Guillermo Martínez Pérez

Elongation of labia minora in Uganda: including Baganda men in a risk reduction education programme

Okukyalira ensiko or ‘visiting the bush’ is how, in Uganda, the Baganda people name the practice of elongating the labia minora, which young girls start performing before menarche. As a mandatory rite of passage that identifies membership of the tribe, one of its main purposes is to enhance sexual pleasure for both male and female partners. The conditions in which it is practiced involve certain physical health risks. In this qualitative study carried out in Wakiso district, a semi-structured interview was conducted among 31 Baganda men, in order to understand their perceptions, attitudes and knowledge toward the way in which their daughters practise labia minora elongation. According to our results, men highly value this practice for its capacity to enhance sexual stimulation even though they are aware of its risks. Since genital stretching is likely to endure, the authors discuss the possibility of addressing Baganda men by health workers in an education programme aimed at minimising the risks attached to the procedure and, hence, improving the sexual and reproductive health of Baganda girls.

Labia Minora Elongation and its Implications on the Health of Women: A Systematic Review

ABSTRACT Objectives: Labia minora elongation (LME) is a female genital modification practice categorized among the types included in the fourth group of female genital mutilation. In this article, we display the results of a systematic review of the evidence-based knowledge published on the health risks and benefits of LME as informed by African female respondents who are insiders of the practice. No other systematic review on this specific topic has been published before. Methods: A methodological bibliographic search was done in scientific databases by manual referencing and by contacting experts on this area of knowledge. Seventeen articles were eligible for this review, which corresponded to nine different studies. Eight of these studies were conducted in Eastern and Southern African countries and one was carried out in Italy. Results: This review concludes that pain at the beginning of the practice, nuisances related to the use of caustic herbs, and stigmatization in failing to comply with the practice are the principal health risks associated with LME. At the same time, there is evidence that labial elongation may benefit the sexual health and well-being of women. Conclusions: More research of a quantitative nature is necessary to determine the prevalence of LME across the practicing cultures and to determine its implications on the sexual and reproductive health of women who engage in this female genital modification.

Zambian Women in South Africa: Insights Into Health Experiences of Labia Elongation

Labia minora elongation consists in the manual stretching of the inner lips of the external genitalia. This practice is documented in east and southern Africa. The experiences of African women in the diaspora practicing elongation are not thoroughly understood. The purpose of this qualitative study was to explore the health harms and benefits associated with this practice of Zambian women who have migrated to Cape Town, South Africa. Twenty women and seventeen men participated in this study. Between December 2013 and May 2014, in-depth interviews and natural group discussions were conducted with the participants. The focus of this article is to report on the emic of the women related to notions of health, hygiene, and well-being. Labial elongation is perceived as a practice involving minor, short-term adverse effects that can be prevented by following some basic hygiene. Overall, personal and social value is placed on this practice because of its reported benefits for the sexual health of men and women, and for womens femininity and self-image. Further research is necessary on how female genital modifications influence Zambians’ sexual preferences to inform the development of culturally appropriate health promotion interventions.

Autoerotism, Homoerotism, and Foreplay in African Women Who Practice Labia Minora Elongation: a Review

ABSTRACT. Objectives: Labia minora elongation is a female genital modification in which some women in certain linguistic groups from Africa engage. One of the purposes is to enhance sexual pleasure for their male partners. Methods: The literature has been reviewed to describe how labia minora elongation serves for women to increase their sexual pleasure, both as an autoerotic method and in the context of homoerotic and heterosexual relationships. Results and Conclusions: This aspect deserves to be investigated, as there are narratives from some women practitioners of labial elongation that this practice might contribute to improve the sexual health of some of the women who engage in it.

