Female Genital Cutting
Grand Rounds Presentation
April 13, 2012
Erin Black, PGY3
Objectives
To understand the historical and cultural
significance of female genital cutting (FGC)
and its prevalence worldwide
To recognize the various types of FGC and
their management protocols
To develop the skills necessary for delivering
appropriate care to circumcised women
To understand the legal and ethical issues
pertaining to FGC
Background
Female Genital Cutting (FGC), also known as
female circumcision or genital mutilation refers to a number of practices that involve
the cutting of a female’s external genitalia.
FGC is estimated to have affected over 130
million females worldwide
Because of recent immigration patterns,
women’s healthcare providers will
increasingly encounter patients who have
undergone FGC.
What is FGC?
“All procedures involving partial or total
removal of the external female genitalia
or other injury to the female genital
organs whether for cultural or other
non-therapeutic reasons.”
 World Health Organization. Female Genital Mutilation: a joint
WHO/UNICEF/UNFPA statement
 Geneva: WHO, 1997.
What is FGC?
FGC is generally performed by a
medically untrained person - however,
the circumciser will vary from culture to
culture.
In some cultures, the person
performing the act of FGC has limited
medical training - midwives, nurses,
and some physicians.
Many different names have been used
to describe FGC - “female circumcision”
or “female genital mutilation”
It is important to recognize that most
women who have undergone FGC, do
not recognize themselves to be
mutilated
Most are offended by the term mutilation.
Health care providers should determine
how each woman refers to this practice
and adopt individual terminology.
FGC is performed predominately on
girls aged 8-12
In some cultures, it is performed several
months after birth
In other cultures, it is performed closer to
marriage
Origins
There is no definitive evidence
documenting when or why this ritual
began
Some theories suggest that it was
practiced in ancient Egypt, as a sign of
distinction
Other theories suggest its origin in ancient
Greece, Rome, Pre-Islamic Arabia, and
Russia
It is crucial to recognize that FGC is
unrelated to Islam.
It is not mentioned in the Qur’an, or the
Hadith.
FGC is not required by any religion
FGC is practiced by members of Jewish,
Christian, Muslim, and indigenous religions
Although FGC is practiced
predominately in Africa, variations have
been found in Yemen, UAE, Malaysia,
Indonesia, Pakistan, and India.
Until the mid-20th century, some US
physicians performed clitoridectomies to
treat erotomania, lesbianism, hysteria, and
clitoromegaly
Worldwide Perspective
African Perspective
Reprinted with permission from: United Nations Children’s Fund. Coordinated strategy to abandon female genital
mutilation/cutting in one generation: a human rights-based approach to programming. New York (NY): UNICEF; 2007.
Available at:
http://www.childinfo.org/areas/fgmc/docs/Coordinated_Strategy_to_Abandon_FGMC%20_in_One_Generation_eng.
pdf. Retrieved August 31, 2007.
US Perspective
Of the at-risk population, close to 63%
live in 7 states:
California, Minnesota, NY, New Jersey,
Maryland, Texas, and Virginia
46% live in 5 metropolitan areas:
New York-New Jersey, Washington-Baltimore,
Los Angeles-Riverside-Orange County,
Minneapolis-St. Paul, and San FranciscoOakland-San Jose areas
Minneapolis - St. Paul
New York - New
Jersey
San Francisco
Washington Baltimore
Los Angeles
Data obtained from African Women’s Health Center, Brigham and Women’s Hospital.
Why is FGC Performed
In some cultures, the practice of FGC is
based on love and the desire to protect
A cultural norm - a tradition allowing
young females their inclusion into society
A rite of passage from childhood to
womanhood
The lack of research pertaining to FGC
presents a major difficulty in obtaining
accurate statistics.
It is estimated (in 2000) that up to 228,000
females in the US had undergone FGC or
were at risk for the practice
Of the at-risk females, 27% were < 18 years old
An increase of 35% when compared to data collected in
1999.
Why is FGC performed
FGC is seen as protection in some
societies
In cultures that practice FGC, virginity is
prized because it ensures marriagability.
