ROADS OF RESTORATION AND RESILIENCE:
A JOURNEY INTO CLITORAL RESTORATION SURGERY IN CANADA
by
Kiah Leone
B.A., Vancouver Island University, 2014
M.A., York University, 2018

DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
IN
HEALTH SCIENCES

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
March 2025
© Kiah Leone, 2025

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Abstract
Female genital cutting (FGC) has a profound impact on the physical, mental, and sexual
health of survivors - leading to various long-term health complications overtime. Clitoral
restoration surgery (CRS) has emerged as a potential solution to these complications through the
surgery’s acclaimed ability to alleviate pain, restore sexual function, and improve survivors’
sense of self. However, these claims have been challenged, highlighting insufficient evidence
and lack of consideration for the psychosexual and cultural contexts that influence survivors’
surgical outcomes. Therefore, understanding FGC as an ongoing experience rather than a onetime event emphasizes the complexity of its effects on survivors. In order to account for this
complexity, this study employs a combination of theoretical perspectives, including complexity
theory, intersectional feminist theory, and multisystemic resilience. These frameworks help to
investigate questions of Canadian survivors’ motivations in electing to undergo CRS, the specific
complications they must present with in order to qualify for this surgical procedure, and
physicians’ decision-making when it comes to identifying potential candidates. Through
survivors, care providers, and FGC-related organizations, this study explores these questions.
By examining the decision-making process between physician and their patient, this
study emphasizes the importance of individualized care that accounts for survivors’ unique
physical, social, and cultural contexts. Additionally, this research underscores the importance of
more holistic treatment options, such as psychosexual therapy and sexual education, as potential
alternatives to CRS. These approaches may help to address survivors’ health concerns without
the need for surgical intervention. By promoting awareness of these alternatives, the study
encourages a more comprehensive understanding of healing that moves beyond physical health
to also emphasize survivors’ mental and emotional well-being along their healing journeys.

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Lastly, by contributing to the limited body of knowledge on CRS and FGC-related care more
broadly in Canada, this research helps to raise awareness of the challenges faced by survivors,
combat stigma in health-care settings, and support the development of relevant health policies.
Insights gained from survivors, care providers, and FGC-related organizations in this study
highlight the interconnectedness of these groups - fostering collaborative efforts to improve
survivor care and support services in both Canada and abroad.

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Table of Contents
Abstract…………………………………………………………………………………………..ii
Table of Contents…………………………………………………………..……………………iv
List of Figures…………………………………………………………………………………..vii
Acknowledgement..…..…………………………………………………………………...........viii
Chapter One: Introduction ..........................................................................................................1
Vignette .......................................................................................................................................1
Preamble…..................................................................................................................................3
The Clitoris .................................................................................................................................3
Statement of the Problem ...........................................................................................................6
Clitoral Restoration Surgery .......................................................................................................6
Research Questions .....................................................................................................................7
Summary .....................................................................................................................................8
Chapter Two: Background ........................................................................................................11
Female Genital Cutting (FGC)..................................................................................................12
Legal Framework of Female Genital Cutting (FGC)................................................................17
FGC and Gender-Based Violence (GBV).................................................................................23
The Clitoris and Clitoral Restoration Surgery (CRS)................................................................26
CRS in the Context of Other “Elective” Female Genital Surgeries & Medical Terminology..32
Experiences of FGC Survivors & the Perceptions of “Normative” Bodies …….....................35
Chapter Three: Theoretical Framework ..................................................................................39
Intersecting Perspectives ...........................................................................................................39
Feminist Intersectionality Theory .........................................................................................39
Complexity Theory ...............................................................................................................41
Resilience Theory .................................................................................................................45
Resilience and FGC ..................................................................................................................46
Resilience and Community-Led Organizations ........................................................................47
Resilience and Health Care .......................................................................................................48
Multisystemic Resilience ..........................................................................................................49
Chapter Four: Methodology and Research Methods ..............................................................53
Methodology .............................................................................................................................53
Positionality Statement..........................................................................................................53
Methods ....................................................................................................................................56
FGC-Related Organizations .....................................................................................................59
The End FGM Canada Network ...........................................................................................59
Sahiyo: United Against Female Genital Cutting ..................................................................62
Women’s Health in Women’s Hands ...................................................................................63
Restore FGM ........................................................................................................................64

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Tadwein Center for Gender Studies ......................................................................................67
Participant Sampling and Primary Data Collection ..................................................................69
Survivor Demographic and Survey Component ...................................................................69
Physician Demographic and Data Collection .......................................................................75
Data Analysis ............................................................................................................................80
Chapter Five: Findings ...............................................................................................................86
Politics of Decision-making ......................................................................................................86
Anatomy ................................................................................................................................87
Complexity ............................................................................................................................89
Patient Choice .......................................................................................................................90
Storyline ....................................................................................................................................92
Trauma ..................................................................................................................................93
Learning ................................................................................................................................94
Healing ..................................................................................................................................96
Resources ..................................................................................................................................97
Survivors ...............................................................................................................................98
FGC Organizations ...............................................................................................................99
Care Providers .....................................................................................................................101
The Canadian Issue .................................................................................................................103
Chapter Six: Discussion ............................................................................................................108
Politics of Decision-making ....................................................................................................108
Storyline ..................................................................................................................................112
Resources ................................................................................................................................115
The Canadian Issue .................................................................................................................118
Journey of Discovery ..............................................................................................................122
Chapter Seven: Conclusion ......................................................................................................125
Study Limitations ....................................................................................................................125
COVID-19 Pandemic ..........................................................................................................125
Recruitment .........................................................................................................................126
Study Strengths .......................................................................................................................127
Provincial Inclusions ...........................................................................................................127
Holistic Perspectives ...........................................................................................................128
Comparative Insights ..........................................................................................................128
Contributions ..........................................................................................................................129
Questions I Am Left with for Additional Research ................................................................130
Closing Reflection ..................................................................................................................133
References ..................................................................................................................................134
Appendices .................................................................................................................................144
Appendix A .............................................................................................................................144
Appendix B .............................................................................................................................146
Appendix C .............................................................................................................................147

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Appendix D .............................................................................................................................148
Appendix E .............................................................................................................................149
Appendix F ..............................................................................................................................150
Appendix G .............................................................................................................................151
Appendix H .............................................................................................................................152

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List of Figures
Figure 1. Restore FGM’s clinic consultation mirror………………………………………………3
Figure 2. Clitoral Anatomy……………………………………………………………………....28

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Acknowledgement
I want to acknowledge all the survivors of female genital cutting (FGC) and those who
have dedicated their time and energy into raising awareness about this topic through education
and advocacy. I want to acknowledge each of the FGC-related organizations comprised of deeply
caring and dedicated individuals committed to the support of survivors. I want to acknowledge
the physicians in this study who, often without the guidance of their governing institutions, have
taken the initiative to inform themselves on the topic of FGC, who strive to provide care in a
culturally safe and competent way, and who work to expand the quality and quantity of treatment
options available for survivors in Canada and abroad.
I want to acknowledge my supervisors – Dr. Angèle Smith and Dr. Shannon Wagner.
This journey would not have been possible without your belief in the project, your time, and your
support. I am so grateful for your guidance, your words of encouragement, and for the
opportunity to learn under your mentorship. I want to acknowledge my committee members –
Dr. Annie Duchesne and Dr. Bettina Shell-Duncan, your input has been instrumental in the
development of this dissertation. I am deeply appreciative of your expertise, thoughtful insights,
and valuable feedback which has helped to shape my work. I want to acknowledge my external
examiner – Dr. Bilkis Vissandjée, and express my gratitude for your time, comments, and
invaluable perspectives, which greatly contributed to the refinement of this dissertation. I would
like to acknowledge the financial support provided by the University of Northern British
Columbia. This funding enabled me to carry out my research, without which this work would
have not been possible.
Lastly, I want to acknowledge the unconditional love and support of my friends, family,
husband, and feline writing companion, Chelsea. I could not have done this without you, and I
am beyond blessed for your encouragement, patience, and understanding throughout this
journey.

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Chapter 1 - Introduction
Vignette
February 20th, 2024
The pale pink hospital stood out amongst a sea of sand-coloured exteriors. I hopped out
of the Uber – thanking the driver.
“Shukran”, I said closing the door behind me.
As I made my way through the entrance doors I was met by two smiling clinic
administrators.
February 20th, 2023
The first time I heard about Restore FGM was while I was conducting fieldwork in
Toronto, Ontario. During this period, I came across an Aljazeera article titled ‘“Starting over”:
FGM clinic gives hope to traumatised Egyptians’. However, it was not the title itself that caught
my attention, but rather what came after – reconstructive surgery and multidisciplinary
treatment. Restore was the first clinic in Egypt to offer FGC survivors this type of care. The type
of care I was exploring in Canada.
Now exactly one year after since I had read the article and subsequently reached out to
Restore FGM, I was in Cairo ready to meet with the clinic’s founding physicians.
“As-salamu alaykum. I’m here to see Dr. Awwad”, I said.
The administrators smiled and told me it would be 400 EGP.
“Oh, I’m sorry, I’m not here for a doctor’s appointment”, I explained. “I am here for a
meeting – a research meeting.”
The administrators smiled again and nodded in understanding as one excused herself
around the corner – letting me know she would only be a moment.

2
Upon reading through the article, I was quick to reach out to Dr. Awwad to learn more
about the types of services she and her colleagues’ offered survivors. Three days after our initial
email exchange, I met with Dr. Awwad and her collaborator Dr. Seifeldin over Zoom. While I sat
at the dining table in my Toronto apartment rental, Dr. Awwad, Dr. Seifeldin, and myself
connected over their work on clitoral restoration, their clinic operations, and their emphasis on
non-surgical treatment options for survivors. After this initial meeting, Dr. Awwad and I kept in
touch – emailing ever so often over the next few months.
When I came around the corner, I was greeted by Dr. Awwad in her office. Despite this
being our first time meeting each other in-person, after months of talking it felt like reconnecting
with an old friend. In addition to Dr. Awwad, we were briefly joined by Dr. Seifeldin and a
visiting medical student from America. The Restore team had just arrived back in Egypt from
Geneva, Switzerland where they had attended their first ever masterclass in surgical
interventions for FGC survivors where Dr. Seifeldin was invited to moderate. It was an event
that brought together experts in the field of FGC-related care and relevant procedures from all
corners of the globe – including Canada. We spent the next few hours chatting, Dr. Awwad
sharing about their time in Geneva and plans for upcoming publications and I about my research
and past few days in Egypt.
I asked for a tour of their clinic and Dr. Awwad brought me to a patient room. The room
was comprised of a surgical bed, chairs, desks, and a small wooden table that housed some of
their consultation equipment. Alongside a box of medical gloves, Q-tips, and bottle of hand
sanitizer was a handheld mirror. Circled in sky blue-coloured plastic, the handheld mirror had
Restore FGM written in black marker on the back in both English and Arabic.

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This is the mirror that Dr. Awwad would use in her consultations with patients. As noted
in their Aljazeera article, as well as in our own conversations, Dr. Awwad had expressed how the
mirror gave survivors the opportunity to familiarize themselves with their bodies in ways that
most have never before. Here, with the guidance of a physician, the mirror functioned as a tool of
exploration – offering survivors a chance to survey their body, their genitalia, and most
importantly their clitoris.

Figure 1. Restore FGM’s clinic consultation mirror.
Preamble
The Clitoris
The first “discovery” of the clitoris is complex, highly debated, and most notably lacking
female perspectives (Charlier et al., 2019). Dating back hundreds of years, historical accounts
will argue that it was Realdo Colombo, an anatomist and surgeon from Cremona, Italy who first
“discovered” the clitoris in 1559 at the age of 43 (Stringer & Becker, 2020). Here Colombo

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described a woman’s “seat of pleasure” in his book, Realdi Columbi Cremonensis De re
anatomica libri XV (Charlier et al., 2019, p. 47). Others, such as some linguists, would contest
that the “discovery” of the clitoris was in fact much earlier due to the uncovering of “kleitoris” in
the works of Rufus of Ephesus back in the first or second century CE (Pauls, 2015, p. 377). Here
the linguistic origins of “kleitoris” were found in ancient Greece and, and according to Pauls
(2015), were “synonymous [with] “the veiled”, “myrtle berry”, and “organ hidden under the
skin”’ (p. 377).
If the origins of the clitoris’ discovery were not complex enough on their own, it’s
purpose and function have been even more highly contested throughout time with descriptions
ranging from “passive and unimportant” to “the most critical anatomical structure for female
sexual arousal and orgasm” (Pauls, 2015, p.378). Frequently compared to male sexual anatomy,
Greek philosopher and polymath, Aristotle “positioned the clitoris as a body part of embarrassing
insignificance” in his 300 BC comparisons. Here the perceived “underdeveloped” female sexual
organ was contrasted against the “superior” male penis (Stiritz, p.251).
This concept of female inferiority, and more specifically women’s genital inferiority, was
furthered centuries later by Austrian neurologist Freud who, according to Stiritz, made this belief
“the bedrock of his female psychology” (p. 253) when he “re-discovered” the clitoris in 1905
(Puppo, 2013, p.145). Here Freud declared clitoral stimulation and its related clitoral orgasms as
“infantile” and “superficial” in contrast to vaginal stimulation and its derived orgasms, which he
argued were “mature” and much more “powerful”, and therefore, similar to those experienced by
men by way of penile stimulation (Puppo, 2013).
The impacts of such comparisons and descriptions have contributed to beliefs of female
inferiority that continue to be felt today. Unfortunately, it would not be until 2005 that we would

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have our first comprehensive description of clitoral anatomy. In quoting O’Connel, Sanjeevan,
and Hutson (2005, Charlier et al. (2019) stated,
It was concluded that “the entire cluster of related tissues (distal vagina, distal urethra,
and clitoris including the bulbs, ceuta, body, and glans) should be included in the term
clitoris”. This cluster appears to be the locus of female sexual function and orgasm
(p.48).
Finally, the clitoris was being acknowledge not for what it was not, but rather for what is
– “the most critical anatomical structure for female sexual arousal and orgasm” (Pauls, 2015,
p.378) – housing 10,000 nerve fibers, which is a 20% increase from pre-2023 estimates (Uloko et
al., 2023). Such findings contributed to significant advancements in medical knowledge that
have helped to strengthen our understanding of the clitoris as we have come to know it today.
Despite countless attempts to demonize, underestimate, or presume unimportant, the
clitoris prevailed – unbothered by history’s one-sided mission of comparison and devaluation.
Such a journey across centuries reveals a symbolic sense of resilience despite centuries of
historical, medical, and social neglect and misunderstanding (Pieters et al., 2023). Ultimately,
what this brief introduction into the clitoris, and its complex journey of demystification, seeks to
highlight is that these beliefs are not isolated to any one place or particular group of people but
rather have existed for centuries in all parts of the world. What is revealed is that these negative
perceptions and inaccurate representations of the clitoris have contributed to ideas and practices
across time and space which have greatly impacted this foundational component of female
sexual anatomy in addition to beliefs around women and women’s sexuality more broadly.

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Statement of the Problem
Clitoral Restoration Surgery
One of the most impactful practices on female sexual anatomy is the practice of female
genital cutting (FGC). Many survivors of female genital cutting (FGC) will experience negative
and life-long health complications associated with the cutting. These negative health
complications can often be a combination of both physical and mental. To help alleviate these
complications, clitoral restoration surgery (CRS) has emerged as a reparative option for
survivors with the potential to help diminish pain, restore clitoral orgasm, and improve body
image. In a study which offers a comprehensive review of the clitoris and its role in female
sexual function, Mazloomdoost and Pauls (2015) argue, “despite these purported anatomical
impacts [of female genital cutting], clitoral innervation appears resilient” (p. 259) – it is this
resilience of clitoral innervation that makes CRS possible.
As a rising field of surgical work in Canada, this surgery has garnered attention by
Canadian survivors across several provinces. Much of this attention stems from several
surgeons’ claims that the procedure can enable survivors to become clitorally orgasmic, enhance
sexual satisfaction, and help address issues related to sense of self and poor body image due to
survivor beliefs that their anatomy differs from biomedical definitions of “normal” (Foldès et al.,
2012; Karim et al., 2022). However, these statements have been contested by studies that argue
that there is not enough evidence to support these claims (Abdulcadir et al., 2015; Sigurjonsson
& Jordal, 2018; Mohamed et al., 2020; Auricchio et al., 2021). For instance, Abdulcadir et al.
(2015) cite the noteworthy psychosexual and cultural implications that can impact a survivor’s
surgical outcome and raise caution against interventions that fail to account for these other
dimensions of one’s overall health. Similarly, in a study on rethinking female genital cutting,

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principal author Käkelä (2020) encourages readers to, “conceptualize FGC as a process rather
than a one-off event, as women’s experience of FGC is continuously shaped in response to their
surroundings” (p.97). This understanding of FGC and its related impacts as a process offers a
more in-depth understanding of the associated complexity when it comes to FGC as
multilayered.
Research Questions
As discussed, the FGC-related health complications that survivors will most often
experience are not simply physical. Moreover, by offering a surgical “solution” that only repairs
one aspect of a survivor’s condition it fails to account for the complexity of many survivors’
health complications. Therefore, with that understanding and the matter of global support for
CRS remaining largely unclear, it becomes important to ask what survivors in Canada truly
hope to gain from undergoing CRS in Canada? Understanding why survivors are seeking out
CRS as a reparative procedure and what they are hoping to achieve by doing so helps to
determine whether CRS would be the most suitable treatment option for a prospective candidate.
From this main research question, two sub-questions emerged. Firstly, with which FGCrelated complications must survivors present in order to qualify for surgical referral, and
secondly upon receiving surgery, how do their postsurgical outcomes align with their initial
motivations? With the recent introduction of CRS in Canada, it is important that studies related
to CRS and FGC-related care more broadly are undertaken to help improve provider knowledge
in this field. By strengthening health care professionals’ knowledge base, they will be better
equipped to help guide, support, and care for their patients. Additionally, studies such as this can
be used to inform the development of provincial and national health care recommendations for
medical policy and clinical guidelines. The healthcare needs of survivors in Canada are

8
multifaceted and it is precisely this multifaceted nature of CRS and other potential interventions
that requires a theoretical lens varied enough to effectively analyse the inherent complexity of
this procedure and related actors. By employing a multi-system resilience perspective, this study
offers insights into the introduction of clitoral restoration surgery (CRS) in Canada by way of the
survivors who seek out this procedure, the physicians trained in this surgical technique, and the
organizations that aid in the facilitation of FGC-related supports and services which are
inherently linked to CRS.
Summary
This dissertation is organized into 7 chapters. Following this introductory Chapter,
Chapter 2 offers a review of the important literature in order to situate the study’s research
questions and key concepts relevant to the understanding of CRS – particularly within the
Canadian context. The practice of female genital cutting (FGC) is outlined in-depth as the
precursor to CRS, thus emphasizing the social, medical, and legal implications of the practice
which can impact a survivor’s decision to opt for CRS as a potential reparative option. Through
discussions around national and international perceptions of FGC, comparisons of CRS with
other elective genital surgeries, and issues around surgical funding and accessibility, this section
outlines the complexity of investigations into CRS.
This matter of complexity is then explored in more depth in Chapter 3 which outlines the
study’s three theoretical perspectives that account for the study’s conceptual framework:
intersectional feminist theory, complexity theory, and multi-system resilience. Here Chapter 3
opens with a discussion on feminist research whereby I position myself as the researcher before
outlining intersectional feminist theory and how it aligns with complexity theory based upon
complementary approaches to understandings of systemic oppressions. In continuation of this

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discussion, the concept of resilience is situated with the context of complex systems based upon
a system’s adaptive capacity, which is a key component to complex systems. This chapter then
concludes with a description of multisystemic resilience, which further highlights this adaptive
capacity at the individual, community, and organizational level.
In line with the intersectional feminist theoretical underpinnings of this study, Chapter 4
opens with a discussion on feminist methodology. Here Chapter 4 details the guiding feminist
methodology and related qualitative methods employed in order to undertake this study. Through
an overview of each of the study’s key demographics, a detailed journey of rapport building is
shared – highlighting relevant actors, informants, and organizations and associated secondary
data. Included within is an overview of the primary data collection including focus group
discussions with physicians, qualitative surveys of survivors, and the gathering of secondary data
during my fieldwork in Canada and Egypt. Lastly, the chapter concludes with an outline of my
process of thematic analysis whereby I familiarized myself with the data I had collected, shared
my coding practice, generated themes, reviewed these themes, finalized, and named these
themes, and began my report to share these findings.
With the support of rich qualitative accounts from focus group participations, interwoven
with qualitative survey responses from survivors, and secondary data collected through FGCrelated organizations, Chapter 5 identifies the study’s four major themes and corresponding subthemes. These themes include: the politics of decision-making (anatomy, complexity, and patient
choice), storyline (trauma, learning, and healing), resources (survivors, FGC organizations, and
care providers), and the Canadian issue.
Following the introduction and description of the study’s themes, the findings are
analyzed within the context of the study’s theoretical framework and situated within existing

10
literature. Chapter 6 highlights the complexity of an investigation into CRS and reveals the
resilience of each demographic at multiple levels to adapt to the challenges they have
encountered throughout the process. This chapter concludes with a description of a complex
journey of discovery which critically analyzes the potential outcomes of CRS and other nonsurgical treatment options, the guidance of care providers, and the role of FGC-related
organizations in improving the supports, services, and healthcare landscape for survivors in
Canada.
Lastly, in Chapter 7 I offer my concluding remarks. I identify some limitations as well as
highlight several of the study’s strengths before outlining important contributions this project
makes to the field of CRS research – particularly in Canada, in addition to key contributions to
FGC-related research specifically as it pertains to health. In conclusion I share a closing
reflection that speaks to the many roads of restoration and resilience – reflecting back upon early
“discoveries” of the clitoris and what more there is to uncover.

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Chapter Two – Background
The purpose of the background chapter is to help contextualize the study and
corresponding research questions by providing an overview of relevant literature and addressing
key themes significant to the discussion of clitoral restoration surgery (CRS) in Canada. This
chapter opens with a discussion on female genital cutting (FGC) more broadly – as a gendered
socio-cultural practice it is imperative that the practice is situated within appropriate contexts –
doing so helps to strengthen our understanding of the factors that may influence a survivor’s
decision to undergo CRS. The following section explores the legal framework surrounding FGC,
which is crucial in terms of differentiating FGC, a criminalized genital procedure performed for
non-medical reasons, from CRS, an elective genital procedure performed for medical purposes.
The legal status of FGC in Canada is a crucial context from which to understand CRS and a
survivor’s decision to reach out for support from health care professionals. As part of this legal
discussion, FGC as a form of gender-based violence (GBV) is briefly explored. This examination
offers further insights into experiences of GBV within healthcare systems and how these
instances are linked to governmental support for anti-FGC initiatives, and therefore, FGCorganizational funding.
Clitoral restoration surgery (CRS), as a site of intersecting power dynamics, is then
outlined explicitly with a return to a discussion about the clitoris more generally as the focal
point in this study. The origins of CRS as a surgical procedure are explored along with a
discussion of some of the outcomes that practitioners claim are achievable by way of surgery.
Following the introduction of CRS, the surgical procedure is then explored in relation to other
forms of elective genital surgeries. Comparing and contrasting CRS with other elective genital
surgeries helps to differentiate the procedure. Lastly, this chapter concludes with an examination

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of perceptions of what is considered “normal” biomedically versus socio-culturally and how
these perceptions of normalcy can contribute to survivors’ motivations to undergo CRS.
Female Genital Cutting (FGC)
According to the World Health Organization (WHO), female genital cutting should be
understood as the practice of piercing, cutting, or removing of parts of a woman’s genitalia for
non-medical purposes (World Health Organization, 2016). There are several different terms used
to describe this practice including female genital cutting1, female genital mutilation, female or
pharaonic circumcision, and infibulation. The choice of terminology varies based on the context
in which practice is being described. For instance, in comparison to sociocultural descriptions or
even medical studies, the use of ‘female genital mutilation’ is much more prevalent in legal
discourses. The word mutilation itself is a confronting term that can often trigger a visceral
response from the reader. As such, the use of the term mutilation is to position the practice in
such a way that it is emphasized first and foremost as an act of violence against women and girls
(Vissandjée et al., 2014).
However, in Khadija et al.’s 2009 study exploring the perspectives on FGC of Somali
women living in Canada and the United States, women shared negative perceptions of the use of
female genital mutilation. In their view, the use of this term was degrading, insulting,
stigmatizing, and racist (Khadija et al., 2009, p.734). This terminology led the women
interviewed to feel a sense of inferiority in comparison to uncut women (Khadija et al., 2009).

1

Terminology surrounding the practice of FGM/C is greatly complex and often context specific. Within community
spaces, the preferred term is female genital cutting (FGC) as it accounts for the scope of cutting practices without
negative connotations or judgement-laden language. However, within legal and human rights contexts, the term
female genital mutilation (FGM) is most commonly used as it emphasizes the harmful effects associated with
cutting and is thus more in line with efforts to discontinue to the practice (Vissandjée et al., 2014). Ultimately, with
the expansion of FGM/C research and a growing pool of literature, what becomes clear is that preferences in FGM/C
terminology are continuously evolving and through that process my own terminology use will continue to grow
alongside it.

