We report the case of a 31-year-old Sudanese G2P0 in the second trimester of pregnancy referred to our institution to discuss defibulation. Our patient had undergone female genital mutilation/cutting (FGM/C) type IIIa as classified by the World Health Organization (WHO)  (“narrowing of the vaginal opening with the creation of a covering seal by cutting and apposition of the labia minora”). She stated that she was cut around the age of 5 in rural Sudan; she experienced no immediate complications. However, she suffers from long-term symptoms including superficial dyspareunia, prolonged menstrual periods with primary dysmenorrhea, and obstructed micturition with voiding efforts. Besides the FGM/C, the woman had no significant medical, psychophysical, or surgical history and was not taking any medication. She had recently resettled in Switzerland with the help of the Humanitarian Corridor. She did not experience any violence or trauma during her journey to Europe. Conversely, prior to immigrating, she experienced psychological and physical violence due to political persecution: in 2014, she was kidnapped and beaten because she had defended a group of women from a university community who had undergone a group rape. At that moment, she was pregnant at 8 gestational weeks (GW), but the pregnancy ended in miscarriage soon after this episode. She felt guilty about this loss, mainly toward her family, because of the concern she thought she had caused. She had a baccalaureat in Human Rights and had been involved in humanitarian work in her country. She was fluent in Arabic and English.
At her preoperative appointment, the woman was not depressed, although she described some symptoms of mild dysthymia (emotional instability, sleep disorders, anhedonia, and lack of appetite) mainly related to her housing situation and site of resettlement. She had two preoperative appointments before scheduling defibulation at 23 weeks of gestation: one in English and the second with a certified female Arabic interpreter. We detailed the procedure, the options for anesthesia (local and locoregional), and the option to undergo the defibulation either during her second trimester or during the first stage of labor. We discussed the anatomical changes to expect after the procedure using multimedia resources such as drawings and videos [1, 12]. In particular, we informed her that she would experience a change in micturition, which would no longer be obstructed. The patient chose defibulation under local anesthesia in her second trimester. She was instructed to apply local lidocaine cream 2 hours before the office procedure.
Defibulation was performed in our outpatient clinic under local anesthesia and was uneventful and painless. After disinfection and injection of one ampoule of local lidocaine 1%, we sectioned the tissue bridge above the urethral meatus and the vaginal introitus. The labia minora were then reconstructed with simple stitches of Vicryl 3-0. The fetus’s heartbeat was checked and found to be normal before and after the surgery.
After the intervention, the patient was dressed and ready to urinate for the first time. Going to the toilet, she quickly became distressed and burst into tears, experiencing hot flashes, tachycardia, and hyperventilation. All vital signs were regular. When questioned, she explained that she had started to experience flashbacks of the first micturition after her FGM/C when she was 5 years old. At that time, she had been afraid to urinate due to vulvar pain and had refused to drink and void her bladder. Her aunt had forced her to urinate with insults and physical violence. The gynecologist who performed the defibulation reassured and counseled the patient.
Notwithstanding her cries, urination was painless, uneventful, and psychologically relieving, even though she experienced vivid flashbacks of her childhood. The gynecologist admitted the patient to the prenatal ward to offer her psychiatric support. A few hours after the onset of symptoms, the psychiatrist’s evaluation revealed anxiety and depressive symptoms with sad thymia, anhedonia, decreased motivation, tendency to withdraw into herself, sleep disturbance, and decreased appetite, all of which had been present for several months. Besides these chronic symptoms, she also experienced an acute state of stress, with flashbacks and neurovegetative symptoms, which reactivated past traumas, not only of the FGM/C and the physical violence inflicted by her aunt but also the events she had endured in 2014.
According to the DSM 5th edition 2015 , the patient presented with signs and symptoms of post-traumatic stress disorder as she met the following criteria: exposure to severe violence (criterion A), unwanted upsetting memories, flashbacks, emotional distress after exposure to traumatic reminders (criterion B), avoidance of the external stimulus linked to the stressor event (micturition, criterion C), altered cognition in the form of dissociative amnesia and depression (criterion D); modification of consciousness in response to a trauma (hypervigilance, excessive startling, criterion E). Criterion F was fulfilled after a month of follow-up with persistence of flashback and anxiety surrounding micturition.
The patient was discharged 2 days postoperatively. Her psychological state was improved, presenting as mild anxiety. The psychiatrist established psychiatric and psychotherapeutic follow-up consisting of appointments every 2 weeks for 3 months, combined with lorazepam 1 mg anxiolytic treatment for the acute episode and oxazepam 15 mg for 1 month. The patient experienced a progressive decline in anxiety, depressive symptoms, and acute stress symptoms.
Postoperative follow-up was physically uneventful, and dyspareunia and obstructed micturition had completely resolved. Follow-up with the surgeon ended at 4 months after the surgery, and the patient continued to be followed by her obstetrician.
She delivered a healthy baby by vaginal delivery at 41 gestational weeks after induction for prolonged pregnancy. The delivery and post partum period were uneventful; she did not experience any relapsing symptom of anxiety, PTSD, or depression.