It is strongly believed that only a circumcised
woman is desirable for marriage
Uncircumcised woman are usually outcast
Cultural Beliefs
In some societies, the practice of FGC is
driven by cultural beliefs
The clitoris is considered unattractive
The clitoris is believed to contribute to
infertility
The clitoris may be considered lethal
If the clitoris comes into contact with a baby’s
head during birth, the newborn may die.
Lastly, in some societies, a narrow
vaginal opening is believed to heighten
men’s sexual pleasure
In reality, many men are unable to
penetrate the narrow vaginal opening and
experience sexual dissatisfaction.
Types of FGC
The WHO has classified FGC into 4
types, based on the extent of genital
excision
Type
Type
Type
Type
I
II - Excision
III - Infibulation
IV - Other
FGC: Type I
Excision of the prepuce and/or partial
or total clitoridectomy
The mildest form
Because healing results in a smooth scar Type I FGC may be missed by the
untrained examiner
Courtesy of Nawal M. Nour, MD, MPH
FGC: Type II - Excision
Removal of the clitoris, accompanied by
partial or total excision of the labia minora
The most common form of FGC
Approximately 80% of FGC cases
Although no stitching is performed during Type II
FGC, deep cutting of the labia minora may result
in raw surfaces that fuse together during healing
Creating a false infibulation or pseudo-infibulation
Courtesy of Nawal M. Nour, MD, MPH
Type II FGC
Courtesy of National Committee Against Excision, Burkina Faso, © RAINBO
FGC: Type III - Infibulation
Partial or total removal of the external female
genitalia, and
Infibulation
Reapproximation of the remnant labia majora
Creation of a neo-introitus
- Approximately 15% of FGC cases
- Extensive damage may be done to the external genitalia,
resulting in immediate and long-term health consequences.
- Although Type III is mainly described as involving cutting of
the clitoris, some women may have infibulation over an
intact clitoris.
Courtesy of Nawal M. Nour, MD, MPH
Type III FGC
Courtesy of Nawal M. Nour, MD, MPH
FGC: Type IV - Other
Describes any other form of genital
manipulation
Pricking, piercing or incising
Stretching
Cauterization
Corrosive substances
Manipulation
Health Complications of FGC
Anesthesia may or may not be administered
Instruments may include knives, razors, or
heated stones
 Instruments may be old, rusty, or dull
 Instruments may not be cleaned between each
procedure
Hemostasis via catgut suture, egg, warm oil,
tar, dough, or animal excrement
Girls’ legs may be bound at the ankles,
above the knees, or at the thighs
 The girls may lie in this immobilized position for
approximately one week, during the healing process.
Immediate Complications of
FGC
Although numerous, they are rarely seen in
the US
Complications depend on the severity of the
procedure
Hemorrhage (4-19%)
 Laceration of the dorsal artery of the clitoris, or the labial
branches of the pudendal artery
Fever (22%)
Acute cellulitis (15%)
Tetanus (2%)
Sepsis (2%)
Type III FGC is especially prone to
complications
Binding the legs during the healing process
interferes with wound drainage and may
promote upward spread of infection
Oliguria secondary to dehydration, urinary
retention, and injury to the bladder and/or
urethra may also occur
Long Term Complications of
FGC
Common
Dysmenorrhea, dyspareunia, urinary
issues, infection(s), infertility
Rare
Hematocolpos, keloids, fistula
*psychosocial issues
*most long-term complications are seen in women with Type II and
III FGC
Keloid Formation
Courtesy of CNLPE,
Burkina Faso, © RAINBO
Inclusion Cyst Formation
Courtesy of Douglas W. Laube, MD
Documentation of short- and long-term
complications are unreliable, as families
rarely seek medical attention for fear of
prosecution
It is important to note that not all
women undergoing FGC experience
complications
For these women, acknowledging their
circumcision may be the most culturallysensitive and appropriate health care
practice
Is HIV transmission increased?
2 theories
At the time of circumcision - the same instrument may
be used to circumcise many girls
At the time of intercourse - the small neo-introitus (Type
III) may become more traumatized during intercourse.
Open lacerations could provide and easy site for HIV
transmission
Currently, studies have not shown an increase in HIV in
FGC populations*
 *statistics may not be as accurate, due to under-reporting
of FGC
FGC: Obstetric Challenges
Those with Type I or II FGC are less
likely to experience obstetric difficulties.
