Clitoridectomy

Clitoridectomy or clitorectomy is the surgical removal, reduction, or partial removal of the clitoris.[1] It is rarely used as a therapeutic medical procedure, such as when cancer has developed in or spread to the clitoris. It is often performed on intersex newborns. Commonly, non-medical removal of the clitoris is performed during female genital mutilation (FGM).[2]

Clitoridectomy
Other namesClitorectomy
Specialtygynecology

Medical uses

Malignancies

A clitoridectomy is often done to remove malignancy or necrosis of the clitoris. This is sometimes done along with a radical complete vulvectomy. Surgery may also become necessary due to therapeutic radiation treatments to the pelvic area.[3]

Removal of the clitoris may be due to malignancy or trauma.[3][4]

Intersexuality and other conditions

Female infants born with a 46,XX genotype but have genitalia affected by congenital adrenal hyperplasia and are treated surgically with vaginoplasty that often reduces the size of the clitoris without its total removal. The atypical size of the clitoris is due to an endocrine imbalance in utero.[1][5] Other reasons for the surgery include issues involving a microphallus and those who have Mayer-Rokitansky-Kuster disorder. Treatments on children raise human rights concerns.[6]

Technique

Clitoridectomy surgical techniques are used to remove an invasive malignancy that extends to the clitoris. Standard surgical procedures are followed in these cases. This includes evaluation and biopsy. Other factors that will affect the technique selected are age, other existing medical conditions, and obesity. Other considerations are the probability of extended hospital care and the development of infection at the surgical site.[3] The surgery proceeds with the use of general anesthesia, and prior to the vulvectomy/clitoridectomy an inguinal lymphyadenectomy is first done. The extent of the surgical site extends one to two centimeters beyond the boundaries of malignancy. Superficial lymph nodes may also need to be removed. If the malignancy is present in muscular tissue in the region, it is also removed. In some cases, the surgeon is able to preserve the clitoris though the malignancy may be extensive. The cancerous tissue is removed and the incision is closed.[3]

Post operative care may employ the use of suction drainage to allow the deeper tissues to heal toward the surface. Follow up after surgery includes the stripping of the drainage device to prevent blockage. A typical hospital stay can be up to two weeks. The site of the surgery is left unbandaged to allow for frequent examination.[3] Complications can be the development of lymphedema though not removing the saphenous vein during the surgery will help prevent this. In some instances, foot elevation, diuretic medication and compression stockings can reduce the build up of fluid.[3]

In a clitoridectomy for intersex infants, the clitoris is often reduced instead of removed. The surgeon cuts the shaft of the elongated phallus and sews the glans and preserved nerves back onto the stump. In a less common surgery called clitoral recession, the surgeon hides the clitoral shaft under a fold of skin so only the glans remains visible.[7]

Society and culture

General

While much feminist scholarship has described clitoridectomy as a practice aimed at controlling women's sexuality, the historic emergence of the practice in ancient European and Middle Eastern cultures may have possibly derived from ideas about intersex people and the policing of boundaries between the sexes.[8]

In the seventeenth century, anatomists remained divided on whether a clitoris was a normal female organ, with some arguing that only intersex people had one and that, if large enough to be visible, it should always be removed at birth.[9] In the 19th century, a clitoridectomy was thought by some to curb female masturbation.[10] Isaac Baker Brown (1812–1873), an English gynaecologist who was president of the Medical Society of London believed that the "unnatural irritation" of the clitoris caused epilepsy, hysteria, and mania, and he worked "to remove [it] whenever he had the opportunity of doing so", according to his obituary in the Medical Times and Gazette. Peter Lewis Allen writes that Brown's views caused outrage, and he died penniless after being expelled from the Obstetrical Society.[11]

Occasionally, in American and English medicine of the nineteenth century, circumcision was done as a cure for insanity. Some believed that mental and emotional disorders were related to female reproductive organs and that removing the clitoris would cure the neurosis. This treatment was discontinued in 1867.[12]