13
It is not my intention for my choice of words to either ignore the harm that some
survivors may experience, to inflict harm by way of using terms that may be stigmatizing, or to
deny the autonomy of the women who may choose for themselves to practice, and therefore, for
the purpose of this research, I intend to use female genital cutting (FGC). Instances where FGC
is not used will only be in reference to direct quotes, organizations, and/or initiatives that have
demonstrated a difference in preference. Choosing female genital cutting thus accounts for the
scope of practices without the risk of inciting any negative connotations that other terms may
hold in addition to being in alignment with the terminological preferences of the affected
community for which this work intends to serve.
Moreover, when discussing the individuals themselves who have personal experience
undergoing some form of FGC, I will be using the term survivor. My reasoning for using
survivor is fourfold: 1) survivor has emerged as the preferred term for most community-led
organizations; 2) survivor is a non-gendered term and is applicable to a larger scope of gendered
identities; 3) survivor is more concise, which helps to improve the overall readability of
statements related to individuals who have previously undergone some form of FGC; and 4)
survivor centers the individual. In a discussion on the importance of language in discussions
around GBV, Kalisch argues, “unlike “victim”, “survivor” shifts the focus onto the individual,
emphasizing their resilience rather than their victimization” (Kalisch, 2024, para. 3). This
emphasis on resilience is also relevant to the themes associated with theoretical perspectives that
underpin this study. However, despite this reasoning, it is necessary to acknowledge that all
terms have their limitations. A key limitation of this particular term is that it may not resonate
with all FGC-affected individuals. This raises the importance of expanding our explanatory
frameworks in reference to FGC-affected individuals and FGC discourses more broadly. For

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instance, in a discussion on the “survivor” in contemporary culture and public discourse, Orgad
(2009) argues for a “need in contemporary public and highly mediated spaces to expand the
range of explanatory frameworks through which individuals, especially those experiencing
suffering, come to think, judge, and act” (p.132). While beyond the scope of this study, in-depth
critical investigations into the use of the term survivor, particularly in relation to FGC, health and
illness, gender-based violence, and sexual abuse, will be necessary in order to improve the ways
in which we discuss, research, and support individuals
According to the World Health Organization (WHO), the practice of FGC can be broken
down into four categories ranging from a minor prick of the clitoris with a sharp implement, to a
complete excision of the clitoris and labia and the sewing together of the vulva. The WHO’s
classifications include: partial or total removal of the clitoral glans and/or clitoral hood (type 1),
partial or total removal of the clitoral glans and labia minora with the potential to leave or
remove the labia majora (type 2), the minimization/sealing of the vaginal opening by way of
removing the labia minora/and or labia majora and suturing the area sealed with the potential to
leave or remove the clitoral glans and/or clitoral hood (type 3), and any other non-medical
procedures to female genitalia that could be considered harmful (type 4) (WHO, 2020).
The purpose of this type of classification is to categorize the various ways in which
cutting takes place; however, this classification has faced scrutiny from FGC survivors and
healthcare providers who have found this classification system to be limiting. This limiting belief
is based on the fact that often survivors do not fit neatly into any one of these WHO-designated
categories. Additionally, such a classification system would suggest that there is one “universal”
guide that professional cutters all around the world follow on how to cut, which is simply not the
case. The type of cutting that a woman may experience, and thus the physical outcomes of their

15
FGC, is as unique as their vulva and any attempts to categorize them differently would fail to
accurately reflect individual experiences and bodies.
The extent and variety of complications of undergoing some form of female genital
cutting (FGC) is dependent upon the type of cutting a woman has experienced. For instance,
women who have undergone type 3 of FGC are more likely to experience long-term health
complications due to the fact the labia minora, labia majora, and clitoris are all completely
excised, and the remaining tissue is sutured together with the exception of a small hole, less than
a centimetre wide, to allow for the passing of urine and menstrual blood (Nyangweso, 2014).
Long-term complications may include cysts, abscesses, scarring, injury to the urethra, and
painful or unmanageable intercourse (Nyangweso, 2014). In addition to possible physical health
complications, survivors may also experience psychological consequences. Such psychological
consequences include post-traumatic stress disorder, amnesia, anxiety, concerns around body
image and gender identity, depression, and mental blocks related to sexual intercourse that may
result in difficulties reaching orgasm (Schrijver et al., 2016, p.270).
In 2006, Berggren et al. interviewed Sudanese women regarding why they underwent
FGC (specifically infibulation) to identify whether the women viewed themselves as victims or
beneficiaries of the practice. Based on researchers’ collection of narratives they noted three
themes: pressures to succumb to sociocultural norms, struggles to manage traditional practices
while simultaneously desiring change, and a sense that they held little influence in the fight to
discontinue FGC.
Many of the women interviewed emphasized the practice’s believed benefits of
purification and beautification of their genitalia – arguing that FGC represented one’s sexual
restrain in contrast to uncut women who were viewed as being hypersexual (Berggren et al.,

16
2006, p. 29). This perceived hypersexuality was then said to influence a woman’s marriageability
as it would reflect poorly on her family (Berggren et al., 2006). This was observed in the
women’s discussion around family involvement in FGC, whereby the women interviewed shared
complaints of the immense pressure from older female family members.
However, based on their own personal experiences, the women interviewed determined
that had they not previously undergone infibulation, that they would be in better health and their
sex lives would have likely improved (Berggren et al., 2006). In their view, undergoing FGC
resulted in lifelong health complications, which ultimately impacted their ability to enjoy sexual
intercourse. As a result, the women interviewed stated that they would not have their daughters
infibulated – with some going as far to not wanting their daughters to experience any form of
cutting despite the societal pressures discussed.
This sentiment was mirrored in a 2000 study conducted in Canada and the USA amongst
17 circumcised Somali women. Khadija et al. interviewed women to identify how to improve
FGC prevention and intervention attempts by assuring they are more culturally competent.
During these interviews, women described their parents reasoning for having them undergo FGC
– emphasizing the importance of the practice to Somali culture (Kahdija et al., 2000). However,
when providing their own perspectives on FGC, the women were unanimous in their desire to
see the end of the practice. This end, they hoped, would come as a result of educational
campaigns rather than through criminalization, as criminalization was considered to result in
secrecy that would eventually lead to the practice’s continuation. This exact phenomenon of
continuation was observed in Kenya amongst the Maasai and Samburu in Graamans et al.’s
community study, which looked at these groups’ perspectives on FGC. According to Graamans
et al. (2019), criminalization of FGC in Kenya has not only led to the continuation of the practice

17
in secret, but also to the practice being performed on girls of much younger ages than previously
recorded (p. 80).

Legal Framework of Female Genital Cutting
The long list of potential physical and psychological consequences to female genital
cutting (FGC) have contributed to the practice’s criminalization on an international scale. After
decades of repeated calls to action from various human rights groups and feminist organizations
across the globe that sought to bring an end to FGC, the practice was finally deemed in violation
of human rights and as of 1997, FGC has been prohibited in Canada. Exploring this prohibition
of FGC is relevant to this project’s aims for three main reasons. Firstly, the matter of legality
influences the type of language used when discussing FGC, which affects the way surgical
interventions pertaining to FGC are marketed, managed, and thought about in Canada. Secondly,
the history of the practice’s criminalization can influence survivors’ willingness and degree of
comfortability in discussing this topic within a health care setting. And, lastly, analyzing
Canada’s Criminal Code helps to differentiate between medically “acceptable” genital cutting
and genital cutting performed for nonmedical reasons.
The Interagency Statement on Eliminating Female Genital Mutilation published in 2008
is an example of using this type of language in stance documents. The Interagency Statement on
Eliminating Female Genital Mutilation is a shared statement put forth in collaboration with the
following organizations: OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR,
UNICEF, UNIFEM, and WHO. The statement calls for the international community to maintain
the rights of girls and women and to bring about the end of FGC as a practice. Authors of this
statement emphasize that FGC as violation is more likely to encourage national and international

18
advocacy groups to pursue the practice’s abandonment (p.22). Even though the statement
acknowledges the negative associations with the word “mutilation” it maintains that it’s use is
important in terms of advocacy (p.22). Still Cook et al. (2002) argues, “this [female genital
mutilation] is not a neutral description but is a means of condemnatory advocacy” (p.282).
What this usage fails to consider are individuals who do not consider themselves to be
“victims of mutilation” or that their bodies should be viewed as “mutilated”. Persistence in using
this term can come across as discriminatory and stigmatizing (Vissandjée et al., 2014). It is
important that we differentiate between the intent of the language we use and the actual impacts
of its usage (Vissandjée et al., 2014). Statements describing the practice as “mutilation”, such as
those in the Interagency Statement, may intend to convey the severity of FGC, but in the process
the choice of words may negatively impact those they wish to help through stigmatization. This
can similarly be observed when we take a look at these international organizations’ stances and
the long road it has taken to achieve an agreed upon position, categorization, and mandate.
Presently, the act of female genital cutting (FGC) is recognized as a human rights
violation (World Health Organization, 9). Laws and regulations reinforce this stance at the
international, national, and local levels (Boyle & Corl, 2010). The specific rights the practice is
stated to violate include: the principles of equality and non-discrimination on the basis of sex; the
right to life when the procedure results in death; and the right to freedom from torture or cruel,
inhumane or degrading treatment or punishment (World Health Organization, 9). Although the
act of causing bodily harm has long been considered a crime, FGC was initially difficult to deem
unlawful due to its culture associations and significance (Cook et al., 2002).

19
Culture was viewed as something to be preserved and is protected under the United
Nations Educational, Scientific, and Cultural Organization (UNESCO) mandate, which dictates
that all human beings have a right to participate in cultural life (World Health Organization,
p.10). However, this is subject to certain conditions whereby if the cultural freedom is believed
to violate the freedom and protection of others within society it may not be considered
justifiable, as is the case with FGC (World Health Organization, p.10).
By the mid 1970s, attention on FGC continued to grow at the international level, this time
from western feminists (Boyle & Corl, 2010). Western feminists argued that FGC was the result
of a culture of patriarchy and that the practice was in direct violation of the right to nondiscrimination based on sex. This stance caused an upset amongst African women in policy who
found this type of argument to be more divisive than it was unifying in the sense that they were
the targets of Western feminist interventions. To counteract concerns of cultural discrimination
and accusations of patriarchal influence, the United Nations decided to take a position based on
health (Boyle & Corl, 2010). According to Boyle and Corl (2010), “international actors
portrayed medicine as acultural and apolitical2, and, because health problems are a universal
concern, this basis for intervention did not appear to be singling out African nations for reform”
(198). Therefore, the practice of FGC was determined to be in violation of a person’s right to the
highest attainable standard of health (World Health Organization, 2010). This approach to FGC
was much more quickly accepted, both by political decision-makers as well as community
members, in terms of justifying local interventions and international prevention campaigns
(World Health Organization, 2020).

2

I recognize that despite international actors’ attempts to portray medicine as acultural and apolitical, that medicine,
and health more broadly, is inherently political and cultural.

20
In 1997, the World Health Organization, in collaboration with the United Nations
Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA), released a shared
statement against the practice of FGC (WHO, 2020). This international response was founded
upon the years of calls to action to raise awareness and garner attention towards an ending of
FGC. Since that time, 26 African countries and 33 other countries that are home to immigrant
populations, have instituted laws and regulations against FGC (WHO, 2020). For the purpose of
this research, we will now look to Canada more explicitly and how international human rights
laws have influenced our country’s political position and management of FGC.
Since 1997, Canada’s stance has aligned with that from the World Health Organization,
World Medical Association, and the International Federation of Gynaecology and Obstetrics
(Vissandjée et al., 2014, p.3). When Canada’s criminal code was updated, FGC was added under
section 268 for aggravated assault under subsection 3, whereby the excision, infibulation, or
mutilation of an individual’s labia and/or clitoris was criminalized (Huston, 2000; Section 273).
In an evaluation of Canada’s response to FGC, Packer et al., (2015) stated, “under the code, it is
prohibited to aid, abet or counsel such assault and to interfere with genitalia for nonmedical
reasons” (E188). The code goes on to include the criminalization of sending a child outside of
national borders for the purpose of having FGC performed (Packer et al., 2015). If someone is
found guilty under one of these offences, they could face up to 14 years behind bars and/or
receive a fine (Packer et al., 2015).
Packer et al. (2015) emphasizes the importance of not assuming that because there have
yet to be any prosecutions under this code that it means that FGC is not being performed in
Canada. Canada has an exceptionally high rate of international migration – with international

21
migration accounting for 92.0% of Canada’s overall growth in the third quarter of 2024
(Statistics Canada, 2024). This includes immigrants and refugees from countries with the greatest
prevalence rates of FGC, such as Egypt, Eritrea, Sierra Leone, and Somalia (Packer et al., 2015).
The reality of low rates of prosecution in Canada may ultimately come down to the fact that it
can be extremely difficult to prosecute. Often young women and girls are reluctant to come
forward if they have experienced FGC, or are at risk of undergoing it, out of fears that they may
implicate their parents in a crime (Packer et al., 2015). In addition to fears around potential
family involvement, if the cutting occurs abroad, it can be even more challenging to track, which
further decreases the likelihood of prosecution (Packer et al., 2015).
Under this legal framework, Canadian physicians and other healthcare professionals hold
a crucial responsibility to report if they believe an individual has experienced some form of FGC
or is at risk of undergoing it (Perron & Sennikas, 2012). In addition to the Society of
Obstetricians and Gynaecologists of Canada, who have released a national policy statement,
some provinces have released their own statements. The current provincial Canadian Medical
Organizations with FGC statements include: the College of Physicians and Surgeons of British
Columbia, the College of Physicians and Surgeons of Ontario, the College of Physicians and
Surgeons of Alberta, the College of Physicians and Surgeons of Manitoba, Collège des Médecins
due Québec, and the College of Physicians and Surgeons of Nova Scotia (Huston, 2000). The
majority of these statements are brief, ranging from a few short sentences to a maximum of a
handful of paragraphs, and typically include a link to position statements made by other national
medical organizations and/or the criminal code.

22
Within these position statements it is also common to briefly acknowledge potential
requests for re-infibulation and how to navigate them. Re-infibulation is the practice of resuturing a survivor’s genital tissue post-delivery and can sometimes be requested by a survivor,
their partner, or a survivor’s family. This is relevant to discussions around the criminal code,
which specify under subsection 3 (a) and 3 (b), that genital surgical procedures must improve the
physical, reproductive, and/or sexual health of an individual who is at least 18 years old, and that
the procedure is performed by a qualified medical professional (Section 273). In these instances,
the practice of re-infibulation may be difficult to reconcile. Currently, the policy statement from
the Society of Obstetricians and Gynaecologists of Canada (SOGC) strictly states that physicians
should deny these patient3 requests for re-infibulation; however, they also note that it ultimately
comes down to the better judgment of the medical professional.
According to the Canadian Medical Association’s (CMA) Code of Ethics section, under
Responsibilities to Society, Vissandjée et al. (2014) states,
Health professionals must recognise that community, society and the environment are
important actors, and the health care professionals are faced with the legal obligation to
notify statutory bodies of the occurrence or risk within the host society of FGC, ethical

3

The term “patient” is used throughout this dissertation when in reference to medical literature, clinical settings, and
physicians’ accounts. The social and philosophical underpinnings of the term “patient” are explored by Whyte et al.
(2024) in their study on terminological significance for individuals with long-term conditions. Here, Whyte et al.
acknowledge the importance of language when discussing interactions between healthcare providers and individuals
seeking care. The term “patient” has been criticized for failing to address imbalances of power between providers of
care and recipients of care (Neuberger, 1999; Whyte et al. 2024). Additionally, the term “patient” can also portray
individuals as passive – patiently tolerating their suffering in wait of an intervention from a medical expert
(Neuberger, 1999). As such, by using the term “patient”, it is not my intention to contribute to such medical
hegemonic discourses, but rather to simply maintain the accuracy of literature referenced and physician participants’
accounts in this study. Whenever possible, in all other instances, the term survivor is used in order to centre the
individual in their search of care.

23
considerations of article 41 need to be carefully weighed with their legal requirements to
report (3).
This matter of ethical considerations is further highlighted in Askew et al.’s (2016) paper,
which explores a repeat call for the complete abandonment of FGC. Here, Askew et al., reflect
upon movements which sought to replace traditional forms of FGC with a “symbolic nick” – a
small surgical cut that would be performed by medical professionals in healthcare settings in lieu
of more culturally conventional forms of cutting (Abdulcadir et al., 2011). According to Askew
et al. (2016), “the performance of the ‘nick’ by medical personnel would likely perpetuate the
practice through future generations by seeming to legitimise it” (p.619). Therefore, it is
important for health care providers to emphasize that there is no medical justification for FGC
and physicians are encouraged to recognize the practice as a form of gender-based violence,
which violates the rights of women and girls (Askew et al., 2016).
FGC and Gender-Based Violence (GBV)
As outlined above, the practice of FGC is considered a form of gender-based violence.
The UNHCR defines gender-based violence (GBV) as violence that is committed against a
person based on their sex or gender (UNHCR GBV Toolkit) and is inclusive of any harmful
physical, sexual, mental, or socio-economic acts that may cause suffering (Wei et al., 2024, p.2).
All people can be subject to GVB; however, some groups are more likely to experience violence
including women, women of colour, women living with disabilities, and 2SLGBTQQIA+
individuals (Government of Canada, 2022). The effects of GBV can be even more extreme for
women who already experience marginalization, racism, and discrimination in their daily lives
(Wei et al. 2024).

24
In Heidari and Moreno’s 2016 study, they explore how these experiences of GBV can
create a barrier to sexual and reproductive health rights. Due to the fact that GBV is rooted in
gender inequality, authors highlight the impacts of disrespectful and neglectful treatment of
women in healthcare settings – particularly when it comes to childbirth. According to Heidari
and Moreno, this type of GBV is referred to as “obstetric violence” (2016, p.2). Unfortunately,
the experiences of FGC survivors who have experienced obstetric violence in Canada is welldocumented (Chalmers & Omer-Hashi, 2001).
Chalmers and Omer-Hashi review the accounts of survivors living in Canada in their
2003 book titled ‘Female Genital Mutilation and Obstetric Care’. Here Chalmers and OmerHashi recount the experiences of Somali women who had undergone needless and traumatizing
caesarean sections solely due to the fact that the performing physicians were uneducated in the
proper care and treatment of birthing FGC survivors. At this time, because Canadian physicians
were unfamiliar in caring for women that were infibulated or had undergone “type 4” FGC,
whereby the labia majora, labia minor, and clitoris were all removed leaving the skin to be
sutured back together with the exception of a small hole for urine and menstrual blood to pass
through, Canadian physicians were opting for caesarean sections citing “safety precautions”
(Chalmers & Omer-Hashi, 2003). However, these procedures were particularly traumatic for the
Somali women giving birth as they held certain cultural beliefs that associated hospitals and
caesarean sections with death (Chalmers & Omer-Hashi, 2003).
When it comes to these types of practices under the guise of “treatment” or “medical
intervention”, Heidari and Moreno argue,

25
Addressing this form of mistreatment and abuse from a human rights perspective and
within a violence against women framework aims to highlight the structural dimension of
this violence, increase its visibility, and generate actions from health systems to ensure
that all sexual and reproductive health services are provided in a manner that fully
respects women’s choice, autonomy, and rights (2016, p.2).
The Canadian government has since claimed to have taken a proactive approach in
support of anti-GBV initiatives, particularly against cases of violence within healthcare systems.
For instance, in a 2022 statement made by Canadian Prime Minister Justin Trudeau, Trudeau’s
government announced an average of $1.4 billion annual investment from 2019 to 2023 to
“support the health and rights of women, children, and adolescents around the world through
global organizations and Canadian and international non-governmental organizations” (Prime
Minister of Canada Justin Trudeau, 2022). As part of this annual $1.4 billion investment, $700
million per a year is said to be allocated for sexual and reproductive health and rights more
specifically (Prime Minister of Canada Justin Trudeau, 2022).
The discussion of Canadian investment in projects against GBV is also relevant to
examinations of FGC-related organizational funding and governmental support. Since the
introduction of the zero-tolerance approach to FGC by the United Nations, FGC-related
organizations have adopted it into practice (O’Neil et al., 2020). In their article on rethinking
anti-FGM zero-tolerance policy, O’Neil et al. argues “this is not merely a moral and legal issue
but also an economic one because awareness raising activities, which are mainly run by nongovernmental organizations, are funded only by international institutions if they apply the zerotolerance approach” (2020, p.267). In Berer’s (2015) study on the history and role of criminal

26
law in anti-FGC campaigns, Berer offers an example of Ugandan programs and organizations,
which were funded so long as they upheld these anti-FGC positions. For instance, when
describing the Reach Programme and Reproductive Health Uganda, Berer (2015) states, “[they]
were making money only insofar as they were funded by UNFPA to “sensitise communities
against FGM through elders’ associations, community meetings, in schools, and on radio
stations” (p.150). Unfortunately, in this case, petitioners for these programs and organizations
experienced backlash from community members who argued their anti-FGC position was simply
a means of profiting from campaigns against FGC (Berer, 2015, p.150).
When looking to Canada, the Governmental Department for Women and Gender Equality
(WAGE) is one of the largest financial backers of FGC-related organizations in Canada. For
example, in February 2022, when issuing a statement on the International Day of Zero Tolerance
for Female Genital Mutilation, the Prime Minister of Canada, Justin Trudeau stated, “Canada is a
strong advocate for gender equality and the empowerment of women and girls at home and
abroad. Last August, the Government of Canada announced $530,000 in funding toward End
FGM Canada Network’s Joining Hands Project, to address systemic discrimination against girls
at risk of FGM/C and survivors” (Prime Minister of Canada Justin Trudeau, 2022). Therefore, in
order to receive substantial financial support to fund FGC-related supports, programs, and
initiatives for survivors, it is imperative that these organizations are align with the zero-tolerance
approaches and anti-FGC governmental stances more broadly.
The Clitoris and Clitoral Restoration Surgery (CRS)
The terminology used to describe clitoral restoration surgery (CRS) is varied and includes
several terms such as clitoral reconstructive surgery, clitoral restoration, genital reconstruction,

27
clitoral transposition, or clitoral re-exposition. The preferred terminology used depends on
individual preferences and I find that even my own terminology preferences have evolved over
the course of this investigative journey. These differences in one’s terminology preferences stem
from the reality that surgeons are not truly constructing something new but are rather restoring
what it already there. Urogynecologist and cosmetic gynecologist, Dr. Seifeldin explains,
“because most erectile structures are not excised, healthy women with FGM can reach orgasm
and experience satisfying relationships, since more of the clitoris remains” (2016, p.1) – it may
be under scar tissues, but it is still there, just beneath the surface.
This is why it becomes increasingly important to have a workable understanding of
clitoral anatomy before continuing with descriptions of this procedure. The clitoris is a much
larger sexual organ than one might originally think based on what is often visible externally.
What we see outside the body is only a small portion, approximately three quarters of an inch to
an inch of the clitoral glans. The entire clitoris, so including what we find internally, can measure
anywhere from 3.5 to 4.35 inches long and 2.5 inches wide and hosts more than 10,000 nerve
fibres, which is a significant increase from pre-2023 estimates that identified 8000 nerve fibres
(Uloko et al., 2023).

28

Figure 2. Clitoral Anatomy (Source: Natural Cycles, 2024)
In Pauls’ article on the anatomy of the clitoris and the female sexual response, Pauls
describes the clitoris as, “the most pivotal structure for female sexual pleasure” (2015, p. 378).
As discussed in the study’s introduction, the clitoris has been identified, celebrated, demonized,
forgotten, and “rediscovered” countless times over hundreds of years; however, it has only very
recently been described with any anatomical accuracy (Pauls, 2015; Stinger & Becker, 2010;
Charlier et al., 2019). With the help of scientific advancements in anatomical dissection and
magnetic resonance imaging (MRI), researchers and physicians have been able to accurately map
out this sexual organ’s composition and determine its dense innervation (Pauls, 2015).
Anatomically speaking, the clitoris is comprised of seven main components which include: the
glans clitoris, the prepuce/clitoral hood, suspensory ligament, body or corpora, crura, root, and
bulbs (Pauls, 2015, p. 377). Of these seven main components, only two parts are external: the
glans clitoris and the clitoral hood. The fact that the majority of components that make up the
clitoris are internal, and thus are not typically visible, has greatly contributed to false beliefs
regarding the sexual organ’s form and intended purpose.

