Tools
Female Genital Mutilation or Cutting
Introduction
Women of all ages are at risk of female genital mutilation or cutting (FGM/C) in societies and regions where this practice is a tradition.[1] Cultural and societal rationales vary. Justifications of FGM/C are often motivated by religious beliefs and cultural values surrounding marriage, virginity, sexuality, reduction of promiscuity, and the perception of womanhood.[1][2] The practices that encompass FGM/C affect millions of women and girls worldwide.
The associated procedures can result in chronic pain, infections, obstetric complications, and even death. Moreover, the trauma related to FGM/C can lead to lasting mental health issues, including anxiety, depression, and posttraumatic stress disorder (PTSD). Recognized globally as a human rights violation and a form of gender-based violence, efforts to combat FGM/C involve a multifaceted approach, including education, advocacy, legal intervention, and community engagement.[3] These efforts aim to protect the rights of women and girls, eradicate the practice, and provide care and support for those affected.
Etiology
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Etiology
In 1996, the World Health Organization (WHO) adopted the term “female genital mutilation” to describe the various types and subtypes of this procedure, which involve partial to complete removal of female genital tissue for nonmedical reasons. Multiple terms have been used to describe this practice, including “female circumcision”; the use of this term has widely fallen out of favor due to its comparisons to male circumcision, which mitigates the severity and extent of the practice.
Type I FGM/C, sometimes referred to as clitoridectomy, involves the removal of the prepuce, also referred to as the clitoral hood, and part or all of the clitoris.[4][5][6] It is further subdivided into Type 1a, which is the removal of the clitoris or prepuce only, and Type Ib, which is the removal of both the clitoris and the prepuce.[6]
Type II, also referred to as excision, involves the removal of the clitoris and partial or complete removal of the labia minora without excision of the labia majora.[6] Type II is further subclassified into type IIa, the removal of the labia minora only; type IIb, the partial or complete removal of the clitoris and the labia minora; and type IIc, the partial or complete removal of the clitoris, the labia minora, and the labia majora.[6]
Type III FGM/C or infibulation, which means “to fasten with a clip or buckle,” is considered the most invasive form of the practice and is frequently seen in African countries such as Somalia, Ethiopia, parts of Kenya, and Sudan.[4] This involves the intentional narrowing of the vaginal opening by complete removal of the labia minora, partial or complete removal of the labia majora, and closure of the vulva by stitching or pinning.[4][6] This can be performed with or without the partial or complete removal of the prepuce and the clitoris. Type III is further subclassified into Type IIIa, removal and subsequent apposition of the labia minora, and Type IIIb, removal and subsequent apposition of the labia major.[6] Typically, a narrow opening is purposefully left for urinary and menstrual outflow.[4]
Type IV FGM/C encompasses all other harmful procedures that may be performed on the external female genitalia, including piercing, pricking, stretching, scraping, or cauterization.[4][6]
Individuals who perform FGM/C are known as circumcisers or cutters and include community elders, nurses, midwives, and physicians.[7][8] These operations, rarely approached under sterile conditions and typically without anesthetics, have been performed using razor blades, knives, glass, sharpened rocks, and scissors.[8] Those who perform FGM/C provide many rationalizations to justify this practice, which include satisfying religious and cultural obligations, avoidance of shame for the individual and their relatives, decreasing sexual promiscuity, and enhancing male sexual pleasure, hygiene, societal status, and marriageability.[9] Regardless of the rationale, the societal pressure to practice this tradition is a strong motivator to continue the practice.
