It is early morning and 34-year-old Sandrine feels her stomach tighten as she arrives for an operation at the sprawling hospital complex at Saint-Germain-en-Laye, a 45-minute train ride from Paris. In the pre-op room, she visibly relaxes as she is greeted by a tall, powerfully built, softly spoken man in his 60s.
Dr Pierre Foldès sits on her bed and calmly summarises the procedure they have discussed at their initial consultation. At 11am he will remove the appalling scars that have been inflicted on her.
Sandrine is one of millions of women around the world wounded by a process called female genital mutilation (FGM). Much more extreme than the pricking of the clitoris common as a ritual female circumcision in parts of Asia, most FGM involves removal of some, or all, of the external female genitalia. The United Nations describes it as a violation of the human rights of women and girls that also “violates the rights to health, security and physical integrity of the person”.
The World Health Organization says that long-term consequences of FGM, which has no medical justification, include recurrent bladder and urinary tract infections, cysts, infertility and an increased risk of childbirth complications and newborn deaths.
Foldès is fighting back against the ‘cutters’, who mutilate millions of women like Sandrine. “In reality it is the whole woman who suffers for the rest of her life,” says Foldès, a courteous man with expressive hands that point to the passion that has driven him to pioneer an operation in which he has repaired damage to 15,000 women, giving them the chance to lead the kind of lives that most take for granted.
According to the UN’s 2016 figures, there are more than 200 million mutilated girls and women alive today in 30 countries across Africa and the Middle East, where FGM is mostly carried out. Worldwide, it is estimated that five girls are subjected to FGM every minute.
The ritual is usually inflicted on girls somewhere between infancy and 15. Traditionally, the mutilation is performed by female cutters. Often they use crude knives, razor blades and shards of glass.
But FGM is also a European issue that some medics choose to ignore. According to the European Parliament, 500,000 women and girls living in Europe of African, Middle Eastern and Asian origin – many of them born in European nations – have suffered FGM.
The problem is at its worst in England, Wales, France, Italy, Germany and the Netherlands. Every single year 180,000 more girls are at risk of horrendous operations, performed without anaesthetic and often in insanitary conditions. The practice persists, even though it is now illegal in an increasing number of African countries, across Europe and is condemned by the UN.
Those communities that cut claim it is a matter of culture and tradition, and that – among other reasons – genital mutilation preserves virginity, suppresses feminine sexuality and that without it girls are impure and unacceptable as wives.
“It is none of those things,” Foldès maintains. “It is like rape. Rape is sex as violence. FGM is violence against sex. Both enforce the dominance of men.”
Shockingly, Foldès says that, of those on whom he has operated, 1500 (10 per cent) were mutilated in France. Alarmingly, there is no comprehensive research on how many girls and women living in Europe undergo FGM in Europe as opposed to those who are taken abroad to have it done.
“It is assumed that most undergo FGM abroad, but we know that there are FGM practitioners in Europe,” says Natalie Kontoulis, the Brussels-based coordinator of End FGM European Network, a campaign group of 11 national NGOs in EU states.
“In FGM-practising communities, people are very reluctant to turn them in to the authorities for fear of being stigmatised and ostracised,” she says. “We know some practitioners come from abroad, perform FGM on several girls and then leave the country, making them hard to catch.”
All EU countries have laws criminalising FGM. However, only eight member states have FGM prevalence studies, and prosecutions are pitifully low: one failed case in the UK, the same in the Netherlands, none in Finland, just two in Switzerland. France leads the way, with 40 prosecutions resulting in the punishment of more than 100 cutters and victims’ parents. The maximum sentence is 20 years, with fines of up to €150,000.
Sandrine, originally from Ivory Coast, a former French colony, was just three when she was infibulated, the most severe form of FGM. Her outer labia – the labia majora or lips that surround the vagina – were then cut and sewn together, leaving just a tiny vaginal opening through which to pass urine and menstrual fluid.
Women who have been infibulated then have to be cut open to have sex or give birth, increasing the likelihood of infection. Luckily, Sandrine recalls little beyond abject pain as her legs were forced apart and she was held down by her own family while her clitoris was cut away. “I am happy to be coming to Dr Foldès, but I am also scared of my father finding out,” Sandrine says. “I have heard stories of women returning to Ivory Coast after surgery who are re-excised.”
Other forms of FGM are clitoridectomy, the partial or total removal of the clitoris, and excision, which involves the partial or total removal of the clitoris and the labia minora – the inner labia or lips – with or without the excision of the labia majora.
“Before I talk about reconstructive surgery the first consultation is to give women back their voice,” explains Foldès. “It is important that Sandrine said for the first time: ‘I have been excised.’ Until then she had been walled up in her own silence. Now she could pour out her suffering built up over many years.”
It was only then that Foldès showed Sandrine pictures of how genitally intact women appear, and explained to her how he could make her look and feel the same.