29
An understanding of the anatomy and physiology of the clitoris, along with the factors
that have contributed to its misrepresentations, can help us to better understand why some
survivors of FGC might want to undergo CRS and can offer certain insights into a few of the
desired outcomes they may hope to achieve. For instance, survivors who are unaware of the
internal components of the clitoris and complex nerve supply may be surprised to learn that they
still have functioning nerve endings beneath their scar tissue.
When it comes to clitoral restoration as a relatively recent medical development – very
few studies have been conducted to evaluate the postoperative outcomes. In 2015 Abdulcadir et
al. performed a systematic review on the surgical procedure and determined that FGC survivors
electing to undergo CRS should be cautious when making their decision as limited evidence was
available. Upon identifying these gaps, Abdulcadir et al. (2015) called for an increase in studies
to evaluate the effectiveness of the procedure, identify the benefits patients might receive, and
the long-term outcomes. Out of the current available studies, the majority come from Dr. Pierre
Foldès.
In the late 1990s, French surgeon Dr. Pierre Foldès, in collaboration with his colleague
Jean-Antoine Robein, developed clitoral restoration surgery (CRS) in order to address any
urological, obstetric, and/or vulvar pain experienced by women with some of the more extreme
forms of female genital cutting (FGC) as part of a humanitarian pilot project in Burkina Faso
(Jordal et al., 2019). Following the success of CRS within a humanitarian context, Foldès began
offering it in France in the early 2000s as a reparative option for both immigrant FGC- affected
women living in France who had experienced FGC prior to immigrating to France as well as
French women who had experience FGC in France (Foldès et al, 2012). In a cohort study
beginning in 1998 and ending in 2009, Foldès performed reconstructive surgeries on 2938

30
patients (Foldès et al., 2012). Foldès et al. state that, “expectations before surgery were identity
recovery for 2933 patients (99%), improved sex life for 2378 patients (81%), and pain reduction
for 847 (29%)” (Foldès, 2012, p. 134).
The surgery itself can be performed in 30 minutes or less, and while the use of local
anesthesia is an option, performing physicians will often opt for the use of general anesthesia as
a preventative measure against re-traumatizing survivors who underwent FGC without any
anesthesia (Schrijver et al., 2016, p. 270). During CRS the performing surgeon will remove the
scar tissue, make a deep incision to draw the clitoris out, and then suture the exposed glans into
place while preserving the sensory nerve endings (Foldès et al., 2012). In their study exploring
the impacts of post-traumatic stress disorder amongst FGC survivors that chose to undergo CRS,
Abdulcadir et al. (2017) describe the following reparative technique in detail stating,
We resected the cutaneous scar covering the clitoris with scissors and dissected the
clitoral stump to the upper edge of its elbow with electrosurgery. We removed the
subcatneous periclitoral fibrosis and sectioned the suspensor ligament of the clitoris
remaining near the periosteum of the pubic symphysis to maintain the neurovascular
pedicle of the clitoris intact. Once the healthy body of the clitoris was released, we
reconstituted a healthy new glans by two lateral continuous sutures of Monocryl 3.0 and a
superior anchorage stitch fixing the neoclitoris to the two bulbocavernous muscles.
Hemostatis was performed with electrosurgery. On the upper part of the neoglans we
created a prepuce of the vulvar skin. (p. 372)
Detailed descriptions of the variety of complications some survivors may experience as a
result of undergoing CRS are significantly lacking (Abdulcadir et al., 2017). Further research is
needed in order to gain a greater understanding of why certain survivors may experience some

31
complications while others may not. However, a study conducted in Switzerland observed
“infections, wound dehiscence, keloids, hyperesthesia of the clitoris, and decreased sexual
function” all as possible complications that survivors may be at risk of experiencing as a result of
undergoing CRS (Abdulcadir et al., 2017, p. 374).
In addition to addressing physiological issues, CRS may also provide a surgical option to
address some sexual and/or mental issues that can impact FGC-affected women. However, while
this procedure may enable FGC-affected women to be clitorally orgasmic, it is not a promise of
clitoral orgasms (Jordal et al., 2019). This reinforces the importance of a multidisciplinary
approach to the care of survivors seeking to undergo CRS in order to manage survivors’ hopes
and expectations. While this surgery has the potential to improve the sex lives of survivors, it is
not simply a matter of the physical changes through surgery. Sexuality itself is exceedingly
complex and often relies as much on mental stimulation as physical. Therefore, any physical
changes that occur will have to be taken into consideration in combination with how those
changes influence shifts in survivors’ mindsets and/or perceptions of themselves.
Foldès et al. (2012) state, “sexual pleasure varies from one sexual partner to another, and
this could therefore be another major limitation. The complexity of the sexual dysfunction that
can be associated with female genital mutilation [sic] underlines, for us, the need to
systematically offer sexual therapy for patients” (p. 139). This is particularly important to note,
as a significant number of studies have been conducted regarding the perceived sexual
dysfunction survivors may experience due to having undergone some form of FGC. However,
what researchers have found is that some survivors are not necessarily any more likely to
experience sexual dysfunction from a physiological perspective (Catania et al., 2007; Jordal et
al., 2019; Schrijver et al., 2016). For instance, in a study on pleasure and orgasm in women with

32
FGC, Catania et al. (2007) note that the external clitoris is only the “top of the iceberg” and that
some survivors are still able to reach orgasm through vaginal/internal clitoral stimulation
(p.1673). Here, instances of sexual dysfunction were more so linked to cultural perceptions of
pleasure and limited sexual education (Catania et al., 2007, p.1676). Therefore, such findings
emphasize the importance of the psychosexual role and how CRS, in combination with different
therapeutic measures and/or a holistic approach, could positively impact survivors’ sex lives and
issues around body image.
CRS in the Context of Other “Elective” Female Genital Surgeries and Medical
Terminology
While clitoral restoration surgery (CRS) as a reparative option for survivors is a relatively
recent phenomenon within the medical community, surgical procedures for women and girls’
genitalia are not. Such surgeries are often conceptualized as reparative in nature, for instance
operations on girls and women with congenital adrenal hyperplasia (CAH) are performed with
the intent to return, what is deemed as “physiologically abnormal genitalia”, back to “normal”
from an anatomical perspective (Johnston, 2012). Justifications for cosmetic genital surgeries are
comparably founded on the premise that there is a “right” or “normal” way for women’s
genitalia to be both in appearance and in function (Davis, 2002).
In a discussion on labiaplasty, which is a surgical procedure where a woman’s labia
tissue is trimmed, and/or fat is removed from another area of the woman’s body and inserted into
the labia to plump it, Davis (2002) describes the motivational factors that encourage women to
undergo cosmetic genital surgery (p.7). In combination with the influence of media and
pornography, Davis (2002) highlights the issue of medical supremacy noting, “bringing the

33
authoritative language of medical science to the aestheticization of the vagina is one keyway to
trigger such anxiety” (p.7). Such language legitimizes women’s fears, concerns, and/or anxieties
regarding their genitalia and leads them to believe that something is wrong with their bodies if
what they see in the mirror deviates from the medical doctorate of “normalcy”. These concerns
can further exacerbate any pre-existing psychological or sexual issues whereby women believe
that undergoing surgery is the only solution to the problems that they feel they are experiencing
(Berer, 2010, p.9).
Like the pervasive authoritative nature of medical jargon, our choice in words holds
significant power and plays a major role in how we come to understand things. Moving forward,
the way in which clitoral restoration surgeries are defined within the medical context will
influence not only how the surgeries and procedures are viewed, but also in how individuals who
seek to undergo these surgeries are viewed as well. In the case of clitoral restoration surgeries,
this procedure presents a bit of a categorical dilemma as its purpose changes with increased
learning of its potential physical, mental, and sexual outcomes.
As previously discussed, CRS was initially developed in order to alleviate any pain
survivors may experience from having previously undergone some of the more invasive forms of
female genital cutting (i.e., clitoridectomy and/or infibulation). In addition, although the surgery
does not promise clitoral orgasms, it does maintain the possibility of making survivors clitorally
orgasmic and boasts its ability to return external genitalia back to physiological definitions of
“normal”. This recategorization from a pain-relieving procedure to one that may enhance
women’s sex lives and/or body image will need to be considered in the development of future
policies.

34
Currently, CRS is considered an elective surgery. In McCarthy and Finkle’s (1978) study
exploring second opinion elective surgery programs, the authors define elective surgery as “nonemergency procedures” (p.985). Although CRS may help to address pain – it is not performed
with the intent of saving a woman’s life, nor is anyone forcing a woman to undergo the
procedure; thus, such surgeries are categorized as “elective”. However, external pressures from
societal norms of idealized bodies can hold great influence over one’s personal desire to undergo
“elective” surgeries. In a comparative study between acceptance of female genital cutting versus
genital cosmetic surgery procedures, Johnsdotter and Essén (2010) highlight several factors that
may influence women to “fix” their bodies citing, “victims of patriarchy, of the beauty industry,
of the pressuring ideals of today, or their own inner insecurities” (p.32). Such procedures extend
well beyond the realm of genital modification to include breast augmentation, gluteoplasty,
liposuction, and more. Many of these elective procedures are marketed towards women to “help”
them overcome an insecurity that society instilled in them to begin with. Therefore, when
women’s bodies are scrutinized and pressured by society to modify their appearance it does raise
the question of how truly elective “elective” surgeries are.
Latham (2010) highlights concerns around autonomy in patient decision-making when it
comes to cosmetic surgery in the United Kingdom stating, “autonomy can be taken to refer to the
ability of patients to make their own fully informed decisions about their treatment, necessitating
information about choice of procedures, standards of treatment, risks and possible outcomes, and
the ability of the health professional to carry out the procedures. A patient’s physical integrity is
respected in this way” (p.49). In this view, patients maintain the right to formulate an
autonomous decision free from coercion (Latham, 2010, p.49). However, in this example,
Latham is preoccupied with coercion from medical professionals and/or salespeople from clinics

35
in the United Kingdom who are likely to profit from coercing potential patients into undergoing
surgery (Latham, 2010, p.49).
Experiences of FGC Survivors and the Perceptions of “Normative” Bodies
These issues around body image and concerns of altering one’s appearance to meet some
type of “ideal” largely stem from perceived deviations from the idealized “normal” body.
However, an individual’s perception of what constitutes normal can vary greatly depending on
the biomedical or sociocultural context in which it is applied. For instance, according to the
American Heritage Medical Dictionary (2007) “normal” is defined as, “functioning or occurring
in a natural way; lacking observable abnormalities or deficiencies”. Within medicine, certain
parameters are assigned to manage and calculate pathology (Banerjee, 2011). Deviations from
these parameters, either above or below these “healthy” ranges, are then flagged as abnormal.
Therefore, under this biomedical definition, a survivor’s external genitalia would be viewed as
“abnormal”.
However, a biomedical definition of normality is but one definition of normal. Another
definition of “normal” is “that which is most common”. For this conceptualization of “normal”,
the frequency of which something occurs is an indicator of normalcy. Koeslag (1993) provides
the example of shortness of breath and usualness to explore the idea of that which is “normal” is
that which is most common (p.47). For instance, if you live at the top floor of a 10-story
apartment building, it is likely that you will be winded climbing up multiple flights of stairs to
reach your apartment. However, if you find yourself short of breath after bending down to tie
your shoes it may be a sign that you should seek medical advice. In this example, it is much
more common to experience shortness of breath after engaging in moderate to intense physical

36
activity compared to becoming winded by performing mundane tasks that should not require
significant physical exertion. A deviation from this “usualness” would be considered
“abnormal”, and thus justify consulting a physician to discuss potential interventions.
However, even the use of medical interventions has impacted our perceptions of what is
“normal” in this case. Rudnick (2000) emphasizes the commonness of certain disabilities and
how these variants can be considered “normal” based on their frequency of occurrence. For
example, Rudnick argues, “disability presents itself as a pathological only when selforganization is impaired and there is a resulting handicap” (p.3). Therefore, with the
development of new medical technologies that change the lives of people living with disabilities,
so can they change our understandings of what is “normal”.
These changes in our understandings can also apply to sociocultural norms. In this
instance, the understanding of “normal” as “a cultural norm” emphasizes the social implications
that contribute to one’s perception of health, illness, and disease (Harris et al., 2015). In this
context, what is viewed as “normal” is socially constructed and influenced via any number of
individual, social, cultural, economic, and/or environmental factors (Harris et al., 2015, p.178).
Due to the fact that this conceptualization is socially constructed, many different groups may
develop their own unique understandings of what is “normal”. Therefore, this concept of
“normal”, meaning to conform to a cultural norm, is challenged by our own cultural differences
as people. Harris et al. (2015) provides an example of this from their study on the sociocultural
constructions of obesity and excessive weight among African American women. Harris et al.
found hair to be one of the main determinants of whether or not an African American woman
was going to engage in physical activity. For many African American woman, taking care of

37
their hair can be both expensive and time consuming; therefore, African American women were
found to avoid physical activity if it meant that they would run the risk of ruining their hair
(Harris et al., 2015, p.178).
In addition to hair, Harris et al. (2015) also emphasized other sociocultural constructions
that impacted African American women’s health, the second being ideal body image. According
to Harris et al. (2015), “larger body sizes for women are often socially constructed to symbolize
health, beauty, sexual attractiveness, wealth and being a good mother/wife” (p.180). These ideals
influence various cultural and ethnic groups’ perceptions and understandings of what it means to
be obese or overweight. This is particularly relevant when we consider scientific measurements
of obesity or overweight, such as the body mass index (BMI), which according to Harris et al.
(2015), “impose a “White Body Norm” ideal onto other racial/ethnic groups to whom the
measure may not adequately apply” (p.181). Therefore, even when considered within a
sociocultural context, the way in which the term “normal” is applied can often shed light upon
what, or in some instances who, society values (Banerjee, 2011).
When words such as “normal” can convey a multitude of meanings it is important that
their users define them appropriately. The act of defining not only provides clarity, but also
justification when the usage holds real life implications for those in reference to “being normal”.
This is the case for FGC survivors living in Canada. Bodies of FGC-affected women are
medicalized and criminalized through policies and regulations that imply they are not “normal”.
These categorizations have financial, legal, and cultural impacts on women’s lives.
According to Caita et al. (2020), from a perspective of comparison, deviations from what
is “normal” can justify “medical intervention, health insurance policies, and public health

38
measures” (1). Under the Canada Health Act (CHA), the act specifies that, “all eligible residents
of Canada have reasonable access to medically necessary services on a prepaid basis without
direct changes in the point of service for such services” (Asanin & Wilson, 2008, p.1272).
However, similarly to the use of “normal”, the act fails to define what the CHA implies by
“medically necessary”. This failure to define “medically necessary” has resulted in
inconsistencies cross-provincially and territorially as to what is and is not covered under the
CHA and increases the risk of perpetuating pre-existing health inequities in Canada (Chowdhury
& Chowdhury, 2018).
By providing a literature review of key themes associated to the research aims of this
study, this background chapter has helped to situate CRS within the relevant larger contexts. In
order to further situate the themes of this study, the next chapter will outline the project’s
theoretical perspectives. As described here, the introduction of CRS in Canada is much more
complex than previously conceived and holds real implications at the individual, interpersonal,
and institutional levels. As such, in order to accurately reflect these interacting factors, it is
important that a theoretical lens is applied that can account for this complexity within the study’s
analysis. Therefore, Chapter Three – Theoretical Framework, introduces the study’s theoretical
perspectives, offers justification for their application, and provides an outline for how it should
be understood in relation to the study’s aims.

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Chapter Three – Theoretical Framework
In order to account for the complexity of CRS experience in Canada, three
complementary theoretical perspectives have been chosen. These theoretical frameworks include
feminist intersectionality theory, complexity theory, and multisystemic resilience. Feminist
intersectionality theory is explored first – highlighting the role of feminist research in attending
to the voices of marginalized groups particularly within the context of health research.
Complexity theory is then introduced as a complementary approach to feminist intersectionality
theory through its larger systems perspective. According to McGibbon and McPherson, when
combined, these two theoretical perspectives “create a view into the complex landscape of
inequity” (p.77). This issue of inequity is inherently linked to discussions around adversity,
which is a key component to multisystemic resilience. As a result, multisystemic resilience offers
a more in-depth understanding of how each of this study’s key demographics (i.e., survivors,
healthcare providers, and FGC-related organizations) confront, adapt, and overcome instances of
adversity related to the introduction of CRS and provision of FGC-related care more broadly in
Canada.
Intersecting Perspectives
Feminist Intersectionality Theory
In the literature review, several factors were explored related to FGC-survivors’
experiences navigating Canada’s health care system and emphasizing their unique health care
needs – especially in relation to the development of a newly elective genital surgery here in
Canada. Stories of FGC survivors are similarly explored in Kiguwa’s investigation of women’s
gendered experiences, here Kiguwa (2019) shares two narratives, the content of which center on
the practice of FGC and survivors’ personal accounts. According to Kiguwa, “the autonomy that

40
women have over their own bodies and the violence that may be enacted against these bodies
have inspired much theorising, research, and policy framing the world over” (p. 222). It is
through both of these stories, that Kiguwa emphasizes the issue of the autonomy of women’s
bodies, and argues, “is of central concern to much feminist work” (p. 222).
The purpose of feminist research, as described by Kiguwa (2019), is “to attend to
women’s marginalised and often silenced voices, not just in the social world, but also in the
production of knowledge” (p. 255). This issue of marginalization is relevant to investigations of
CRS, as the procedure is intended for FGC survivors who, within the context of Canada, are
most commonly immigrant women of racialized backgrounds who have experienced a gendered
sociocultural ritual that affects their sexual anatomy (Nwoke & Leung, 2020).
According to Nwoke and Leung (2020), “compared to any other group, immigrant
women from racialized backgrounds, including recent immigrants, continue to experience the
most significant challenges in accessing healthcare, ultimately leading to poorer health outcomes
than their non-immigrant counterparts” (p.1447). An individual’s immigration status, ethnicity,
and gendered reality influences their ability to, and experiences of, accessing and navigating a
healthcare system, particularly when that system is intended for a privileged group (i.e., white,
wealthy, educated, male) (Collins, 1989). All of these factors combine to impact a survivor’s
experience when it comes to accessing CRS and related treatment options, which therefore
necessitates a theoretical perspective, such as feminist intersectionality theory, to support an
understanding of each of these factors and how they intersect.
There is no universally agreed-upon definition of feminist intersectionality theory
(Hankivsky et al., 2009; Collins, 2017); however, there are some key principles that can be
identified within. For instance, Collins and Bilge (2020) identify six core ideas within

41
intersectionality, which include: “social inequality, intersecting power relations, social context,
relationality, social justice, and complexity” (p.35). According to Collins and Bilge, scholarly
interest in intersectionality has grown within healthcare research due to “intersectionality’s focus
on complex social inequalities” and this framework’s capacity to “shed light on health and
illness” (p.48). Similarly, McGibbon and McPherson state, “feminist intersectionality theory
provides a comprehensive foundation for interrogating the multiple ways that SDH [social
determinants of health] shape women’s health across the lifespan” (p.63). As a demographic, the
health and well-being FGC survivors in Canada is greatly affected due to the barriers in care they
experience (Nwoke & Leung, 2020). By employing an intersectional feminist lens to the study of
CRS, it allows for a deeper understanding of these complex challenges in accessing CRS,
affording the procedure and associated treatment options, and receiving culturally safe and
compassionate care.
Complexity Theory
In order to further account for this complexity, in addition to feminist intersectionality
theory, this study also applies complexity theory as a complementary theoretical lens to account
for each of these intersections interacting within the frameworks of a larger complex system.
McGibbon and McPherson (2011) argue, “although feminist intersectionality theory allows us to
envision the ways that oppressions come together to compound women’s struggles, it may be
argued that it falls somewhat short of describing the interactions within this web of larger
systems, particularly health and social service systems” (p.72). To illustrate their argument,
McGibbon and McPherson provide the example of a young girl named Marya who lives with
chronic illness and cannot afford transportation to her medical appointments (76). Marya is
raised in a low-income household with minimal education and experiences several challenges as

42
she attempts to navigate the intersection of these various social determinants of health. These
challenges are then further exacerbated by the reality of poor government funding, which has
resulted in substandard public transport leading to geographic barriers. Additionally, a shortage
of public policy to provide universal access to medication leads to high costs of over-the-counter
prescriptions (McGibbon and McPherson, 2011). Therefore, McGibbon and McPherson argue
that these systemic oppressions (e.g., classism, racism, sexism) then “operate within a complex
public service systems” (p.76). In terms of FGC, while intersectionality is interested in the
characterization of different axes of marginalization, complexity theory adopts a system
approach to further situate the experiences of FGC survivors in Canada. This is where the
addition of a multisystem perspective makes for a complementary approach to the established
feminist lens to strengthen the overall analysis of CRS in Canada.
Physicist Fritjof Capra (1975) is argued to be one of the original theorists in the
conceptualization of complexity theory. In Capra’s conceptualization, natural and social
phenomenon were described within the context of a complex web of systems, all of which are
interconnected. This conceptualization goes on to suggest that in order to develop an accurate
understanding of a system as a whole, one must explore the individual parts of which that system
is made (McGibbon & McPherson, 2011). This concept was later expanded upon to make a
distinction between a system and the system’s environment (Walby, 2007). This distinction was
developed in order to negate any rigidity associated with the “parts as a whole” conceptualization
and to account for the fluidity of a system’s ability to change and grow over time. In this view,
according to Walby (2007), “each social system (whether economy, polity, violence nexus, or
civil society) takes all other systems as its environment. Likewise, each set of social relations
(e.g., gender, ethnicity, class) is a system, taking all others as its environment” (p.458). The

43
expanding interpretations of complexity theory have garnered attention amongst multiple
disciplines as its breadth of applicability has enticed multi- and inter-disciplinary researchers
alike (McPherson, 2008).
To illustrate the relevance of a larger complex systems perspective to FGC-related
research we can look to the economic impacts of FGC globally. When the rates of women and
girls at risk of undergoing FGC are calculated, we can view how FGC and its related health
complications are capable of impacting the larger global economic system. For instance, between
1990 and 2012, Goldberg et al. (2012) determined that in the United States alone, the number of
women and girls at risk of undergoing FGC rose by 224%. Based on data collected from 27
countries, the World Health Organization (WHO) determined that the economic costs of treating
FGC-related health complications accounts for 1.4 billion USD a year (WHO, 2016). If
prevalence rates remain unchanged over the next two to three decades, this amount is expected to
increase to 2.3 billion USD annually (WHO, 2016). The results of these external factors, such as
economic impacts (e.g., costs to receive FGC-related treatment) in addition to legal pressures
(e.g., anti-FGC laws) can influence the internal dynamics of the practice. Therefore, McGibbon
and McPherson (2011) argue that, “local, regional, national, and international systems of
inequity are inextricably linked and cannot be ameliorated without an analytic focus on how
these complex systems act together in a complex web of larger systems” (p.70). Analyzing the
intersections of oppression as they operate within a larger complex system will not only deepen
our understanding of the issue at hand, but also enhance our ability to institute change at larger
health, social, and economic levels.

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In a 2018 study on CRS in Sweden, Jordal et al. argue, “FGC and CR [clitoral
reconstruction] have medical, social, gendered, and psychosexual implications” (p.703). Many of
these implications are the result of the intersection of oppressions that survivors face. In Canada,
survivors are likely to face challenges based on their race, gender identity, immigrant status,
level of education received, and socioeconomic position. All of these challenges, at varying
degrees, will influence an FGC-affected woman’s ability to access CRS as a reparative option,
due to the fact that the larger healthcare system is designed for, and sustained by, more
privileged groups (i.e., white, wealthy, educated, male, national). Analyzing the introduction of
CRS from an intersecting feminist lens in addition to a larger systems perspective will help to
better conceptualize this complexity.
In Jordal and Wahlberg’s review they identify several interconnecting factors that
contribute to the complexity of providing quality care for FGC-survivors in Sweden. These
challenges exist at the macro/societal level, the exo/institutional level, the meso/interpersonal
level, and the micro/individual level (2018, p.94). A key component in the analysis of complex
systems is a system’s adaptive capacity (Craig, 2020, p.1758). Holling, one of the founders of
resilience theory, defines adaptive capacity as the “capacity of actors, both individuals and
groups, to respond to, create, and shape variability and change in the state of system” (Craig,
2020, p.1758). Given the link between resilience and complex systems it becomes ever more
important that we define resilience for the purpose of this discussion. By doing so, it allows us to
explore how associated notions of adversity, adaptability, and change are relevant to
examinations of newly introduced surgical procedures – particularly those that are intended for
gendered and racialized populations.

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Resilience Theory
Defining resilience can prove challenging given its wide range of applicability within
ecological, biological, psychological, and social fields of study (Ungar, 2020). According to
Brown (2020), the fact that resilience is well suited across several disciplines speaks to “its
theoretical, conceptual, and methodological richness” (p.778). Despite several formulations of
resilience, there are some key defining terms that emerge repeatedly, such as adversity,
adaptation, and change/transformation. In an exploration of community resilience in a rural
Australian community, Buikstra et al. emphasize the variability of resilience definitions but
found that the most common denominator when it came to conceptualizing resilience was that it
was linked to overcoming adversity (2010, p. 966). Furthermore, when examining this
progression of resilience definitions over time, Dahlberg’s (2015) article on conjoining resilience
and complexity discourses states, “note the emphasis on adaptation: what makes a complex
adaptive system resilient is it’s learning and transformational capabilities, not its ability to
merely resist a shock” (p. 545). Therefore, a consistent theme in the progression of resilience
definitions has been an emphasis on its complex, interrelated, dynamic qualities, ability to
“fluctuate over time”, and link to adversity (Buikstra et al., 2010). This emphasis on adversity
and perseverance is especially important in terms of helping to differentiate resilience from other
similar and complementary concepts like “adaptation”. For instance, in a review on the
differences and similarities between resilience and adaptability, Busch states, “while resilience
tends to be in a response to some kind of adversity, stress, or pressure, adaptability does not
necessarily involve any kind of negative situation” (n.d., para.8).
For the purpose of this study, the preferred understanding of resilience is that which is
outlined in the multisystemic model of resilience (Hiebel et al., 2021). This definition accounts

46
for intra-individual source of resilience, interpersonal source of resilience, and socio-ecological
sources of resilience (Hiebel et al., 2021, p.2). According to Wiig et al. (2020), “in this view,
there is an emphasis on the individual’s, communities’, or organizations’ ability to regain
equilibrium in circumstances of changes or to adapt to new norms, forms, and practices” (p.3). In
the case of CRS in Canada and FGC-related care more broadly, there are several actors that have
exhibited this adaptive capacity including survivors (micro), community-led organizations and
healthcare providers (meso), and policy makers, hospitals, and universities (macro/exo) – all of
which shape this complex system. Therefore, as Massari et al. argues in their study of complex
systems approaches – resilience is thus a property of complex systems “which spontaneously
emerges from the bottom as a result of both the actions of the system’s agents and their complex
interactions” (p. 209). This emphasis on multifaceted adaptation is especially important given the
recent introduction of this surgical procedure in Canada, which impacts survivors, the
community-led organizations which offer FGC-related related supports, and the providers and
clinics that specialize in this type of care. This next section will break down each level of
resilience further in relation to this study’s demographics and then will conclude with a return to
the application of a multi-system resilience lens.
Resilience and FGC (Intra-Individual/Micro Level Resilience)
An important consideration when defining resilience is raised by Duit et al. (2010) who
encourages resilience theorists working in social science spaces to consider the question
“resilience of what, and for whom?” (p.265). This is a question I posed to myself in the process
of identifying different instances of resilience amongst the various demographics explored in this
study. For instance, Duit et al. (2010) argue, “notions of resilience as the ability to “bounce
back”, “return to equilibrium” and to “reorganize after a disturbance” may have wholly different

47
meanings, depending on how the social system was configured to begin with and from whose
viewpoint resilience is assessed” (p.365). Therefore, provided the different interpretations,
meanings, and measurements of resilience, approaches to resilience that solely focus on an
individual’s ability to “bounce back” can actually contribute to an increase in an individual’s
sense of isolation – exacerbating their challenges in facing adversity (Auburn et al., 2020).
For survivors of FGC, resilience is often discussed within the context of psychological
resilience (Glover et al., 2007; Conner et al.; 2021). In their study on the psychological and
social challenges, Glover et al. (2007) highlight the emotional, physical, and identity impact
FGC has for survivors (p.231). These challenges can be exacerbated particularly amongst FGC
survivors who have immigrated to other countries and are encountered with health practitioners
who are poorly adapted to meet their specific health needs (Jordal & Wahlberg, 2018). These
exchanges with other actors across different systems (e.g., legal systems or health care systems)
help to highlight the importance of a multisystem approach to resilience.
Resilience and Community-Led Organizations (Interpersonal/Meso Level Resilience)
Non-profit organizations, particularly those which serve immigrant populations, often
encounter instances of adversity (Carrillo, 2016). Such adversity frequently consists of limited
funding, lack of governmental support or acknowledgement, constrained capacities (i.e., time
and energy) of members, geographic challenges, and more (Carrillo, 2016). In Witmer and
Mellinger’s study on organization resilience their focus is on non-profit organizations’ response
to change. For Witmer and Mellinger, organizations that are resilient are those which have
exhibited an adaptive capacity (2016, p. 255). As described in the section on situating resilience,
adaptive capacity refers to the capacity of individual actors or groups and their ability to respond
to adversity and create change (Craig et al, 2020, p.1758).

