Caring for Women who have Undergone Genital Cutting/ Circumcision
Female circumcision and genital cutting (FGC), commonly called female genital
mutilation (FGM) is a practice that affects millions of women but is poorly understood by
many health care providers. FGM is defined as the procedures that intentionally alter or
cause injury to the female genital organs for non-medical reasons and includes partial
or total removal of female genital organs (World Health Organization [WHO], 2014).
There are four major types of female genital cutting, as described in Table 1.
Table 1: Types of Female Genital Cutting
Excision
Type I
Excision of the prepuce with a partial or total removal
of the clitoris. May include excision of the labia
majora.
Clitoridectomy Type II
Partial or total removal of the clitoris and total or
partial removal of the labia minora.
Infibulation
Type III
Narrowing of the vaginal opening through the creation
of a covering seal. The seal is formed by cutting and
repositioning the labia minora and/ or labia majora,
with or without removal of the clitoris.
Other
Type IV
All other harmful procedures to the female genitalia for
non-medical purposes, can include cauterization of the
tissue, introduction of corrosive substances to cause
narrowing or tightening, pricking, piercing, incising, or
scraping
(Balogun, 2013; Braddy, 2007; Campbell, 2004; Harris, 2013)
These procedures, which have no medical value, are most often carried out sometime
between birth and puberty, and occasionally on adult women (WHO, 2014). Women
from Africa and the Middle East are most likely to have undergone these procedures,
but women with permanently altered genitals are likely to be seen in any country. The
causes for genital cutting vary but usually include a mix of cultural, religious, and social
factors with a theme of cleanliness, promoting modesty and premarital virginity (El
Sharwarby, 2008; World Health Organization, 2014; Balogun, 2013).
Newsweek magazine (Westcott, 2015) recently reported that there are currently
513,000 women and girls with altered genitals from female genital cutting. This
estimate is supported by a recent report by the Population Reference Bureau (Mather,
2015). Given the current rise in immigration to the US from African born people, this
number is likely to rise. It remains unclear how many women and girls are hospitalized
or seek healthcare as a direct result of FGC. However, as these women and girls
approach childbearing age, they are likely to require intervention to reverse procedures.
These procedures are often performed by traditional practitioners with little or no
medical training, though as many as 18% are performed by health care providers
(WHO, 2014). When performed by a traditional practitioner, instruments such as razor
blades or glass may be used, with or without anesthesia (El Sharwarby, 2008). Women
and girls residing in the US are often sent back to their home country to undergo FGC a practice known as vacation cutting (Westcott, 2015). Whether performed by
traditional practitioners or health care practitioners, these procedures are associated
with significant medical risks. Long and short term consequences are described in
Table 2.
Table 2: Long and Short Term Consequences of Female Genital Cutting
SHORT TERM CONSEQUENCES
LONG TERM CONSEQUENCES
 Death
 Abscesses
 Fractures of clavicle, humerus or
 Cyst formation
femur from restraints during the
 Depression
procedure
 Dysmenorrhea
 Hemorrhage
 Dysuria
 Infection
 Higher incidence of cesarean delivery
 Injury to adjacent tissues such
 Incontinence
as urethra or bowel
 Increased risk for HIV due to
 Pain
increased friction, abrasions, and/ or
 Sepsis
skin tears during sexual intercourse
 Shock (due to hemorrhage or
 Infertility as a result of ascending
vaso-vagal reaction)
infection in the genital tract
 Urine retention
 Keloid scarring
 Loss of sexual desire and ability to
achieve orgasm
 Maternal death
 Painful intercourse
 Pelvic inflammatory disease
 Perineal tears in childbirth
 Post-partum hemorrhage
 Post-traumatic stress disorder
 Prolonged and obstructed labor
 Rectovaginal fistula
 Recurrent bladder and urinary tract
infections
(Braddy, 2007; Frega, 2013; Harris, 2013; Lundberg, 2008; Paterson, 2012; Reyners,
2004; Vloeberghs, 2012; World Health Organization, 2014)
The vast majority of articles about female genital cutting focus on stopping these
practices. Most use negative terms such as mutilating or mutilation to describe the
procedures, as does the World Health Organization. An estimated 125 million women
have undergone these procedures (World Health Organization, 2014), often as children.
As adolescents and adults, these women require medical care from health care
professionals who can provide safe and culturally sensitive care.
Healthcare interventions for women and girls who have undergone genital cutting are
most likely to include deinfibulation, episiotomy, removal of cysts, treatment of
infections, and counseling. During antenatal care, healthcare providers may dissuade
women and their partners from undergoing reinfibulation after childbirth (Balogun,
2013).
When they have relocated to a country where these surgeries are less common,
locating culturally sensitive care can be difficult. While the term, genital mutilation is
accurate for policy makers and human rights activists (Braddy, 2007), it is judgmental
and potentially harmful for women whose genitals are permanently altered, particularly
when used by someone outside of their own culture (Braddy, 2007; Odemerho, 2012).
The idea of FGC may elicit feelings of shock and horror, making these women reluctant
to seek medical care or to disclose their condition to their provider. One third of women
with FGC reported symptoms of depression and anxiety in a study conducted in the
Netherlands (Vloeberghs, 2012). These feelings of depression and anxiety were
intensified during childbirth or when suffering from physical problems. These women
felt ashamed to be examined by a physician and avoided visiting providers who failed to
conceal their shock about the woman’s appearance (Vloeberghs, 2012). Women who
fear embarrassment, humiliation, or judgment from their healthcare provider may delay
essential medical care (Braddy, 2007; Odemerho, 2012). Thus, it is important that the
health care provider is culturally competent in their provision of care. Suggestions for
culturally competent care of the woman with FGC are outlined in Table 3.
