What is Female Genital Mutilation or Cutting?
All women, regardless of their age, are at risk of female genital mutilation or cutting (FGM/C) in societies and parts of the world that view this practice as a tradition. The reasons for FGM/C can differ significantly, often based on cultural values or religious beliefs. Some of these reasons can involve ideas related to marriage, virginity, sexuality, preventing promiscuity, and the general perception of womanhood. This harmful procedure affects millions of women and young girls around the globe.
The procedures linked to FGM/C can cause lasting pain, infections, difficulties during childbirth, and in extreme cases, death. Additionally, the psychological trauma caused by FGM/C can trigger long-term mental health problems like anxiety, depression, and post-traumatic stress disorder (PTSD). It’s widely recognized globally as a violation of human rights and a form of violence against women.
Efforts are being made worldwide to combat FGM/C, including education, advocating for the rights of affected women and girls, legal intervention, and community involvement. The goal of these efforts is to protect the rights of women and girls, put an end to the practice, and provide much-needed support and care for those who have been affected by FGM/C.
What Causes Female Genital Mutilation or Cutting?
In 1996, the World Health Organization (WHO) began using the phrase “female genital mutilation” to refer to different procedures that involve the partial or full removal of the female genital tissue but not for medical reasons. This practice has been referred to by various names, including “female circumcision”. But that term is not widely used any more because it reminds people of male circumcision, a very different procedure.
Type 1 of female genital mutilation, also known as clitoridectomy, involves removing the clitoral hood and some or all of the clitoris. It has two subcategories: Type 1a involves removing the clitoris or the clitoral hood only, while Type 1b involves removing both.
Type II, also known as excision, refers to removing the clitoris and partially or entirely removing the inner lips of the vagina without removing the outer lips. Type II also has three subclasses: Type IIa which only removes the inner vaginal lips; Type IIb removes the clitoris and the inner vaginal lips, either partially or totally; and Type IIc that removes the clitoris, and both inner and outer vaginal lips, either partially or totally.
Type III of female genital mutilation, called infibulation, is the most severe form. It consists of narrowing the vaginal opening by removing the inner vaginal lips, the outer vaginal lips either partially or totally, and then closing the vaginal area by stitching or pinning. The clitoral hood and the clitoris may or may not be removed. There are also two types for this: Type IIIa where the inner vaginal lips are removed and sewn up, and Type IIIb where the outer vaginal lips are removed and sewn up. Afterwards, a tiny opening is purposely left for urine and menstrual flow.
The least defined form, Type IV, includes any other harmful procedures performed on the external female genitalia, such as piercing, pricking, stretching, scraping, or burning.
People known as circumcisers or cutters perform female genital mutilation. They may be community elders, nurses, midwives, or even doctors. Usually, these operations are performed in non-sterile conditions and without anesthesia. They use tools like razor blades, knives, glass pieces, sharpened rocks, and scissors. People have given various reasons to justify these practices, such as religious and cultural obligations, avoiding shame for the person and their family, controlling sexual activity, enhancing male sexual pleasure, and improving hygiene and social status. Regardless of these reasons, social pressure plays a big part in keeping this tradition alive.
Risk Factors and Frequency for Female Genital Mutilation or Cutting
It is estimated that over 200 million women have experienced Female Genital Mutilation/Cutting (FGM/C), with approximately 2 million procedures carried out each year on girls under the age of 11. However, these statistics come from only 30 countries and likely do not represent the full global scope of this practice.
Historically, regions like Africa, the Middle East, and Asia have seen high rates of FGM/C. However, due to migration, its prevalence has spread worldwide. Some of the countries where a large number of women and girls living with FGM/C are: Egypt, Ethiopia, Tanzania, Somalia, Mali, Burkina Faso, Gambia, Guinea, Nigeria, Sierra Leone, Iraq, Iran, Yemen, India, Malaysia, and Indonesia.
According to UNICEF, FGM/C is particularly pervasive in countries like Somalia, Guinea, and Djibouti, where more than 90% of women and girls aged between 15 to 49 have undergone some form of FGM/C. Reports also reveal that an overwhelming 96.6% of girls in Sudan undergo FGM/C before they turn 6 years old.
Signs and Symptoms of Female Genital Mutilation or Cutting
When taking the medical history of a patient who is at risk for or has undergone female genital mutilation or cutting (FGM/C), it’s important not to make assumptions about her beliefs or her family’s beliefs. FGM/C is often bound up in generational tradition, so the issue needs to be approached with sensitivity and respect for its cultural significance. This practice may be hard for women to talk about due to its sensitive nature – particularly when it involves topics of sexuality.
During these discussions, it’s crucial that the healthcare provider uses language that isn’t perceived as judgemental. Many women worry about the stigma attached to FGM/C. Providers should familiarize themselves with the variety of terms used in different parts of the world to describe FGM/C, such as cutting, circumcision, or purification. It’s important to understand that many women and girls may not remember having the procedure, as they were very young at the time. So, gathering a medical history might require speaking with family members who are aware of the practice.