Epidemiology
Over 200 million women are estimated to have undergone FGM/C, with around 2 million procedures conducted annually on girls younger than 11.[4][7] This estimate is based on data from over 30 countries. However, these estimates are limited to published data and likely do not represent the global prevalence of this practice.[10]
Historically, Africa, the Middle East, and Asia have the highest prevalence of FGM/C.[7] However, migration has significantly influenced the prevalence and incidence of FGM/C worldwide. Documented countries with the highest prevalence of women and girls living with FGM/C include Egypt, Ethiopia, Tanzania, Somalia, Mali, Burkina Faso, Gambia, Guinea, Nigeria, Sierra Leone, Iraq, Iran, Yemen, India, Malaysia, and Indonesia.[7] According to UNICEF, FGM/C is nearly universal in Somalia, Guinea, and Djibouti, with more than 90% of women and girls aged 15 to 49 having undergone some form of FGM/C in Guinea and Somalia. Additionally, reports indicate that 96.6% of girls in Sudan routinely undergo FGM/C before the age of 6.[7]
History and Physical
When obtaining a medical history from a patient who has been affected by or is at risk for FGM/C, it is essential not to make assumptions about her or her family’s beliefs. For many patients, FGM/C is steeped in generational tradition. Thus, clinicians should be sensitive and not undermine the perceived cultural significance of this practice.[11] Providers should be mindful that FGM/C may be difficult for women to discuss, given its taboo nature, especially regarding sexuality.[5]
When interviewing patients, it is essential to avoid utilizing language that may be perceived as judgmental, as many women have concerns regarding the stigma associated with the practice.[5] Furthermore, clinicians should familiarize themselves with the different terms that are used to describe FGM/C in various regions, including cutting, circumcision, or purification.[5] It is essential to recognize that the majority of women and girls affected by FGM/C may not remember undergoing a procedure, given their young age. Therefore, history-taking may need to include the patient and relatives familiar with the practice.[5]
The physical examination must be conducted with utmost care, ensuring the patient feels safe and respected throughout the process. Pelvic examinations may be difficult to perform in women affected by FGM/C and should be approached with sensitivity. A genital examination should include visualization and inspection of the external genitalia to determine the type of FGM/C. The subtype of FGM/C may be determined by visualizing the prepuce, clitoris, and urethral meatus. Inspection and examination with a speculum may be difficult or impossible in the setting of apposed labia minora or labia majora.[5] Assessing for complications such as scarring, infections, or obstructive damage to the genital area is crucial. In prepubertal girls, initial identification of the clitoris may be difficult. Thus, the prepuce may need to be retracted to facilitate identification.[12]
Evaluation
Currently, no studies or validated tools exist to evaluate the benefits of screening for FGM/C.[5] To anticipate potential pregnancy-related issues, prepare for findings on pelvic examination, and assess FGM/C-related risks, most experts recommend screening patients from where FGM/C is a common practice.[5]
In select patients, laboratory and radiologic evaluations may be necessary to assess both immediate and long-term complications. Laboratory tests may include screening for infections, such as sexually transmitted infections or bacterial vaginosis, which can be more prevalent in individuals with FGM/C. Blood tests might also be used to assess anemia or other systemic effects related to complications. Pelvic ultrasounds can help visualize internal structures and identify any obstructive issues or abnormalities in the reproductive organs.
Additionally, FGM/C can have profound psychological effects. Thus, evaluating a patient's mental and emotional health is essential once she has been identified. The mental and emotional health assessment may involve assessing for symptoms of depression, anxiety, PTSD, and any issues related to body image or sexual function.
Treatment / Management
Given the potential impact of FGM/C on sexual function and reproductive health, clinicians should offer counseling on these topics. This includes discussing potential issues with sexual intercourse, menstruation, fertility, and childbirth. The patient's concerns and preferences should guide the conversation, and referrals to specialists like gynecologists or sexual health counselors may be necessary.
There are limited guidelines on surgical approaches to FGM/C repair, as this has mainly been described by various case reports. Indications for surgery include physical symptoms such as chronic pain, recurrent urinary and vaginal infections, and menstrual issues. Surgery can also potentially enhance sexual function, self-esteem, body image, and obstetrical outcomes. The decision to undergo surgery should involve shared decision-making between the surgeon and patient, considering the sensitive nature of each patient's experience and goals. A thorough preoperative exam and psychological assessment of the patient are necessary to assess the type and extent of FGM/C. The patient should be thoroughly counseled on the proposed procedure's indications, risks, benefits, and alternatives. Finally, FGM/C repair should be performed by a trained and experienced surgeon in a safe and supportive environment.
The goals of surgery include restoring normal anatomy and restoring or improving the function of the female genitalia while still understanding that surgery cannot cure the physical or psychological issues stemming from FGM/C. Surgical techniques largely depend on the type and extent of the prior procedures performed and when and how they were executed. Risks of surgical repair include pain, bleeding, infection, and scarring. Long-term risks include sexual dysfunction, chronic pain, and possible recurrence of FGM/C. Surgical repair potentially risks triggering psychological trauma from a patient's experience with FGM/C.
Several types of procedures have been documented to address complications from FGM/C. One method involves clitoral hood reconstruction and clitoroplasty. This method is commonly performed after Type I or II FGM/C and involves constructing a clitoral hood using autologous skin flaps to protect the exposed clitoris.
Clitoroplasty is the removal of scar tissue to reshape the clitoris to improve function and appearance. Excision and scar revision are typically reserved for Type II or III FGM/C to remove scar tissue and reconstruct the labia minora and majora. Local skin flaps or grafts are utilized to restore the appearance of the genitalia.
Vaginoplasty addresses the vaginal opening, which is often compromised in Type III FGM/C, or infibulation, and involves the removal of scar tissue from the introitus to correct a narrowed vaginal introitus. This is often performed for dyspareunia and prevention of obstructed labor. Deinfibulation is achieved by making a vertical incision over the scar tissue to expose the introitus and urethra. A combination of these techniques and multiple procedures may be necessary to address and restore both function and appearance.