Table 3: Culturally Competent Care







Use nonjudgmental words (female circumcision, female genital surgery)
and approach to the interview and exam. When in doubt, use the term
used by the woman or ask her about the preferred term.
Don’t act surprised, disgusted, sad or shocked upon seeing the perineum.
Focus on the care needed rather than the circumcision.
Provide an interpreter as needed
Refrain from making assumptions about sexuality of the woman.
Provide privacy and confidentiality; don’t call in colleagues to look at the
perineum.
Use a standardized tool to assess the type of procedure the woman had
and any complications she has experienced as a result. The woman may
not attribute complications to the procedure – ask about specific
conditions, not what she has experienced as a result of the procedure.
This worksheet can be located in: “Care of Women with Female
Circumcision,” by C. Campbell, 2004, Journal of Midwifery & Women’s
Health, 49, p.365.

Use a pediatric speculum for exams. If the introitus is too small to
accommodate the speculum, a bimanual exam with the use of 1 to 2
fingers, including a rectovaginal examination is recommended.
(Braddy, 2007; Campbell, 2004; Odemerho, 2012; Vloeberghs, 2012)
A comprehensive look at FGC is beyond the scope of this article. However, there are a
number of helpful resources for clinicians who wish to understand more about providing
optimal care for women who have undergone these procedures. Table 4 provides a
partial listing of resources for health care providers.
Table 4: Resources for health care providers caring for FGC patients
The American College of Obstetricians and Gynecologists Female Genital Cutting:
Clinical Management of Circumcised Women (2nd Ed.) This is a multimedia kit designed
for health care providers and includes slides, speakers notes, objectives, and resource
listing. Available at: http://sales.acog.org/Female-Genital-Cutting-Clinical-Managementof-Circumcised-Women-Second-Edition-P349.aspx
Royal College of Obstetricians and Gynaecologists Green-top Guideline No. 53 –
Female Genital Mutilation and its Management. Available at:
https://www.rcog.org.uk/globalassets/documents/guidelines/greentop53femalegenitalmu
tilation.pdf
The World Health Organization Female Genital Mutilation Teachers Guide to Integrating
Prevention and Management of the Health Complications into the Curricula of Nursing
and Midwifery. Available at: http://www.who.int/gender/other_health/teachersguide.pdf
The FGM Report – Canadian Women’s Health Network. Available at:
http://www.cwhn.ca/sites/default/files/resources/fgm/fgm-en.pdf
FGC is an important and culturally sensitive issue for an increasing number of women
seeking obstetric and gynecologic care in the United States. It is important that health
care providers seek to understand the cultural beliefs and values of women who have
undergone these procedures and provide informed and sensitive care.
REFERENCES
Balogun, O. H. (2013). Interventions for improving outcomes for pregnant women who
have experienced genital cutting (Review) . The Cochrane Collaboration . Wiley.
Braddy, C. (2007). Female genital mutilation: Cultural awareness and clinical
considerations. Journal of Midwifery & Women's Health , 52(2), 158-183.
doi:10.1016/j.jmwh.2006.11.001
Campbell, C. (2004). Care of women with female circumcision. Journal of Midwifery
and Women's Health , 49, 364-65.
El Sharwarby, S. R. (2008). Female genital cutting . Obstetrics, Gynaecology and
Reproductive Medicine, 18(9), 253-55.
Fahs, B. (2014). Genital panics: Constructing the vagina in women's qualitative
narratives about pubic hair, menstrual sex, and vaginal self-image. . Body Image,
11, 210-218. doi:10.1016/j.bodyim.2014.03.002
Frega, A. P. (2013). Obstetric and neonatal outcomes of women with FGM I and II in
San Camillo Hospital, Burkina Faso. Arch Gynecol Obstet, 288, 513-519.
doi:10.1007/s00404-013-2779-y
Harris, T. (2013). Female genital mutilation: A literature review. Nursing Standard,
28(1), 41-47.
Lundberg, P. G. (2008). Experiences from pregnancy and childbirth related to female
genital mutiliation among Eritrean immigrant women in Sweden. Midwifery, 24,
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Mather, M. &.Feldman-Jacobs, C. (2015, February). Women and girls at risk of female
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Reference Bureau: http://www.prb.org/Publications/Articles/2015/us-fgmc.aspx
Odemerho, B. B. (2012). Female genital cutting and the need for culturally competent
communication . The Journal for Nurse Practitioners, 8(6), 452-57.
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Paterson, L. D. (2012). Female genital mutilation/ cutting and orgasm before and after
surgical repair. Sexologies, 21, 3-8. doi:10.1016/j.sexol.2011.09.005
Reyners, M. (2004). Health consequences of female genital mutilation. Reviews in
Gynaecological Practice, 4, 242-251. doi:10.1016/j.rigp.2004.06.001
Vloeberghs, E. V. (2012). Coping and chronic psychosocial consequences of female
genital mutilation in the Netherlands. Ethnicity & Health , 17(6), 677-695.
doi:10.1080/13557858.2013.771148
Westcott, L. (2015, February 6). Female genital mutilation on the rise inthe US.
Newsweek. Retrieved from http://www.newsweek.com/fgm-rates-have-doubledus-2004-304773
World Health Organization. (2014, February). Female Genital Mutiliation. Retrieved from
WHO Media Centre: http://www.who.int/mediacentre/factsheets/fs241/en/