48
From data collected in their study, Witmer and Mellinger emphasized the connection
between a strong commitment to the mission of the organization and the level of resiliency of
that organization. Organizations that held a clear mission statement and were supported by
members who shared in the beliefs and values of that organization, exhibited a high level of
resilience. When a group of actors believe in an organization’s mission – its purpose and its
goals – it helps to bolsters members’ spirits and empowers them to respond collectively to
challenges (Witmer and Mellinger, 2016). Members of FGC-related organizations are often
compiled of survivors, human rights activists and advocates, researchers, care providers,
educators, and more. These members are individuals who align themselves with the
organization’s mission and are passionate about raising awareness around FGC, eliminating
FGC, protecting women and girls at risk of FGC, and offering supports to FGC survivors.
Therefore, through their commitment to a shared cause, group members ultimately contribute to
the organization’s overall resilience (Witmer and Mellinger, 2016).
Resilience and Health Care (Socio-ecological/Macro Level Resilience)
In Auburn et al.’s article, authors explore the social reality and resilience of health care
professionals. Here Auburn et al. note that the conceptualization of resilience is often conceived
at the individual level despite the connection to larger structural factors (2020, p.1). Behrens et
al. (2022) describes the health care system as “a part of the critical infrastructure (on a local,
regional, national, and even international level) …making health care systems resilient is
therefore of utmost societal importance” (p.468). This conceptualization of resilience helps to
move beyond the micro-level (Auburn et al., 2020; Behrens et al., 2022; Ungar, 2020).
Acknowledging the resilience of health care systems within these broader contexts also
helps to highlight health care systems’ overall adaptive capacity to transform in order to meet the

49
changing needs of a population (Behrens et al., 2022, p.469). For instance, when we consider a
substantial aging population, it requires some restructuring of health care system developments
to ensure that the health demands of this population are met (Behrens et al., 2022). These
demands may look like larger investments in home and hospital care for seniors or increases in
specialist services like geriatricians, oncologists, or ophthalmologists (Royal College of
Physicians and Surgeons of Canada). The same can be said for an increasingly globalized
population in Canada – in order to continue to provide quality care, particularly within the
context of FGC-related care, it becomes ever more important for the Canadian health care system
to adapt as a means to provide cross-cultural health services, supports, and training.
Multisystemic Resilience
Due to the complex and dynamic nature of resilience, it is common for researchers to sing
its praises – recognizing its relevancy and vast applicability amongst a variety of disciplines at
different interacting levels (Buikstra et al., 2010; Ungar, 2020). However, it is often for those
same reasons that resilience as a theoretical concept is subject to criticism (Buikstra et al., 2010;
Newsom & Myers-Bowman, 2017; Wiig et al., 2020; Shevell et al., 2021). When defining
resilience for the purpose of this study, I discussed some of the challenges researchers faced,
therefore, this section will focus on some of the main criticisms of resilience applications, offer
some alternative ways of understanding resilience, and conclude the chapter with a return to the
preferred understanding of resilience and its relevance for the purpose of this study.
One of the most common critiques of resilience is against its conceptualization as a personal
characteristic or trait (Newsom & Myers-Bowman, 2017; Bogar Hulse-Killacky, 2006).
Arguments against this type of understanding are not only based on the implication that
resilience is static but also that it puts the onus on the individual (Newsom & Myers-Bowan,

50
2017; Ungar, 2020). Such individualized approaches to resilience, which celebrate a person’s
ability to “cope”, “bounce back”, or “overcome”, can actually cause more psychological harm,
stress, and isolation (Auburn et al., 2020, p.2). Ungar (2020) explores this reductionist approach
to resilience further in his examination of multidimensional approaches to resilience within the
context of mental health. Here, according to Ungar (2020), when resilience is reduced in this way
it “serves neoliberal agendas by blaming those who fail to thrive” (p.7)4. For instance, such
perspectives fail to consider the differential access to resources that individuals might have
access to in order to adapt. An approach to resilience which fails to account for the social,
structural, and ecological determinants of resilience will only help to maintain social injustices
(Ungar, 2020).
Similarly, in Ryan’s article on everyday resilience as resistance, she seeks to further
problematize this association between resilience and neoliberalism (2015, p.299). According to
Ryan, “if we look for resilience “from below” as a tactic or strategy employed intuitively by
populations, rather than something imposed from above, we can clearly see that not only is it
much more prolific than the current literature implies, but that it can be a practice of resistance
rather than simply a practice of coping” (2015, p.300). This alternative understanding of
resilience also helps to counter arguments which situate resilience approaches in opposition to
resistance approaches.
It is for that reason, as Shevell et al. (2021) states, “resilience must be seen as a
“multidimensional construct”, demanding a coordinated multisystem response” (p.2). A
multisystem approach to understanding resilience successfully challenges the above criticisms

4

Neoliberalism is an economic and political philosophy that has faced criticism for contributing to several harmful
socioeconomic consequences including “increased poverty, unemployment, and deterioration of income
distribution” (Gatwiri et al., 2019, 90).

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while simultaneously accounting for the complexity of these interconnected factors. This point is
emphasized by Jaya et al. (2024), who in their article on the complexity of FGC within the
Indonesian context, argues “by comprehending the complex factors, the actors involved can
work towards promoting the health and well-being of girls and women” (p.7). This perspective is
similarly shared by Jordal and Wahlberg (2018) in their examination of difficulties providing
quality care for survivors. Here the adaptive capacity of actors is recognized not only at the
individual level, but also at interpersonal and institutional levels as a means of coming together
to overcome shared challenges. Therefore, a theoretical analysis like multisystemic resilience,
that helps to illuminate the adaptive capacity of actors will help contribute to a more in-depth
understanding of these complex systems and their connections to the successful introduction of
CRS in Canada.

The combination of feminist intersectionality theory, complexity theory, and
multisystemic resilience help to best conceptualize this complex research problem. As a study
which seeks to explore the introduction of an elective genital procedure for survivors of FGC
living in Canada, there are several components to this investigation which contribute to the
study’s overall complexity at different levels. Firstly, the intersecting identities of this study’s
main demographic are deeply entwined and affect their ability to access and receive quality care.
By employing a theoretical perspective which accounts for these various forms of oppression, it
allows for a more in-depth understanding of the study’s problem. Secondly, the inclusion of a
complexity theoretical framework allows for a more complete picture of the CRS landscape in
Canada and abroad – emphasizing the geographical, financial, and legal dimensions relevant to
this study’s exploration. Lastly, by situating this project within a multisystemic resilience

52
perspective, it helps to highlight the adaptive capacity of key actors (i.e., survivors, healthcare
providers, and FGC-related organizations) as they persevere despite the challenges that they face
in navigating these complex systems and intersecting factors.

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Chapter Four: Methodology and Research Methods
Outlining the study’s theoretical frameworks is not only relevant to conceptualizing of
the study’s research problem but is also connected to the ways in which this study was
undertaken. As such, it is important to outline how these theoretical perspectives inform the
study’s methodology and methods used. This research adopts a complementary methodological
approach that blends qualitative data, including focus groups and qualitative surveys, to achieve
a more in-depth understanding of the study’s research problem. Additionally, this approach also
draws from secondary sources including organizational webpages, reports, and community
outreach initiatives, to further enrich the study’s primary data and showcase how my
understanding of CRS evolved throughout the research process. Lastly, thematic analysis is
outlined as the chosen method of analysis for this study – well-suited to explore the complexity
of investigations into the introduction of CRS in Canada.
Methodology
Positionality Statement
According to Landman (2006), “feminist methodology is specifically concerned with
how, or whether, knowledge produced about social life can be connected with the social realities
of women” (p.430). However, it is of great importance to emphasize that “women” is not a
singular category (Landman, 2006). As previously discussed within the theoretical framework,
women’s social realities are influenced by several intersecting variables that impact their lived
experiences and over the course of this study my interactions with participants and exchanges
with community organizations and clinic team members was almost exclusively with women.
Apart from one male physician, who took part in an information gathering event, every

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physician, survivor, researcher, organization coordinator, and support worker I interacted with in
relation to this study was a woman.
It therefore becomes important that I situate myself within the research when observing
and interpreting the experiences of the women who shared their time and stories with me, who
choose to participate in this project, and who supported the aims of the study. Particularly as
Haraway (1988) argues, “there is no single feminist standpoint because our maps require too
many dimensions for that metaphor to ground our vision” (p.590). For instance, as a woman, I
can understand the feelings of discomfort and vulnerability in interactions with medical
professionals (particularly male physicians) related to my sexual health, reproductive health, and
concerns related to the functionality and appearance of my sexual anatomy. This sense of
vulnerability is heightened through the level of trust we are forced to place in a medical
professional – someone dealing with our health and the most intimate parts of our lives and our
bodies. It can be an uncomfortable and overwhelming feeling to put your trust in someone and to
believe they have your best interest in mind, the knowledge to know what is best, and the ability
to competently do what is best if and when the time comes.
However, while I can empathize with that vulnerability, as a white woman born and
raised in Canada, whose only interactions as a patient have taken place in the medical system
within the culture in which I was raised, I can only imagine how these feelings of discomfort and
vulnerability are amplified when you are navigating a healthcare system different to the one in
which you were raised, may not speak the favoured language of that system, and have
experienced a body-altering ritual of sociocultural significance that is often likely to be an
unfamiliar practice to the providers responsible for your care and wellbeing. This matter of
positionality is particularly relevant as it is in line with approaches to feminist-informed research

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methodology, for which underpin this study. Here, by reflecting on the influences of my own
identity, background, and experiences, I recognize my role as researcher, which according to
Nencel (2014) in their study on situating reflexivity in feminist ethnographic texts, “comprises an
essential component of this endeavor” (p.76).
A denounced misconception of feminist methodology had been that female researchers
were better suited for emotionally laborious qualitative methods, such as interviews rather than
numerical quantitative approaches, based on outdated beliefs that women were more
compassionate than men and thus better listeners. This belief of qualitative research as “soft” has
persisted within health and health science research where similar untruths and methodological
prejudices continue despite evidence to suggest otherwise (Pope & Mays, 2020, p. 212). For
instance, in their chapter on the quality in qualitative research, Pope and Mays highlight the
often-complex nature of qualitative data and that the analysis of such data requires a high level of
interpretative skill (Pope & Mays, 2020, p. 212).
Furthermore, Landman (2006) argues that there are in fact no research methods which are
more distinctly feminist than others. Rather, it is through a feminist methodological perspective
that researchers can help to improve upon current methods by way of emphasizing women’s
social realities in their application – leading feminist methodologists to advocate for the usage of
a diversity of methods in their research pursuits (Landman, 2006).
In a comparative piece on the subjective view of objectivity in research, Westmarland
emphasizes the complementary nature between interviews and surveys arguing, “rather than the
“us against them” relationship, interviews can give a deeper, more complex knowledge of the
issues named by survey research” (Westmarland, 2001, p.9). Therefore, for the purpose of
employing a complementary approach that would account for the diversity of women’s social

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realities, I employed a methodological approach which included the observation and analysis of
organizations involved in the support of survivors in Canada and abroad, the surveying of
survivors in relation to their interest and experience related to CRS in Canada, and a focus group
of Canadian physicians responsible for the referral and facilitation of CRS to take part in an open
discussion format. The following section is an overview of the organizations I collaborated with
and their involvement in the study’s recruitment efforts, participant sampling, and data
collection.
Methods
In 2018, I completed a study that explored the experiences of Canadian physicians who
provided reproductive health care to immigrant women in Canada with previous experience of
some form of female genital cutting (FGC) (Leone, 2018). This study consisted of qualitative
interviews with Canadian obstetricians and gynaecologists (OB-GYNs), family physicians, and
registered nurse practitioners across Ontario and Québec (Leone, 2018). Each research
participant graciously shared with me their time and expertise – providing invaluable insight into
the care of survivors in Canada.
My fieldwork for this study took place between 2016-2017, during which information on
FGC-related care specific to the Canadian context was exceptionally limited. There were,
however, some exceptions which included interested healthcare providers, researchers, and
activists and advocates working to raise awareness of FGC as a Canadian issue. Due to the
efforts of passionate individuals who acknowledged the importance of addressing the topic of
FGC in Canada, Canada received the brief clinical guidelines document offered by the Society of
Obstetricians and Gynaecologists of Canada (SOGC), statements shared by human rights
organizations such as the Ontario Human Rights Commission, independent FGC-specific

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healthcare modules in development by some university medical programs, and a few clinics that
specified “female genital mutilation/cutting” in their clinic services and specialization.
Through these small-scale changes, awareness about FGC as a Canadian issue began to
expand as a result, particularly with the foundation of the End FGM Network Canada in 2018.
The End FGM Network is an organization that seeks to bring an end to FGM globally by way of
education and awareness. Other End FGM Networks include End FGM European Network and
the End FGM/C U.S. Network. Having our own faction of the End FGM Network helped to
bolster arguments that FGC was in fact a Canadian issue – one deserving of public attention and
governmental action in order to help protect Canadian women and girls at risk of FGC as well as
to support survivors living within our nation’s borders. The momentum sparked by the End FGM
Canada network helped to expand these awareness-raising efforts with an emphasis on
collaboration and community outreach whereby the End FGM Canada Network helped to spread
its message not only through amplifying the voices of Canadian survivors, but also by bringing
together individuals who were specialists in their respective fields and held frontline positions
working in and alongside survivor communities.
Accordingly, by the time I began research preparations for this study in 2022, it was
important to reach out to organizations like the End FGM Canada Network and I did so in the
role of volunteer – volunteering my time, knowledge, and research and writing skills. The
purpose of volunteering was fourfold: to build rapport with FGC-related organizations, to gain
further insights into FGC research within the Canadian context, help contribute to the
organization’s initiatives to support survivors living in Canada and abroad, and to engage with
likeminded individuals who are passionate about improving the lives of survivors living in
Canada. As part of this volunteer work, I was also able to establish professional relationships

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with various network coordinators to help in the distribution of my study as well as support my
participant recruitment efforts.
During this period as a volunteer, I would take notes, join meetings with other volunteers
and members, and attend conferences and speaking series. My involvement with these
organizations offered a pathway into the communities that provide support to survivors in
Canada and abroad – while also offering further insights into the needs and experiences of
survivors, clinicians, and other front-line workers by way of indirect, secondary data through
their organizational webpages, reports, initiatives, workshops, and more. In a paper on the
importance of secondary research, Thin (2013) argues that by engaging with secondary sources,
the researcher demonstrates how they are “drawing inspiration and information from a rich
variety of other knowledge sources” (p.42), sources which ultimately help to complement and
support the study’s primary modes of data collection. Therefore, offering an overview of
secondary sources is not only important to help illustrate what they offer directly, but also, as
Thin describes, “more indirectly for what they reveal about the cultural processes and institutions
they are associated with” (p.42). In this next section I will describe each of the FGC-related
organizations and clinics, their connection to the goals of the study, and how they helped to
contribute to the primary data collection process. By doing so, the following section helps to
illustrate how my research evolved through interactions and exchanges with what Thin (2013)
describes as “knowledge producers” – organization directors and volunteers, clinicians, activists,
researchers, casual acquaintances – and engagement with the work they produce in relation to
CRS and FGC more broadly (p. 41).

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FGC-Related Organizations
I engaged with different FGC-related organizations and clinics in Canada and abroad in
order to develop a deeper understanding of the needs of survivors, service providers, advocates,
and other types of frontline workers with regards to CRS and FGC-related care more broadly. By
engaging with these various organizations and clinics they became instrumental not only in terms
of the insights that they provided, but also in terms of supporting the study goals – often both in
terms of simply believing in the aims and importance of the project as well as helping to
disseminate recruitment materials. These organizations included the End FGM Canada Network,
Women’s Health in Women’s Hands, Sahiyo: United Against Female Genital Cutting, Restore
FGM, and Tadwein Centre for Gender Studies. Each of these organizations and clinics have
established initiatives to improve the quality of care and support that survivors receive in Canada
and abroad through collaborative efforts between survivors, human rights activist, healthcare
professionals, researchers, social workers, educators, and writers.
The End FGM Canada Network
The End FGM Canada Network is an organization that seeks to bring an end to FGC by
way of education, awareness, and prevention efforts. In addition to increasing the number of
supports available for FGC survivors, the organization also engages with professionals to offer
trauma-informed culturally sensitive training and tools. Sessions developed for healthcare
professionals are intended to improve providers’ understanding and competency around FGCrelated care in order to prevent instances of discrimination and stigmatization that many
survivors face in their healthcare encounters.
My volunteer experience with the End FGM Canada Network began in the fall of 2021. I
reached out to express my interest in the organization’s purpose and initiatives and to inquire

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about volunteer opportunities. During this period, the End FGM Canada Network was in the
process of launching several different projects including their Joining Hands Project and Miss
Klitty. Funded by the Canadian Department of Women and Gender Equality Canada (WAGE),
The Joining Hands Project was created to help develop systems of support for women and girls
living in Canada that may be at risk of FGM/C as well as survivors. The Joining Hands Project
takes a culturally sensitive and trauma-informed approach in their online training modules,
which were developed for Canadian professional who work in FGM/C-impacted fields such as
medicine, mental health, education, social work, and law enforcement (End FGM Canada
Network).
The End FGM Canada Network’s Miss Klitty Project was developed to help normalize
discussions around the female body – particularly in terms of female sexual anatomy. By
normalizing discussions around female sexual anatomy, it was the organization’s intent to help
remove the shame and stigma that is often associated with female genitalia. To accomplish this,
the End FGM Canada Network’s Digital Communications Officer created a cartoon depiction of
an anatomically correct clitoris. The clitoris cartoon, Miss Klitty, would be depicted as cute,
colourful, and confident. My involvement in this project took place in the very early stages
where I would meet virtually with the organization’s directors, digital communications officer,
and other volunteers to discuss how best to launch the organization’s new global goodwill
ambassador. In order to share Miss Klitty’s message far and wide, two methods of creative
distribution were developed. Firstly, one could make their own Miss Klitty by following the End
FGM Canada Network’s sewing pattern with instructions. The purpose of this sewing pattern
was not only to create a fun and interactive way to share Miss Klitty’s important message, but
also to give individuals the opportunity to create their own unique Miss Klitty that best

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represented their personality. Secondly, individuals were also encouraged to colour their own
Miss Klitty with the help of the End FGM Canada Network’s colouring pages. The Miss Klitty
colouring pages depicted a smiling Miss Klitty topped with a crown and a heart illustration
situated in the centre of cartoon ambassador’s chest. Surrounding Miss Klitty was positive
messaging such as “born perfect”, “I am unique”, and “protect me” printed between smaller
depictions of anatomically correct clitorises. The colouring pages offered another creative outlet
to help celebrate and appreciate one’s own clitoris. To help distribute Miss Klitty’s message
further, each of these interactive materials were tagged with the End FGM Canada Network’s
social media accounts and relevant hashtags so users could share and post their own Miss Klitty
creations.
During this period as a volunteer for the End FGM Canada Network, I was also asked to
participate in their annual conference in recognition of the International Day of Zero Tolerance
for Female Genital Mutilation on February 6th. This conference was the organization’s first ever
two-day conference which was held virtually on both February 6th and 7th 2024. My participation
in this conference was two-fold – I was asked to both moderate a panel and participate as a
research panelist in their Research Panel titled, “Exploring FGM/C Research in Canada and
Abroad”. This allowed me the opportunity to not only share about my own research, preliminary
findings, and participant recruitment materials, but also gave me the chance to connect with other
researchers in the field of FGC-research and engage in meaningful discussions regarding the
future of FGC research in Canada and abroad.
In terms of participating in the study’s recruitment efforts, the End FGM Canada
Network helped to circulate recruitment materials via their organization’s email list serve,
Instagram page, and quarterly newsletter. Additionally, the organization’s director helped to

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connect me with survivors that were able to review the study’s online survey prior to
dissemination.
Sahiyo: United Against Female Genital Cutting
Sahiyo: United Against Female Genital Cutting (Sahiyo) advocates for the rights of girls
and women against the continuation of FGC and is one of the largest FGC-related nongovernmental organizations in the United States. Established in 2015, Sahiyo’s initial focus was
on the Dawoodi Bohra community in India, but the organization has since branched out to not
only include other Asian communities that are affected by FGC, but also other FGC-affected
communities more globally. Sahiyo employs a committed team of activists, advocates,
researchers, writers, and more – all of whom contribute their expertise towards supporting the
organization’s various programs, educational campaigns, community outreach initiatives, and
international FGC research projects.
I began volunteering with Sahiyo in February 2023. During this period, I connected with
the organization’s Communications Coordinator and Research Coordinator. After several
meetings to finalize our shared memorandum of understanding it was decided that I would write
blogs for Sahiyo in exchange for the organization to help distribute the study’s recruitment
materials. Sahiyo’s Blog Platform helps to highlight survivors’ FGC stories, FGC-related news
articles, FGC-research projects, and more. During this period, I published four blogs with
Sahiyo, which included: ‘Exploring Canadian Physician’s Experiences Providing FGC-Related
Care’, ‘Psychosexual Care for FGM/C Survivors: An Interview with Dr. Reham Awwad’,
‘FGM/C Sexual Education and Prevention: An Interview with Dr. Reham Awwad’, and ‘The
African Women’s Clinic: An Interview with Australia’s Only FGM/C Clinic’.

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In terms of participating in the study’s recruitment efforts, Sahiyo was instrumental in
circulating the study’s recruitment materials via the organization’s members email list serve,
social media pages (Facebook and Instagram), blog postings, and monthly newsletter.
Women’s Health in Women’s Hands
Women’s Health in Women’s Hands (WHIWH) is a Toronto-based Community Health
Centre that specializes in the care of racialized women. WHIWH’s excellent team of physicians,
nurses, counsellors, community outreach workers, and more have contributed to the centre’s
reputation as a safe and accessible space for racialized women to receive quality care. WHIWH
offers a wide range of health services, such as pre and postnatal care programs, mental health
support and counselling, HIV-AIDS prevention education, and female genital mutilation/cutting
(FGM/C) projects like Flourish.
Launching as a collaborative community-based project to support survivors, Flourish was
established in 2018 as the product of nearly 25 years of WHIWH’s advocacy work in FGM/C.
According to the Flourish webpage, “using arts-based workshops and advocacy initiatives,
Flourish engaged survivors, promoted a framework for compassionate service delivery, and
improved dignified and appropriate healthcare” (Flourish Communities Collaborating to Address
FGM). To help improve the access and delivery of services for survivors in Canada, Flourish
developed an online access map to help connect survivors to safe and reliable services. The map
allows users to filter by province, service, and/or type of violence experienced (e.g., female
genital mutilation/cutting, domestic violence, sexual violence, human trafficking, etc.). For
instance, survivors looking to find clinics that offer clitoral restoration surgery can simply select
the “Reconstructive Surgery” option and can filter their selections – directing them to two
specialized Canadian clinics: Sensolia and Lotus Obstetrics and Gynecology.

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I first contacted WHIWH in February 2023 after learning more about the clinic’s Flourish
project during a presentation by the project’s coordinator in the End FGM Canada Network’s
annual conference on February 6th, 2023, for the International Day of Zero Tolerance of Female
Genital Mutilation. After meeting with the project’s coordinator to learn more about the project
and share about my study, it was decided that in exchange for distributing the study’s recruitment
materials that I would share any relevant insights from my Physician’s Forum with the project
coordinator that may prove helpful in the development of their Access Map. WHIWH helped to
circulate the study’s recruitment materials via their social media accounts (i.e., Instagram) and
through their email listserv.
Restore FGM
I first reached out to Restore in February 2023 after coming across an Aljazeera article
published on March 25, 2022, titled, ‘‘Starting Over’: FGM Clinic gives hope to traumatised
Egyptians’. After several unsuccessful attempts of connecting with other Canadian healthcare
clinics and professionals, FGC researchers, and FGC-related organizations, I began to expand
my search for experts in the field of FGC restorative procedures more globally – particularly
those who were taking a uniquely multidisciplinary approach to FGC-related care. My thought in
doing so was that I would not only be able to engage with more experts in this field, but that I
could also learn what was working successfully internationally – particularly in countries with
higher prevalence rates – that may be helpful to implement here in Canada given the procedure’s
more recent introduction in Canadian healthcare services.
Restore FGM is Egypt’s first multidisciplinary clinic for FGC survivors located in the
bustling city of Cairo. Still today, Egypt maintains some of the highest rates of FGC amongst
other high prevalence-rate countries on the globe with a rate of 87.2% for women and girls aged

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between 15 and 49 (FGM/C Research Initiative). According to FGM/C Research Initiative, an
initiative hosted by Orchid Project, “with a population of nearly 95 million, Egypt has the
greatest number of women and girls who have experienced FGM/C of any country in the world”.
To further add to these numbers, Egypt has also experienced an influx of refugees in recent years
from countries with similarly high rates of prevalence. For example, since April 2023, Egypt has
received nearly 450,000 Sudanese refugees escaping conflict, many of whom are women and
girls who have either undergone FGC or are at risk.
In terms of FGC, Sudan shares similar prevalence rates to Egypt with approximately
86.6% of women and girls experiencing FGC (FGM/C Research Initiative). However, the type of
cutting differs from that which is found in Sudan where infibulation is the “type” of cutting most
commonly practiced compared to Egypt where the preferred methods of cutting fall under the
WHO’s categorization of “Type I” and “Type II”. Although the types of cutting are different, the
preferred agents of cutting are largely similar. For example, Egypt is the most medicalized
country in the world when it comes to performing FGC with 78.4% of incidences being carried
out by healthcare professionals (FGM/C Research Initiative). Cutters in Sudan are similar to
Egypt in that approximately ¾ of incidences are performed by either nurses, midwives, or other
types of medical professionals (FGM/C Research Initiative). Information about Egypt’s
prevalence rates and contributing factors to their rise in numbers are important because they help
to offer insights into the specific needs of survivors visiting Restore and accessing their services.
Since the initial outreach period in 2023, Dr. Awwad and I kept in touch – sharing
updates if and when relevant. For instance, I interviewed Dr. Awwad for two of my blog
postings for Sahiyo to help raise awareness about their work across North American audiences.
Eventually I was able to meet Dr. Awwad in person by flying to Cairo, Egypt the following year

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in February 2024 to visit Restore in-person. When I arrived at the clinic I was greeted by Dr.
Awwad, Dr. Seifeldin, and a visiting medical student from the United States – all of whom had
just arrived back in Cairo the night before following a conference in Geneva moderated by Dr.
Seifeldin. The team’s energy was palpable – feeling rejuvenated in their efforts to expand clinic
operations, initiate new projects, and publish ongoing works that could revolutionize FGCrelated care and offer non-invasive alternatives to CRS.
Co-founded by aesthetic and reconstructive surgeon Dr. Reham Awwad, and
urogynecologist and aesthetic gynecologist, Dr. Amr Seifeldin, Restore opened their doors in
June 2020 – offering a patient-centered approach to health care, where every FGC survivor’s
treatment plan was uniquely tailored to meet their individual needs. Clinicians at Restore offer
several different treatment options to patients, but what makes Restore multifaceted is their
emphasis on non-surgical interventions and helping survivors by prioritizing their psychosexual
health and sexual education first and foremost.
Restore offers survivors a number of different surgical and non-surgical treatment
options, ranging from clitoral reconstructive surgery to regenerative and functional gynecology
to platelet rich plasma (PRP) injections into specific sites of the genitalia. As pioneers in this
field, Dr. Awwad and Dr. Seifeldin were invaluable in terms of helping me to achieve a deeper
understanding of the challenges and triumphs of running a multidisciplinary FGC-clinic –
especially one that opened in the height of the COVID-19 pandemic. Through our meetings and
our conversations, I became increasingly aware of some of the difficulties physicians encounter
when it comes to offering this type of specialized care. Despite their ground-breaking work and
an overwhelming desire for the services they provided, clinicians continued to encounter
financial and administrative barriers that mirrored those experienced by Canadian practitioners.