Grounded Theory: A Methodology Choice to Investigating Labia Minora Elongation Among Zambians in South Africa

A study on how Zambian migrants living in Cape Town perceive and experience the implications of labial elongation on women’s health was conducted. Labia minora elongation (LME) is a genital modification that some women in east and southern Africa practice. This tradition is not common in Western Cape province (southwestern part of South Africa). The aim of this article is to discuss the methodological choices made in the design and conduct of this study, in which a White European male interviewed the female study participants on the health implications of a practice that is considered a woman’s private issue. Constructivist grounded theory informed by a feminist perspective was chosen as the most suitable methodological approach to enable cogeneration of knowledge with the female participants. The methods and tools used by the lead investigator facilitated access to the participants’ emic views. Grounded theory methodology holds the potential to be an appropriate methodological approach for researchers who seek to erode the power imbalances influencing research processes that aim to explore the associated meanings and health implications of female genital modifications, such as LME, as narrated by the women who practice them.

On MeSH: Have Female Genitalia Fallen into Oblivion?

MeSH, or Medical Subject Headings, is the most reputable controlled vocabulary in the biomedical community. First introduced in 1963 by the U.S. National Library of Medicine (NLM), it consists today of 26,853 descriptors. Its use enables health information seekers to search and retrieve scientific articles from among the more than 20 million that are indexed in the NLM databases MEDLINE and PubMed [1]. Most descriptors are accompanied by a definition and are organized in a hierarchical tree that permits searching at various levels of specificity [1]. Medical specialties, study designs, diseases, anatomical body parts, and many chemical and pharmaceutical components share the privilege of existing as MeSH descriptors. The most intimate parts of the body—penis, vagina, vulva, foreskin, anal canal, Bartholin’s glands, breasts—are well located, organized, enumerated, and defined in the MeSH repository. “Labia minora” and “labia majora,” however, do not yet appear in MeSH. “Clitoris” does exist as a descriptor, though still undefined. Its tree number is A05.360.319.887.436: “All MeSH Categories” > “Anatomy category” > “Urogenital System” > “Genitalia” > “Genitalia, Female” > “Vulva” > “Clitoris”. It can also be linked to 23 other subheadings [1]. One must ask, why is the MeSH descriptor “Clitoris” not defined? The MeSH Section staff is the board entitled with the task to update the controlled vocabulary. Any accusation that the undefined status of “Clitoris” is due to MeSH being a primarily masculine institution oblivious to the idea of female genitalia would be unfounded, as four of the ten MeSH Section staff board are women [1]. Neither can we say that the MeSH section staff has not felt compelled to describe “Clitoris” because the term has not drawn enough attention from the scholarly community. If one adds “Clitoris” to the PubMed search builder, the database will retrieve 1,263 references. This figure is far from the 32,747 articles tagged under the MeSH descriptor “Penis.” But it is a far larger number than the 336 articles tagged under the MeSH descriptor “Onchocerciasis, Ocular” or the 443 under “Anisakiasis,” and it is closer to the 1,288 tagged under “Larva Migrans” (all parasitic diseases that affect the population of most of the Southern Hemisphere). To those of us dedicated to the study of female genital mutilation (FGM), it is almost insulting that “Clitoris” remains undescribed. The reasons behind this absence can be traced back in history. Across the ages, the word “clitoris,” its significance, and the organ’s function as a sexual organ have been controversial [2]. By not defining it, the MeSH repository follows the historical trend of blurring, erasing, and sweeping away the concept, image, and reminiscences of the clitoris [2]. We could write to the MeSH section staff and propose a definition. However, if we scrutinize each one of the ethnic groups in the world, we will come to different conclusions on what “clitoris” means. One can attempt to name a few. The clitoris is that part of the female genitalia that Rwandese men call rugongo and have to strike with the glans of the erect penis during sexual foreplay [3]. In KwaZulu-Natal, South Africa, the clitoris is that part of the body where women perform cuttings and rub “love medicines” on the scars, aiming to increase desirability [4]. Since Mosotho women in Lesotho are aware of the importance of the clitoris in sexual pleasure, some girls consider the clitoris to be a part of their body they would prefer to elongate—instead of attempting to elongate their labia minora [5]. The clitoris is also what Somali girls have excised because it is thought of as the male part of the female body, which needs to be removed in order to humanize a woman [6]. This belief should not be foreign to Westerners; in 1561, the Italian botanist Gabrielo Fallopio established an analogy between the penis and the clitoris, and it was not until 1987 that somebody—the psychologist Josephine Lowndes Sevely—argued that these organs were not similar at all [2]! The clitoris is what more than 3 million girls are at risk to get mutilated, excised, circumcised, cut, scarred, nicked, pricked, or pierced every year [7]. Thousands of those girls live in Northern, high-income countries where recent migrations have brought these issues to light. This has highlighted the need for more evidence-based research to guide health practitioners in the treatment and provision of care for the victims of FGM [8,9]. “Genital Mutilation, female” can be found in PubMed, not as a MeSH descriptor but as an entry term—a mere synonym of what MeSH considers a similar term, the descriptor “Circumcision, Female.” A total of 712 articles are indexed tagged under this descriptor in PubMed. The search (“Circumcision, Female”[Mesh]) AND “Clitoris”[Mesh]) gives only 40 results. The MeSH definition of “Circumcision, Female” agrees with the WHO definition of the non-MeSH descriptor “Female Genital Mutilation” [1,7]. Nevertheless, many scholars advocate that the word “circumcision” not be used indiscriminately as a synonym of “mutilation.” Putting aside all of its diverse cultural connotations, it cannot be denied that the clitoris is a part of the female genital anatomy. Anatomically, it is an erectile organ composed of cavernous bodies and a glans clitoridis. Microscopically, in vivo dissection followed by histomorphological evaluation of the cavernous erectile tissues of the clitoris has demonstrated the role that the number and characteristics of its smooth muscle cells and its intricate vascular network can play in female sexual arousal response [10]. Functionally, it plays a key role in enhancing female orgasm [2]. The clitoris exists for the scholars aiming to increase the evidence on FGM. It exists for the decision makers working to table new laws against FGM in the parliaments, design health interventions to tackle its gyno-obstetrical complications, and fund campaigns to eradicate FGM. And it exists for the health practitioners caring for the victims of the cultural norms which dictate that their clitoris must be removed [8,9]. Hence, in justice to the estimated hundreds of millions of women in the world who have undergone FGM and also to the millions at risk, the MeSH descriptor “Clitoris” deserves to be properly described.