Data on the surgical outcomes following FGM/C repair are limited due to a lack of access and standardization among these procedures. Studies regarding deinfibulation have shown high satisfaction rates with minimal surgical complications.[13] Clitoral hood reconstruction and clitoroplasty have also been reported to restore sexual pleasure and decrease pain.[14] Yet, it is essential to note that no scales currently exist to precisely assess pain and clitoral pleasure. Personal experience and willingness to disclose surgical outcomes are individually and culturally driven. Lastly, studies assessing surgical outcomes are unlikely to be performed in countries where reconstructive surgery is rarely accessible. This poses a challenge to creating robust prospective studies with long-term follow-up data aligned with the intent of creating evidence-based techniques.
FGM/C-related complications can be long-term, so establishing a plan for ongoing care is crucial. This may include regular follow-up visits to monitor physical health, mental well-being, and any surgical outcomes if reparative procedures are performed. Continuous support and education can also help the patient navigate any future health challenges related to FGM/C.
Patients may benefit from additional support beyond what is provided in the clinical setting. Referrals to community organizations, support groups, and legal resources can help the patient access broader support networks. These services can offer assistance with the psychological, social, and legal challenges related to FGM/C.
For patients from communities where FGM/C is practiced, healthcare professionals should provide education on the health risks associated with FGM/C and discuss preventive measures. This might include strategies for protecting daughters or other family members from undergoing FGM/C, understanding the legal ramifications, and connecting with community advocacy programs that work to end the practice.
Differential Diagnosis
The differential diagnosis for FGM/C requires distinguishing it from other conditions that can cause alterations or trauma to the female genitalia. Clinicians should consider congenital anomalies, such as labial agglutination or vaginal atresia, which may present in young girls and adolescents with anatomical differences similar to some forms of FGM/C.[12] Traumatic injuries, whether accidental or related to sexual abuse, can also mimic the appearance of FGM/C and should be thoroughly investigated. Infections like genital herpes or syphilis may lead to scarring or ulceration that could be mistaken for FGM/C-related changes. Furthermore, iatrogenic conditions, such as scarring from previous surgeries like episiotomies or other gynecological procedures, must be differentiated from FGM/C. A careful history and examination, with attention to the patient's cultural background and any known history of FGM/C, are crucial in accurately diagnosing and differentiating FGM/C from these other conditions. Understanding the specific type and extent of FGM/C is also essential, as identifying the type can guide appropriate management and referral to specialized care.
Prognosis
The prognosis for patients with FGM/C varies widely depending on the type and severity of the procedure, the presence of complications, and the availability of appropriate medical and psychological care. Many women can manage or mitigate the long-term effects with timely and comprehensive care, including medical treatment for physical complications, psychological counseling, and community support. Importantly, the prognosis also depends on the patient’s access to culturally sensitive care and available support systems, which can play a critical role in their overall well-being and quality of life.
Complications
FGM/C has acute and chronic consequences and medical complications. Acute complications include but are not limited to severe pain, excessive bleeding, injury to surrounding tissue and structures, sepsis, shock, and death. Additional and less apparent complications include limb dislocation and fracture secondary to restricting movements during these procedures, which are routinely performed without anesthesia.[1][7] Long-term complications include clitoridal cysts, keloids, neuromas, dysuria, recurrent urinary tract infections, recurrent vaginal infections, genitourinary fistulae formation, dysmenorrhea, hematocolpos, and sexual dysfunction including dyspareunia, decreased satisfaction, and anorgasmia.[15]
While reliable evidence about the effects of FGM/C on obstetrical outcomes is scarce, various studies and case reports cite difficult delivery, excessive bleeding, obstructed labor leading to cesarean delivery, and newborn death as some of the related complications.[16] Women with Type II and Type III FGM/C have been reported to be significantly more likely to experience cesarean delivery and postpartum hemorrhage.[17] The overall risk of perinatal death has been reported to be significantly higher in infants born to women with Type I and II FGM/C.[17] FGM/C is estimated to result in 1 to 2 additional perinatal deaths per 100 deliveries.[17]
Patients who have undergone FGM/C, specifically infibulation or type III FGM/C, are often subjected to deinfibulation, which is the practice of cutting open the sealed vagina to allow for sexual intercourse and vaginal delivery. This can lead to additional morbidity and mortality related to subsequent multiple procedures, sometimes involving infibulation after childbirth. These consequences, however, do not encompass the devastating long-term psychological problems that arise from such practices, including depression, anxiety, and PTSD, which may also contribute to postpartum depression.
