1
Infectious Complications after Type I Female Genital
Mutilation
Abdulrahim A. Rouzi , MB, ChB, FRCSC
Departments of Obstetrics and Gynecology at King Abdulaziz
University Hospital, Jeddah, Saudi Arabia
Corresponding author
Abdulrahim A. Rouzi
Associate Professor
Department of Obstetrics and Gynecology
King Abdulaziz University Hospital
P.O. Box 80215 Jeddah 21589
Kingdom of Saudi Arabia
E-mail address aarouzi@hotmail.com
2
Infectious Complications after Type I Female Genital
Mutilation
Introduction:
Female genital mutilation (FGM) is defined as procedures that involve
partial or total removal of the female external genitalia and/or injury to the
female genital organs for cultural or any other non-therapeutic reasons
(WHO 2000). The practice is of different types according to the degree of
damage to the female external genitalia. Many classifications exist. The
most commonly used is the World Health Organization (WHO)
classification of four types (WHO 1996). Type I is excision of the prepuce,
with or without excision of part or all of the clitoris, Type II is excision of
the clitoris with partial or total excision of the labia minora; Type III is
excision of part or all of the external genitalia and stitching/narrowing of the
vaginal opening (infibulation), and Type IV is unclassified [pricking,
piercing or incising the clitoris and or labia; stretching of the clitoris and/or
labia; cauterization by burning off the clitoris and surrounding tissue;
scraping of tissue surrounding the vaginal orifice (angurya cuts) or cutting of
the vagina (gishiri cuts); introduction of corrosive substances or herbs into
the vagina to cause bleeding or for the purpose of tightening or narrowing
it]. The least invasive form is called Sunna circumcision (subtotal
3
clitoridectomy). It is the only type which can be truly considered as
circumcision even by the Council on Scientific Affairs of the American
Medical Association (American Medical Association Council on Scientific
Affairs 1995). Under the WHO classification it is included as Type I.
Complications after Sunna circumcision are very rare. The objective of this
case series was to report the occurrence of vulval sepsis and abscess
following Sunna circumcision.
Materials and Methods:
Case 1:
A two-month old girl was seen in the out-patient clinic because of severe
infection in the external genitalia of three days duration. She was taken by
her grand-mother five days before to a Daya (local elderly mid-wife) for
Sunna circumcision. On examination she was stable but her temperature was
38.7 degrees Celsius. Local examination revealed signs of moderate
inflammation of the vulva especially around the clitoris. There was pus at
the site of cutting of the genitalia. Cultures were taken. She was treated with
antibiotics and local cleaning of the area. Follow-up visits revealed that she
responded to the treatment without further immediate consequences.
4
Case 2:
A ten-years-old girl presented with fever and painful mass in the vlulva. She
underwent Sunna circumcision two years before. Subsequently, she
developed 2 × 3 cm mass around the clitoris. She was told by her mother
that it was “normal after circumcision.” On examination she was sick and
her temperature was 39.3 degrees Celsius. There was 4 × 4 cm clitoral
abscess. Incision and drainage under general anesthesia was uneventful. She
was given antibiotics intravenously. She was discharged home after two
days in good general condition. Follow-up in the clinic was satisfactory.
Case 3:
A 17-years-old, Gravida 1 Para 1, presented with fever and painful mass in
the vlulva of few days duration. She underwent Sunna circumcision as a
child and developed 2 × 2 cm clitoral mass few months after the procedure.
She was married and complained of lack of sexual desire and satisfaction.
She sought medical advice and was told to undergo surgery to remove the
clitoral cyst but disappeared from the clinic and became pregnant. She
delivered normally. On examination, she was well but her temperature was
39.8 degrees Celsius. There was 4 × 3 cm clitoral abscess. Incision and
drainage under general anesthesia was done. She was given antibiotics
5
intravenously. She was discharged home after three days in good general
condition. Follow-up in the clinic later on revealed persistence of her sexual
complaints.