Aesthetics may determine clitoral norms. A lack of ambiguity of the genitalia is seen as necessary in the assignment of a sex to infants and therefore whether a child's genitalia is normal, but what is ambiguous or normal can vary from person to person.[13]

Sexual behavior is another reason for clitoridectomies. Author Sarah Rodriguez stated that the history of medical textbooks has indirectly created accepted ideas about the female body. Medical and gynecological textbooks are also at fault in the way that the clitoris is described in comparison to a male's penis. The importance and originality of a female's clitoris is underscored because it is seen as "a less significant organ, since anatomy texts compared the penis and the clitoris in only one direction." Rodriguez said that a male's penis created the framework of the sexual organ.[14]

Not all historical examples of clitoral surgeries should be assumed to be clitoridectomy (removal of the clitoris). In the nineteen thirties, the French psychoanalyst Marie Bonaparte studied African clitoral surgical practices and showed that these often involved removal of the clitoral hood, not the clitoris. She also had a surgery done to her own clitoris by the Viennese surgeon Dr Halban, which entailed cutting the suspensory ligament of the clitoris to permit it to sit closer to her vaginal opening. These sorts of clitoral surgeries, contrary to reducing women's sexual pleasure, actually appear aimed at making coitus more pleasurable for women, though it is unclear if that is ever their actual outcome.[15]

Human rights concerns
Further information: Female genital mutilation and Intersex human rights

Clitoridectomies are the most common form of female genital mutilation. The World Health Organization (WHO) estimates that clitordectomies have been performed on 200 million girls and women that are currently alive. The regions that most clitoridectomies take place are Asia, the Middle East and west, north and east Africa. The practice also exists in migrants originating from these regions. Most of the surgeries are for cultural or religious reasons.[16]

Clitoridectomy of women with intersex conditions is controversial when it takes place during childhood or under duress. Intersex women exposed to such treatment have spoken of their loss of physical sensation, and loss of autonomy.[17][18] In recent years, multiple human rights institutions have criticized early surgical management of such characteristics.[19][20][21]

In 2013, it was disclosed in a medical journal that four unnamed elite female athletes from developing countries were subjected to gonadectomies and partial clitoridectomies after testosterone testing revealed that they had an intersex condition.[22][23] In April 2016, the United Nations Special Rapporteur on health, Dainius Pūras, condemned this treatment as a form of female genital mutilation "in the absence of symptoms or health issues warranting those procedures."[24]