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Tadwein Center for Gender Studies (Tadwein)
I first learned of Tadwein during one of my meetings with Dr. Awwad where she had
shared about their recent collaboration to help develop an FGC-prevention campaign with
messaging targeted towards men. Tadwein was first established in 2014 with the goal of
promoting gender equality in Egypt. Since its foundation, Tadwein has consistently produced
some of the best research in Egypt around gender-based violence interventions. Tadwein has
developed several different campaigns including: ‘Don’t Touch Me’ – a campaign addressing
incidents of child sexual abuse, ‘I Have my Period’– a campaign in recognition of World
Menstrual Hygiene Day, ‘My Pain is Real’ – a campaign to support women in Egypt and abroad
who have experienced medical discrimination, ‘Slayed By Harassment’ – a campaign that calls
attention to the high rates of sexual harassment that women in Egypt experience, and ‘Her Body
is not Yours’ – a campaign held during the 16 Days of Activism Against Gender-Based Violence
(GBV) to combat gender-based violence worldwide.
In terms of FGC-related campaigns, Tadwein has created the ‘She is Intact’ Campaign
and ‘Endless Pain’ Campaign, both of which are in acknowledgment of June 14th – Egypt’s
national day for the elimination of female genital mutilation along with ‘Stop the Medicalization
of FGM’ to denounce the harm caused by medical professionals who participate in cutting and
“Say No To FGM” Campaign for the International Day of Zero Tolerance for FGM.
When speaking about their FGC-related campaigns, Tadwein employee, Layla5,
emphasized the importance of a unified message. In order to achieve this unified message, it is
crucial that there is no religious or medical content. The medical aspect was of special interest
given the fact that the majority Western FGC-related organizations and clinicians rely on

5

A pseudonym was assigned to protect the employee’s privacy.

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emphasizing the medical health complications associated with different forms of cutting to
encourage practitioners to abandon the practice. However, by emphasizing these health
complications, associates of Tadwein have instead found that rather than influencing women to
reject FGC practices, it (unintentionally) encourages women to make a shift in the “type” of
cutting they perform. Layla offered an example of this shift with the recent influx of Sudanese
women who most commonly practice infibulation – here Layla noted that when women were
made aware of the associated health complications of infibulation upon arrival in Egypt, that
they would shift to a form of cutting that emphasized fewer health complications, such as the
WHO’s categorization of Type 1 or Type 2 instead of abandoning the practice altogether.
Tadwein works hard to tackle issues impacting women and girls in Egypt, such as
femicide, child marriage, and FGC and tried to highlight how such issues are often linked –
increasing during times of conflict where decreases in security, education, and economic
prosperity lead to higher rates of gender-based violence. Like most FGC-related organizations,
Tadwein is reliant on outside funding and receives most of their financial support from
international organizations and governmental bodies that promote gender equality. Therefore,
when it comes time to “package” their various programs it is common for Tadwein to organize
them together. By doing so, it is not only cost effective for them as a non-for-profit organization,
but also helps to highlight the interconnectedness of femicide, child marriage, and FGC under the
overarching theme of gender-based violence (GBV).
Discussions with Egyptian healthcare providers and FGC-related organization employees
offered a turning point in the way I conceived my research problem. The challenges highlighted
by these groups provided invaluable comparative insights around access to FGC-related supports
and services for survivors, roadblocks in financing FGC-related care, and difficulties in sourcing

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support for community-led projects and initiatives – each of which were observed in Canada.
Therefore, by looking outside of Canada it helped me to better understand what was happening
within it – allowing for a more well-rounded perspective of the complex factors that impact
Canadian physicians and survivors in the Canadian diaspora when it comes to CRS and FGCrelated care more broadly.
This review of several FGC-related organizations and clinics, helped not only identify
how the recruitment materials for the study’s primary data collection methods were distributed
and circulated, but also offered insights which further highlight the complexity of the study’s
research problem – emphasizing a “close dependence” of several key factors (de Figueiredo,
2018, p. 16). The focus on this complex interconnectedness, is similarly linked to discussions on
primary modes of data collection, which as Thin (2014) describes, “must always be inspired and
informed by what we have learned from other sources” (p.39). Therefore, by outlining what was
learned from FGC-related organizations and clinics – largely through their webpages, reports,
initiatives, and workshops – these secondary sources help to inform the following section, which
focuses on participant sampling and primary data collection. This section is broken down by
demographic – outlining the target population, expanding on recruitment efforts, and methods of
data collection for each group.

Participant Sampling and Primary Data Collection
Survivor Demographic and Survey Component
As a recent reparative option for survivors in Canada, it was important for me to develop
a deeper understanding as to why survivors in Canada were interested in CRS, what they hoped

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to achieve by having the surgery, and what their post-surgical outcomes were (if they had
undergone CRS) given the limited data available particularly within the Canadian context.
An online survey was chosen as the desired method of data collection for this demographic to
reach as many survivors as possible who would be interested in sharing their experiences and
opinions around CRS – especially those who had no desire for a sit-down interview – whether
due to personal time constraints or a lack of comfortability around sharing their thoughts inperson.
According to Creswell and Poth (2016), “online data collection helps create a
nonthreatening and comfortable environment and provides greater ease for participants
discussing sensitive issues” (p.159). Braun et al. (2021) highlight this quality of “felt anonymity”
within online surveys that can increase perspective participants sense of comfortability (p.7).
Here “felt” is emphasized because, technologically speaking, factors like IP addresses may
prevent online surveys from being classified as entirely anonymous (Braun et al. 2021). Despite
not being entirely anonymous, that does not prevent online survey users from feeling completely
anonymous – a feeling which can encourage participants to be more open in what they choose to
share (Braun et al. 2021). Due to the personal nature of CRS and FGC more broadly, it was
important to me to offer a secure and accessible method of participation that would offer
participants that sense of anonymity.
In order to further expand the pool of qualifying participants, the categories for survey
participants were diversified to include survivors who had undergone CRS (with no limit on the
amount of time that had passed since the surgery was performed); survivors who, after
counselling, decided not to move forward with CRS; survivors who were denied CRS; and
survivors who were in the early stages of deciding whether or not to undergo CRS. Therefore,

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employing a survey helped to improve participant accessibility to participate in the study while
also reaching a greater number of potential participants.
An initial skeleton survey (see Appendix A) was developed, which included
demographic questions (e.g., current age, sociocultural background, age, and location of cutting,
and country of origin); ranking questions to identify motivations for undergoing CRS (e.g., pain
relief, sex-life enhancement, and body image); and a combination of matrix and open-ended
questions to determine survivors’ experiences and postoperative outcomes (e.g., what were the
postoperative functional outcomes, did the surgery meet expectations, in what ways have their
lives improved following CRS, and how have their views on CRS changed since migrating to
Canada).
In Braun et al.’s article on online surveys as qualitative research tools, they emphasize the
role and relevancy of open-ended questions in online surveys. Braun et al. (2021) argue, “that
qualitative survey datasets can provide richness and depth, when viewed in their entirety, even if
individual responses might themselves be brief” (p.3). As noted above, the use of online surveys
not only provides a level of flexibility, accessibility, and felt anonymity, but also, with the
inclusion of open-ended questions, can help to capture the personal experiences and views of
participants, which is well aligned with my feminist methodological approach.
A meeting to review the skeleton survey was organized with a survivor to incorporate the
insights, suggestions, and recommendations from FGC community members in order to ensure
that the survey questions were reflective of the realities and concerns of participants. This
collaborative construction of the qualitative survey component aligned with the feminist
informed research methodologies which underpin this study’s methods section. By including

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participant community members in the research design phase this helped to ensure that the voices
of survivors were at the centre of this research process (Liu, 2025). The compensation for this
meeting was $50. The review took place over Zoom, where the community member reviewer
and I met to go over the survey skeleton for feedback, recommendations, and suggested edits.
The community member was instrumental in providing valuable insights to help improve the
proposed questions. The review was focused on inclusive terminology, accessible language, and
improving the overall flow and clarity of the online survey. Following this discussion, I
incorporated the feedback received and made the recommended changes to the survey skeleton.
Once the changes were made, I sent the survey back to the community member reviewer for any
final edits where we confirmed that the survey was ready for dissemination. The survey
questions were then organized into SurveyMonkey and the associated survey link and QR code
were inserted into the online survey recruitment materials.
The aims identified in the survey recruitment materials were as follows: to develop a
greater understanding of survivor’s interests, motivations, and/or expectations in electing to
undergo CRS, to identify how well a survivor’s surgical outcomes meet their initial expectations,
to improve the referral process for survivors who wish to undergo CRS, and to highlight the
importance of quality care for survivors in Canada. Survey recruitment materials included
posters, PDFs, and images. These materials were shared via email, blog postings,
organization newsletters, social networking forums, and Instagram story and grid posts
(see Appendices B-G). Organizations such as the End FGM Canada Network, Sahiyo: United
Against Female Genital Mutilation, and Women’s Health in Women’s Hands were instrumental
in the sharing of recruitment materials. In addition to these methods of dissemination,

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recruitment materials were also shared with participating physicians, advertised during
conference participations, and linked in forum-based social networking sites like Reddit.
Six survivors completed the online qualitative survey. With this emphasis on survivors,
this method of data collection aligned with my feminist-informed research methodology, as it
employed an individual-centered approach whereby the experiences and voices of participants
were prioritized (Winfield, 2024). Of the six survivors who completed the online qualitative
survey, two had undergone CRS, three were interested in undergoing CRS, and one was not
interested in undergoing CRS. Pseudonyms have been assigned to each of the online qualitative
survey participants. Below is a description of each of the survey participants.
Dela
Dela is between the ages of 25 and 34, married, and has completed some graduate-level
education. Of the different types of FGC, Dela stated that Type 2 (the partial or total removal of
the clitoral glans and labia minora – with or without the labia majora) most accurately aligned
with the type of cutting she experienced. In terms of CRS, Dela first heard about the surgical
procedure from her obstetrician and gynecologist (OBGYN). Despite learning about the
procedure and expressing interest in it, Dela has yet to undergo CRS or do any further research
into the procedure. However, according to Dela, her interest in CRS stems from her desire to
“get their clitoris back as it was removed”.
Nadine
Nadine is between the ages of 25 and 34, married, and has completed college/university.
Of the different types of FGC, Nadine stated that Type 2 (the partial or total removal of the
clitoral glans and labia minora – with or without the labia majora) most accurately aligned with

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the type of cutting she experienced. Nadine is one of two survey participants to undergo CRS.
For Nadine, the decision to undergo CRS took 1-2 years to make.
Chelsea
Chelsea is between the ages of 25 and 34, single, and never married. Chelsea was born in
Toronto and has completed college/university. Of the different types of cutting, Chelsea most
accurately aligns with Type 1 (the partial or total removal of the clitoral glans and/or the
prepuce/clitoral hood). When it comes to CRS, Chelsea first heard about it online; however, she
is not interested in undergoing the procedure. When asked why she was not interested in CRS,
Chelsea stated that it was due to fact that “only the clitoral hood was removed” and she has not
personally experienced any impacts that would warrant surgery.
Marie
Marie was born in Somalia and is between the ages of 19 and 24. Marie is single – nevermarried and has completed some college/university. Of the different types of cutting, Marie most
accurately aligns with Type 2 (the partial or total removal of the clitoral glans and labia minora –
with or without the labia majora). Marie first learned about CRS through the social media app
TikTok. Marie has not yet undergone CRS but has expressed interest doing so. When looking for
more information about CRS, Marie has relied on other peoples’ experiences in addition to
online sources like Google and YouTube. Marie’s interest in CRS stems from her negative
experiences in undergoing FGC, which according to Marie, left her feeling mutilated, lied to, and
incomplete.
Lauren
Lauren is between the ages of 35 and 44, single/never-married, and has completed
graduate-level education. In terms of cutting, Lauren most accurately identifies with Type 1 (the

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partial or total removal of the clitoral glans and/or the prepuce/clitoral hood). Lauren expressed
an interest in undergoing CRS. This interest stems from Lauren’s desire for improved sensitivity
as she stated she currently has none. When Lauren first started looking for information about
CRS, she would look online on Reddit.
Aisha
Aisha was born in Somalia and is between the ages 35-44 years old. Aisha is married and
has completed college/university. Of the different types of FGC, Aisha’s experience most
accurately aligns with Type 3 (infibulation – the narrowing of the vaginal opening through the
creation of a covering seal. Formed by the cutting and repositioning of the labia minora, labia
majora, and removal of the clitoral prepuce/clitoral hood and glans). Aisha is the second
participant to undergo CRS – a decision which took her over 5 years to make. Aisha expressed
that her experience of living with FGC had not been good, which influenced her decision to
undergo CRS along with the fact that she felt that all her glans had been removed. Aisha was
also interested in CRS to help alleviate pain she was experiencing from complications of her
cutting and for increased clitoral stimulation. In terms of which areas Aisha experienced the most
improvement, Aisha noted pain relief and body image. Overall, Aisha was satisfied with the
referral process and the level of support she received following surgery; however, when it came
to the surgery itself, Aisha was left dissatisfied with the recovery process and her post operative
outcomes.
Physician Demographic and Data Collection
Through my previous study on the reproductive healthcare of immigrant women living in
Canada who had previously experienced FGC, I had established working relationships with

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various healthcare providers who had exhibited an expertise in FGC-related care. Although these
providers were familiar with the specificities of FGC-related care, only one of those previous
informants was trained in the surgical procedure for which this study intended to explore. As a
result, I began online searches for physicians who had been referenced in relation to CRS in
Canada. Due to the recent introduction of this surgical technique in Canada there were very few
names to appear in the search – limiting the scope of potential healthcare participants.
Purposeful sampling technique was used in identifying participants to take part in the
Physicians’ Forum focus group. Participants were identified via online searches and selected
based on their skills and expertise in the realm of FGC-related care – particularly in terms of
their knowledge of restorative procedures. Participants were contacted via their public email
addresses and/or professional website contact information and asked to take part in the
Physicians’ Forum focus group discussion following an information gathering phone call. I
remained in contact with physicians throughout the data collection phase – keeping in touch and
slowly building a rapport over several months.
In December 2023, after securing a date and time suitable for all participants, I held the
Physician’s Forum focus group discussion with 3 practicing physicians. Each participant had
professional experience providing FGC-related care in Canada and was trained in restorative
surgical techniques. The selection of participants offered a broad representation of FGC-related
care insights nation-wide with physicians based in Alberta, Ontario, and Québec. In line with the
Research Ethics Board (REB) protocols and recommendations, physicians were required to
provide their consent in advance of participating in this study’s focus group discussion.
Physicians who consented in the study were offered a series of options in terms of identification
in the study’s write up, which included the option for participants to choose their own

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pseudonym, have a pseudonym assigned, or choose their own name. Participants identified their
preferences over a year after their initial focus group participation, which emphasized the
evolving nature of researcher-participant relationships and the importance of on-going consent.
According to Winfield (2024), this matter of on-going consent is foundational to strategies for
feminist and equity-oriented research. Here, each participant in this study made their choice
freely and independently and the document both reflects and respects their individual
preferences.
Dr. Cathy Flood
Dr. Flood is a Urogynecologist at the Lois Hole Hospital for Women at the Royal
Alexandra Hospital as well as a Professor in the Department of Obstetrics and Gynecology,
Faculty of Medicine and Dentistry at the University of Alberta in Edmonton, Alberta. Dr. Flood
has practiced medicine for over 30 years and has encountered many patients with FGC
throughout her medical career. Due to her experience providing care to FGC survivors, Dr. Flood
began teaching her medical students about FGC and has been doing so for quite some time.
Dr. Flood does not have an FGC-specific clinic in Edmonton, Alberta; however, as a
surgeon with a special interest in FGC-related care, she was trained in clitoral restoration under
Dr. Marci Bowers from California, USA. Despite performing CRS on several occasions, Dr.
Flood has since discontinued this surgical procedure as she does not believe the literature fully
supports the surgery’s claims at this time. Although Dr. Flood no longer performs CRS, she
remains open to referring survivors who are interested in undergoing CRS to clinicians in other
provinces.

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Dr. Angela Deane
Dr. Deane is an obstetrician and gynecologist based out of Toronto, Ontario. Dr. Deane
first learned about FGC during her time as a labour and delivery nurse. Since receiving her
medical degree, Dr. Deane’s interest in FGC-related care has continued and she has worked to
improve the healthcare experiences of survivors by way of education and implementing a
multidisciplinary approach to her practice.
In terms of CRS, Dr. Deane traveled to San Francisco, California to learn the clitoral
restoration surgical technique under Dr. Marci Bowers and joined two larger surgical missions
with Dr. Bowers to Kenya. Dr. Deane opened a clinic in Ontario where she offers care to
survivors. Currently, the clinic team is comprised of Dr. Deane and three of her colleagues who
are all Obstetricians and Gynecologists with the hopes of one day having a psychologist. On
average Dr. Deane sees two patients a week who have been affected by FGC.
Dr. E
Dr. E is a Gynecologist who specializes in Gynecologic Surgery an Aesthetic Medicine in
Québec. Dr. E’s clinic offers a variety of treatments including face and body, gynecological, and
aesthetic treatments. What sets Dr. E’s clinic apart from other women’s health or gynecology
clinics, is direct mention of FGC. When it comes to sexual health and wellness, Dr. E’s clinic
highlights that, “with great care and discretion, we will work with you to alleviate any social,
psychological, and physical pain you may be suffering from associated due to sexual
dysfunctions”. Included in this list of sexual dysfunctions is female genital mutilation/cutting.
Additionally, under Dr. E’s gynecological surgery offerings, vulvar aesthetic surgery is identified
as a potential corrective surgery for patients who may have experienced congenital
malformations after undergoing FGC.

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Dr. E first became interested in the topic of FGC in 2000 after she was contacted by a
team in Geneva and Brussels who were conducting a study on the sexual functioning of FGC
survivors. From a surgical perspective, Dr. E worked with reconstructive surgery of the vulva for
several malformation types during her pediatric and adolescent gynecology fellowship.
The Physicians’ Forum focus group discussion was approximately 1-hour long and took
place over Zoom via a recorded video call to account for the geographic distance between
providers. During the Physicians’ Forum, semi-structured questions were asked to generate
discussion (see Appendix H). Physician participants were encouraged to speak freely and openly
in a casual online setting. In Tritter and Landstad’s (2020) chapter on focus groups and their
application as a qualitative method of data collection within health science research, they
describe focus groups as, “a type of group interview but one in which the primary aim is to
promote interaction between the group members rather than to have each participant answer
every question” (p.58). This was precisely my aim in conducting a focus group with care
providers – to encourage open dialogue and communication between experts in the field.
Moreover, as the claims of the surgical outcomes from CRS continue to be debated amongst
healthcare professionals, a focus group approach would foster a space for different views and
opinions to be discussed in real time. Here my role was more so that of a moderator where I
helped to facilitate the discussion – learning more about their experiences providing FGC-related
care in Canada and identifying their process of decision-making in terms of referring survivors
for CRS. Therefore, this method of discussion, whereby participants were required to interact
with one another, was especially useful in terms of generating a more in-depth understanding of
key topics.

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The use of this qualitative data collection method was also in line with my feminist
informed research methodology and intersectional feminist informed theoretical framework.
Firstly, as a method of data collection, focus group formats help to empower participants to share
their own experiences and perspectives – prioritizing participant voices (Leavy, 2007; Spadacio
et al., 2024). According to Leavy (2007), this method of qualitative data collection “offers the
opportunity for conversation to move beyond generalized and public meanings to encourage
more intimate and private expressions” (p.149). By uplifting participant voices, this method
aligned with feminist informed research methodologies which seek to prioritize participant
voices. Additionally, a focus group format was also consistent with the collaborative nature of
feminist informed research methodology. For instance, according to Leavy (2007),
“collaboration exists on a continuum…there are various degrees and ways in which that
collaboration can occur” (p.169). Therefore, in terms of this open discussion forum setting, it
enabled participants to lead the discussion – thus accounting for a more collaborative role in the
production of knowledge.
The 1-hour long video recording of the Physicians’ Forum focus group discussion was
manually transcribed. Supplementary data collected by way of notes recorded during the focus
group were also typed and included alongside the detailed discussion transcription.

Data Analysis
The chosen method of analysis for data collected was thematic analysis. Thematic
analysis is especially relevant to this study’s aims as it focuses on identifying, analyzing, and
reporting themes or patterns within qualitative data, but what makes it most applicable is that it
moves beyond just counting words and towards a more dynamic search for underlying meanings

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and insights (Xu & Zammit, 2020). This description of the interpretative nature of thematic
analysis highlights this mode of analysis’ flexibility in application – particularly in studies which
draw from several data sources. Clarke and Braun emphasize this versatility when it comes to
analyzing different types of data and thematic analysis’ ability to identify larger patterns of
shared meaning across a wider range of data sources (Clarke & Braun, 2013; Xu & Zammit,
2020). This method of analysis was especially suitable given the variety of different forms of
data being analyzed for the purpose of this study including data from the physicians’ focus
group, survivor qualitative survey responses, and secondary data collected from FGC-related
organizations and online sources. In a paper on the development of complexity theory-informed
methodologies, Gear et al. (2022), argue that a complexity informed methodology and methods
“allow observation of the problem from multiple standpoints” (p.7). Therefore, by including
different standpoints it allowed me to produce a multilevel analysis across data collected from
several different primary and secondary sources – further accounting for the study’s complexity.
Similarly, as Riger and Sigurvinsdottir (2016) describe, “thematic analysis allows an
understanding of complexity and context-specific variation” (p.35). By employing a method of
analysis that can account for this study’s complexity, thematic analysis offers a more in-depth
understanding of the interconnections amongst individuals, community, and organizations.
Lastly, thematic analysis can also be applied “across a variety of different theoretical frameworks
and worldviews” (Riger & Sigurvinsdotter, 2016, p. p. 36) – further reinforcing its relevance to a
study which employs not only a complexity-informed approach, but rather a combination of
complementary theoretical perspectives. For example, in addition to aligning with the study’s
complexity lens, the qualitative method of thematic analysis is also well suited for intersectional
feminist approaches. For instance, Riger and Sigurvinsdottir state, “qualitative methods such as

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thematic analysis are also valued as a means of giving voice to “the other”, that is, of allowing
those traditionally unrepresented or underrepresented in research to present their viewpoints in
their own words, unhindered by predetermined response categories” (p.36). In order to perform a
thorough thematic analysis, Clarke and Braun identify six phases which include: familiarisation
with the data; coding; searching for themes (generating themes); reviewing themes;
defining and naming themes; and writing up (Clarke and Braun, 2013, p. 4). In this section I
describe my process of data analysis as it aligns with each of these six phases.
During my period of familiarisation with the data I implemented Creswell’s method of
reading and memoing (Creswell & Poth, 2016, p. 183). The practice of reading and memoing
occurs early in the data analysis stage as a means of exploring the data base (Creswell & Poth,
2016). During this period, I would repeatedly listen to the video and audio recording of the focus
group, review the transcript from the discussion, return to the survey and read through the openended responses, reflect on conversations, read through field journal entries, and make notes to
myself in the margins of the transcribed document.
After familiarizing myself with the data, I began the process of coding. Creswell and
Poth (2016) define the process of coding as, “aggregating the text or visual data into small
categories of information, seeking evidence for the code from different databases being used in
the study, and then assigning a label to the code” (p.184). Each time I came across a relevant
piece in the data set I would code it. This process of inclusivity in coding proved particularly
important in the early stages as it is much easier to refine and or discard codes later on rather
than attempting to begin from scratch and recode (Braun and Clarke, 2012, p. 61). According to
Braun and Clarke (2012), “codes can also go beyond participants’ meanings and provide an
interpretation about the data content…such interpretation or latent codes identify meanings that

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lie beneath the semantic surface of the data” (p.61). Therefore, as Braun and Clarke (2012)
describe, “codes will almost always be a mix of descriptive and interpretative” (p. 61). This
practice of coding, whereby I uncovered meanings beyond the semantic surface, allowed me to
begin identifying moments of resilience.
Following the process of coding, I began to generate themes. Within the context of
thematic analysis in qualitative research, Creswell and Poth (2016) define themes as, “broad
units of information that consist of several codes aggregated to form a common idea” (p. 186).
Here it is important to note that the generating of themes is an active process and not one where
“[themes] are passively waiting in the data to be found” (2016, p.9). During this period, I
searched for similarities in the coded data where I began to identify larger categories from a
collection of smaller codes. This stage was challenging due to the complexity at times as there
were instances where I would find an overlap of smaller codes across larger themes. However, as
Braun et al. suggests, moments of overlap are not unusual during this generative process and
may actually help to “provide a unifying framework for telling a coherent story about what is
going on in the data” (p.65). Therefore, it was not my intention to downplay the study’s
complexity by appearing to minimize it through the separation and generation of themes, as
moments of overlap continue to be present, and connections can still be made through this
unifying framework. This emphasis on connection is further highlighted by Braun and Clarke
(2012) who argue, “conclusions can and should be drawn from across the whole analysis…, so,
an analysis needs to make interconnections between themes and say something overall about the
data set” (p.67).
The reviewing of themes was a repetitive process where I returned to my data set and
reviewed my emerging themes alongside what I had previously coded and collected. According

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to Braun and Clarke, “this phase is essentially about quality checking” (2012, p. 65). During this
period of review, I asked myself critical questions to determine if I needed to make any changes
and to ensure I was identifying what was most important (Braun and Clarke, 2012). As part of
this review process, it was crucial that the themes accurately captured the content of what
participants were saying rather than simply describing questions that were asked (Braun and
Clarke, 2012). In Murray and Chamberlain’s review of qualitative health psychology theories
and methods, they note the appeal of qualitative methodologies for feminist researchers is an
emphasis on “giving voice to the subjective views of women and valuing them in their own
right” (2005, p.99). Therefore, this phase of review became a reflective practice to ensure that
the themes identified were what was important while also staying true to the participants’
experiences.
Following this review of the themes, I began the process of defining and naming them.
This stage is ultimately one of refinement where, according to Riger and Sigurvinsdottir (2016),
“the critical task here is to identify the central idea in each theme and provide a name of which
concisely captures that” (p.35). This was particularly important in terms of conveying my
interpretation of the data and its meaning to the reader (Braun & Clarke, 2012). In order to
ensure that these central ideas were captured accurately, several of the themes’ names were
drawn from the words of participants themselves. This process of defining and naming resulted
in four major themes and nine sub themes which included: politics of decision-making (anatomy,
complexity, and patient choice), storyline (trauma, learning, and healing), resources (survivors,
care providers, FGC organizations), and the Canadian issue.
When writing up the report, the selection of extracts from the physicians’ focus group,
the survivors’ qualitative survey responses, and secondary public data sources was done

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mindfully and intentionally. According to, Braun and Clarke (2012), “the extracts you select to
quote and analyze provide the structure for the analysis – the data narrative informing the reader
of your interpretation of the data and their meaning” (p.67). This concept of interpretation is
especially important when outlining the analysis. Braun and Clarke (2012) argue that the analysis
should move beyond the data – stating, “it does not just report words – it interprets them and
organizes them within a larger overarching conceptual framework” (p.67) - in this instance, the
data is then situated within the context of a combination of complementary theoretical
frameworks including complexity theory, intersectional feminist theory, and multisystemic
resilience in the study’s Discussion Chapter where the themes are explored in connection to these
perspectives and other scholarly work more broadly.

