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Female genital cutting or mutilation refers to the cutting of girls’ external genitalia. Due to migration from contexts where female genital cutting is common, it is estimated that around 38 000 cut women and girls live in Sweden. Clitoral reconstruction, a relatively new form of surgical healthcare offered to women with female genital cutting, was established in Sweden in 2014. This surgery aims at restoring clitoral function and anatomy, but there is yet a dearth of evidence demonstrating the effects of the surgery. The aim of this study was to explore how women undergoing clitoral reconstruction in Sweden between 2016 and 2019 experienced the surgical process and its aftereffects from a physical, sexual and psychosocial perspective. Eighteen women who had undergone clitoral reconstruction at a university hospital in Sweden agreed to participate in the study. The women were interviewed using semi-structured interviews, which were recorded, transcribed and analysed using thematic analysis. The results, based on self-categorization and labelling theory, demonstrated both benefits and disappointments following the surgery. Several women reported positive outcomes in terms of sexual, psychosocial and aesthetic terms. They experienced reduced genital pain, improvements in their sex lives, and a sense of feeling more empowered and at ease in their bodies. Yet, some women reported aesthetic, functional and process-related disappointment related to clitoral reconstruction. Nonetheless, the women expressed gratitude for the possibility of undergoing the surgery. In conclusion, the women reported that they experienced physical, sexual and psychosocial benefits of the surgery.

Female genital cutting (FGC) involves the removal of women's external genitalia for non-therapeutic reasons. An estimated 38,000 women living in Sweden have undergone some form of the procedure. These women often belong to marginalised minorities of immigrant women from countries where FGC is widespread. Clitoral reconstructive surgery following FGC has recently been introduced in Sweden. This study investigates women's perceptions of FGC and clitoral reconstructive surgery with a particular focus on: (1) reasons for requesting reconstructive surgery, and (2) FGC-affected women's expectations of the surgery. Seventeen women referred for clitoral reconstructive surgery at the Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, Stockholm, participated in the study. Findings revealed five factors motivating women's request for clitoral reconstruction (CR): (1) symbolic restitution - undoing the harm of FGC; (2) repairing the visible stigma of FGC; (3) improving sex and intimacy through physical, aesthetic and symbolic recovery; (4) eliminating physical pain; (5) and CR as a personal project offering hope. These factors were highly interconnected, suggesting that the reasons for seeking surgery were often multiple and complex.

Purpose of the Review The aim of this review is to give an overview of the recent evidence on clitoral reconstruction and other relevant reconstructive plastic surgery measures after female genital mutilation/cutting (FGM/C). Recent Findings Recent publications present refinements and modifications of the surgical technique of clitoral reconstruction along with reconstruction of the labia majora and clitoral hood. Novel approaches with reposition of the clitoral nerve, anchoring of the labia majora, fat grafting, and full thickness mucosa grafts have been introduced. The current evidence on outcomes of clitoral reconstruction shows potential benefits. However, there is a risk of postoperative complications and a negative outcome. Experts in the field advocate for a multidisciplinary approach including psychosexual counseling and health education with or without subsequent clitoral reconstructive surgery. Summary The evolution of reconstructive treatment for women with FGM/C is expanding, however at a slow rate. The scarcity of evidence on clitoral reconstruction halters availability of clinical guidelines and consensus regarding best practice. Clitoral reconstruction should be provided by multidisciplinary referral centers in a research setting with long-term follow-up on outcomes of postoperative morbidity and possible benefits.

Introduction Gender dysphoria is a state in which the individual shows strong and persistent identification with the opposite sex. After thorough diagnostic assessment, the treatment includes gender confirming surgery (GCS). The efficacy and benefit of GCS has been advocated to effectively resolve the patient’s gender dysphoria as well as improve quality of life and psychosocial functioning. The aim of the studies described here was to assesssurgical techniques, complications, quality of life and functional outcomes of GCS.Patients and Methods Study I is a retrospective study of surgical outcomes for patients who underwent male-tofemale (MtF) GCS over a 14-year period (n=205). Study II describes a prospective study (n=80) of vaginal depth after vaginoplasty performed using solely penile skin for intra vaginal lining. Factors predicted to correlate with poor outcomes were analyzed using a multivariate regression model. Study III is a prospective study (n=193) examining patient-reported outcomes on health-related quality of life. We used the Swedish version of the Short Form-36 Health Survey (SF-36), which measures QoL across eight domains. The questionnaire was distributed to patients pre-operatively, as well as 1,3 and 5 years post-operatively. The results were compared between the different measure points, as well as between the study group and the general population. Study IV is a cohort study (n=22) of the sensitivity of the neoclitoris and its patient-reported functionality. Tactile and vibratory sensitivity was measured with the Semmes-Weinstein monofilaments and the Bio-Thesiometer vibratory measurement device, respectively. A body image questionnaire was provided to patients and the patients were asked about orgasm, pain and general satisfaction with the surgery.Results In study I, the most common short-term complications were bleeding (11%) and infection (10%). Other complications, such as wound dehiscence (2%), rectovaginal fistula (2%), pulmonary embolus(2%) and deep vein thrombosis (0%), were rare. In study II, the average neovaginal depth was 10.2 cm (range 1-16 cm). Noncompliance with dilation protocol (p<0.001) and postoperative complications (p=0.01) were associated with decreased vaginal depth. Neither circumcision nor age affected the outcome of vaginal depth. In study III, transgender women reported significantly lower quality of life in most dimensions when compared to the general population. One year postoperatively, there was a trend towards higher scores compared to the preoperative measurement point; however, these scores then declined. In study IV, the average pressure threshold for the neoclitoris was 12.5 g/mm2 and the average vibratory threshold was 0.3 µm. The vast majority of the study participants could reach orgasm (86%), and reported satisfaction with having undergone GCS (86%).Conclusions MtF GCS can be performed with a low rate of major complications. Using solely penile skin is sufficient to create the vaginal lining, although adhering to a dilation protocol is crucial to attaining sustained vaginal depth. Quality of life among MtF patients compared to the general population is improved one year after GCS, but then declines. The sensate neoclitoris has a protective tactile sensation, gives the patient erogenous sensitivity and the ability to reach orgasm in the majority of patients. Over all, the vast majority of patients who undergo MtF GCS are satisfied.