See also
  • List of surgeries by type

References
  1. Hiort, O. (2014). Understanding differences and disorders of sex development (DSD). Basel: Karger. ISBN 9783318025583.
  2. "New study shows female genital mutilation exposes women and babies to significant risk at childbirth" (Press release). World Health Organization. 2006-06-02. Archived from the original on June 2, 2006.
  3. Hoffman, Barbara (2012). Williams gynecology. New York: McGraw-Hill Medical. ISBN 9780071716727.
  4. Horbach, Sophie E.R.; Bouman, Mark-Bram; Smit, Jan Maerten; Özer, Müjde; Buncamper, Marlon E.; Mullender, Margriet G. (2015). "Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques". The Journal of Sexual Medicine. 12 (6): 1499–1512. doi:10.1111/jsm.12868. ISSN 1743-6095. PMID 25817066.
  5. Gundeti, Mohan (2012). Pediatric Robotic and Reconstructive Urology a Comprehensive Guide. City: Wiley-Blackwell. ISBN 9781444335538; Access provided by the University of Pittsburgh{{cite book}}: CS1 maint: postscript (link)
  6. Human Rights Watch (2017-07-25). I Want to Be Like Nature Made Me: Medically Unnecessary Surgeries on Intersex Children in the US (Report). Human Rights Watch. Retrieved 2021-12-17.
  7. Fausto-Sterling, Anne (2000). Sexing the body : gender politics and the construction of sexuality (1. ed., [Nachdr.] ed.). New York, NY: Basic Books. p. 48. ISBN 978-0-465-07714-4.
  8. Norbert Finzsch, Der Widerspenstigen Verstümmelung: Eine Geschichte der Kliteridektomie im „Westen”, 1500-2000. Bielefeld: Transcript, 2021.
  9. Alison M. Moore, Victorian Medicine Was Not Responsible for Repressing the Clitoris: Rethinking Homology in the Long History of Women’s Genital Anatomy. Signs: The Journal of Women in Culture and Society 44 (1) August 2018, 53-81. DOI: 10.1086/698277.
  10. Duffy, John (October 19, 1963). "Masturbation and Clitoridectomy: A Nineteenth-Century View". JAMA. 186 (3): 246–248. doi:10.1001/jama.1963.63710030028012. PMID 14057114.
  11. Allen, Peter Lewis. The Wages of Sin: Sex and Disease, Past and Present. University of Chicago Press, 2000, p. 106.
    • For the obituary, see J.F.C. "Isaac Baker Brown, F.R.C.S.", Medical Times and Gazette, 8 February 1873.
    • Also see Brown, Isaac Baker. On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females. Robert Hardwicke, 1866.
  12. Atoki, Morayo (August 1995). "Should female circumcision continue to be banned?". Feminist Legal Studies. 3 (2): 229. doi:10.1007/BF01104114. S2CID 144198914; Access provided by the University of Pittsburgh.{{cite journal}}: CS1 maint: postscript (link)
  13. Kessler, Suzanne J. (2000). Lessons from the intersexed (2. Paperback printing. ed.). New Brunswick, NJ [u.a.]: Rutgers Univ. Press. p. 43. ISBN 978-0813525297.
  14. Rodriguez, Sarah (2014). Female Circumcision and Clitoridectomy in the United States: A History of Medical Treatment. University of Rochester Press.
  15. Relocating Marie Bonaparte’s Clitoris. Australian Feminist Studies 24 (60), April 2009, 149-165.
  16. "Female genital mutilation". World Health Organization. February 2016. Retrieved 2016-03-26.
  17. Holmes, Morgan. "Is Growing up in Silence Better Than Growing up Different?". Intersex Society of North America. Retrieved 2016-08-26.
  18. Bastien-Charlebois, Janik (August 9, 2015). "My coming out: The lingering intersex taboo". Montreal Gazette. Retrieved 2016-08-26.
  19. Méndez, Juan (February 2013). "Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Juan E. Méndez, A.HRC.22.53" (PDF).
  20. Council of Europe; Commissioner for Human Rights (April 2015), Human rights and intersex people, Issue Paper
  21. Asia Pacific Forum of National Human Rights Institutions (June 2016). Promoting and Protecting Human Rights in relation to Sexual Orientation, Gender Identity and Sex Characteristics. Asia Pacific Forum of National Human Rights Institutions. ISBN 978-0-9942513-7-4.
  22. Fénichel, Patrick; Paris, Françoise; Philibert, Pascal; et al. (June 2013). "Molecular Diagnosis of 5α-Reductase Deficiency in 4 Elite Young Female Athletes Through Hormonal Screening for Hyperandrogenism". The Journal of Clinical Endocrinology & Metabolism. 98 (6): –1055–E1059. doi:10.1210/jc.2012-3893. ISSN 0021-972X. PMID 23633205.
  23. Jordan-Young, R. M.; Sonksen, P. H.; Karkazis, K. (April 2014). "Sex, health, and athletes". BMJ. 348 (apr28 9): –2926–g2926. doi:10.1136/bmj.g2926. ISSN 1756-1833. PMID 24776640. S2CID 2198650.
  24. Pūras, Dainius; Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (April 4, 2016), Sport and healthy lifestyles and the right to health. Report A/HRC/32/33, United Nations
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