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Effective evidence-based medicine: considering factors not included in research studies

Published:September 06, 2017DOI:https://doi.org/10.1016/j.ajog.2017.08.115
      To the Editors:
      Rouzi et al
      • Rouzi A.A.
      • Berg R.C.
      • Sahly N.
      • et al.
      Effects of female genital mutilation/cutting on the sexual function of Sudanese women: a cross-sectional study.
      recently published a cross-sectional study showing a direct correlation between the severities of mutilation and subsequent sexual dysfunction. The horrific practice of female genital mutilation/cutting has been carried out for thousands of years in different societies.
      I would be interested to know whether certain physiological or cultural aspects were taken into consideration during this research. According to the applied survey, a lower score increased the suspicion of sexual dysfunction.
      • Rouzi A.A.
      • Berg R.C.
      • Sahly N.
      • et al.
      Effects of female genital mutilation/cutting on the sexual function of Sudanese women: a cross-sectional study.
      A score of zero (0) was obtained when a participant replied “no sexual activity”/“did not attempt intercourse,” and fewer points were awarded for painful or less pleasurable sex. Why was intercourse not attempted?
      Of note, type III female genital mutilation/cutting was 1 of the 2 major subcategories of participants studied. These women also tended to be older and less educated and with more children.
      • Rouzi A.A.
      • Berg R.C.
      • Sahly N.
      • et al.
      Effects of female genital mutilation/cutting on the sexual function of Sudanese women: a cross-sectional study.
      There is no separate category for uninterested females suffering from loss of libido secondary to burdens of sustaining a household, fatigue, illness, postpartum injury, or feelings of low self-image.
      Some Sudanese follow the tradition of forced, cruel, and polygamous marriage.
      • Lawry L.
      • Canteli C.
      • Rabenzanahary T.
      • et al.
      A mixed methods assessment of barriers to maternal, newborn and child health in Gogrial West, South Sudan.
      Was the husband significantly older than the bride? Was he attending to a second spouse? Was he abusive? I propose that any of the previously cited factors are grounds for lack of interest and/or pleasure in sexual activity.
      I comprehend that such an extensive research endeavor may have been outside the scope and time constraint of this cross-sectional study and do not argue that female circumcision undoubtedly plays a role in dyspareunia. Nevertheless, I would have liked more conclusive information encompassing factors that may have skewed the data, and a great practitioner should keep these limiting factors in mind when practicing evidence-based medicine.

      References

        • Rouzi A.A.
        • Berg R.C.
        • Sahly N.
        • et al.
        Effects of female genital mutilation/cutting on the sexual function of Sudanese women: a cross-sectional study.
        Am J Obstet Gynecol. 2017; 217: 62.e1-62.e6
        • Lawry L.
        • Canteli C.
        • Rabenzanahary T.
        • et al.
        A mixed methods assessment of barriers to maternal, newborn and child health in Gogrial West, South Sudan.
        Reprod Health. 2017; 14: 12

      Linked Article

      • Effects of female genital mutilation/cutting on the sexual function of Sudanese women: a cross-sectional study
        American Journal of Obstetrics & GynecologyVol. 217Issue 1
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          Female genital mutilation/cutting (FGM/C) is a cultural practice that involves several types of removal or other injury to the external female genitalia for nonmedical reasons. Although much international research has focused on the health consequences of the practice, little is known about sexual functioning among women with various types of FGM/C.
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        American Journal of Obstetrics & GynecologyVol. 218Issue 1
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          We thank Ms Sakyi-Agyekum for her close review of our article.1 The points she raises emphasize the difficulty in assessing sexual functioning in women with female genital mutilation/cutting (FGM/C), and we encourage other researchers to investigate this issue, taking, for example, physiological and cultural covariates into consideration.
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