Discussion:
Approximately 130 million women and girls have undergone FGM and
another 2 million are estimated to experience it every year. It is practiced in
28 African countries, some countries in the Arabian Peninsula and Asia, and
increasingly in Europe, Canada, and the United States of America because of
the immigration patterns (Rahman and Toubia 2000). Its prevalence ranges
from nearly 90 per cent or higher in Egypt, Eritrea, Mali and Sudan, to less
than 50 per cent in the Central African Republic and Côte d'Ivoire, to 5 per
cent in the Democratic Republic of Congo and Uganda. Type III or
infibulation is practiced mainly in some African countries while milder
forms of Type I including Sunna circumcision are practiced by some
Muslims in the Arabian Peninsula. The aim is to remove very small part of
the prepuce. However, more parts of the genitalia can be unintentionally
removed. This is because of the lack of expertise of the “traditional
6
practitioner” and the circumstances in which FGM is done. The three cases
underwent this procedure by local women at home.
Complications following FGM include hemorrhage, pain, infection,
urinary retention, death, scarring and keloid formation, vulval epidermoid
cysts, vulval abscess, recurrent urinary tract infection, psychological effects
(flashbacks, anxiety and depression), sexual problems, and obstetrical
sequelae. The rate of occurrence of these complications depends on many
factors. The more severe forms are associated with serious complications.
Milder forms of Type IV and minor forms of Type I are rarely associated
with complications (Rouzi et al 2001).
Type III and other aggressive forms of FGM are forbidden and
punishable by Islamic Laws. In contrast, removal of very small part of the
prepuce is considered by some Muslims as Sunna. This means that those
who practice it will be rewarded by God and those who do not practice it
will not. But it is not mandatory. This is very important distinction. Detailed
discussion of the religious aspects of FGM is beyond the scope of this paper.
However, it is worthwhile to mention that it is a subject of intense debate
among religious authorities in the Muslim World. The view that it has
religious justification together with other reasons prompted the health
Minster of Egypt to legitimize the procedure in hospitals. This was banned
7
later on. However, the ban was challenged legally by Islamic groups. The
Supreme Court of Egypt ruled in favor of the ban.
Recently, FGM gained a lot of medical and public interests. Nearly all
major medical professional organizations had condemned the procedure and
considered it human right violation. Major efforts are in place to prevent and
eliminate FGM. Progress in many aspects of achieving this objective has
been made (Toubia and Sharief 2003). Many approaches including
criminalizing the procedure are being used. This may be effective for the
aggressive types of FGM but not for the mild forms (Cook et al 2002). Other
strategies including education and awareness of the medical profession, the
public, and religious authorities that long term complications may follow
Type I FGM are necessary to eliminate FGM altogether. This case-series
documented the occurrence of vulval sepsis, abscess, and even loss of sexual
desire and satisfaction after Type I FGM. The publication of this paper will
encourage others to document other complications of Type I FGM. This will
constitute the initial medical basis to support banning Type 1 FGM by the
religious authorities.
8
References:
- American Medical Association Council on Scientific Affairs. Female
Genital Mutilation. JAMA 1995;274:1714-16.
- A. Rahman and N. Toubia, Editors, Female genital mutilation: a guide to
laws and policies worldwide, Zed Books, London and New York (2000) p.
7.
- Department of Women's Health, Family and Community Health, World
Health Organization A systematic review of the health complications of
female
genital
mutilation
including
sequelae
in
childbirthWHO/FCH/WMH/00.2, World Health Organization, Geneva
(2000) p. 11.
- N. F. Toubia and E. H. Sharief. Female genital mutilation: have we made
progress? Int J Gyn Obstet 2003: 82: 251-61.
- Rouzi AA, Sindi O, Radhan B, Ba'aqeel H. Epidermal clitoral inclusion
cyst after type I female genital mutilation. Am J Obstet Gynecol
2001;185:569-71.
- R. J. Cook, B. M. Dickens and M. F. Fathalla. Female genital cutting
(mutilation/circumcision): ethical and legal dimensions. Int J Gyne Obstet
2002;79:281-87.
9
- WHO. Female Genital Mutilation: Report of a WHO Technical Group,
Geneva, 17-19 July 1995, World Health Organization, Geneva (1996).