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Chapter 5 – Findings
This chapter will outline the study’s key findings. As discussed in the previous chapter,
thematic analysis was performed through which four major themes and nine corresponding subthemes were identified. The first major theme is the politics of decision-making (sub themes
include anatomy, complexity, and patient choice) which reveals how physicians identify
potential candidates for CRS, the complexity surrounding this decision-making process, and the
role and influence of patient choice. The second major theme is storyline (sub themes includes
trauma, learning, and healing) where survivors’ motivations for undergoing CRS are explored in
connection to the role of learning and its influence on survivors’ healing experiences. The third
major theme is resources (sub themes include survivors, care providers, and FGC organizations)
where individual, organizational, and professional challenges of affording and funding CRS and
its related treatment options are investigated. Lastly, the fourth and final major theme is an
examination into the Canadian issue where the focus is on the increased demand for specialized
healthcare services and what situating FGC as a Canadian issue means for the future of CRS and
FGC-related care in Canada.
Politics of Decision-making
“It’s not me who chooses”
With the recent introduction of clitoral restoration surgery (CRS) in Canada, a key
component to the study’s aims was in understanding what types of FGC-related complications
must survivors present with in order to qualify for a surgical referral; how providers identify
potential candidates for surgery; and how do physicians determine who will (or will not) benefit
from this procedure? To answer these questions, providers who participated in the Physicians’
Discussion Forum focus group were asked about their decision-making process. When it comes

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to the matter of medical decision making within the context of CRS, three sub-themes emerged:
anatomy, complexity, and patient choice. Using excerpts from the physicians’ focus group
discussion, survivors qualitative survey responses, and secondary data these three sub-themes
will be explored.
Anatomy
When investigating the types of FGC-related health complications survivors must present
with in order to qualify for surgical referral, it makes sense to first consider anatomy. The clitoris
is a much larger sexual organ than is commonly realized with most erectile structures remaining
in place after cutting. Therefore, depending on the type of cutting experienced, some survivors
are unlikely to benefit from surgical intervention. For instance, if a survivor has not experienced
any disruptive alterations to their sexual anatomy and are maintaining sexually satisfying
relationships then it would not offer sufficient justification for them to undergo CRS.
Anatomically speaking, in order for a survivor to qualify for CRS, they would have to
present in clinic with some form of FGC from which they have experienced complications that
are negatively impacting their health and well-being. Dr. Deane explained how she makes that
determination:
In my practice, those that are candidates for clitoral reconstruction typically don’t have a
visible clitoral glans…so we start by identifying what anatomy is present.
An example of this was offered by a survivor who participated in the survey component
and expressed they were not interested in CRS because “only the hood was removed” and they
have not personally experienced any negative health complications from this removal. According
to Santos-Longhurst from Health Line, “the clitoral hood is a fold of skin that surrounds and
protects the glans clitoris” (para. 1). The clitoral hood functions more as a protective covering –
offering a varied level of glans protection depending on an individual’s anatomy – ranging from

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complete, partial, to none at all. Therefore, in this scenario, as described by the respondent,
despite having experienced FGC, there would be no benefit to this particular survivor in
undergoing CRS based on their anatomy and the type of cutting they have experienced.
Similarly, when discussing other instances where undergoing CRS might not be in the
best interest for the survivor, Dr. Flood argued,
I think surgery is very rarely needed and if they want restoration surgery what does that
even mean? And what will it accomplish? There’s so much other sexual dysfunction and
emotional trauma.
Here Dr. Flood highlights how the physical impact on a survivor’s anatomy alone does
not offer enough justification to move forward with CRS and that it is important for providers to
consider additional factors that may be contributing negatively to a survivor’s overall sexual
function and satisfaction and/or psychological and emotional well-being. Dr. Deane explained
further:
There can be a lot of emphasis on the missing anatomy and so it is just as important to
identify healthy parts of their [survivors’] normal anatomy. Not everybody is a candidate
for surgery. I’m finding patients often want us to have a consultation about their anatomy
and an opportunity to share their experience. But there is a subset that do want surgery,
some that want deinfibulation.
In an interview for Sahiyo: United Against Female Genital Cutting, Dr. Awwad reiterated
similar points to Canadian physicians regarding consultations with survivors about their
anatomy. Dr. Awwad stated, “it’s an uncomfortable part of their body that they don’t feel the
same about as they do with the rest of their body. At least that’s the impression that I’ve gotten
from the women I’ve spoken to” (Leone, 2023).
As discussed in this section, we can see how the appearance and functionality of a
survivor’s sexual anatomy can be a contributing factor in a physician’s overall decision-making

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process when it comes to identifying potential candidates for CRS; however, it is just the first of
several factors that physicians must consider when supporting a survivor on their path to healing.
Complexity
A physician’s process of evaluation can be challenging when a survivor presents with
complex needs. This matter of complexity is raised frequently amongst surgeons trained in CRS
and it is a topic that was brought up during the Physicians’ Forum focus group discussion. When
describing the surgical techniques required to perform CRS it is often framed as a rather straightforward procedure – one which is relatively uncomplicated. However, the physical
transformation via the surgery is just one aspect of a survivor’s overall healing process – one that
is exceptionally layered and must be taken into consideration when referring potential candidates
for CRS. In addition to any physical changes, CRS can also impact a survivor’s psychological,
sexual, and social well-being, thus making the decision to perform CRS much more complex
than previously conceived. Dr. Deane explained:
Yes, there’s surgical technique and expertise that’s involved; however, greater
complexity lies in establishing the right candidates for surgery and the great importance
of pre- and post-op counseling.
In order to address this complexity, it has become common practice for providers to meet
with survivors interested in CRS for several consultations prior to any decisions being made on
whether or not surgery would be the most appropriate treatment option. Most commonly,
physicians will recommend that survivors attend a minimum of five consultations. Dr. E
described what a typical visit looks like for a perspective candidate who wants CRS:
And for the surgery it’s the same. We do 5 visits. But with the psychologist – not only
with me. So, the first visit is really more telling their story, anatomy, a lot of sex ed. And
then we do more psychological work. But they have to go through the psychological
work to get to the surgery.

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During these consultations there is a greater emphasis on the survivor’s experience, their
background, and their level of sexual education. Such an emphasis was similarly found amongst
clinicians at Restore. For instance, in an interview with Dr. Awwad she noted her desire to
provide her patients with as much information as possible and stated, “I usually like to explain
specifically about the clitoris – the anatomy of it, how it works. We talk about reaching orgasms,
how a woman reaches them, and the misconceptions that around vaginal orgasms versus clitoral”
(Leone, 2023). For Dr. Deane, during these visits the topic of surgery typically accounts for only
a fraction of the topics discussed throughout these initial consultations:
I emphasize surgery is not for everyone. We’re surgeons – of course we love to operate,
but this is your body and your story, and there are deeper layers of healing that surgery
cannot address. The follow up is so important, the lead up is so important – if there is
even going to be surgery. So, I really try and step back in my consultation and hear what
this patient is experiencing. Surgery is one aspect we might talk about.
Here Dr. Deane notes how she tries to take a step back in these consultations – allowing
survivors the space to express what it is they are looking for and what they are hoping to achieve.
Such statements help to highlight physician respondents’ emphasis on patient choice and patient
involvement in the development of their own treatment plan.
Patient choice
Medical decision-making frequently involves not just the physician, but also the patient.
This aspect of medical decision making was a common sub-theme amongst physician focus
group respondents and further illustrated by survivor qualitative survey responses in terms of
where survivors look for information to inform their own decision-making. When it comes to the
topic of CRS, it is common for survivors to have an idea of what they want prior to their first
clinic visit. Survivor respondents identified using different online sources like Google, YouTube,
TikTok, or Reddit to learn more about CRS, reaching out to those with personal experience, or

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contacting their obstetrician and gynecologist for more information. Here providers emphasized
the role of patient choice when it came to discussion of CRS. For example, Dr. Deane stated:
I find that it’s really from the needs of the patient. They actually say what they need and
want. Sometimes they come, you know, and they’re like, “I want this procedure” right?
But it is definitely an exploration of what is your issue? And then we’ll see if surgery
might be an option. But I really do focus as much as possible on the symptoms and what
their experience is because often a lot of it can come down to education.
Dr. Flood agreed:
I think being guided by what the patient wants is the best way to go.
This emphasis on the survivor’s needs and the influence of patient choice was also noted
by Dr. E, who stated:
It’s coming from where the patient is starting and what their needs are and what they’re
expressing that they want. It’s not me who chooses…except for the fact that they need to
go through the process to get surgery if that’s what they want.
The decision to move forward with undergoing CRS is deeply personal and survivors’
decisions can also be influenced by their own social and cultural contexts. When reflecting on
these impacts – particularly the role of family influence on patient decision-making, Dr. Flood
noted that she has had several individuals on a wait list for surgery that never followed through.
According to Dr. Flood,
People don’t even tell their parents, even though they’re in their twenties.
Due to the fact that a survivor’s choice to undergo CRS is often private and deeply
personal, it becomes ever more important for the provider to offer their knowledge and support
to ensure that the survivor is confident and comfortable in their decision to move forward with
surgery or not to move forward. For example, Dr. Deane described:
I’ll usually say we’re going to meet at least 5 times and this one is just about me meeting
you, and maybe we do an examination today, and maybe we learn a little bit more. But…

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I try to be like I’m here to support you in how[ever] I can support you with what I know
as a gynecologist.
As Dr. Deane explained, physicians use their medical expertise as gynecologists or
urogynecologists to help survivors in their own decision-making and offer support along the way.
It is not their intention to tell the survivor what they must do, particularly in instances of elective
surgery, but rather they offer survivors a safe space to share their experiences and express their
needs. By being receptive to survivors’ needs, providers can work alongside them to help curate
a treatment plan that will be most beneficial in helping them meet their desired health outcomes.
Here the role of physician, when it comes to providing this type of care, is not just a one-off
encounter or limited to that of a surgical expert, but rather involves a series of in-depth meetings
over an extended period of time. During this extended period, the physician takes on more of the
role of guide where they help survivors along as they navigate this complex process of decisionmaking – one which might not even include the decision to undergo CRS.
Storyline
“You need to heal your mind and your heart”
As part of this study, I have been interested in better understanding survivors’
motivations around CRS and identifying how survivors’ post operative outcomes aligned with
their initial expectations. Previous studies have highlighted pain relief, sex life enhancement,
identity recovery, and improved body image as some of the motivations expressed by FGC
survivors who wish to undergo CRS, and this study similarly found that survivors have identified
comparable motivations. But as this study progressed, what I have found in Canada is that
surgery (if and when appropriate) is but one part of a survivor’s story, and as noted above, it is a
story that might not even include CRS. In order to better explore this theme of storyline three

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sub-themes have emerged: trauma, healing, and learning. The following sub-themes will be
explored in that order.
Trauma
When survivors were asked what results they would hope to achieve in undergoing
clitoral restorative surgery, some responses were direct and focused on the anatomical such as,
“seeking improvements in clitoral sensitivity”. However, other responses spoke to the trauma
that is often associated with experiences of FGC:
“I was mutilated without my knowing. I was lied to. I don’t feel like my body is complete.”

“I want to get my clitoris back as it was removed completely without my consent at aged
10, when I was subjected to FGC.”

“To have [what] was cut off back. To feel fully complete. That I am normal.”
Each of these responses speak to the pain, sense of loss, and trauma that many survivors
experience as a result of FGC. It is often the experience of these difficult feelings that lead
survivors interested in restorative procedures on their journey in pursuit of healing. As discussed
in Chapter 2, individuals who experience some form of FGC may experience several health
complications. In addition to these physical health complications, survivors may also experience
negative psychological impacts related to having undergone FGC. These impacts can include
post-traumatic stress disorder, amnesia, anxiety, concerns around body image and gender
identify, depression, and mental blocks related to sexual intercourse that my result in difficulties
achieving orgasm (Schrijver et al., 2016, p.270). According to Dr. E,

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So many people [survivors] remember having it [FGC] done, and that hasn’t been
addressed…the trauma is real. I cannot count how many – it’s just so many of them
[survivors].
This issue of unaddressed trauma has influenced the way in which physicians formulate
intake questions for their prospective patient consultations. Physicians reported finding that their
patients’ memory of having undergone FGC and the associated trauma is rarely discussed prior
to these types of meetings. Some providers even noted the frequency in which a survivor’s first
time speaking openly about their experience occurs during their initial consult. For instance, Dr.
Deane explained:
One of my intake questions is “who in your life knows about this?” And it is very rare
that their sisters even know. Or [I’ll ask] “have you ever talked to your mom about this” –
no. And so, it’s trying to honor that privacy for them and their own journey, while
ensuring they have the support that they need to address their trauma. Some of them do
exceptionally well going through a surgical procedure and it is like an awakening – a new
beginning – and surgery is [a] defining moment.
Dr. Deane agrees with her colleagues stating that “there is so much to be said about the
trauma piece” and explains that it is the reason why she has incorporated a minimum of five
consultations for her patients before moving forward with surgery stating, “that’s really become
my practice”. In addition to this type of practice, the inclusion of some sort of sexual education
of one’s own sexual anatomy and physiology has become common place – accounting for a
learning piece of a survivor’s story of healing.
Learning
Dr. Seifeldin from Restore FGM argues, “many women mistakenly believe that sexual
dysfunction in women with FGM results from the cutting of sexual organs, for which no
treatment is available” (2016, p.1). This belief around sexual dysfunction is often the result of
mistruths perpetuated by health organizations who have falsely reported that FGC can result in
the total removal of the clitoris which, and as discussed in Chapter 2, this is simply not the case

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(Seifeldin, 2016). False beliefs surrounding the practice of FGC are ultimately compounded by a
limited understanding of one’s own sexual anatomy and physiology. For instance, when
discussing the topic of sexual education, Dr. Awwad stated, “they [survivors] don’t speak to their
families [about sex], they can’t speak to their friends…you’ll find that no one spoke to their
moms either and they kind of just figured it out on their own” (Leone, 2023). It is important to
note that this limited understanding is by no means the fault of the individual but is rather the
result of a series of medical, political, and cultural factors over decades that have contributed to a
poorer understanding of women’s bodies and women’s health on a global scale (Kline, 2010).
This reinforces the importance of learning and the role that sexual education ought to play in a
survivor’s story of healing.
In reiterating the importance of sexual education during the Physician’s Forum focus
group discussion, Dr. Flood explained:
We’re just leaning [about] clitoral anatomy or teaching clitoral anatomy. We never used
to teach before informing patients that, you know, they haven’t lost their clitoris. They’ve
lost their clitoris glans, even a basic thing like that, showing pictures of what a normal
vulva looks like or whatever “normal” is that there’s such a variation.
In addition to conversations around sexual anatomy – particularly clitoral anatomy,
physicians incorporate different learning tools in their practice ranging from illustrations to using
a hand-held mirror as shown in the introductory chapter to help familiarize the patient with their
own bodies. Another tool that physicians include in their teaching is the use of models or silicone
molds of female genitalia. When explaining why she uses models in her clinic, Dr. Flood stated:
I find [them] really helpful. They really help to show patients that you know they haven’t
lost what they thought they lost.

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Dr. E agreed:
I can’t count the number of patients that I’ve had in the last few years who said that they
had no orgasms, no sexual pleasure, no sex life because of their FGC and I examine
them, and their clitoris is normal, and I can see the external glans. Everything is fine.

For survivors, the realization that their clitoris is normal, or they have not lost what they
previously thought they had can be a precursor to healing – illustrating how learning can be a
part of a survivor’s treatment plan and overall story towards healing. In a discussion on how Dr.
E helps her patients navigate any scar tissue, Dr. E stated:
It’s more the education of how to stimulate it [the clitoris] and use a toy or vibrator to get
to stimulate your clitoris more than to actually treat the scar I find.
This example shows that despite having clitoral cutting, a survivor may still be able to
stimulate their clitoris and achieve orgasm when supported by a combination of proper guidance
and tools. Again, this helps to highlight the role of sexual education and learning along a
survivor’s recovery journey toward healing and showcase the variety of treatment options
available to survivors beyond the surgical variety.
Healing
There is often the perception amongst survivors that undergoing CRS will “fix” whatever
issue they are facing. Given the complexity of addressing unresolved trauma, breaking down
sexual anatomy, and learning the several causes for sexual dysfunction it may be disheartening to
find that CRS is not only not a “quick fix” but may not even be recommended for some survivors
depending on the particular needs they have expressed. For instance, in quoting American
gynecologists and surgeon, Dr. Marci Bowers, Dr. Deane stated:
I’ll give you new legs, but you need to learn how to walk again.

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This quote stresses the point that there is no “quick fix” and even with CRS, the surgery
may just be one piece of a survivor’s larger healing experience. While this initially may be a
disappointing realization, what providers try to emphasize is that healing is not linear and there
are many different avenues of recovery. Dr. Deane explained:
You need to heal your mind and your heart. Your body is one aspect of this [healing], and
it is so layered.
This emphasizes the assorted opportunities for healing along a survivor’s journey. When
psychotherapy and sexotherapy are offered, Dr. E finds that only 10% of survivors will actually
proceed with CRS. When offered proper care and follow up, providers find that survivors will
rarely need to go down the surgical route. While this offers insights into the various treatment
options available to survivors, it is important to also review the affordability of these types of
treatments.
Resources
“Getting those resources is the hard part”
The issue of resources, or more accurately, the issue of a lack of resources was
reoccurring. Survivors, FGC organization contributors, and care providers all experience the
impacts of limited financial resources and thus represent the three sub-themes of the larger
resources theme. For survivors, this is often in the form of being unable to afford the types of
care they may benefit from, such as intensive psychological counseling, sexotherapy, platelet
rich plasma injections (PRP shots), or surgical restoration procedures. For FGC organization
contributors, limited financial resources can impact the organization’s ability to support
survivors and can restrict their capacity for different community outreach initiatives. Lastly, for
care providers, a lack of financial resources can impact their ability to offer the type of care that
survivors may benefit from.

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Fortunately, in Canada we now have some healthcare providers who are not only trained
in CRS surgical techniques but have also developed an expertise in FGC-related care more
broadly, yet for survivors, this path to recovery is not without costs – most notably financial.
Barriers in access arise when we consider access not only in the sense that relevant and varied
services exist here in Canada, and are offered by competent service providers, but also in terms
of access as affordability of such treatments. As noted above, this issue of affordability is threefold and exists for survivors, organizations that support survivors, and care providers.
Survivors
For survivors as prospective CRS patients it is a matter of how they can afford the types
of services they might benefit from. As Dr. Deane expressed in her decision-making process,
survivors who wish to move forward with CRS are encouraged to undergo multiple sessions of
psychosexual counseling as part of their treatment plans. Dr. E points to the financial challenges
this can impose for survivors:
They can go private for sexology or for psychotherapy, but many of them don’t have
enough for rent for the month, so they won’t pay for a psychologist at $120 per week,
you know? And this is Montreal prices. The prices are even more in Toronto for a
psychologist.
Here in Canada, we are currently experiencing a cost-of-living crisis where most
Canadians are struggling to cover basic necessities like food and housing, which makes the
likelihood that one could afford costly psychological counselling appointments, ranging from
$100-$250 an hour for an appointment, unrealistic for one session let alone meeting the
minimum number of appointments needed over an extended period of time, which is required for
survivors who wish to undergone CRS. This was highlighted by Dr. Awwad who shared that
when costs are high, it is common for her patients to discontinue their therapy sessions

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prematurely when faced with financial constraints (Leone, 2023). In addition to counseling costs,
survivors must also cover the cost of CRS if they chose to do so.
This is unlike other FGC-specific procedures like deinfibulation, which is covered in
Canada. Dr. Deane explained:
There’s a de-infibulation code within the Ontario Physician fee guide, which is
significant in terms of recognition for care of those impacted by FGM/C. So, someone
along the way, has advocated for FGM/C care.
The example of de-infibulation shows what is possible when there is a public push for the
Ministry of Health to get a new code, because once there is a code for a procedure, people can
bill for it, and it becomes funded. Dr. Deane and her colleagues are trying to push for similar
momentum when it comes to covering the cost of CRS. However, in the meantime there has been
some creativity in minimizing costs for survivors under different related codes, such as those for
vulvar trauma or the removal of cysts for pain-related needs.
FGC Organizations
In terms of organizations that support survivors, the need for psychological supports for
survivors was highlighted in an email from the End FGM Network Canada in August 2024. In an
announcement regarding the launching of the organization’s health care modules for care
providers, End FGM Network Canada included a statement regarding a support fund for
survivors. The email stated,
Recently, we have seen a significant increase in FGM/C survivors seeking immediate
counseling support. Unfortunately, the number of requests has surpassed our current
financial resources. We kindly invite out members and supports to consider contributing
to our Survivors Fund. Your donations will directly help those in urgent need of

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counseling, ensuring they receive the essential care and support they deserve (End FGM
Canada Network, personal communication, August 11, 2024).
It is common for such organizations to allocate funds to support survivors; however,
when an organization struggles to afford basic operations, then their ability to provide support or
even participate in the facilitation of that support for survivors becomes limited.
In breaking down different dollar amounts, Sahiyo United Against Female Genital
Cutting’s donations webpage helps to showcase what work can be achieved by way of donation.
For instance, $50 can fund activist training, $75 can contribute towards the provision of
educational webinars for both advocates and front-line workers, and $100 can support survivors
to attend the organization’s digital storytelling workshops – workshops that Sahiyo states enables
survivors to “share their story and heal in a supportive group setting” (Sahiyo United Against
Female Genital Cutting). Additional efforts to afford to offer FGC-related care services include
packaging them alongside other initiatives as shared by Tadwein employee, Layla. By bundling
various initiatives together based on similarities in association with gender-based violence
(GBV) (e.g. FGC, femicide, child marriage, etc.), non-profit employees have found this method
to be cost effective when funding for different projects is scarce.
Although these call to actions do not explicitly mention CRS, their efforts to provide
support for all FGC survivors – particularly psychological counseling and group healing – is
directly aligned with the type of treatment and care outlined by providers in the Physician’s
Forum focus group discussion. Therefore, funding of FGC-related organizations can directly
contribute to improving the health and well-being of all survivors whether or not they are
interested in CRS.

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Care Providers
For care providers, it is an issue of being able to afford to offer care – something that I
have found not only in Canada but also in countries with similar prevalence rates like Australia
or even in places with some of the highest rates of FGC like Egypt (Leone 2024; Leone 2023).
Providers will often have to rely on inconsistent grants from various organizations, if and when
available, in order to cover clinic over-head. Others might offer their services pro-bono or rely
on colleagues to do the same by volunteering their time and expertise on a needs basis. For
instance, it is common for Dr. Awwad to offer her patients at least one free assessment with their
clinic counsellor or psychosexual therapist (Leone, 2023). These lengths that providers go to in
order to offer this type of care is admirable; however, it is not a sustainable way forward.
When asked how providers navigate the financial aspect of providing these types of
services, Dr. E shared how their clinic receives funding from WAGE (Canada’s Department of
Women and Gender Equality) to study the health care needs of survivors in Canada:
You know in Canada, I find that it’s easy to be funded for research for these subjects
[FGC and CRS], but not very much for care. So, for us the foundation we get funding
from [is] WAGE to study the needs of the women, so we have that funding, but they
won’t fund the actual care. They won’t fund my psychologist who spends 4 hours a week
with these women. So, that’s the thing. And it’s always because of the health services that
are funded by the provinces. I feel that right now [the rest of] Canada may be a little bit
more open than Québec for this subject.
In comparing FGC-related care and health services to urogynecology more broadly, Dr.
Flood explained:
I could not do it privately because I could not pay for all the physios, the nurses, advisors,
dieticians, and everything we have – that’s all publicly funded…there’s such a pressure to
keep - to be private and paying your overhead would be tough. Just doing this kind of
work wouldn’t be possible.