The physical examination needs to be conducted very carefully to ensure the patient feels safe and respected. It may be challenging to conduct pelvic examinations on women who have undergone FGM/C, and these should be done with extreme care. A genital examination includes looking at and inspecting the external genitalia to determine the type of FGM/C. The specific type of FGM/C may be identified by examining the prepuce, clitoris, and urethral opening. A detailed inspection, or the use of a speculum, might not be possible in situations where the labia minora or labia majora are pressed together. It’s essential to look out for complications such as scars, infections, or blockages in the genital region. In very young girls, it might be hard to locate the clitoris, so the prepuce might have to be retracted for correct identification.
Testing for Female Genital Mutilation or Cutting
At the moment, there are no studies or approved methods for assessing the advantages of screening for Female Genital Mutilation/Cutting (FGM/C), a harmful practice performed in some cultures. However, most health professionals recommend that patients where FGM/C is common should undergo screening to help anticipate potential pregnancy issues, prepare for what may be found during a pelvic examination, and evaluate any risks related to FGM/C.
In certain cases, your doctor might need to perform laboratory tests and imaging studies to look for immediate and long-term complications of FGM/C. Lab tests may check for infections such as sexually transmitted diseases or bacterial vaginosis, which are often found in individuals with FGM/C. Blood tests could help determine if there are any systemic—or whole-body—effects, like anemia, that are related to complications from FGM/C. Your doctor may also order a pelvic ultrasound to get a better view of your internal reproductive organs and to check for any blockages or abnormalities.
On top of physical health, FGM/C can have a big impact on psychological health, that’s why it is crucial for an individual’s mental and emotional health to be checked once FGM/C has been identified. Doctors might be looking for signs of depression, anxiety, post-traumatic stress disorder (PTSD), and issues concerning body image or sexual function.
Treatment Options for Female Genital Mutilation or Cutting
If you have undergone female genital mutilation/cutting (FGM/C), it is crucial to discuss its potential impacts on your sexual and reproductive health with your doctor. They should provide counseling about possible problems with sexual intercourse, periods, fertility, and childbirth. This discussion should focus on your concerns and preferences. If needed, your doctor may refer you to a gynecologist or sexual health counselor for further advice.
Surgical repair of FGM/C can sometimes be done to alleviate physical symptoms, such as chronic pain, frequent urinary and vaginal infections, and menstrual issues. It might also help to enhance sexual function, improve self-esteem, boost body image, and provide better outcomes during childbirth. However, these surgeries should not be taken lightly. To decide if surgery is the right choice for you, it’s essential to have in-depth conversations with your surgeon about your personal experience and goals. This decision-making process should factor in a thorough examination of the impacted area and an assessment of your psychological state. Your surgeon should thoroughly explain the reasons for the surgery, its risks, benefits, and possible alternatives. Remember that the surgeon performing FGM/C repair should be experienced and perform the procedure in a supportive environment.
Surgery’s primary goals are to restore normal anatomy and improve the function of the female genitalia. However, keep in mind that surgery cannot completely fix the physical or psychological issues caused by FGM/C. The surgical methods largely depend on the type and extent of the prior procedures. The risks include pain, bleeding, and infection, with potential long-term issues like sexual dysfunction, chronic pain, and FGM/C recurrence. It’s also important to note that surgery can potentially trigger psychological trauma linked to a patient’s FGM/C experience.
Several types of surgeries can be offered to address FGM/C complications. One method, often performed after Type I or II FGM/C, involves clitoral hood reconstruction and removing scar tissue to reshape the clitoris to improve its function and appearance. Excision and scar revision are typically offered for Type II or III FGM/C to remove scar tissue and reconstruct the genitalia. Procedures like vaginoplasty and deinfibulation target the vaginal opening, which might be compromised in Type III FGM/C. These aim to correct a narrowed vaginal opening for comfort during sexual intercourse and to prevent issues during childbirth. Often, combinations of these methods and multiple procedures are needed to restore both function and appearance.
Unfortunately, information about outcomes following FGM/C repair is limited due to the lack of access and standardization of these procedures. Still, some studies have shown high satisfaction rates and minimal complications. It’s worth noting that the assessment of pain and clitoral pleasure is not entirely accurate as it varies with individual and cultural influences. Lastly, due to restrictive access, perspective studies on surgical outcomes in countries where surgery is rarely accessible are unlikely.
Because complications related to FGM/C can be long-term, it’s important to have a plan for ongoing care. This care might include regular check-ups to monitor physical health and mental well-being. If you’ve undergone reparative surgery, your doctor should keep track of your surgical outcomes. Continued support and education can also help you manage any future health challenges related to FGM/C.
Supplemental support can be beneficial, too. Your doctor might refer you to community organizations, support groups, and legal resources to help you cope with the psychological, social, and legal challenges associated with FGM/C.
Last but not least, if you’re from a community where FGM/C is practiced, healthcare professionals should educate you on FGM/C’s health risks and preventive measures. This might include strategies to protect daughters or other family members from undergoing FGM/C, understanding the legal consequences, and connecting with community programs that strive to end this practice.
What else can Female Genital Mutilation or Cutting be?