Perceptions of Men on Puxa-Puxa, or Labia Minora Elongation, in Tete, Mozambique

ABSTRACT Labia minora elongation has been documented as being practiced by 98.6% of the women in Tete province, Mozambique. Women engage in this procedure before the first menstruation. In this article we report on the findings from the male respondents from Tete province that participated in the qualitative component of the World Health Organization–supported multicountry Gender, Sexuality, and Vaginal Practices study. The men reported that the main motivation behind labia minora elongation is to enhance the sexual pleasure for both female and male partners. Researching what men know and perceive of labia minora elongation is crucial to understanding the contribution of this practice for sexual health. This knowledge is helpful to inform the development of new human immunodeficiency virus (HIV)/sexually transmitted infection (STI) prevention technologies and culturally appropriate information, education, and communication interventions.

On MeSH Setting Equivalences Between Female and Male Genitalia

In 2013, we wrote a letter, “On MeSH: Have Female Genitalia Fallen into Oblivion?,” addressing the responsibility that the US National Library of Medicine (NLM) had in defining the “clitoris.” Today, a terse definition of the “clitoris” is indexed in the Medical Subject Heading (MeSH). The “clitoris” is “an erectile structure homologous with the penis, situated beneath the anterior labial commissure, partially hidden between the anterior ends of the labia minora.” Its primary erotogenic function is not mentioned. In contrast, the MeSH definition of “penis” mentions its reproductive function but does not equate it to being homologous to the “clitoris.” This is problematic.