Female genital mutilation: What ob/gyns need to know

Dr Lee is Director, Maternal-Fetal Medicine at Mount Sinai-Beth Israel Hospital, New York, New York. She has no conflicts of interest to report in respect to the content of this article. 

Dr Strong is Assistant Professor, Icahn School of Medicine, Mount Sinai Hospital, New York. She has no conflicts of interest to report in respect to the content of this article.

Female genital mutilation (FGM), also known as female genital cutting or female circumcision, has been practiced in some form or other for several thousand years. It has been performed on more than 125 million women and girls worldwide, according to a 2013 report by the United Nations Children’s Fund (UNICEF).¹ While the practice is predominately concentrated in 29 countries of Africa and the Middle East (Figure), recent immigration patterns have led to an increase in the number of women who have undergone FGM who are being seen by obstetricians, gynecologists, and other women’s health practitioners in the United States and other countries unfamiliar with the practice.^2,3

Origins

The origins of FGM are largely unknown, but theories as to its beginnings trace it back as far as ancient Egypt, pre-Islamic Arabia, and ancient Rome.^4-6 The history behind FGM includes a mix of cultural and social factors. In societies in which female genital mutilation is a social convention, the pressure to conform to what others do and have been doing is a motivating factor. It often represents a rite of passage and is considered a necessary part of raising a girl. FGM has been reinforced by customary beliefs that it maintains a girl’s chastity, prevents illicit sexual behavior, preserves fertility, ensures marriageability, improves hygiene, and enhances sexual pleasure for men.⁷ As such, parents in these societies feel obligated to have the procedure performed on their daughters to aid in improving their livelihoods. In many such cultures, to forgo circumcision is viewed as condemning one’s daughter to a life of isolation by taking away her eligibility for marriage. In concordance with this belief, many women who have undergone genital cutting do not believe that they have been subjected to mutilation or torture.

Despite the acceptance of FGM within certain communities, it has been recognized internationally as a violation of the human rights of girls and women. The WHO recognizes it as a practice that reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women as well as a practice that also violates a person’s rights to health, security, and physical integrity; the right to be free from torture and cruel, inhuman, or degrading treatment; and the right to life when the procedure results in death.^2,7 Because FGM is nearly always carried out on minors, it is also recognized as a violation of the rights of children.²

NEXT: Procedure >>

Procedure

FGM includes any of the procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for nonmedical reasons. It is generally performed between infancy and age 15 and only occasionally reported in adult women. Most female circumcisions are performed by traditional nonmedically trained operators, such as birth attendants, who often play other central roles in their communities. In these circumstances, anesthesia and antibiotics are rarely administered and the instruments used are often primitive and nonsterile.^7,8 Hemostasis is achieved by placement of catgut sutures or thorns, or by application of homemade adhesive concoctions or animal excrement.

In more urban settings, the procedure may be performed by healthcare providers under sterile conditions with or without administration of anesthesia and antibiotics. Female circumcision performed by healthcare providers currently accounts for nearly 20% of cases of FGM and illustrates a trend towards medicalization. While the aim of medicalization is to decrease short-term procedural complications, it does not eliminate the long-term gynecologic, obstetric, and urologic complications associated with the procedure. In 2013, the United Nations General Assembly passed a resolution to advise the elimination of FGM, emphasizing that the practice has no health benefits and puts girls and young women at risk for serious complications.^8,9

Classification

The World Health Organization United Nations International Children’s Emergency Fund-United Nations Fund for Population Activities (WHO-UNICEF-UNFPA) Joint Statement classified female genital mutilation into 4 major types (Table 1).^2,15 Type I, also referred to as clitoridectomy, is the partial or total removal of the clitoris and/or the prepuce. When it is important to distinguish between the major variations of Type I mutilation, the following subdivisions are proposed: 

Complications

Both short-term and long-term complications can arise secondary to FGM (Table 2).^13,15,19 Immediate complications can include severe pain, shock, hemorrhage, urinary retention, tetanus, infection, and sepsis, as well as injury to surrounding organs. Many of these complications can be traced to lack of surgical precision secondary to lack of adequate anesthesia and subsequent movement of the child during the procedure, inadequate experience of the operator, and lack of sterile technique.¹⁹

Women who have undergone type II or III FGM tend to suffer more long-term complications than those who have undergone type I or IV. The most common consequences include dysmenorrhea, dyspareunia, and chronic vaginal infections, as well as urinary complications such as recurrent infection and retention. Other complications from scarring include fibrosis, keloids, epidermal cysts, vulvar abscesses, vaginismus, and fusion of the labia, which can lead to hematometra and hematocolpos.

The practice has also been associated with increased infertility. Rates as high as 25%–30% are reported in women who have undergone FGM, compared to 8%–14% in the general population.10 The frequency of infertility appears to be correlated with the extent of genital cutting.¹¹ Introital and vaginal stenosis acts as a physical barrier and many couples may attempt coitus for months before completing penetration.¹² Failure to succeed and persistent dyspareunia can lead to apareunia.¹³ Infertility may also arise from tubal damage secondary to ascending infections related to the procedure.

