Recommendation 7 - Sexual health counselling is suggested for preventing or treating female sexual dysfunction among women living with FGM.
- Summary of the evidence -
The evidence review was conducted to determine the effects of sexual health interventions – including sexual health counselling, physical therapy or psychotherapy – for women with FGM who experience sexual dysfunction, and to assess any improvements in sexual health outcomes, psychosexual functioning and/or quality of life. The review updates a previous review that explored the evidence on sexual health counselling for treating or preventing sexual dysfunction in women with FGM, which did not find sufficient evidence to provide conclusive answers to the review questions. This evidence review identified one RCT from Egypt by Sakr et al., which evaluated the effect of sexual health counselling in conjunction with a clitoral therapy device versus sexual health counselling alone (control group) in terms of improvements in scores in the six domains of female sexual dysfunction, measured using the Arabic version of the Female Sexual Function Index (FSFI), among 80 women with sexual dysfunction resulting from FGM. The certainty of evidence from this study was assessed as low for the outcome of interest. Compared with the control group, women who received both counselling and the clitoral therapy device had significantly improved FSFI scores related to domains around pain, orgasm, satisfaction, arousal, lubrication and desire after three months. There were also significant improvements in the pre- and post-intervention scores among women in the device-plus-counselling arm of the study. Pre- and post-intervention scores among the women in the control group also showed an increase in all sexual function domains except for orgasm, which showed a nonsignificant increase. GRADE Table 13 in section 6 of Web Annex A provides details of the study included in the review for this topic. Rationale The GDG was hesitant to make a recommendation based on the presented evidence regarding a specific clitoral therapy device from one study with limited sample size. GDG members emphasized that survivors of FGM should be treated holistically – addressing all aspects of sexual dysfunction, including those that are unrelated to their FGM status. GDG members referred to the existing recommendation in the previous WHO guidelines on FGM and the evidence demonstrating the sexual health complications of FGM, including increased pain and reduction in sexual satisfaction and desire, as an impetus for issuing a recommendation on sexual health counselling for treatment of sexual dysfunction. Depending on the setting, resources and preferences of the woman and her partner, and on the particular sexual dysfunction or sexual health complication a woman presents with, the health worker should refer to available guidelines and scientific evidence on all the biological and psychosocial factors that could be responsible for the sexual complaint, including FGM, and should manage these using available resources and interventions. In addition, studies show that the use of medical interventions like gels or clitoral therapy devices may not be acceptable to women and their partners, depending on personal sexual practices and the degree to which men exercise influence in determining whether and how these products are used. The GDG also emphasized that when clitoral reconstructive surgery is performed, as discussed in the next section (on Recommendation 8), it should be conducted in conjunction with sexual health counselling, which could also involve her partner’s participation upon the request of the woman.
- Implementation remarks -
In light of the above, and in recognition that women’s sexuality is multifactorial and depends, among other things, on the interaction of anatomical, cognitive and relational factors, the GDG noted that offering treatment alternatives for sexual dysfunction – in this case sexual health counselling – to this population continues to be a priority. Based on clinical experience and indirect evidence that supports sexual health counselling as an effective treatment for sexual dysfunction in other populations, including patients with breast cancer and cardiovascular disease, the GDG considered the intervention to be beneficial, provided it is adequately adapted to different countries and cultural contexts. Sexual health counselling as an intervention to address sexual dysfunction is also described in the WHO clinical handbook for the care of girls and women living with FGM. The GDG agreed that to avoid unintended adverse effects (e.g. intimate partner violence or social stigma), characteristics such as client/patient age and marital status, and potential inclusion of the partner in the session, must be taken into consideration when offering sexual health counselling to women living with FGM. The GDG also acknowledged the importance of adequate referral networks for more specialized sexual dysfunction management in case the diagnosis is made at lower-level health facilities. Additionally, according to General Recommendation No. 24 on Article 12 of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), State parties to the convention should ensure, without prejudice or discrimination, the right to sexual health information, education and services for all women and girls. In this regard, the GDG emphasized that offering sexual counselling helps promote the fulfilment of the right of women and girls living with FGM to a healthy sexual life.
- Research gaps -
Existing research has established an association between FGM and sexual health complications, and while some gaps remain in understanding the sexual health complications of FGM, there is a need for intervention research to test the effectiveness of sexual health counselling and other psychosexual support interventions in a range of contexts, considering the values and preferences of women and girls, and health systems factors. WHO’s clinical handbook, Care of girls and women living with female genital mutilation, includes a component on sexual health counselling and support. Implementation research on models of care to implement this content among women living with FGM who are experiencing sexual dysfunction and other sexual health complications would greatly contribute to reducing the burden of FGM on health.
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