or reduced pain, and immediate complications affected about 5% of patients. The procedure is covered by the Assurance maladie (French national health insurance) and should be accompanied by psychological and psychosexual follow-up.
Who is clitoral reconstruction for?
The procedure concerns adult women who have undergone genital mutilation affecting the clitoris (types I, II and sometimes III of the WHO classification). The reasons for requesting it vary:
- to regain a body perceived as complete and an identity as a woman;
- to reduce pain from the scar or pain during intercourse;
- to improve sensation and pleasure.
In Foldès's study published in The Lancet, almost all women (99%) cited "recovering their identity" as their main expectation, 81% an improvement in their sexual life and 29% a reduction in pain.
The request is never urgent. It is part of a broader care pathway, described in the article "Female genital mutilation: consequences, support and care".
How is the procedure prepared?
The decision is based on several consultations.
- Surgical consultation: listening to expectations, examining the scar, explaining the technique, possible benefits and limitations.
- Psychological or psychosexual interview: the HAS (French National Authority for Health) recommends that surgery be combined with psychological and psychosexual support. This time makes it possible to check that the decision is a personal one, to prepare for changes in sensation and to address any trauma.
- Time for reflection: the patient may take as long as she needs, come back with her questions, and withdraw at any time.
- Anaesthetic consultation, mandatory before the procedure.
How is the operation performed?
The most widely used technique is the one described by Dr Pierre Foldès. During excision, only the visible part of the clitoris (the glans) is removed; the body of the clitoris, several centimetres long, remains in place under the skin. The surgery relies on this anatomy.
The steps described in the Lancet publication are:
- opening the skin covering the clitoral stump;
- dividing the suspensory ligament, which holds the clitoris upwards, in order to mobilise it;
- removing the scar tissue from the exposed part;
- fixing the new glans in a normal position, on the outside.
The procedure is generally performed under general anaesthesia, at the Hôpital privé Geoffroy Saint-Hilaire (Paris 5th), the Clinique de la Muette (Paris 16th) or the Clinique Ambroise Paré (Neuilly-sur-Seine). The length of hospital stay is explained to you at the consultation.
What is recovery like after the operation?
Recovery involves gradual healing, which requires patience.
| Period | What is usual | What should raise concern |
|---|---|---|
| First few days | Moderate pain, swelling, slight bleeding, discomfort when sitting and passing urine | Heavy bleeding, enlarging haematoma, fever |
| First few weeks | Healing of the new glans, presence of scabs or fibrin (a normal whitish deposit) | Increasing pain, foul-smelling discharge, wound breakdown |
| First few months | New sensations, sometimes hypersensitivity, then gradual change | Persistent or disabling pain |
Care at home
- washing with water, several times a day, without harsh soap;
- gentle drying, cotton underwear;
- painkillers prescribed on discharge;
- avoiding prolonged baths and friction until healing is complete.
Return to activities
As a guide, the hospital stay is usually one night; time off work is generally about 10 days after discharge, renewable if needed. Intercourse resumes once the area is pain-free, often after 5 to 8 weeks, and sport after 6 to 8 weeks depending on healing; these guidelines are adjusted at the consultation. A post-operative consultation generally takes place 4 to 6 weeks after the operation (earlier if needed); further check-ups are arranged at that point.
Sexual activity is resumed at your own pace, once healing is complete. The new sensations often take some getting used to: this is one of the aims of psychosexual follow-up.
What are the risks?
Like any surgery, reconstruction carries risks. In the series of 2,938 patients published in The Lancet, immediate complications (haematoma, suture breakdown, moderate fever) occurred in 5% of women, and 4% were briefly readmitted to hospital.
Other risks to be aware of:
- slow healing or retraction of the new glans, which may become less visible again;
- persistent pain or hypersensitivity;
- no perceived improvement, or even a deterioration: the systematic review published in the BJOG reports that up to 22% of women describe a worsening of certain aspects of their sexual life after reconstruction.
This is why prior information must be complete and the decision shared.