Those patients having undergone Type
III FGC may pose the greatest risk
Narrow neo-introitus
Difficult
Difficult
Difficult
Difficult
to
to
to
to
perform accurate cervical exams
place internal monitors (FSE, IUPC)
place Foley catheter
deliver fetal head
What if a patient presents in labor with an
infibulation scar?
An anterior incision (defibulation) may be
considered
Consider blood loss, patient discomfort, psychosocial
concerns
If a defibulation incision is not performed
The fetal head may lacerate the perineum causing
hemorrhage
Due to the high resistance at the introitus, the 2nd stage
of labor may be prolonged
It is important to discuss with your
patient the possible obstetric challenges
FGC patients should be given an adequate
trial of labor
Cesarean Deliveries should be offered only
for specific fetal and maternal indications
FGC: Obstetric Challenges
Studies have documented an increased risk
of:
Cesarean Deliveries
Postpartum hemorrhage
Perineal lacerations
Wound infections
Prolonged 2nd stage of labor
Separation of episiotomy scars
Extended maternal hospital stay
Sepsis
FGC: Fetal Complications
Studies (in developing nations) have also
documented an increased risk of:
Lower APGAR scores
Infant resuscitation
Low birth weight
Neural damage
IUFD
Majority of complications occurred among women with FGC
Type III
Complications are unlikely to occur as frequently in the US
because of extensive fetal monitoring and access to
operating facilities.
Defibulation
AKA De-infibulation
Anterior incision that opens up the
infibulation scar
Recreating the labia majora
Removing the obstruction
More difficult in patients with
Infibulation inclusion cysts, abscesses, or
extensive keloid formation
Benefits of Defibulation
Even in a patient who has not suffered FGC
complications, Defibulation may prevent
potential future complications.
Defibulation may decrease the incidence of
Chronic urinary tract infections
Vaginitis
Dysmenorrhea
Labor complications
Dyspareunia
Issues surrounding
Defibulation
Optimum timing of Defibulation procedure
May be performed at any time during a woman’s
life
May be preferential to perform prior to the first coital
experience
 Decreased perineal lacerations, pain, infection, bleeding
The medically optimal time for performing
Defibulation may not be the best time socially or
psychologically for the patient.
In pregnant women, Defibulation can
be safely performed during the 2nd
trimester, or at least 4-6 weeks prior to
delivery.
Timing allows for healing of the incision
prior to labor
Regional anesthesia recommended due to
decreased fetal and maternal risks
General and Local anesthesia are also options
Defibulation Counseling
Counseling regarding the benefits of
Defibulation may take time and may require
multiple visits.
Patients may not feel the procedure is necessary
Risks of a surgical procedure
Bleeding, infection, etc.
Psychosocial issues
Cultural beliefs
Defibulation Procedure
In Brief,
Local, regional, or general anesthesia
Anterior Incision
Subcuticular, absorbable sutures placed on
the newly formed labia
Long-acting local anesthesia
Assurance of hemostasis, and placement of
urinary straight catheterization
FGC and Physician
Competency
To appropriately care for a woman with FGC,
the physician should display cultural
competence
There are many similarities and differences among
women who have undergone FGC
A routine gyn exam may require more explanation
and time
Counseling needs and psychosocial issues should
be considered
Be SENSITIVE !
Acknowledge the patient’s individual and cultural beliefs
FGC Questions and
Considerations
Circumcised women may have language
barriers - they may communicate
primarily through their husband or
other family members
Some FGC patients may request
postpartum Reinfibulation
What if a minor requests confidential
Defibulation?
In 1997, it became a US federal crime
to perform FGC on a girl < 18 years of
age
Applies to the person performing the
procedure and the person consenting for
the procedure
Questions?
References
 Female Genital Cutting: Clinical Management of Circumcised
Women, 2nd edition. ACOG 2007
 World Health Organization. Female genital mutilation - a joint
WHO/UNICEF/UNFPA statement. Geneva: WHO; 1997
 http://www.who.int/reproductivehealth/publications/fgm/fgm_statement.html.
 http://www.state.gov/g/drl/rls/hrrpt/2006.
 http://www.brighamandwomens.org/africanwomenscenter/FGC
metro.aspx.
 http://www.who.int/mediacentre/factsheets/fs241/en/.