On the “International Day to End Obstetric Fistula” — 23 May – UnCUT/VOICES calls out failure to mention one preventable cause: FGM

The United Nations writes: “Obstetric fistula is one of the most serious and tragic injuries that can occur during childbirth. It is a hole between the birth canal and the bladder or rectum caused by prolonged, obstructed labour without treatment.”[1] What the U.N. does not write is that female genital mutilation (FGM) increases the risk of VVF (vesico-vaginal fistula), especially in younger mothers whose pelvis is not yet mature. “The condition typically leaves women incontinent,” the UN goes on to point out, “and as a result they are often shunned by their communities … endur[ing] depression, social isolation and deepening poverty. Many … live with the condition for years – or even decades – because they cannot afford to obtain treatment.”

FRFRF Trustees
Trustees of the Clitoris Restoration and Fistula Repair Fund l to r Hilary Burrage, Nolan Victory, Dr Tobe Levin von Gleichen, Dr Phoebe Abe with Dianna Martin, patients’ host in France, at Lady Margaret Hall, University of Oxford

“An estimated 2 million women in sub-Saharan Africa, Asia, the Arab region, and Latin America and the Caribbean are living with this injury, and some 50,000 to 100,000 new cases develop each year.”

Granted, not all of these females have also suffered FGM. Fistula, for instance, had been a nineteenth century problem in the USA and Europe.[2] Nonetheless, the UN falls short of its own mission, not merely to repair but also to PREVENT this dismal outcome. Comforting readers by assuring us that “fistula is almost entirely preventable,” the UN offers a wholly inadequate explanation. “Its persistence is a sign that health systems are failing to meet women’s essential needs.” They are indeed remiss by not financing operations that sufferers desperately need. But burying FGM, a human-authored scourge, behind impersonal ‘systems’ does a disservice to the aim of abolition.

Admittedly, of course, the international body intends to prevent: “In its resolution A/RES/67/147, the General Assembly calls on the international community to use the International Day to significantly raise awareness and intensify actions towards ending obstetric fistula.”

UnCUT/Voices is answering this call with an excerpt from prize-winning novelist Hubert Prolongeau’s ground-breaking biography, Undoing FGM. Pierre Foldes the Surgeon Who Restores the Clitoris. Foreword Bernard Kouchner. Trans. and Afterword Tobe Levin. Frankfurt am Main: UnCUT/VOICES Press, 2011. The following passages from Chapter 3, “His first patient,” provide a prologue to the discovery of clitoral restoration.

“Mission fistula”

[Jean-Antoine ] Robein [a pioneering physician] convinces his friend to join him in the battle to prevent and cure this curse. Looking for teams of African physicians able to deal with fistula, they find only two: one led by Dr. Hamelin in Addis Ababa, the other by Dr. Ben Chekroun in Rabat, and that won’t do! So they separate to pay both men a visit. Robein leaves for Addis, Foldes for Rabat, to learn to repair such harsh trauma. They bring videos with them. Later, the head of Foch Hospital will invest the first days of retirement in editing a handbook on fistula. Undoing cover

Pierre lands in Rabat, suave Moroccan capital, discrete and charming little sister to the booming Casablanca. He finds Dr. Ben Chekroun, a specialist in urology who studied at Pierre’s alma mater and did his residency at Necker Hospital. The man is not without enemies. In the public eye, he has been subject to more than a little jealousy. Surgeon to the king, the royal family’s urologist, lifetime member of the French Association of Urology, he lives in a house in Rabat that shares a wall with the sister of Hassan II – all this to say he’s beyond reach. And he knows it. He’s a mandarin but very open to other elites, and this includes Foldes who, in spite of himself, feels close to Chekroun because Chekroun isn’t one of the privileged who just sits on a pension. He’s inventive, trying to import urological techniques from Europe. Faced with various kinds of urinary cancer, a type of pathology frequent in Africa, he adapted the art of the stoma or artificial opening to local conditions. To overcome the absence of disposable pouches he pioneered a subcutaneous technique without a pouch using catheters that could be reused after sterilization by immersion in alcohol, a thoroughly empirical procedure. “We modified modern processes to serve African realities instead of buying expensive materials that proved useless. The approach really impressed me. How often had I seen the opposite result, instruments left untouched. What a monstrous waste.”

After fine-tuning the urological procedure, Ben Chekroun then turned to fistula; he invented an artificial urethra, constructed from the remaining tissue of the vagina or urethra to recreate a conduit. Together with Foldes, he would describe and inventory repair techniques that had not existed before and produced a manual with which to confront the damage. “It was a passionate inversion of the usual North-South dialogue. We went South not as scalpel musketeers carrying the good news of Northern medical advances. No. This time Africans knew what to do, and we descended upon them to learn, to imitate and witness our two kinds of knowledge embrace for the benefit of sufferers everywhere. It’s a magnificent way to work.” The two men would go on to make films about their mutual experience; these would be shown in Saint-Germain-en-Laye.

Robein later asked Pierre to join him in launching “fistula missions.” They decided to leave for Africa, Jean-Antoine for Ethiopia, Mali and Niger where he would focus on hospitals, and Pierre for Morocco and Burkina Faso. The WHO commissioned the project to evaluate treatments possible in rural maternity clinics, seek out midwives’ networks, and evaluate their training and mortality figures. Yet, as his plane was landing in Ouagadougou, Dr. Foldes remained unaware of how what he was soon to find would change his life.

The next section, The Ouaga Patient, records Foldes’ meeting with the woman who leads him to discover that clitoral function can be restored. This triumph, in turn, has benefited more than 5000 women and is the main subject of Hubert Prolongeau’s book.

Books, of course, address a reading public. Broader approaches imply personal outreach and for that, the Clitoris Restoration and Fistula Repair Fund (CRFRF) (UK charity # 1169186) was created.

For further information about the fund or to order the book at a 40% discount, email Tobe Levin von Gleichen

Tobe.levin@uncutvoices.com     or      tlevin@fas.harvard.edu


[1] http://www.un.org/en/events/endfistuladay/ Retrieved 23 May 2017.

[2] See for instance Ojanuga, D. The medical ethics of the ‘father of gynaecology’, Dr J Marion Sims. Abstract: “Vesico-vaginal fistula (VVF) was a common ailment among American women in the 19th century. Prior to that time, no successful surgery had been developed for the cure of this condition until Dr J Marion Sims perfected a successful surgical technique in 1849. Dr Sims used female slaves as research subjects over a four-year period of experimentation (1845-1849). This paper discusses the controversy surrounding his use of powerless women and whether his actions were acceptable during that historical period.”

http://dx.doi.org/10.1136/jme.19.1.28 Retrieved 23 May 2017.



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