What results can be expected after clitoral reconstruction?
Anatomical appearance
At one year, in Foldès's study, 42% of the women seen again had a visible glans without a hood, 28% a clitoris of normal appearance, 24% a visible projection and 6% a palpable projection; less than 1% noted no change. The BJOG review, which pools several studies, found a visible clitoris in about 77% of women.
Pain
Of 840 women seen again at one year in the Lancet series, 821 described pain that was improved or at least not worsened.
Sexual function
In the same series, 815 of 834 women described improved or stable clitoral pleasure, and 51% reported orgasms at one year. The BJOG review confirms an improvement for the majority of women, but highlights the variability of results.
Limitations of these data
They should be interpreted with caution: less than a third of the women operated on in the Lancet series returned for the one-year consultation, and the questionnaires used were not standardised. The BJOG review concludes that women should be informed of the low level of evidence regarding the benefits. The result also depends on personal experience, support and time.
Why psychosexual support?
Surgery repairs an organ; on its own, it does not repair a personal history. The sensations of a clitoris long buried under a scar are new and sometimes disconcerting. Working with a sex therapist or psychologist helps to:
- understand one's anatomy and new sensations;
- overcome apprehension about pain;
- integrate this change into the couple relationship;
- address trauma related to the excision.
The HAS recommends this support in addition to surgery. It may begin before the procedure and continue for several months afterwards.
Is it reimbursed?
Yes. The HAS states that clitoral repair is a reconstructive, not cosmetic, surgical procedure, covered by the Sécurité sociale (French social security). A written estimate is given to you before the operation.
When should you seek urgent medical advice?
After the procedure, contact the surgical team without delay, or call 15 (SAMU) or 112 in France, or your local emergency number, in case of:
- heavy bleeding or an enlarging haematoma;
- fever above 38.5 °C;
- pain that worsens despite painkillers;
- inability to pass urine.
Frequently asked questions
Is reconstruction painful?
The first few days are uncomfortable and require painkillers. In the great majority of published cases, pain subsides as healing progresses, and many women eventually notice a reduction in their previous pain.
Can I have a vaginal delivery after reconstruction?
The mode of delivery is decided by the obstetric team, who should be informed of the procedure so that monitoring of the delivery can be adapted.
Are the sensations immediate?
No. Sensations develop gradually over several months. Temporary hypersensitivity is possible at first.
Do I need to be supported by a psychologist to have the operation?
Psychological or psychosexual support is recommended by the HAS. It is not an administrative requirement.
Does my partner need to give consent?
No. The decision is yours. You may, if you wish, involve your partner in the consultations.
How long does healing take?
Healing takes several weeks. As a guide, the hospital stay is usually one night; time off work is generally about 10 days, sex can be resumed once the area is no longer painful, often after 5 to 8 weeks, and sport after 6 to 8 weeks. A post-operative appointment generally takes place 4 to 6 weeks after the operation; these guidelines are adjusted to each patient.
References
- Foldès P, et al. Reconstructive surgery after female genital mutilation: a prospective cohort study. The Lancet, 2012. doi:10.1016/S0140-6736(12)60400-0 — PMID 22695031
- Berg RC, et al. The effectiveness of surgical interventions for women with FGM/C: a systematic review. BJOG, 2018. doi:10.1111/1471-0528.14839 — PMID 28755440
- Haute Autorité de santé. Prise en charge des mutilations sexuelles féminines par les professionnels de santé de premier recours [Management of female genital mutilation by primary care health professionals]. Recommandation de bonne pratique [Good practice guideline], février 2020. https://www.has-sante.fr/upload/docs/application/pdf/2020-02/reco307__recommandations_mutilations_sexuelles_feminines.pdf
Dr Olivier KadochObstetrician-gynaecologist and gynaecological surgeon in Paris (16th and 5th arrondissements). Former chef de clinique-assistant (senior registrar) at the Paris public hospitals (AP-HP); individually accredited by the French National Authority for Health (HAS). RPPS 10003957809. Background and practice locations
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