Dr Foldes and the women

A tall, elegant Somalian woman in her late twenties slips nervously into the reception area of the Louise XIV hospital in Saint Germain-en-Laye outside Paris. Elham Farah has been booked in for a two-hour operation to be carried out by a man who has become a saviour to thousands of victims of female genital mutilation (FGM). Dr Pierre Foldes is the only surgeon and urologist to have developed a surgical technique which restores the clitoris.

Elham is unable to give the exact details of what happened to her 20 years ago when she was led to a house outside her village in Somalia and was held down by a number of women including her grandmother and two aunts. Her legs were prised apart by two other women. She passed out when one of the women applied a knife to her genitals. When she came round she remembers an excruciating pain between her legs, which had been tied together. It was not until several weeks later that she discovered that her genitalia had been sliced away.

Elham is just one of 130 million women worldwide who are estimated to have undergone FGM, with an additional two million girls and women undergoing the procedure every year. In some cultures it is seen as a female rite of passage preventing promiscuity, and is mainly performed on girls aged between four and 12 years. The practice is prevalent in 28 African countries, with figures varying widely. About 5 per cent of females in the Democratic Republic of the Congo (formerly Zaire) and Uganda undergo the procedure; that figure rises to 98 per cent in Somalia.

There are three types of FGM: the removal of the clitoris only; the excision of the clitoris and surrounding labia; and, most radical of all, the removal of clitoris, inner and outer labia and the sewing-up of the vagina, where only a small opening is left for urine and menstrual blood. It is estimated that 15 per cent of women who experience FGM have undergone this most severe mutilation, known as infibulation.

It was not until Elham arrived in Europe ten years ago with her engineer husband, that she came to understand the extent of her mutilation and how it much it was affecting her psychologically and sexually. Speaking several days before undergoing Foldes’s reconstructive operation, she explains shyly how when her labia and clitoris were cut off she thought it was normal. "All the girls in my town had it done," she says. "Nobody wants to marry you if you are not excised, and as a child you don’t remember what it is like to be complete. At that age you’ve never had a sexual experience, so how do you know what you’ve lost?"

In France she came across articles and programmes on sex and female anatomy. "I realised what had been taken from me and how much I suffered physically and emotionally because of it. I became very angry. My womanhood has been cut away. I have never known what it’s like to have normal sexual feelings. I am not a real woman. I always feel ashamed and dirty."

Every year Dr Fordes, 51, operates on 200 women like Elham, including at least six from the UK. Most of his patients are Africans aged between 18 and 45 living in France. His doctor wife, Beatrice, and five children hardly see him; he performs the operations in addition to his full-time hospital work. He refuses to charge for the operations because he considers his patients to be victims of one of the biggest crimes against humanity. "Victims shouldn’t pay for the crimes against the them. These women have already paid a huge price," he says.

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

The surgery had to be carried out secretly because of death threats from community members. Later, when it became known he was continuing his operations in France, the death threats continued. "The police take them very seriously," he says, "but I won’t let them stop me doing this." He points to a photograph in his office of a bullet hole in a wall in Cambodia. "If I can survive that and keep on working," he says, "why should I be scared of a threatening phone calls and letters?"

He explains the reasons for his determination to continue with his work: "Excision is worse than rape because the family are involved. And it is much worse in terms of the clinical aftermath," he says in his heavily accented English. Short-term complications include severe pain and a risk of haemorrhage; there is also a high risk of infections such as gangrene. Long-term complications include urine retention and infections, obstruction of menstrual flow causing internal infections and infertility, and prolonged and obstructed labour.

With his nonchalant disregard for death threats, his regular stints with Medecins Du Monde in war-ravaged and poverty-stricken countries and his absolute refusal to accept payment for his work for Africa’s mutilated women, Foldes can’t help but stand out in the medical establishment, a world that has a reputation for being conservative. He fiercely defends his decision to pioneer clitoral reconstructive surgery. "While I was removing the scar tissue from the women it occurred to me that I might be able to restore the clitoris," he says. "The African women I operated on in France were asking me if I could do more to help them. ‘I want to be a woman,’ they said. They were marrying men already resident in France who had experience of non-excised women and who were saying their wives were not full women."

When, 15 years ago, Dr Fordes embarked on his mission to develop surgical techniques to restore the clitoris he was shocked to find that the only organ in the human body devoted to pleasure had been metaphorically excised by the male-dominated medical fraternity. "It was invisible," he says indignantly. "It was shocking for me to discover in my research that there was nothing, absolutely nothing on this organ, although there are hundreds of books on the penis, and several surgical techniques to lengthen it, enlarge it or repair it. Nobody was studying the clitoris because it is associated with female pleasure. There was very little anatomical detail on it. It was as if it didn’t exist. I had to start from scratch."

What Dr Fordes discovered was that the organ, which Sigmund Freud, father of psychoanalysis, once likened to kindling wood, is much larger than originally thought, with nerves surrounding the vagina and extending down the thighs. "It’s about ten or 11 centimetres long, like a penis, and changes shape when erect," he explains.

To reconstruct a clitoris, Dr Fordes removes all scar tissue that has grown over the excised tip and snips the ligaments that support it, hence allowing more of the clitoral body to slip down so that it is exposed as a small tip like the original. The ligaments are then repaired. "After six weeks the area starts to look normal, but my patients tell me that it takes four to six months for them to feel anything," he says.

Whether his patients are later able to experience orgasm is something he is not willing to guarantee. "Women tell me they have sexual feelings they didn’t have before, but if you’ve been excised at birth how can you know what an orgasm feels like? It needs to be researched scientifically and that’s being set up with about six women at the moment," he says.

For Elham, the possibility of having an orgasm has transformed her life. "Now I have pleasure, where I had nothing before. I don’t know if it is a little or a lot because this is new to me. I can be with my husband like all other women are with their men. I haven’t anything to hide. I can have a normal sexuality. I can be deeper and more intense in my relationship. Finally, I’ve got my entire body back. I have no fear to be rejected - and I can think of the future."