Obstetric complications

In a large WHO study, obstetrical outcomes in women with and without female genital cutting types I, II, and III were compared.¹⁴ The authors found that women with type II and III FGM were at significantly higher risk of cesarean delivery, postpartum hemorrhage, and extended maternal hospital stay. In addition, their infants were at significantly higher risk of requiring resuscitation and of dying in the hospital than those born to women without FGM. The risks were higher in women with FGM III than FGM II. Rates of episiotomy and perineal tears were also higher among women with FGM compared to those without. These observed complications are likely related to inability to adequately monitor and manage labor in the setting of scarring and infibulation.¹⁴

The narrow neointroitus can make a bimanual exam and the placement of commonly used devices such as fetal scalp electrode, intrauterine pressure catheter, and Foley catheter difficult if not impossible. It may also obstruct crowning and ultimately delivery, which could lead to perinatal asphyxia or demise. Reversal of infibulation is recommended in women with type II and type III FGM.¹⁵ Ideally, defibulation should be performed prior to conception; however, it can be performed safely during pregnancy. If the woman is already pregnant, it is preferable to perform defibulation in the second trimester under regional anesthesia. However, if this option is declined, it can be performed at the time of labor.

NEXT: Reversal >>

Reversal

Defibulation-the process of reversing infibulation and reconstructing normal anatomic structures of the perineum-is generally performed secondary to pregnancy or planned pregnancy or because of apareunia/dyspareunia, dysmenorrhea, or difficulty urinating.¹⁶ The optimal time to defibulate a woman is prior to coitus to prevent dyspareunia, or prior to pregnancy to prevent obstetric complications. However, many women will delay reversal until after marriage to prove their virginal status as dictated by their culture.

Overall positive outcomes have been reported following defibulation or reconstructive surgery. One large prospective study of nearly 3000 women with type II or III FGM who underwent mobilization of the clitoral stump reported only a 5% complication rate. In the subset that completed a 1-year postoperative assessment, 97% had no change or an improvement in sexual pain and pleasure.17

However, some women will request reinfibulation after vaginal delivery. Because the procedure is medically unnecessary and may cause harm, it should be strongly discouraged. If a patient insists upon the procedure and the provider is agreeable, repair with absorbable sutures in a running subcuticular fashion is recommended.¹⁶ Doctors who perform this procedure are protected under the law as reinfibulation is not named in the Federal Prohibition of Female Genital Mutilation Act of 1996.¹⁸

Patient counseling

Women who have undergone FGM may have questions about intercourse and pregnancy. Ob/gyns should provide nonjudgmental counseling about potential complications of FGM. For women who are newly pregnant and seeking prenatal care, social workers can offer counseling regarding the need for defibulation. Cesarean delivery should be reserved for the usual obstetrical indications. 

References

1. UNICEF. Female genital mutilation/cutting: a statistical overview and exploration of the dynamics of change, UNICEF, New York 2013.

2. Female Genital Mutilation. A joint WHO/UNICEF UNFPA statement. World Health Organization 1997.

3. Cappa C, Moneti F, Wardlaw T, Bissell S. Elimination of female genital mutilation/cutting. Lancet. 2013;382:1080.

4. Hedley, R, Dorkenoo, E. Child protection and female genital mutilation advice for health, education and social professionals. London: FORWARD, 1992.

5. Hosken, RP. The Hosken Report Genital and Sexual Mutilation of Females. Lexington: Women International Network News, 1994.

6. Shandall AA. Circumcision and infibulation of females: a general consideration of the problem and a clinical study of the complications in Sudanese women. Sudan Med J. 1967;5:178.

7. World Health Organization. Female genital mutilation. www.who.int/mediacentre/factsheets/fs241/en. Accessed March 25, 2015.

8. UNFPA-UNICEF. Abandonment of female genital mutilation/cutting: accelerating change. http://www.unfpa.org/sites/default/files/resource-pdf/Funding%20Proposal%20for%20Phase%20II%20of%20the%20UNFPA-UNICEF%20Joint%20Programme.PDF. Accessed March 25, 2015.

9. Morgan J. Working towards an end to FGM. Lancet. 2015;385:843.

10. Macleod, T. Female genital mutilation. J SOGC. 1995;4:333.

11. Almroth L, Elmusharaf S, El Hadi N, et al. Primary infertility after genital mutilation in girlhood in Sudan: a case-control study. Lancet. 2005; 366:385.

12. El Dareer, A. Women Why Do You Weep? Zed Press, London 1982.

13. Aziz FA. Gynecologic and obstetric complications of female circumcision. Int J Gynaecol Obstet. 1980;17:560.

14. WHO study group on female genital mutilation and obstetric outcome, Banks E, Meirik O, et al. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet. 2006;367:1835.

15. American College of Obstetricians and Gynecologists. Female circumcision/female genital mutilation: clinical management of circumcised women. American College of Obstetricians and Gynecologists, Washington, DC 1999.

16. Nour NM, Michels KB, Bryant AE. Defibulation to treat female genital cutting: effect on symptoms and sexual function. Obstet Gynecol. 2006; 108:55.

17. Foldes P,Cuzin B, Andro A. Reconstructive surgery after female genital mutilation: a prospective cohort study. Lancet. 2012; 14:380(9837).

18. Federal Prohibition of Female Genital Mutilation Act of 1996. Public Law 104 -140, 11O Stat 1327, 1996.

19. Dirie MA, Lindmark G. The risk of medical complications after female circumcision. East Afr Med J. 1992;69(9):479.