From an economic standpoint, there is also a significant impact on the annual costs of FGM/C-related obstetric complications. Obstetric complications in 6 African countries have been shown to amount to $3.7 million and ranged from 0.1% to 1% of government spending on health care for women aged 15 to 45 years.[18]
Consultations
Patients with FGM/C often require a multidisciplinary approach to address the complex physical, psychological, and social needs resulting from the procedure. Initial consultations with a gynecologist are crucial for assessing and managing any immediate and long-term physical complications, such as infections, scarring, and reproductive health issues. A mental health professional, such as a psychologist or counselor, should be involved in providing support for emotional and psychological trauma, including anxiety, depression, and PTSD. In cases where surgical intervention is needed, a specialist in reconstructive or restorative surgery may be consulted to discuss options for repair and management of physical effects. Additionally, a social worker or case manager can help navigate the patient’s access to community resources, legal support, and advocacy services, particularly if there are concerns about the ongoing risk of FGM/C or related issues within the family.
Deterrence and Patient Education
To thwart FGM/C, efforts have included instating and enforcing legislation, community education, and the engagement of community leaders in abandoning the practice via awareness campaigns from nongovernmental organizations and professional bodies.[7][19] While many of these measures have been successful in decreasing the incidence of FGM/C in many regions, the complete elimination of this practice requires coordinated interventions that engage entire communities. Popular approaches in the collective abandonment of the practice focus on the provision of alternative vocations and sources of income for circumcisers, the training of health professionals on the consequences of FGM/C, and empowering communities to establish alternative rites that hold cultural significance.[19] Such alternative rites of passage involve community education regarding family life and women's roles, exchanging gifts, and public celebrations.[20]
Some regions of the world have made efforts to shift the practice from traditional practitioners and circumcisors to trained healthcare providers to reduce the adverse outcomes and risks associated with FGM/C. The medicalization of FGM/C is rooted in the acceptance of FGM/C as a traditional cultural practice or the belief that the practice will continue regardless of prevention efforts.[3] However, this shift is widely condemned as it violates medical ethics and abuses human rights.
Pearls and Other Issues
While many societies view FGM/C as an effective and acceptable method of controlling women’s attitudes toward sexuality and gender roles, these beliefs have changed because of the increasing awareness of the resulting complications.[4][7] The growing concern about the FGM/C’s violation of basic human rights has resulted in a global response calling for its termination. Since the establishment of the joint United Nations Population Fund and United Nations Children’s Fund Program on the Elimination of Female Genital Mutilation, 13 countries have passed national legislation banning FGM/C.
According to UNICEF, today, girls are one-third less likely to be subjected to FGM/C compared to 30 years ago. Despite decades of concerted efforts to eradicate or abandon the practice, present efforts have not yet been able to effectively curb the number of women and girls subjected to this practice.[3] The United Nations Population Fund estimates that over 4 million girls are at risk of FGM/C each year. In 2021, an additional 2 million cases of FGM/C were predicted to occur over the next decade as a result of COVID-19-related school closures and disruptions to programs that help protect girls from the practice.[21] UNICEF estimates that by 2030, nearly 1 in 3 girls worldwide will be born in the 31 countries where FGM/C is most prevalent, putting an additional 68 million girls at risk.
Enhancing Healthcare Team Outcomes
Societal and cultural influences often create unique challenges for healthcare professionals who are working with women and girls who have undergone FGM/C. Clinicians are often reluctant to address this topic because they may feel they have no role in addressing traditional practices. Furthermore, the majority of healthcare training programs and residencies are not equipped with the training or tools needed to recognize or provide screening for those who have undergone or are at risk of FGM/C.
The treatment of affected individuals requires a comprehensive approach to care and the establishment of an interprofessional referral network. This team should include obstetricians and gynecologists, adolescent gynecologists, urogynecologists, advanced practitioners, pelvic floor physical therapists, and mental health professionals.[5]
Finally, because FGM/C is a human rights violation, healthcare professionals should be cognizant of the legislation concerning FGM/C and associated mandatory reporting duties. In 1996, the United States established a federal ban on performing FGM/C on girls younger than 18 years. The Transport for Female Genital Mutilation Act was amended in 2013 to include “vacation cutting,” the transportation of women and girls out of the country for FGM/C.[5] Individuals who violate these laws face penalties of fines, imprisonment for no more than 5 years, or both. At present, 26 states instated laws prohibiting FGM/C. Of these, 11 states explicitly ban vacation cutting.[5]
According to UNICEF, the number of girls and women undergoing FGM/C will be higher in 2030 than it is today if global efforts are not significantly escalated. The WHO states that treatment of the health complications of FGM/C is estimated to cost health systems $1.4 billion per year, a number expected to rise unless urgent action is taken towards its abandonment. Interprofessional healthcare teams must be empowered to recognize and treat patients affected by FGM/C and to engage with global and community efforts to advocate against and eradicate FGM/C.
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