and Hubert Lepidi1
UER Médecine, Aix-Marseille Université, Marseille, France
Although the purpose of our study is the anatomical analysis of the bulbo-clitoral organ, we must also mention the abominable mutilations which are undergone by certain young girls, at the level of the exteriorised parts of this organ and sometimes also of the vulva. Such mutilations are still practised today. These mutilations are referred to by the general term of SGM (sexual genital mutilations).
Although the purpose of our study is the anatomical analysis of the bulbo-clitoral organ, we must also mention the abominable mutilations which are undergone by certain young girls, at the level of the exteriorised parts of this organ and sometimes also of the vulva. Such mutilations are still practised today.1 These mutilations are referred to by the general term of SGM (sexual genital mutilations).
These acts have appalling consequences and are true amputations as they involve removing and injuring unique and essential anatomical parts and thus depriving the women, who have undergone such operations, of an elementary function of sexuality: female pleasure.
16.1 The Different Types of Mutilation
According to the classification of R. Cook, established in 1995 by the WHO, four types of SGM can be observed:
Type 1: Excision of the clitoral prepuce with or without partial excision of the clitoris.2
Type 2: Excision of the prepuce and the clitoris with partial or total excision of the labia minora.
Type 3: Excision of the clitoris with partial or total excision of the labia minora and almost complete closure of the vulvar orifice.3
Type 4: Any other process, combining the excision of the clitoris, complex mutilations such as scarifications, application of corrosive substances (in the vagina in particular), stretching of the labia, etc.
The most frequent cases concern type 2 (80 % of the cases).
16.2 Brief Historical Reminder
These mutilations have a very ancient origin (5,000 years B.C., on the borders of the Red Sea). Excisions seem to have mainly existed in Egypt due to the fact that certain texts, and especially papyrus from the Ptolemaic era, kept at the British Museum, mention “young girls who had not been cut”. However, formal evidence is lacking (the external genitalia of female mommies, which were found in the North of Germany, between 1915 and 1920, showed scars which may be infibulations, but their conservation condition makes observations difficult to interpret).4 What is certain is that excisions existed before the emergence of the Catholic religion and especially before that of Islam. Therefore, this practice is not a religious rite, but more of an ancestral, clan-type, societal and customary tradition, whose origin is related to an aberrant and totally erroneous concept (a woman can only become a real woman if her masculine attributes, represented by the clitoris, are removed) or to horrible historical bases (infibulation is considered as its origin, a way of preventing women from being raped by invaders).
Another pretext, as horrifying and at the origin of this terrible operation, was to prevent young women from having the slightest desire and from masturbating, so that they are true virgins when they get married and remain faithful… Many old texts refer to the practise of clitoridectomy: Herodotus, a well-known historian (484–420 B.C.), was the first to mention, in his great book, “The investigation”, the existence of excisions in 700 B.C., which were performed by the Colchidians, the Egyptians, the Ethiopians, and the Phoenicians.
Such as recalled by Mr Wehenkel in his thesis, “infibulation, a very widespread custom in the Middle East, then spread to Arabia during the pre-Islamic period”.
The great physicians of Antiquity: Paul from Egina, Albucasis and Avicenna refer to excision in their texts. Aetius, as for him, described a “method for cutting the nymph5” (in current terms, the clitoridectomy technique), a therapy which he considers as… usable in some cases of large clitorises (reported by De Graaf6). In the sixteenth century, Jean Riolan, in his “Discours sur les hermaphrodites” (“Speech on hermaphrodites”), and then Ambroise Paré, in his book entitled “Des monstres et prodiges” (“Monsters and prodigies”), also recommended clitoridectomy for treating certain cases of clitoral hypertrophy. It appears that many European physicians, as well as many parents, proposed, at that time, the amputation of the clitoris, as soon as an anomaly was observed in young girls… Thus, in spite of the major scientific discoveries made during the sixteenth century in relation to the anatomy of the clitoris and its role in woman’s sexuality, this organ was going to be accused of all evils, to the point that during the following centuries and until the nineteenth century, clitoridectomy was going to spread in all Western Europe, as it was supposed to cure the majority of women’s diseases. This technique spread to such an extent that an English physician I.B. Brown (referred to by E. Sheean) wrote, in 1866, a book entitled “On the curability of some forms of insanity, epilepsy, catalepsy and hysteria in females” and acquired celebrity while preaching that clitoridectomy is therapeutic (see Chap. 1, p. 11). Fortunately certain young gynaecologists were going to oppose the serious and absurd theories supported by Brown, until he was discredited. Worse still, in France, during the same period (second half of the nineteenth century), well-known physicians, such as P. Garnier, or the famous neurologist, P. P. Broca (who discovered one of the language areas) dared to recommend clitoridectomy to fight against onanism, i.e. masturbation which was regarded as a psychiatric disease.7 Since the twentieth century and the scientific study of sexuality, these cruel operations, with unthinkable indications, have completely disappeared. Only a few exceptional cases of clitoroplasty8 persist as they are necessary in repair surgery for malformations or transgender surgery. On the other hand, standard excision operations remain in many countries (especially in sub-Saharan Africa) and even in Europe, in emigrated populations, while, at the same time, this practice is against the law in all European countries, including France, and is punished severely. According to the figures of the WHO (World Health Organization): 100–140 million young girls and women in the world have undergone this type of mutilation. Three million young girls per year, in the world, are likely to undergo these types of operations. Many cases are still reported in 28 countries in Africa and several countries in Asia9 and the Middle East, despite the legislations aiming to prohibit this practice, which have been adopted by 13 of these countries. It is necessary to also underline the combined efforts made by major organisations (ONU, WHO, UNICEF) to put an end to these “extremely serious personal injuries”, even if progress is still slow. In France, the legislator has been very efficient and considers excisions as violence causing a permanent mutilation, an offence which is punishable by 10 years in prison and a fine of 150,000 euros.10 This offence should be dissuasive. Alas, many excisions are still performed on this territory (these mutilations, due to their illegal character, are carried out in the most hazardous conditions with a frightening lack of hygiene). In some cases, they are performed with the assistance of healthcare providers, while the law states that all healthcare providers (including physicians) must report all cases of excision, even if they have not been performed yet. However, in this country, due to the high density of the emigrated African population (at least half of this population is in favour of excisions), 12–20,000 young girls are exposed to a risk of mutilation (the mutilation is carried out when the parents go back to their country for their holidays). It is, alas, the same in all countries with a high rate of African emigration.