Foldès first encountered the traumatic effects of excision almost 30 years ago while on a World Health Organization mission in Burkina Faso – a landlocked country in West Africa where three out of four women were excised. “I was brought in to treat obstetric fistula but one day a 30-year-old pregnant woman came to see me, saying she was in great pain.”
When Foldès examined her, he saw that her clitoris had been cut and retracted and that hard scar tissue which had formed over it had attached itself to her pelvic bone.
“Her pain affected me profoundly. She hadn’t come looking for the joys of sex but simply an end to her physical suffering,” he says. “It was the moment that changed my life.”
Foldès gave her a local anaesthetic and managed to prise loose and delicately remove the scarring to reveal healthy tissue beneath. A small lump of clitoris remained. Word spread. More women came for surgery. Could he do more than just relieve their pain? What if there is more clitoris beneath the surface?
In Paris, Foldès began his research using MRI scans and ultrasound examinations on cadavers. His investigations revealed that the clitoris was much larger than previously thought – some 11 cm long – with most of it inside the body.
He was convinced he could cut the ligaments supporting it while preserving blood vessels and nerves that extended down the thighs and then re-anchor it to reveal an external portion that he could reconstruct to as near normal in shape and size to what had been excised. It would free women from pain and embarrassment and potentially give them sensation for the very first time in their lives.
Pierre Foldès was born in Paris in 1951. He was drawn to medicine and then to urological surgery because it was a relatively new field. “I was brought up in an academic family who wanted me to attend a Grande École. But I wanted to be hands-on and involved in something that was not just intellectual. The lucrative consulting rooms of Paris held no interest for me.”
Foldès believes that humanitarian aid is “high-level medical practice”, so he went to work with Médecins du Monde in some of the most dangerous places in the world. “I am powerless to stop wars, but I can assist those who suffer,” he says.
The father of five children, Foldès met his second wife, Beatrice, in Vietnam, where she was directing a hepatitis B project. The walls of his consulting room are filled with photographs, a collage of places where he has employed his healing skills in the wake of wars, earthquakes and torture. One picture is of a bullet hole in a wall.
“I have been shot at three times,” he says matter-of-factly. “This just missed me as I was operating in Kurdistan after Saddam Hussein gassed the Kurds in 1988.” On the wall behind his desk, there is a photograph that shows him standing beside Mother Teresa. He worked with her in 1989, tending to the sick and terminally ill in Calcutta. “She was my teacher,” he says fondly. “She taught me the way to listen.”
Foldès operated on his first FGM patient in Burkina Faso in 1986. It took him just 45 minutes to reconstruct her clitoris. The procedure was groundbreaking but relatively simple.
“When I handed her a mirror afterwards she was completely surprised and perhaps a little shocked at the anatomical change. FGM had had a significant impact on her body image. As she healed and recovered sensation she was amazed that the pain she had endured since childhood had gone.” Foldès smiles. It is a reaction he has seen thousands of times since.
Early on he was afraid that women would feel uncomfortable being operated on by a man. “But later I realised that the main issue for them was recovering normal physical status.”
Now, 30 years since that first patient, women come to Foldès from all over the world via the internet, medical referral and word of mouth. He operates on about 50 women a month and has a waiting list of 800. On the day of Sandrine’s operation, he has been on duty since 5am and has operated on nine other women, including patients from Canada, Mauritania, Kenya and Egypt.
He has shared his techniques with surgeons in Mali, Sénégal and Burkina Faso, where FGM has declined by 31 per cent over those same 30 years. An official follow-up study of 866 patients on whom Foldès had operated between 1998 and 2009 found that 821 reported a decrease in pain, 815 increased clitoral pleasure and 430 had experienced orgasms.
“My patients say it takes four to six months for them to feel anything, but surgery is only the beginning of recovery,” says Foldès, who has been awarded France’s Légion d’Honneur.
“Women have to learn to have something they never had.” Which is why in 2014 he opened the Institut en Santé Génésique at the hospital in Saint-Germain-en-Laye to monitor not just FGM survivors, but women who have suffered any form of physical or sexual violence.
Costing €250,000 a year to run, it follows a holistic approach and is staffed by a 25-strong volunteer team of psychologists, sexologists, lawyers, psychiatrists, nurses and social workers as well as patient-to-patient support groups.
A major issue with patients concerns trust, as psychologist Isabelle Valentin explains. “Those who have been excised have lost the ability to differentiate between good people and bad because it was their parents who had them cut. Their stories can be very hard to hear, but out of them comes a new birth.”
Reconstructive surgery costs around €3000 but Foldès does not usually charge. “These women have already paid a huge price,” he says. “We won the struggle to have the costs covered by French national insurance.”
Foldès returns to Sandrine’s bedside an hour after her surgery for full reconstruction. He asks how she is.
“I feel emotional but very happy. I am now whole again,” she says.
He smiles and turns and says, “Here, at last, women can feel the power of healing, but the healing power comes from them, not from me. I am just the surgeon.”