Female Genital Mutilation

FGM includes all procedures where partial or total removal of the eternal female genitalia, or intentional injury to the female genital organs, is performed for any non-medical reason.

Prevalence

Countries where FGM is practiced, and prevalence in girls 15-49 years of age (%)^[1]: Data comes from studies conducted between the years of 2001 and 2006, with the exception of Yemen (1997)^[1]

• Benin, 16.8%
• Burkina Faso, 72.5%
• Cameroon, 1.4%
• Central African Republic, 25.7%
• Chad, 44.9%
• Côte d’Ivoire, 41.7%
• Djibouti, 93.1%
• Egypt, 95.8%
• Eritrea, 88.7%
• Ethiopia, 74.3%
• Gambia, 78.3%
• Ghana, 3.8%
• Guinea, 95.6%
• Guinea-Bissau, 44.5%
• Kenya, 32.2%
• Liberia, 45.0%
• Mali, 91.6%
• Mauritania, 71.3%
• Niger, 2.2%
• Nigeria, 19.0%
• Senegal, 28.2%
• Sierra Leone, 94.0%
• Somalia, 97.9%
• Sudan, northern, 90.0% (approximately 80% of total population in survey)
• Togo, 5.8%
• Uganda, 0.6%
• United Republic of Tanzania, 14.6%
• Yemen, 22.6%

In other countries, the practice of FGM has been identified, but no prevalence has been calculated or estimated for the total population^[1]. These countries include^[1] :

• India
• Indonesia
• Iraq Israel
• Malaysia
• United Arab Emirates

There is anecdotal evidence that FGM also occurs in other countries, but there are limited accounts and/or reports^[1]. These countries include^[1] :

• Colombia
• Democratic Republic of Congo
• Oman
• Peru
• Sri Lanka

Terminology

Female Circumcision

When this practice was first identified and discussed outside of practicing communities and groups, it was commonly referred to as “female circumcision”^[1]. This term, however, suggests similarity between this practice and male circumcision, and results in confusion between these two distinctively different practices. Male circumcision has significant health benefits associated with a 60% decrease in the risk of HIV acquisition, and minimal health risk when performed by trained providers^[2][3]. In contrast, the practice of female genital mutilation/cutting has no health benefits, and considerable health and psychological consequences^[1]. While the term female circumcision has predominantly been dropped for the international vocabulary, the term is still used by some practicing communities.

Female Genital Mutilation

In the 1970’s the term “female genital mutilation” gained growing support and use. The word mutilation serves two distinct purposes: it linguistically separates this practice from male circumcision, and it draws attention to the gravity and harm of the act^[1]. In 1990, this term was formally adopted at the third conference of the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, in Addis Ababa, Ethiopia^[1]. The following year, in 1991, the WHO recommended that the United Nations adopt the term as well, leading to the widespread use of this term within UN departments and divisions and the international community^[1]. The term “mutilation” was adopted to reinforce the idea that this practice is a violation of girls’ and women’s rights, and promotes the elimination of the practice, internationally^[1].

Female Genital Cutting, Female Genital Mutilation/Cutting

The term “female genital cutting” or “female genital cutting/mutilation” gained support and use within both research and agencies in the late 1990s. The new preference for this term is to some extent a reaction to the negative associations attached to the term “mutilation”^[1]. Furthermore, there is some evidence to suggest that the term “mutilation” may estrange communities that practice this, and may hinder, rather than support, the elimination of the practice through social change^[1]. In order to simultaneously emphasize the importance of the term “mutilation” at a policy level, and embrace the less judgmental term “cutting” for cultural sensitivity, the term “mutilation/cutting” has been adopted by UNICEF and UNFPA^[1]. “Mutilation” as the single term used within the WHO^[1].

Classification of FGM by the World Health Organization (2008) ^[1]

• Type I — Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).

• When it is important to distinguish between the major variations of Type I mutilation, the following subdivisions are proposed:

• Type Ia, removal of the clitoral hood or prepuce only;
• Type Ib, removal of the clitoris with the prepuce.

• Type II — Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

• When it is important to distinguish between the major variations that have been documented, the following subdivisions are proposed:

• Type IIa, removal of the labia minora only;
• Type IIb, partial or total removal of the clitoris and the labia minora; Type IIc, partial or total removal of the clitoris, the labia minora and the labia majora.
• Note also that, in French, the term ‘excision’ is often used as a general term covering all types of female genital mutilation.

• Type III — Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).

• Type IIIa, removal and apposition of the labia minora;
• Type IIIb, removal and apposition of the labia majora.
• Type IV — All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.

Health Consequences of FGM

In general, the health risks associated with FGM increase with the severity of the procedure.