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Providers’ frustration could be felt when describing the issue of finances and limited
resources for this type of work in Canada in particular. Dr. E stated:
We don’t have that in Canada and it’s not only for FGC, it’s for a lot of sexual health
issues. Psychotherapy is not covered. Sexotherapy is not covered. So, we have to try to
do foundations and non-profits and [get] help for people who don’t have the resources. I
don’t think its proper care to just offer surgery and not do the rest.

When discussing how to fund these other types of services survivors might benefit from
Dr. Flood and Dr. E had an exchange:
Dr. Flood: So, getting those resources is the hard part – the personnel and the salaries –
even ours, because you don’t get paid a lot to see this kind of patient.
Dr. E: You don’t actually…or not much. You do it because this is why we went into it…I
always say you know why people do volunteer work for you know helping their society?
My volunteer work is that [FGC-related care]. So, I don’t go…and make soup every
week. But I do that [FGC-related care] as my volunteer.

A key point that was raised in relation to the theme of resources, was the issue of
demand. Currently, due to a lack of funding, providers are unable to keep up with the number of
survivors looking to access their services and expertise. When discussing her clinic, Dr. E
explained:
Our website for the foundation is all created – it’s all there. But we did not post it,
because we have a lot of demands without having it publicized. We can’t have more than
what we’re doing right now because everything is pro bono now. So, until we get more
funding for the actual care, for you know the psychologist – it’s difficult for us to
publicize.
When physicians are struggling to afford to offer the type of services that survivors might
benefit from it impacts the availability of those services despite having competent, skilled
providers with waitlists of prospective CRS candidates. Survivors, FGC-organizations, and care

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providers all recognize the importance of offering this type of care and have been advocating for
governmental recognition and support from the Canadian healthcare system to acknowledge this
need and demand. This is what is explored in the fourth and final theme of this chapter.
The Canadian Issue
“It’s everywhere”
Currently in Canada, physicians are struggling to afford to offer the type of care that
survivors are likely to benefit from and survivors continue to face barriers accessing it. The fact
that this is a global issue helps to highlight that it is not simply of matter of FGC is “not a
Canada” issue, but rather it is a women’s health issue – one which largely impacts racialized
immigrant women of low socioeconomic status and is therefore low on the hierarchy of care. The
issue of demand is important to discussions of CRS and related treatment options as it helps to
justify why these types of services are needed and should be made accessible and available to
survivors living in Canada. The following extracts help to highlight the current issue in Canada
for providers working in this care-space and some of the struggles they encounter in providing
CRS amongst other associated treatment options in order to try and keep up with the demand
from Canadian survivors.
When discussing options to help gain traction and momentum in Canada to increase
awareness and support for FGC-related care, services, and programs for Canadian survivors, Dr.
Deane and Dr. Flood reflected on previous health movements from other marginalized groups in
Canada – referring to examples from provincial gender affirming care movements that were
proven successful. Dr. Flood stated:
My understanding is Toronto, which now offers some gender affirmation care funding –
outside of Montreal – started because of a patient advocacy group saying “why do we
have to wait years and years to go to Montreal in order to get [care]?

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Therefore, based on the previous successes of similar movements, physicians noted how
a community-led patient advocacy group would be the most ideal approach in terms of working
to lobby Canadian health ministries for increased support. In addition to increasing healthcare
supports for survivors, some providers also emphasized the importance of having more diverse
providers and voices in health care spaces to better reflect the diversity of their patients. For
instance, when Dr. Deane was discussing matters of cross-cultural care provision, Dr. Flood
added:
It would be nice to have more providers that look like our patients because we all look
white here and I think that would be helpful.
This would be especially important considering the increase of immigrant populations in
Canada, particularly those from some African countries where FGC is more commonly found.
When reflecting on the current landscape in Canada Dr. Flood stated:
I don’t feel like we have the same population in Alberta as we did when I worked in
Ontario, because I feel like there’s a lot more immigrants from Africa, etc. coming – but
they seem to be younger, so my obstetrical colleagues must see them more than I do. But
you know, in Ottawa it’s [FGC] everywhere, in Toronto it’s everywhere – more
immigrants stay there and in Montreal.
Dr. Deane agreed while reflecting on her own time spent in working in Alberta during her
residency training and shared that while she felt Alberta did not have the same populace as
Ontario or Québec, that survivors can still be found there.
Dr. E added:
When we don’t ask, we don’t know, so I think there are many more [survivors] than we
think.
This matter of the number of survivors has been similarly raised by FGC-related
organizations like the End FGM Canada Network who stated,

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We need further, deeper, and more comprehensive analyses to gain a greater
understanding of the true numbers of girls and women living with the consequences of
FGM/C as well as girls who may be at risk. Only then will there be the proper impetus to
establish programs and services to support those girls and women (End FGM Canada
Network, Canadian News).
The End FGM Canada Network has been putting pressure on the Government of Canada
for years to provide official statistics on the number of survivors living in Canada (End FGM
Canada Network, Impact, 2019). In September 2023, Statistics Canada released a report titled,
“An Exploration of Methods to Estimate the Number of Immigrant Girls and Women at Risk of
Female Genital Mutilation or Cutting in Canada”. As the study title would suggest, the purpose
of this report was to investigate the potential of four methods of “estimating the number of girls
and women currently living in Canada who are considered at risk for female genital mutilation or
cutting (FGM/C) based on their (and their parents’) country of birth” (Statistics Canada, 2023).
However, the report also states that “the results should not be interpreted as official estimate of
FGM/C in Canada” (Statistics, Canada, 2023). Despite the fact the report cannot be used as an
official estimate, the fact that it was undertaken at all helps to bring attention to FGC as a
Canadian issue and the matter of increased demand for relevant healthcare services.
This increase in survivor populations in Canada is further reflected in the level of demand
felt by providers for their expertise and services. For instance, when discussing publicizing her
clinic’s services, Dr. E had expressed it is challenging as the issue is by no means a lack of need
but rather a lack of funds to meet the need. Dr. E stated:
Most of the demands that I have are from email from people that know we exist
(directly). So, I connect with the patients, and we organize their appointments.

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So, here in Montreal many people from the community know that we exist. From the
doctors they know that I exist. So, we have a lot of referrals, even without any publicity.

For Dr. Deane, she is in a funding model in Canada that requires a referral but is willing
to see any patient affected by FGC that she can. It is common for Dr. Deane to get referrals from
walk-in-clinics that will simply say “this patient has had FGC and wants to see you”. The ways
in which survivors reach out to providers is varied, but one thing is clear that there are many,
many survivors in Canada who feel they would benefit from their help and support.
Despite providers willingness to care for survivors and offer their services, physicians
continue to be constrained by issues not only related to FGC-related care, but rather women’s
sexual health more broadly in Canada. For instance, when discussing the small percentage of
survivors who actually choose to move forward with CRS in Canada when counseling is offered,
Dr. E noted that when proper care, counseling, and follow up is provided to patients that she
finds many survivors do not need surgery. However, proper care alternatives – in this instance
structured psychotherapy or sexotherapy – are not always easily accessible in Canada. Dr. E
explains:
And we don’t have that [proper care and follow up related to structured psychotherapy or
sexotherapy] in Canada and it’s not only for FGC – it’s for a lot of sexual health
issues…it’s not just to do the surgery and then I see them 6 weeks post-op and it’s over.
It’s the whole thing that comes with it. And I think in Canada we need to have more of
this multidisciplinary care. Not only for FGC, but a lot of other areas.
This highlights a significant gap in Canada’s current healthcare model, where broader
issues of women’s sexual health remain under-addressed – impacting not only survivors, but
other marginalized groups who require specialized and ongoing care. Without a multidisciplinary
healthcare model – one inclusive of psychotherapy and sexotherapy – survivors and other

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women with unique sexual health needs are left with limited options, which can result in
incomplete or inadequate treatment.

This chapter identified four major themes with corresponding sub-themes, each of which
offers a more in-depth understanding of the complexities surrounding the introduction of CRS in
Canada and the care of survivors more broadly. The theme of politics of decision-making
highlights the balance between anatomy, complex cultural contexts, and patient choice in the
influence of medical decision making around CRS. The storyline theme examines how trauma,
learning, and healing intersect in survivors’ journeys – emphasizing the emotional and
psychological dimensions of recovery. The theme of resources helps to showcase the critical
support systems available to survivors, FGC-related organizations, and care providers – which
can significantly impact the quality and accessibility of care. Lastly, the theme of the Canadian
issue reflects broader systemic challenges within Canada’s healthcare landscape – particularly in
terms of the availability of specialized care for women’s sexual health and the need for more
comprehensive, multidisciplinary approaches. In the next chapter, I will discuss these findings in
more depth – analyzing them within the context of the study’s complementary theoretical
frameworks and existing literature outlined in earlier chapters.

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Chapter 6 – Discussion
This section begins with an analysis of the study’s main findings – politics of decisionmaking (anatomy, complexity, and patient choice), storyline (trauma, learning, and healing),
resources (survivors, care providers, and FGC-related organizations), and the Canadian issue.
Each of these findings highlight the complexity of an investigation into clitoral restoration
surgery (CRS) in Canada and reveals the resilience of each demographic at multiple levels to
adapt to the challenges they have encountered throughout this process. What emerges is an
interconnected journey of resilience as survivors, care providers, and FGC-related organizations
navigate obstacles in accessing and offering CRS in Canada along with providing general FGCrelated supports and services more broadly, which attend to the intersections of survivors’ social,
cultural, and gendered identities. It is through these combined efforts that incremental changes
have occurred, thus improving the landscape for FGC-related care in Canada.
Politics of Decision-making
Providers’ responses during the Physicians Forum focus group discussion along with
secondary data from Restore revealed the underlying complexity of medical decision-making
when it comes to identifying potential candidates for CRS. In a systems perspective, according to
Petticrew et al. (2018), “complexity arises from the relationships and interactions between a
system’s agents (e.g., people or groups that interact with each other and their environment) and
its context” (p.2). At first glance, the issue of anatomy would appear most pressing given the fact
the purpose of the surgery itself is first and foremost to restore what has been physically cut;
however, as the physicians shared, anatomy was just one of several factors that providers must
take into consideration when making their decision. Other factors that contribute to decisionmaking within the context of CRS include a complex intersection of individual, social, and

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cultural factors. As Collins and Bilge (2020) explain, it is precisely this aspect of
intersectionality, which focuses on complex social identities and inequalities, that has led to an
increase of intersectional feminist-informed theory within healthcare research (p.48). In order to
make the most informed decision, physicians must – alongside their patients – consider the
impact of each of these identities and how they interact. In doing so ensures that care is not only
specifically tailored to and sensitive of individual circumstances but also highlights the
importance of addressing broader social inequities that ultimately influence survivor health
outcomes.
As discussed in previous chapters, survivors who wish to undergo CRS typically
identified issues related to pain management, body image, self-acceptance, and sex-life
improvement as their reasons for wanting to have restorative surgery. Such issues and aspirations
are usually shared with providers during preliminary consultations where prospective CRS
candidates will meet with a physician and recount their story, share what has led them to this
meeting, and express what they are hoping to achieve in undergoing this procedure. According to
Petticrew et al. (2019), “in the case of health research, any aspect of an individual’s life could in
principle be described as their ‘context’ – such as their location within any social, spatial,
physical, or cultural space…moreover, the same or similar contexts may affect people in quite
different ways” (p.7). Therefore, intersectional feminist theory helps to emphasize the different
ways in which one may be affected by a similar context, which is relevant to discussions around
decision making and CRS. Despite these similarities in context, physicians need to consider each
instance on a case-by-case basis as every survivor’s experience of these factors will manifest
themselves differently in their lives and bodies.

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According to Brownlee et al., in their report on improving patient decision-making in
health care (2012), authors state,
The patient’s preference for the kind of care he or she wants is especially important when
facing a test, surgery, or other treatment that is “elective.” When a treatment is elective, it
means there is more than one way to treat the patient’s illness or condition, each possible
treatment involves different trade-offs, and individual patients will view those trade-offs
differently (p.3).
As Brownlee et al. describe, when it comes to elective surgeries, there may be several
different treatment options available to prospective patients. For survivors, particularly those
who express the desire to improve sexual functioning or sense of self, they might find that their
circumstances are best aligned with non-surgical options – for instance, psychological
counseling or platelet rich plasma (PRP) shots to improve blood flow into specific female genital
sites (Restore FGM). In a qualitative analysis of health care facilitator perspectives, Amorøe et
al. (2023) found, “when exploring how to deal with complexity the facilitators returned to the
notion that exploring multiple possible solutions was important” (p.7). Therefore, similarly to
Amorøe et al.’s findings, survivors may benefit from undergoing a combination of treatments
even if those treatments do not include CRS.
For survivors who have expressed a sense of loss related to the cutting of their external
genitalia, they may benefit from sexual counseling as part of their treatment plan. As discussed
in Chapter 2, there is often the misconception amongst survivors that because the external clitoris
was cut that the entire clitoris was removed – consequently fueling their desire to return their
genitalia back to “normal”. However, definitions of “normal” are complicated and can convey a
multitude of meanings depending on the context in which they are used – whether biomedical,

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sociocultural, or somewhere in-between (Rudnick, 2000). For instance, Dr. Flood’s statement,
“whatever “normal” is that there’s such a variation” helps to speak to this complexity –
emphasizing the amount of variation that can exist with regards to sexual anatomy, and thus
bringing into question whether a true “normal” is something even achievable let alone desirable.
Such discussions of “normal” are therefore intrinsically linked to the importance of sexual
education for survivors – particularly those unaware of their own sexual anatomy and physiology
(Leone, 2023). This lack of knowledge can contribute to false beliefs of one’s own body, such as
the external clitoris accounting for the entire clitoris as a whole. The clitoris is a much larger
sexual organ than is often acknowledged – most of which is internally located and not visible to
the naked eye. By working closely with a sexologist or sexual therapist, it may be possible for a
survivor to achieve self-acceptance and/or a fulfilling sex life without having to pursue surgical
means. However, again, this is a decision that must be made between survivor and provider.
Brownlee et al. (2012) argue, “many patients are not even aware that the decision about
elective surgery is actually a choice and that it should generally be theirs to make” (p.1). Within
the context of CRS, it is common for providers to offer their expertise – in this case as
urogynecologists and gynecologists – to help advise survivors of the various risks and benefits of
different available treatment options to ensure they are making the best choice for themselves
and their individual needs. It is during this process, based on physicians’ experiences caring for
survivors, that survivors previously interested in CRS may decide that surgery is not the right
choice for them and go down a different route altogether. In a review of the implications of a
complexity perspective in health decision making, Petticrew et al. (2018) argue,
Complex health interventions are often characterised by their sensitivity to context, the
fact that ‘one-size does not fit all’ and that such interventions often interact with and

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sometimes adapt to the context within which they are implemented which may have
implications for the effectiveness, acceptability, and sustainability of the intervention
itself (p.7).
This emphasis on ‘one-size does not fit all’ is especially relevant to discussions of CRS
and medical decision-making. The intersections of a survivor’s immigration status, ethnicity, and
gendered reality shape their particular healthcare needs differently. As Sears (2012) explains in
their study on the utility of intersectionality in understandings of cultural competency, “these
multiple social locations are experienced simultaneously, are mutually reinforcing, and therefore
must be considered in tandem rather than independently” (p.546). Therefore, as each survivor’s
story of experience is different, it is the context of that story that will influence decisions around
potential treatment options best suited to address those individual needs.
Storyline
The intersection of factors that contribute to both physician and patient decision-making
help to introduce the complexity of CRS which is explored in more depth via survivor and
provider responses under this theme in Chapter 5. What emerges in this section by way of a
survivor’s story is a journey of healing. Each survivor’s healing journey will be unique to their
individual story, experience, and specific needs. Within the context of CRS and deciding whether
that is an appropriate treatment option for a perspective surgical candidate, the provider takes on
more of a guiding role – one where they help the survivor navigate through their personal healing
journey. As outlined by the providers, and articulated by Brownlee et al. (2012), as an elective
surgery, the decision to undergo CRS is largely the survivor’s decision to make. If this is a route
that a survivor chooses to take, the physician will support them on that journey – providing preand post-operative care along the way.

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Despite the relatively straight forward nature of the surgery from a technical perspective,
CRS can be a longer route to healing when you take into consideration the multiple
psychological counseling appointments which are required. The intended purpose of these
counseling appointments is to help survivors work through any unresolved trauma they may have
stored as a result of the cutting they have previously experienced. According to Bryant-Davis
(2019), in their study on the cultural context of trauma recovery, “marginalized community
members are more likely to experience interpersonal trauma, to develop severe PTSD, and to
face barriers to safety, justice, and mental health services” (p.400). Therefore, this step in a
healing journey is crucial – especially within the context of CRS as any physical transformations
to the genital area by way of further cutting – including for medical purposes – is likely to bring
up repressed emotions and may put the survivor at risk of re-traumatization (Buggio et al., 2019).
As Dr. Deane shared in the focus group discussion, healing is layered, so to only focus on
enhancing the physical body without supporting one’s psychological, social, and sexual wellbeing can prove impractical if not potentially harmful. This conceptualization of healing aligns
with Bryant-Davis’ (2019) intersectionality-informed approach to trauma recovery care, which
argues “must attend to multiple layers of identity” (p.400). Therefore, if a survivor chooses to
move forward with CRS, they will not only be required to complete several pre-surgical
consultations, but they will also need to continue with post operative counseling well after the
surgery is performed.
As emphasized by physician focus group participants regarding their clinic experiences
with survivors, the realization that CRS is not a ‘quick fix’ can be disappointing for their
patients. The stories shared by providers in Canada in regard to their survivors’ healing journeys
align with the experiences of physicians in countries with even higher prevalence rates. For

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instance, Dr. Awwad from Restore FGM had expressed in an interview for a Sahiyo blog
publication that survivors will often opt for the surgical route based on the belief that it will
allow them to achieve their desired goals much more quickly. However, as Dr. Deane quoted
American gynecologist and surgeon Dr. Marci Bowers, “I’ll give you new legs, but you need to
learn to walk again”. This quote helps to highlight the complexity of challenges that survivors
must overcome along their journey. For instance, if a survivor who experienced sexual
dissatisfaction were to undergo CRS with the goal of improving their sexual satisfaction, it
would be unlikely that their level of sexual satisfaction would improve dramatically overnight.
So much of healing is involved with reconnecting with one’s body – familiarizing yourself with
pleasurable sensations. Therefore, the role of sexual education and learning is paramount in
helping survivors re-identify with their bodies (Leone, 2023).
Ultimately, this discussion helps to illustrate the complexity of a survivor’s healing
journey. Survivors must often face unaddressed trauma, share private and intimate knowledge
with their clinicians, and confront any difficulties or challenges they face in terms of body image
and self-acceptance. The journey to healing is one which is incredibly challenging. Whether or
not a survivor chooses to move forward with a physical transformation by way of surgery– they
will certainly undergo a psychological and emotional transformation throughout this process –
exhibiting a strong sense of resiliency.
A similar emphasis on resiliency and process was explored by Newsom and MyersBowman (2017) in their study on resilience as a journey for female survivors of child abuse.
Participants in this study emphasized resilience as a process with Newsom and Myers-Bowman
stating (2017), “recovery from trauma, reconceptualization of self, and the development of
healthy sexuality included deliberate efforts occurring over time” (p.17). Such deliberate efforts

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are observed amongst survivors along their healing journey where no part is easy. As survivors
of GBV, FGC survivors are more likely to experience instances of marginalization, racism,
and/or discrimination in health care settings (Heidari & Moreno, 2016; Wei et al., 2024).
Therefore, making the decision to reach out for help is not easy, finding and trusting in a
competent and caring provider is not easy, undergoing a series of psychological consultations is
not easy, and despite these immense efforts – survivors in these instances continue to push
through along their road to healing.
In DeVerteuil and Golubchikov’s (2016) discussion on resilience as a metaphor for
change rather than against change, they examine critiques of resilience – one of which suggests
“how resilience is used as a pretence to offload responsibility to vulnerable places and people”
(p. 148). However, in response to such critiques, DeVerteuil and Golubchikov (2016) argue that
researchers “tend to underestimate the degree and agency of resilience in those targeted places
and people, the resolute and obstinate persistence and endurance that build on layers of previous
and existing resilience” (p.148). Through their navigation of the healthcare system, vulnerability
in sharing, and openness to learning, survivors have exhibited significant agency of resilience.
Resources
As discussed, the road to CRS is not easy – it is the culmination of several complex
decisions over an extended period of time. If CRS is the route that a survivor chooses to pursue
on their journey to healing then, in addition to the physical and psychological challenges they are
likely to face, it is also probable that they will encounter some financial barriers along their path.
This issue of resources was a recurrent theme amongst interviews with providers and discussions
with clinicians and FGC-related organizations both in Canada and abroad – further emphasizing
the connection of CRS and FGC-related care more broadly to larger complex economic systems.

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During the focus group, physicians highlighted the significant cost to survivors in terms of
affording the type of care they would likely benefit from along with their own challenges in
affording to offer these sorts of services. Additionally, FGC-related organizations, which often
provide specialized supports for services and/or help to facilitate survivors’ access to service
providers, are also confronted with these financial difficulties.
As outlined in the resource section of the previous chapter, survivors can struggle to
afford the type of care they are likely to benefit from when the median cost of counseling is
beyond what the average Canadian can afford. As an elective surgery, CRS is not covered, nor
are the required psychosexual counseling sessions with specialists that are necessary in order to
qualify for surgery. This ultimately results in a significant barrier to care for survivors who are
unable to account for these costs. When one is unable to afford these services, they are unlikely
to access the quality care and support they need. Additionally, when interventions are costly, the
likelihood that survivors will continue with treatment is minimal – resulting in the
discontinuation of their care plan prematurely.
This need has also been highlighted by organizations who support survivors as illustrated
by the End FGM Canada Network’s most recent call to action. The organization put out a call to
help raise funds to support survivors in need of immediate psychological counseling. Although
such calls to action are not solely intended to support prospective, current, or previous CRS
candidates, as FGC-affected demographics, such individuals would fall under this umbrella and
could benefit from this essential care. In addition to the impact on their ability to support
survivors, limited and inconsistent funding of FGC-related organizations can affect these nonprofits’ abilities to develop crucial educational tools and programs that seek to promote the
education and cultural competency of professional frontline workers (e.g., healthcare

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professionals, educators, social workers, etc.) and restricts the organizations’ opportunities for
community outreach.
In terms of providers, physicians with an expertise in FGC-related care are currently
unable to publicize their services due to the fact that they are struggling to afford to care for their
current number of patients. If physicians were to take on all the survivors on their waitlists, they
would simply be unable to meet each of their needs under this current model. As discussed in the
previous chapter, offering this type of care is not only not profitable, but it is costly for
physicians in Canada when they do receive adequate support from their governing health
ministries. In order to ensure that survivors are receiving the type of multidisciplinary care they
need to support them along their healing journeys, physicians are having to provide their services
for free and/or rely on their colleagues to do the same – particularly those in other specialized
fields. Such instances help to highlight the complexity of health care today (Aburn et al., 2020).
In their study on rethinking resilience amongst health professionals, Aburn et al. (2020) highlight
the effects of this increasing complexity of care and the associated impacts “particularly within
the context of stretched public health systems” (p.2). When overhead costs are taken into
consideration along with hiring experts in the fields of psychology or sexology, it becomes
increasingly more challenging and expensive for physicians to offer these services.
What becomes clear is that providers are working in this field because they believe in the
importance of the work that they do, they believe in supporting survivors, and they believe in
providing the highest quality of care possible. Through their commitment to their patients, the
providers interviewed in this study have demonstrate a level of resilience in the face of a health
care system that does not reward them for this type of work.