When trying to diagnose Female Genital Mutilation or Cutting (FGM/C), doctors should be aware of other conditions that can cause changes to the female genitalia and might look similar. So, it’s crucial for clinicians to differentiate these conditions from FGM/C:
- Birth defects like labial agglutination or vaginal atresia which might cause abnormal genital shape in young girls
- Injuries from accidents or sexual abuse, which might mimic the appearance of FGM/C
- Sexually transmitted infections like genital herpes or syphilis that can cause scarring or sores,
- Scarring from previous surgeries such as episiotomies or other gynecological procedures
Doctors should take a careful patient history, examine thoroughly, pay attention to the patient’s cultural background, and check for any known history of FGM/C to help in their diagnosis. Recognizing the specific kind and level of FGM/C can also guide doctors on the correct treatment strategy and when to refer the patient to specialist care.
What to expect with Female Genital Mutilation or Cutting
The outcome for patients who have undergone FGM/C (Female Genital Mutilation/Cutting) can differ greatly. It depends on several factors such as the type and severity of the procedure, whether there are any complications, and if suitable medical and psychological care is available. Many women can manage or lessen the long-term impacts with prompt and thorough care. This care includes medical treatment for physical complications, psychological counseling, and support from their community.
It’s important to note that the patient’s access to care that respects their cultural background and their access to support systems can also crucially influence their overall health and quality of life.
Possible Complications When Diagnosed with Female Genital Mutilation or Cutting
FGM/C, short for Female Genital Mutilation/Cutting, has both immediate and long-term medical consequences. Direct problems that can happen right after the procedure include serious pain, excessive bleeding, damage to surrounding tissue and organs, infection, shock, and even death. There can also be less noticeable issues, like dislocated or broken limbs due to the lack of movement during the procedure, which is often carried out without anesthesia.
Chronically, there can be lumps forming around the wound area, hard scar tissue forming over time, cysts developing, pain while urinating, frequently returning urinary tract and vaginal infections, abnormalities in the urinary and reproductive systems, painful menstruation, blood trapped in the vagina, and issues with sexual functioning, including pain during intercourse, decreased satisfaction, and inability to reach orgasm.
Reliable data about FGM/C’s impact on childbirth outcomes is limited, however, several case studies and reports have mentioned complications such as difficult childbirth, excessive bleeding, obstructed labor which might lead to cesarean delivery, and newborn death. Women who have Type II and Type III FGM/C are reported to have a high chance of requiring a cesarean delivery or experiencing post-birth bleeding. The overall risk of an infant dying at birth is notably higher for infants born to women with Type I and II FGM/C, with an estimated 1 to 2 additional newborn deaths per 100 deliveries.
Additionally, those who have gone through infibulation, a type III of FGM/C, have to often undergo a procedure called deinfibulation. It involves cutting open the sealed vagina to facilitate intercourse or vaginal delivery. This procedure can lead to further health issues and risks, even death, particularly if repeated procedures are necessary, sometimes including re-infibulation after childbirth.
On the emotional side, these practices frequently lead to long-term psychological distress, including depression, anxiety, and Post-Traumatic Stress Disorder (PTSD). They can also contribute to postpartum depression.
Speaking in financial terms, the cost of dealing with obstetric issues related to FGM/C every year is also significantly high. It has been observed that in six African countries, these costs can amount to $3.7 million, and can represent between 0.1% to 1% of government health care spending on women aged 15 to 45 years old.
Common Health Issues:
- Immediate Severe Pain
- Excessive bleeding
- Damage to surrounding tissue and organs
- Infection
- Shock
- Potential for Death
- Dislocation or Fractures
- Long term formation of lumps
- Hard scar tissue
- Formation of cysts
- Pain while urinating
- Frequently returning infections
- Abnormalities in the urinary and reproductive system
- Painful menstruation
- Blood trapped in the vagina
- Issues with sexual functioning
- Increased childbirth complications
- Higher chance of newborn death
- Need for repeated procedures like deinfibulation
- Psychological distress
- High financial costs related to FGM/C repercussions
Preventing Female Genital Mutilation or Cutting
To stop Female Genital Mutilation/Cutting (FGM/C), various measures are being put in place. These include making and enforcing laws, educating communities, and getting community leaders involved in quitting the practice. This is done through campaigns organized by non-government organizations and professional groups. While these measures have helped reduce the incidences of FGM/C in many places, getting rid of the practice completely needs everyone in the community to work together.
Some common strategies to encourage people to stop the practice include offering alternative jobs and income sources for those who perform the cuttings. Other efforts involve training health workers on the harmful effects of FGM/C, and helping communities create different practices that hold cultural value.
These alternative practices involve teaching the community about family life and the roles of women, gift exchanges, and public celebrations.
In some parts of the world, efforts have been made to shift the practice from traditional circumcisers to trained healthcare providers. The idea here is to reduce the risks and harmful effects tied to FGM/C. This transition, known as the “medicalization” of FGM/C, relates to the acceptance of FGM/C as a cultural tradition, or the belief that the practice will continue regardless of efforts to prevent it. However, this shift is strongly criticized as it goes against medical ethics and human rights.
