'Now I feel whole again'

Millions of women worldwide are living with the traumatic effects of genital mutilation. Now, thanks to the determination of one French surgeon, a pioneering operation offers them the chance of normal lives. Christine Aziz reports

Eight months ago, Fatoumata al-Hussein boarded the Eurostar at Waterloo station. The 32-year-old Sudanese nurse was heading to Paris, but she wasn't going as a tourist - instead she was going for pioneering surgery with the surgeon and urologist Dr Pierre Foldes.

Fatoumata grew up in Khartoum, Sudan, and at the age of six became a victim of female genital mutilation (FGM). After reading about a unique surgical technique performed by Dr Foldes which restores the clitoris, she immediately decided to make the journey to France. Every year Dr Foldes - who has become a saviour to thousands of women - operates on 200 genitally mutilated women at the Louis XIV hospital in Saint-Germain-en-Laye outside Paris. Fatoumata's operation took two hours, and she says that she feels she has finally been transformed into a "complete woman".

Dr Foldes, father of five children and married to a fellow doctor, Beatrice, performs the operations in addition to his full-time hospital work. He refuses to charge for the surgery because he considers his patients to be victims of one of the biggest crimes against humanity. "Victims shouldn't pay for the crimes against them. These women have already paid a huge price," he says. "It is like a violent rape which has involved family members."

Fatoumata lives in west London with her husband, Faroud, a doctor, and her two daughters, aged six and three. She was the same age as her eldest daughter when her mother and grandmother took her to local clinic where a medically trained midwife excised her clitoris, labia majora, and labia minora with the use of a local analgesic. What was left of the outer skin was then sewn together, leaving a pinhole opening. This is the most severe form of genital mutilation, and it is estimated that 15 per cent of the two million girls and women who are genitally mutilated each year undergo this procedure. In other cases, the clitoris only is removed, or the clitoris and the inner labia are removed.

"I can't remember much about it. It was just an explosion of pain," Fatoumata says. "The onset of menstruation was terrible. I had terrible stomach cramps because the blood couldn't flow as normal." When she married at 18, it was more than a year before she managed to have sex with her husband. "Some women have to go with their husbands to midwives to get help. My husband was very patient and loving but intercourse for me was about pain not pleasure. Other couples use little knives to make the opening a bit bigger each time but we couldn't stand the idea of that."

It was not until Fatoumata arrived in London 10 years ago that she realised the extent of her mutilation and how much it affected her psychologically and sexually. "I talked to my husband about it and he never liked the way I suffered, especially after I had our two children. He doesn't agree with the custom, and will never allow our daughters to have it. I am so happy it is illegal here. In Sudan if you don't have it done no one wants to marry you, and you're considered dirty. Even the educated people think this. When I was nursing here and saw the genitals of an English woman for the first time I was very shocked and wanted to cry. 'Is this what has been taken away from me?' I screamed inside."

Dr Foldes was working as a humanitarian doctor in Burkina Faso in West Africa, 25 years ago, when he first encountered the traumatic effects of excision. "Some women came to me complaining of scarring which was very painful to them every time they moved," he recalls. "A special type of scar tissue called a keloid can develop on black skin, and in these cases it grows hard and thick and attaches itself to the pubic bone. The women asked me if I could do something about it. While I was operating, I began to do some reconstruction surgery on the vagina and labia as well as clearing scar tissue." The surgery, he says, was carried out in secret because of death threats from community members supporting the practice.

"The African women whose scar tissue I operated on in France were asking me if I could do more to help them. They wanted to feel like 'proper' women," he says. When Dr Foldes continued his surgery on African women back in France, the death threats continued. "The police take them very seriously but I don't," he says, and points to a photograph in his office of a bullet hole in a wall in Cambodia. "If I can survive that and keep on working, why should I be scared of threatening phone calls and letters?"

Dr Foldes' crusade to restore the clitoris to women who have been mutilated began 15 years ago. He began to research the subject but was shocked to find that the only organ in the human body devoted solely to pleasure had been metaphorically excised by the male-dominated medical fraternity. "It was invisible," he says indignantly. "It was shocking for me to discover in my research that there was nothing, absolutely nothing, on this organ, although there are hundreds of books on the penis, and several surgical techniques to lengthen it, enlarge it or repair it. Nobody was studying the clitoris because it is associated with female pleasure. There was very little anatomical detail on it. Let's say I had to start from scratch."

It is now known that the clitoris is much larger than was originally thought, with nerves surrounding the vagina and extending down the thighs. "It's about 10 or 11 centimetres long, like a penis, and changes shape when erect," Dr Foldes explains.

To reconstruct a clitoris, Dr Foldes removes all scar tissue that has grown over the excised tip and snips the supporting ligaments, allowing more of the clitoral body to be exposed. The ligaments are then repaired and tissue removed from the thighs to create the labia. According to Dr Foldes, the area begins to look normal after six weeks, but it takes between four to six months for his patients to feel any sensation.

More than 130 million women worldwide are estimated to have undergone FGM. According to Comfort Momoh, a midwife at the African Well Woman Clinic at Guy's and St Thomas's hospitals in London, approximately 15,000 of them are living in the UK. Every week she refers three or four women to British doctors for what are termed "reversals" of FGM, but these operations do not involve restoring the clitoris.

"I don't know of anyone else, apart from Dr Foldes, who does this work. But I have my reservations," Momoh says. "The effects of the technique have not been fully researched, and doctors here don't know much about his work, although I think they should. I've discussed the effects of surgery with some of the women here, and while some believe it can be great mentally and psychologically, some women say it could be traumatic and bring back memories." Momoh also points out that, "Just because women have FGM, it doesn't mean they don't enjoy sex. Some women argue that they do, and that other parts of their bodies become very sensitive, such the breasts, nipples and belly. Some insist that they do orgasm."

Dr Foldes agrees that the results of his surgical techniques have yet to be fully researched. "Women tell me they have sexual feelings they didn't have before, but if you've been excised at birth how can you know what an orgasm feels like? It does need to be researched scientifically and moves are afoot for that."

In the meantime, Fatoumata cannot find words to express her gratitude. "Yes, I was in pain after the operation, and yes, it reminded me of that dreadful time, but I feel so happy now. I can be with my husband like all women are with their men. I feel things I never felt before, and I am not in pain. I am feeling like a real woman."

Some names have been changed