We received the comments on our paper published in volume 109, October 2002 of the British Journal of Obstetrics and Gynaecology1. The author(s) of the feedback believe that we have over-interpreted the results of the study by concluding that cutting ‘did not attenuate sexual feelings’.
First, we are happy that the authors acknowledge that the relationship between female genital cutting and sexuality is an important issue to study, as part of efforts to examine the wider implications of the practice in sub-Saharan Africa. This is because the need to reduce sexual feeling and promote chastity have been shown to be the most important reasons proffered by advocates of female genital cutting in many parts of Africa. We recognise that there may be some countries where the opposite is the case (i.e. that female genital cutting is done to enhance sexual pleasure). In such cases, different kinds of genital cutting are usually performed, such as vaginal tightening and labial manipulation. However, our study is context specific, and speaks only to the situation in Africa, where female genital cutting is primarily performed to reduce sexual pleasure.
Secondly, from the onset, we were aware of the difficulties in conducting research on sexuality, especially in our context in Africa, where the subject is often treated as a taboo. Therefore, we conducted the study with great sensitivity to issues that could potentially compromise the validity of such a study. A careful study of the paper will show that most of the points highlighted by the author(s) of this feedback were addressed in various forms.
As presented in the Methods section, the study was based on a questionnaire that was administered to women by trained nurses, who were themselves comfortable with discussing sexuality matters. This approach was used to ensure that women thoroughly understood the questions asked, and where they did not understand, the nurses made further clarifications. To achieve the best results, the nurses underwent a substantial period of debriefing, values clarification and role-playing before undertaking the study. We worked with the notion that sexuality is a universal human experience, irrespective of the background of the individual, and that when women are sensitively approached, they would provide truthful responses to questions on sexuality. Additionally, the use of a hospital setting for the study increases women's willingness to answer questions on sexuality as they perceive this to be a therapeutic environment for which such questions are appropriate.
We had no reasons to believe that ‘sexual experiences might be understood and reported differently by cut and uncut women’, as suggested by the author(s) of this feedback. Although cut women tended to be older and less well educated, these differences had limited effects on the reporting of sexual experiences. In particular, education and age were key covariates included in the multivariate logistic regression, and any effects of these would have been cancelled out in the analysis. Furthermore, our use of a sensitive, one to one approach of counseling and interviewing by the trained nurses increased the validity of reporting of sexual pleasure by all women.
We agree with the suggestion that women sometimes initiate sex for reasons other than for sexual pleasure. However, we cannot ignore the fact that sexual pleasure is a legitimate and under-current goal of every sexual encounter. Indeed, our experience in Nigeria indicates that couples frequently connect sexuality with fecundity, as it is believed that the more pleasurable a sexual encounter is, the higher the chances of pregnancy in the menstrual cycle.
We do not feel that there was a bias in including only women attending family planning and antenatal clinics. We perceived these to be the highly motivated women, most likely to provide truthful answers to questions about their sexuality. We recognise that this approach essentially excludes women attending general gynaecological clinics, the large proportions of which are infertile women. However, available evidence indicates that types I and II female genital cutting that is practiced in this region is not associated with infertility2. Thus, exclusion of infertile women is unlikely to bias the results of the study.
Our use of self-reporting of symptoms of genital tract infection was a pragmatic solution to the lack of laboratory facilities for accurate diagnosis of genital tract infections in our setting. We agree that this is a limitation of the study, which was well alluded to in the discussion. However, because this applied equally to cut and uncut women, it did not introduce significant bias to the study. In particular, our study design reduced any tendency to any differentials in rates of self-reporting of symptoms of genital tract infection in cut and uncut women. Although there may be little correlation between symptoms and actual genital tract infections, self-recognition of symptoms is the end-point that prods women to seek treatment. Therefore, our results merely indicate that cut women are more likely to seek treatment for self-perception of genital tract infections. Whether this means a higher rate of genital tract infection in cut women compared with uncut women remains unclear. However, we are hopeful that future studies will address this issue.
In conclusion, we reiterate that our results indicate a tendency towards attenuation of sexual feelings in women undergoing female genital cutting in Edo State, Nigeria. This conclusion applies to women undergoing types I and II female genital cutting as practiced in Edo State and may not apply to settings where this type of cutting is not prevalent. Readers of this paper should not be clouded by the notion that sexuality studies in Africa are inherently flawed, but should objectively examine how the potential difficulties with such a study have been circumvented.