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In a discussion of health care teams, Amorøe et al. (2023) argues, “health care teams are
in themselves described as complex adaptive systems…such systems are said to be resilient if
they have “the capacity to adapt to challenges and changes at different systems levels, to
maintain high quality care” (p.2). Physicians have exhibited their adaptive capacity through the
ways in which that have continued to provide care despite the challenges they have encountered
in doing so. Additionally, physicians who have developed an expertise in FGC-related care, like
those who participated in this study’s focus group, have individually contributed to incremental
changes in the way that FGC-related care is discussed and understood in Canada.
The Canadian Issue
When discussing resilience, DeVerteuil and Golubchikov (2016) argue, “it can be active
and capacity-building rather than passive, and that it can be a necessary precursor to resistance
and transformation – in short, a metaphor for change, not against change” (p.149). This has been
illustrated by the various incremental changes that have occurred in Canada – particularly in the
last six years – related to increased demand from survivors, care providers, and FGC-related
organizations for improved FGC-related care (inclusive of CRS and its related treatment
options). In order to gain further support and funding to address this growing demand in Canada,
physicians focus group participants reflected on previous healthcare movements from other
marginalized groups in Canada – suggesting a community-led patient advocacy group would be
most beneficial in terms of garnering government support and recognition.
The strengths of such movements were similarly highlighted by Boscoe et al. (2005) in
their study on women’s health movements in Canada. As Boscoe et al. (2005) state, “grassroots
groups and a diverse range of citizen voices must maintain a strong leadership role as we move
forward” (p.12). Additionally, in line with the issue of diversity, physicians acknowledged the

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importance of having Canadian providers who reflect the diversity of their patients. As described
in Chapter 2 when outlining the cultural, medical, and legal dimensions of FGC, it is common
for survivors to be fearful of interactions with healthcare professionals. Due to the
criminalization of FGC, survivors may be reluctant to seek out medical care or support due to
fears of prosecution and/or concerns of potentially implicating their parents in a crime (Packer et
al. 2015). However, it is not solely risks of criminalization that contributes to these fears, but also
instances where survivors may anticipate stigmatization or discrimination. Movements to
improve diversity and inclusivity within the Canadian healthcare system will help to minimize
fears and improve survivors’ experiences within it. Moving ahead, a leading force in these types
of movements will be community members and FGC-related organizations – helping to better
address the social, gendered, and psychosexual implications of FGC and the introduction of CRS
(Jordal et al., 2018).
Previously considered as a practice that occurs “elsewhere” or impacts “others” – views
and public opinion have begun to shift to a point where government-initiated reports on FGC are
now being produced. Such advancements within our own borders have been the result of
continuous efforts from providers in addition to years of advocacy and activism on behalf of
organizations like the End FGM Canada Network. As the End FGM Canada Network’s response
to the report highlighted, this was something advocates and activists working in the field of
FGC-related activism had been pushing for for years. Contributors to the End FGM Canada
Network’s aims and efforts have sought to situate FGC within the Canadian context to highlight
the matter of FGC as a Canadian issue. Activists and advocates in this space have exhibited a
process of resilience as they have worked incrementally towards governmental recognition. As
DeVerteuil and Golubchikov (2016) highlight, “resilience promotes small-scale and incremental

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transformation, so that resiliently alternative spaces become springboards for more fundamental
transformation” (p.150). An example of this is shown by the network’s push for Canadian
provinces and territories to create position statements on FGC. Another example of where
organization’s resilience has resulted in incremental transformation is shown in the Canadian
Prime Minister Justin Trudeau’s acknowledgement of the International Day of Zero Tolerance of
Female Genital Mutilation on February 6th, 2022. In this statement, Prime Minister Trudeau
affirmed his commitment to ending FGC and fighting against gender-based violence. As part of
this commitment, Prime Minister Trudeau committed $1.4 billion annually by 2023 to “support
the health and rights of women, children, adolescents, around the world through global
organizations and Canadian and international non-governmental organizations, including $700
million per year specifically for sexual and reproductive health and rights” (Prime Minister of
Canada Justin Trudeau 2022). This funding of organizations, which implement a zero-tolerance
approach to FGC and participate in the fight against gender-based violence, further emphasizes
the connection of FGC-related care to larger complex economic and legal systems. Therefore,
governmental acknowledgement and funding are crucial steps in supporting organizations in
Canada that champion the overall health and well-being of survivors.
As part of this investment, the Government of Canada allocated $530,000 in funding to
the End FGM Canada Network. Such funding helped to launch initiatives like the Miss Klitty
project, which has helped to shape both national and international understandings and
perceptions of the clitoris. Initiatives that seek to promote understanding and demystify sexual
anatomy play a crucial role in improving body-image and developing self-acceptance not only
amongst survivors but for all individuals with female sexual anatomy. As discussed in terms of
survivors’ motivations for undergoing CRS, sexual education can play a major role in a

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survivor’s healing journey and can thus directly influence their decision to move forward with or
without surgery. Therefore, Canadian initiatives that promote sexual education and contribute to
this form of learning are intrinsically linked to CRS.
Additionally, the collaborative nature of organizations like the End FGM Canada
Network have further helped to challenge beliefs that FGC is not a Canadian issue. The End
FGM Canada Network has connected individuals in front-line professional fields like education,
social work, law, health care, and more. In doing so, the End FGM Canada Network has worked
resiliently to promote the safety, health, and well-being of survivors in Canada. In quoting
Brown (2014), DeVerteuil and Golubchikov (2016) state, “this suggests the potential that
resilience can be deployed in less regressive ways, ‘as an organizing principle…to challenge the
status quo and to design and shape alternative futures’ (p. 113)” (p. 146). Through these resilient
organizational efforts, FGC-related organizations have helped to challenge this status quo and
realize a future that recognizes FGC as a Canadian issue.
The continuous efforts of FGC-related organizations in Canada and abroad have helped
to shape alternative futures by way of small and incremental changes – transforming the futures
for survivors everywhere. The work of FGC-related organizations is deeply connected to the
introduction of CRS and related treatments in Canada. Efforts to enhance the visibility of FGC as
a Canadian issue help to improve the availability and accessibility of all supports and services
intended to improve the health and well-being of survivors. Additionally, initiatives that seek to
enhance provider knowledge work to strengthen physicians’ cultural competency in this area. As
Sears (2012) explains, in their study on the utility of intersectionality in improving cultural
competency, “understanding the ways that social locations intersect to create unique health
trajectories among racial and ethnic minority patients is an important step towards improving

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their health outcomes and promoting health equity” (p.550). Such advancements have been
linked to improving the type of care survivors receive in Canada (Chalmers & Omer-Hashi,
2003). The more aware and knowledgeable providers are in relation to FGC related issues, the
better equipped they will be to provide survivors with quality care along their healing journey
and the more informed they will be to better assist survivors in their decision-making when it
comes to deciding whether CRS is the right treatment choice for them.
Journey of Discovery
When the major themes of this study are reviewed and analyzed, what emerges is a series
of complex interconnected journeys of resilience. Prior to embarking on my own journey to
explore the introduction of CRS in Canada, I had wanted to know why CRS was so highly
contested within the medical field. I wondered if the claims were accurate, and the surgery could
alleviate pain, improve an individual’s sense of self, or enhance one’s ability to achieve clitoral
orgasms, then why wouldn’t someone want it? However, it was through my own personal
journey into the study of CRS in Canada that the true complexity of this exploration was
revealed.
What I found was less about the surgery itself and more about the procedure could
signified – self-acceptance, sexual autonomy and satisfaction, and a sense of “normalcy”.
Outcomes that I would come to learn could be achieved without any surgery at all. I had
previously shared this similarly singular focus on the surgery and the promises it advertised - in
awe of the ease in which urogynecologists and gynecologists could unearth clitoral glans and
situate them into place. However, it is precisely this perceived simplicity that gives one the
impression that CRS is a ‘quick fix’. A ‘quick fix’ for those who may have gone many years
being unhappy, unsatisfied, or uncomfortable. Yes, surgically speaking CRS can be performed

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quickly; however, in order to achieve the desired outcomes – the ones specifically identified by
survivors, they must embark on a healing journey that has proven to be far more complex. It is a
journey that involves addressing unresolved trauma related to their FGC experience, learning
about their bodies through handheld mirrors and unveiling the truths of their sexual anatomy, and
while surgery certainly is a path, what one discovers is that it is not the only path.
Along this journey, physicians guide their patients to help them navigate the complexity
of their particular health context. In highlighting these complex processes of resilience, Njeze et
al. (2020) emphasize the importance of understanding how “individual, social, and cultural
processes overlap and intersect in important ways to support resilience and overall wellness”
(p.2002) – further highlighting the relevance of a complementary intersectional lens. What
physicians have made clear throughout this study and to their patients, is that physical health is
just one aspect of overall wellness. Here physicians use their expertise not only as surgeons but
as care providers to help curate an effective treatment plan unique to each survivor’s individual,
social, and cultural context.
Physicians who participated in this study have demonstrated a commitment not only to
providing quality and culturally informed care but have worked to make sure that this type of
care can one day be accessible to everyone in Canada. Despite challenges in financing the types
of treatments most beneficial for survivors, providers have been adaptive in their money raising
strategies from collaborating with non-profit organizations, undertaking related government
funded studies, or exhibiting creativity with different billing codes while lobbying the Ministry
of Health to expand code availability – providers have been pragmatic in their approaches to
improve the healthcare landscape for survivors in Canada.

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In addition to the physician’s journeys, FGC-related organizations can play a notable role
in the expansion of CRS and related treatment options through their development and promotion
of supports and services that seek to improve the health and well-being of survivors in Canada.
According to Wakefield and Zimmerman (2020), “local, national, and international women’s
rights and gender justice movements are at the forefront of transformational approaches” (p.170).
As leaders in these movements, FGC-related organizations in Canada and abroad have been at
the forefront of the fight for governmental recognition. Women’s right and gender justice
organizations have fought resiliently for government acknowledgement of these important issues
and incremental changes have occurred as a result. As Wakefield and Zimmerman (2020)
explain in their reimaging of resilience supported by feminist women, “feminists have led
thinking about cultural and norms change, required for system-wide transformation” (p.158)
These changes may be small at first, but the effects of these impacts are buildable and can result
in long lasting, wide-scale positive change.
As, DeVerteuil and Golubchikov (2016) ask, “if we cannot hold on to the gains made
previously or presently, what hope have we of transforming the future world” (p.149)? The work
of such organizations helps to highlight the role of small incremental changes and their impacts
on the health and well-being of survivors in Canada. As Njeze et al. (2020) argue in their
analysis of resilience-promoting processes research, particularly studies that that draw from
intersectional feminist theory, it is important that we do not neglect “to examine the intersecting
individual and social factors that enhance resilience and wellness” (p. 2002). Such perspectives
help to illustrate how the advocacy and efforts at multi-levels including survivors, FGCorganizations, and passionate care providers is interconnected with a shared goal of improving
the health and well-being of survivors in Canada.

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Chapter 7 - Conclusion
This conclusion begins by briefly outlining some of the study’s limitations related to the
COVID-19 Pandemic and participant recruitment. This section is followed by a description of
several of the study’s strengths, which include provincial inclusions, holistic perspectives, and
comparative insights. This study’s main contributions to the field of FGC-related research in
Canada are then summarized – particularly in the area of health. I then share some questions that
I am left with that would benefit from further research and exploration before ending with a
closing reflection.
Study Limitations
COVID-19 Pandemic
This study was undertaken during the COVID-19 pandemic, which resulted in significant
delays in the introduction and expansion of CRS and FGC-related care efforts for survivors in
Canada. My original informant had been in the process of opening up a specialized surgical
centre in Toronto, Ontario, but had experienced notable barriers in doing so. By the time a
suitable clinical space was identified in the early Spring of 2020, COVID-19 had spread across
the nation – putting a halt to non-emergency health care services (Sauro et al., 2023). With the
suspension of non-lifesaving surgeries, this informant felt a professional responsibility to join
colleagues on the front lines in the fight against COVID-19. Here this informant dedicated their
time and medical expertise to helping those in hospital during the early stages of the pandemic to
later taking part in Canada’s large-scale COVID-19 immunization efforts by working in
designated vaccination sites.
The impacts of COVID-19 shed light on the fragility of healthcare systems around the
globe. Canada’s healthcare system was no different, where two years following the initial

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expansion of this illness, healthcare operations were still recovering – navigating provision of
services in a post-2020 world. The resulting delays were longer than anyone could have
anticipated, and unfortunately, after decades of service, this informant retired before they were
able to open their CRS surgical centre for survivors in Ontario. This offers just one example of
the effects that the COVID-19 Pandemic had not only on this study, but on the Canadian
healthcare system as a whole – especially in terms of non-life saving surgeries and related
community health and well-being in Canada. The effects of which can still be felt today almost 5
years later.
Recruitment
Some of the study’s second limitations relate to the matter of recruitment. The challenges
of recruitment were two-fold and included the issue of research participant specificity and
gaining access to one of the study’s demographics. Research participant specificity presented a
challenge due to the limited number of potential research participants with the desired
characteristics required for the purpose of this study’s investigation. Firstly, restricting the pool
of prospective participants in Canada to those who had previously undergone FGC limited the
number of potential informants. This pool was decreased further to only including survivors who
had undergone CRS or those who were interested in the procedure. As discussed, COVID-19
delayed the introduction and expansion of CRS and related surgical interventions in Canada.
This delay impacted the number of survivors who had not only experienced CRS but also limited
survivors’ knowledge about the procedure and its availability in Canada.
Similarly, this issue of specificity also affected the care provider demographic of this
study. Limiting the scope of physician participants to those with a specific expertise greatly
influenced the number of eligible participants. Despite advancements in FGC-research in Canada

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and community out-reach projects initiated by FGC-related organizations, there continues to be a
limited number of care providers with a high-level of expertise around FGC. Therefore, limiting
the pool of potential physician participants to those who not only had this expertise in FGCrelated care, but also were trained in CRS, impacted the availability of potential physician
participants.
The second limitation related to recruitment was the case of gaining access to one of the
study’s demographics. It is important to note that despite the level of perceived anonymity when
it comes to participating in online surveys, due to the sensitive nature of the study topics,
potential survey participants may have felt some discomfort at the thought of sharing their
experiences. As noted in the focus group discussions with physicians, it is common for survivors
to rarely discuss their experiences related to FGC, and therefore, it is understandable that
individuals would not feel comfortable doing so in an online survey format, thus limiting the
number of potential survivor survey participants.
Study Strengths
Provincial Inclusions
Despite the specificity of eligible physician research participants, this study was able to
include the perspectives of physicians with expertise in both CRS surgical techniques and FGCrelated care across three different Canadian provinces – Alberta, Ontario, and Québec. Including
the perspectives and experiences of physicians across three Canadian provinces helped to
provide a more in-depth understanding of the CRS and FGC-related care-scape in Canada. As
outlined by physicians during their focus group discussion, health care providers are limited by
the provincial health authorities and regulations in which they work. Such limitations can impact
not only which services physicians provide but also the ways in which they offer those services.

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By including insights from three different provinces, this study was able to identify similarities
and challenges that impact FGC-related care on a more national level.
Holistic Perspectives
In line with providing a more holistic understanding of CRS and FGC-related care in
Canada, expanding the field of inquiry to include qualitative and observational data from
survivors, health care providers, and FGC-related organizations helped to account for the
complexity of this topic. By doing this, this approach not only provided insights into accessing
CRS and related FGC health services, but also around matters of offering, educating, and
facilitating those supports and services. By employing a more holistic approach to this study, it
helped to highlight the interconnections between these group – showcasing the social, medical,
and financial dimensions that complicate the provision and accessibility of CRS and other FGCrelated treatment options in Canada.
Comparative Insights
The strength of comparative insight, nationally and internationally, was incredibly
valuable in terms of recognizing issues physicians were facing when it came to offering CRS and
other FGC-related health services and treatment options. Without this comparison it would have
been comfortable to assume that these sorts of services and procedures were not high on the
hierarchy of care simply because they are intended for individuals who have experienced a
cultural practice that is believed to happen “elsewhere” and is thus not a “Canadian issue”.
However, the difficulties in receiving governmental support and recognition for FGC-related
care is global. This was demonstrated by colleagues at Restore FGM in Egypt who shared about
the many challenges they faced when it comes to receiving adequate funding to meet the needs
of their patients. Egypt is home to some of the highest FGC prevalence rates in the world and yet

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their struggles to offer multidimensional care were similarly echoed by Canadian providers
across each province. Whether in Canada or in Egypt, this study helped to highlight a shared
struggle amongst care providers to afford to offer this type of care for survivors.
Contributions
This study has contributed to a more in-depth understanding of the politics of physician
decision-making when it comes to CRS in Canada. It is not a decision that is made lightly nor
independently, but rather is a shared decision between care provider and FGC survivor that seeks
to account for the complex needs of perspective patients. When providers consult alongside their
patients to develop an appropriate care plan, they must first consider the individual’s context –
their physical, social, and cultural space (Petticrew et al., 2019). As understood within an
intersectional feminist lens, every survivor’s experience of FGC is unique and thus impacts their
physical, mental, and sexual health differently. Based on these differences, a one-size-fits-all
approach is not realistic when it comes to performing CRS – nor is it appropriate for FGC-related
care more broadly. This study has demonstrated that any determinations are made on a case-bycase basis. By taking an individualized approach to CRS, providers are able to account for this
complexity of their patients’ health and well-being.
Furthermore, this study unveiled the intersections and complexities of survivors’ healing
journeys when it comes to CRS and related treatment options for survivors. This study outlined
the various claims associated with the introduction of CRS – the surgery’s ability to alleviate
pain, enable clitoral sensation and orgasm, and improve issues of body image (Foldès et al.,
2012). However, what was revealed, particularly through physician’s accounts, was that several
of the claims of CRS can be achieved without any surgical intervention at all. In recent years,
researchers have emphasized the importance of offering CRS alongside other forms of treatment

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options such as counseling or sexual therapy in order to be successful. Yet this study finds that
“success”, in this case achieving a survivor’s desired outcome, can be achieved without surgery
in many cases. This finding, shifts discussions away from CRS and towards more holistic
approaches to healing. Healing is not one dimensional and, as outlined above, within the context
of FGC, interventions must account for the physical, social, and cultural components to one’s
overall well-being. During clinic visits, survivors should be made aware of their options and
offered non-surgical forms of treatment.
Lastly, this study contributes to the limited pool of existing work that seeks to explore the
issue of CRS and FGC more broadly and shed light on its relevance and importance in Canada.
Despite notable advancements in the field of FGC research in Canada, particularly those led by
FGC-related organizations and their associated out-reach initiatives, much more is needed
especially in areas of health. Canadian FGC studies help to raise awareness about the practice,
combat stigma and discrimination, educate Canadian front-line workers, and offer support in the
fight for necessary services for survivors Canada. By undertaking a holistic investigation into
CRS in Canada with the inclusion of insights from three related demographics – survivors, care
providers, and FGC organization contributors. This study’s contribution is unique in its
highlighting of how each of these three demographics are interconnected. Every study that is
undertaken contributes to expanding our knowledge and understanding of FGC and its related
impacts and is a step towards improving the current care-scape for Canadian survivors.
Questions I am Left with for Additional Research
According to Freeman (2019), “the beauty of feminist qualitative research…we are
setting ourselves and other feminist researchers up for future work, future questions, and actively
changing the nature of qualitative research” (Freeman, 2019, p.15). As part of that research, I

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want to share some questions that I am left with that may one day be taken up by myself or other
feminist researchers for further investigation. The first question I am left with is a more explicit
understanding of what the roles and responsibilities are of FGC-related organizations in terms of
the health and well-being of survivors? FGC-related organizations prioritize efforts towards the
prevention and ending of FGC within their local contexts as well as internationally.
Understandably, under this ethos, organizations’ focus is on the protection of girls and women at
risk of FGC. However, as exhibited in this study, FGC-related organizations also play a major
role in the support and facilitating of survivors’ access to crucial services. Additionally, as
organizations in the realm of women’s issues and gender-based violence, are more likely to
receive governmental support and financial funding. It is important for that funding to be
available to help support individuals in Canada who are living with the physical, emotional,
psychological, and sexual effects of FGC. Doing so may also help to combat the medicalization
of FGC by offering alternative settings to clinic-based sexual education, such as opportunities to
attend community-led sexual education workshops or classes. As Flowers (2018) argues in their
study on black women sex educators, “culturally appropriate, tailored interventions implemented
by cultural congruent educators are key components of developing CSE [comprehensive
sexuality education] programs for diverse communities” (p.319). By offering comprehensive
sexual education within a more culturally appropriate setting, it may help to increase the
likelihood of survivor engagement with sexual educational resources and supports.
The second question that I am left with, when it comes to financing FGC-related care
services and research studies, is who “deserves” funding? How are these determinations made?
This important question was raised by Restore FGM’s visiting medical student from America
during a conversation about resource availability and allocation in their Cairo clinic. The

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increased interest in FGC-related research and restorative treatment options for survivors
globally is incredibly important; however, it is also imperative that we are critical of who is
receiving the funds to undertake such studies. Western countries have been at the forefront of
this work in recent years with studies published out of France, Sweden, Norway (Foldès et al.,
2012, Jordal et al., 2018; Jordal et al., 2019). As discussed in Chapter 2, in order to receive
governmental funding, organizations must align with the stances outlined by their government
institutions when it comes to the criminalizing of FGC. This raises the question of whether
research in this field is more likely to receive funding and governmental support in countries
where the practice of FGC is illegal, and the law is greatly enforced compared to countries where
FGC is also illegal but remains widely practiced – particularly in rural areas (e.g. Egypt and
Sudan).
Lastly, an area of interest for further research is that of survivor’s sexual satisfaction in
relation to their level of clitoral knowledge and sexual education more explicitly. In a
comprehensive review of the clitoris and its role in female sexual function, Mazloomdoost and
Pauls (2015) state, “a thorough understanding of the clitoral anatomy is imperative to preserving
its function and maintain this important aspect [sexual functioning] of women’s health” (p. 259).
Additionally, in a study which explores whether clitoral knowledge translates into orgasm,
Dienberg et al. (2023) argue, “sex education has been shown to increase women’s anatomical
knowledge, self-efficacy to experience sexual pleasure and positive attitudes toward their
bodies” (p.10). These statements were supported by some of the study’s findings, which
emphasized the role of sexual education and learning in survivors’ sexual satisfaction. It would
be of great interest to compare the impacts on sexual pleasure between survivors with extensive

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sexual education and those with limited sexual education to determine the influence of increased
anatomical knowledge.
Closing Reflection
This dissertation opened with a discussion about the “discovery” of the clitoris – briefly
outlining centuries of social, historical, and medical neglect and misunderstanding through which
this component of female sexual anatomy has become a symbol of resilience. This symbol
mirrors the multi-system resilience exhibited by survivors, care providers, and FGC-related
organizations as they navigate journeys in accessing, offering, and facilitating CRS and relevant
FGC-related supports and services.
Ultimately, through the lens of CRS, this dissertation shares many stories of resilience
and highlights opportunities for further discovery. As discussed in Chapter 6, the realization that
CRS may not be the final destination or even a possible option can be difficult for some
survivors to accept – particularly after learning more about some of the surgery’s promises. It is
important to highlight that surgery is just one of many roads that survivors might explore along
their healing path. Survivors may come to discover that their clitoral glans are still intact through
self-exploration, a care provider might facilitate a survivor’s learning and ultimate realization
that they still have an internal clitoris, or a sexual therapist might support a survivor in achieving
a satisfying sex life with their partner through counseling alone. Each of these instances account
for several moments of discovery along a road to healing, but unlike the historical accounts of
early anatomists and linguists come to past, survivors’ stories do not end with these discoveries,
but rather, these discoveries are only the beginning.

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Appendix A – Survey Skeleton
Proposed Survey Skeleton
Demographic Questions:
Q: How old are you? _________
Q: Where were you born? _________
Q: What is your primary language? __________
Q: What is your current relationship status?
Married
Cohabitating
Divorced
Separated
Single, never married
My relationship status is not listed here: _________
Q: Which of the following best describes your HIGHEST level of education?
Some high school
Completed high school
Some college/university
Apprenticeship training and trades
Completed college/university
Some graduate education
Completed graduate education
Professional degrees
Q: What type of cutting have you experienced?
Type 1 – Partial or total removal of the clitoral glans and/or the prepuce/clitoral hood
Type 2 – Partial or total removal of the clitoral glans and labia minora – with or without the labia majora
Type 3 – Infibulation – the narrowing of the vaginal opening through the creation of a covering seal.
Formed by the cutting and repositioning of the labia minora, labia major, and removal of the clitoral
prepuce/clitoral hood and glans
Q: How old were you when this cutting took occurred? _______
Q: How did you first hear about clitoral reconstructive surgery? ___________
Q: How long did your decision to undergo clitoral reconstructive surgery take?
Less than 6 months
1 year
2-3 years
3-5 years
Longer than 5 years
Ranking Question(s):

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Please rank the following from most important to least important.
What is the largest motivating factor in undergoing clitoral reconstructive surgery?
A) Pain relief
B) Increase clitoral stimulation and/or sex-life enhancement
C) Body Image
D) Other ___________
Please rank the following areas from most impactful to least impactful
Following the surgery, which area did you experience the most to least improvement?
A) Pain relief
B) Increased clitoral stimulation and/or sex-life enhancement
C) Body Image
D) Other ______
Matrix Question:
How satisfied or dissatisfied are you with each of the following?
1 – Very satisfied 2- Somewhat satisfied 3 –Neither satisfied no dissatisfied 4 – Somewhat dissatisfied 5- Very Dissatisfied N/A

1.
2.
3.
4.

My experience with the referral process
My recovery from the procedure
The surgery met my expectations
The postoperative outcomes

Open-ended Questions:
How have your views on clitoral reconstructive surgery changed since migrating to Canada?

Reflecting on your experience, what is one thing you wish you would have known before undergoing
clitoral reconstructive surgery?

In what way(s) has undergoing clitoral reconstructive surgery improved to your day-to-day life?

Please use this space for additional comments regarding your experience undergoing clitoral
reconstructive surgery.

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Appendix B – Research Survey PDF for Recruitment Emails

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Appendix C – Research Survey Social Media Story Image

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Appendix D – Research Survey Instagram Grid Post (Sahiyo)

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Appendix E – Research Survey Instagram Grid Post (WHIWH)

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Appendix F – Research Panel Instagram Grid Post (ENDFGMCANADA)

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Appendix G – Research Survey Newsletter Recruitment Message (Sahiyo)

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Appendix H – Focus Group Semi-Structured Questions
Example Physician’s Forum Semi-Structured Focus Group Questions
Topic 1: Physician Background
Topic 1: Physician Background
1.1 What is your medical background and where do you practice?
1.2 When did you first learn about female genital cutting (FGC)?
1.3 How did you begin to offer FGC-related care?
1.4 In your view, what makes FGC-related care unique?
1.5 Are you involved with any FGC-related organizations or initiatives? If so, which ones?
Topic 2: Canadian Context
2.1 How would you describe the state of FGC-related care in Canada?
2.2 From a healthcare perspective, what is Canada’s healthcare system doing right when it comes to
offering FGC-related care?
2.3 From a healthcare perspective, what could Canada’s healthcare system do to improve FGC-related
care?
2.4 I have heard from a number of healthcare providers that funding for FGC-related care is limited. Have
you found this to be true in your experience? If so, why do you think that is and what do you think can be
done to improve funding?
Topic 3: FGC-Related Healthcare Services
3.1 What type of healthcare services do you offer FGC-affected women?
3.2 In your experience, what services do you find FGC-affected women are most interested in?
3.3 What type of FGC-related health complications must women present with in order to qualify for
different services? How do you make those decisions?
3.4 What are the financial costs of these healthcare services?
Topic 4: Clitoral Reconstructive Surgery (CRS) in Canada
S) in Canada
4.1 When did you first hear about CRS for FGC-affected women?
4.2 Where and how were you trained in this surgical technique?
4.3 In your opinion, why do you think women are electing to undergo CRS?
4.4 What type of FGC-related health complications must women present with in order to qualify for CRS?
How are suitable candidates identified?
4.5 What challenges do you face in providing CRS to FGC-affected women?
Topic 5: General Discussion Questions on FGC
5.1 What is your preferred terminology and why? (For example – FGC, FGM, FGM/C and clitoral
reconstructive surgery VS clitoral restoration)
5.2 In the literature on female genital cutting, a lot of discussion revolves around perceptions of what is
“normal”. How would you define “normal”?