Immediate risk of complication from Types I, II, and III

Severe pain: FGM types I, II, and III involve cutting nerve ends and sensitive genital tissue, which causes sever pain. Anesthesia is rarely used when the procedures are performed, and when it is used, it is not always effective^[4][5]. Type III FGM is a more extensive procedure that involves more cutting, and longer procedure times (15-20 minutes)^[6]. As a result, the intensity and duration of pain is generally greater, and the healing period is longer and more intense^[1][6][7][8].

Shock: Shock can be caused by sever pain and/or hemorrhage, both of which are health risks associated with FGM^[1][7][9].

Excess bleeding/hemorrhage: Excess bleeding, septic shock, and hemorrhage have all been documented as outcomes related to FGM procedures^[1][5][8].

Difficulty passing urine: Swelling, oedema and pain can all cause difficulty in passing urine and also in passing feces^[1][5][7].

Infection: Infection can occur and spread when procedures are performed in non-sterile environments, and when contaminated instruments are used, and/or instruments used for multiple procedures. The healing period can also result in infections^{[1][9][8][10]}.

HIV: While the risk of HIV increases when the same surgical tools are used for multiple procedures between girls, direct HIV transmission has never been documented^{[1] [11][7]} This is most likely due to the rarity of mass genital cutting with the same instruments, as well as the low prevalence of HIV among girls at the age of this procedure^[1][11][12].

Death: Death can occur as a result of hemorrhage and infection. This can also be related to tetanus and shock^[1][13].

Psychological consequences: Many women describe the experience of FGM as a traumatic even. This psychological trauma is often attributed to pain, shock, and the physical force used to perform the procedure^[1][4][6].

Unintended labia fusion: Several studies have described procedures in which, what was intended to be a Type II FGM became a Type III FGM as the result of unintended labia fusion after cutting^[1][5][7].

Repeated female genital mutilation: For women that have undergone Type III FGM, there appears to be frequent repeat procedures due to unsuccessful healing with the first procedure^[1][14][10] The repeat procedure has all the same health risks associated with the first procedure performed, increasing the overall risk for the women who undergo repeat procedures^[1][14][10].

Long-term (life-long) risks from Types I, II, and III

Pain: Chronic pain can be a long-term result of FGM due to trapped and unprotected nerve endings^[1][15][16].

Infection: Multiple types of infections can occur over a woman’s life-time as a result of FGM, all with varying health consequences and severity. Dermoid cysts, abscesses and genital ulcers can all develop, which can cause superficial loss of tissue. FGM can result in chronic pelvic infections, which often lead to chronic back and pelvic pain. Urinary tract infections are more common and severe with FGM in both women and girls. These infections can ascend to the kidneys, potentially resulting in renal failure, septicemia, and death, in the most severe cases^{[1][9][8][12][16]}.

Keloid: Excessive scar tissue can form at the site of cutting^[1][16].

Reproductive tract infections and STIs: Certain specific infections have been documented with increased frequency in women who have undergone these procedures. Specifically, these women are at greater risk for bacterial vaginosis and other bacterial infections, as well as genital herpes. No increased risk has been identified for any other common STIs^{[1][11][12][16]}.

HIV: Women who have undergone FGM often bleed during sexual intercourse, especially those women with Type III FGM, which may increase the risk of HIV transmission and acquisition. Genital herpes, which have an increased prevalence in women with this procedure, are also a risk factor for contracting HIV^[1].

Birth Complications: The incidence of both cesarean section and postpartum hemorrhage are significantly increased for women who have undergone FGM Type I, II, and III. There are also substantial increases in tearing and the need for episiotomies. These risks increase with the severity of the procedure performed. Prolonged and obstructed labor, which are often the indicators for needing caesarian section, are also causes of obstetric fistula which may also be associated with FGM^[1][17][18].

Danger to the Newborn: Higher infant mortality is associated with mothers who have undergone FGM, with risk increasing as the severity of the procedure increases. Specifically, the increased risk is estimated to be 15% higher for those whose mothers had Type I, 32% higher for those with Type II and 55% higher for those with Type III FGM, as compared to women who have not had these procedures^[1][17][18].

Additional risks associated with Type III

Later Surgeries: Infibulations (the medical term used for Type III FGM) must be undone and re-opened later in life by defibulations (the opening or partial revrsal of Type III FGM) in order for a woman to have sexual intercourse and for childbirth. In some cultures, this re-opening is then followed by re-closure (re-infibulation) after childbirth. This leads to a life for some women that consist of multiple genital surgeries throughout life to allow for childbirth and maintain Type III FGM completion^{[1][19][20][21]}

Urination and Menstruation Problems: FGM Type III often results in slow and difficult urination and menstruation, due to the nearly complete sealing off of the vagina and urethra. Accumulation of blood in the vagina, known as haematocolpus, can also occur and may require surgical interventions to treat. Urine leaking is also common for women with Type III FGM, most likely due to the difficulty in emptying the bladder completely and the trapping of urine within the hood of the scar tissue^{[1][7][9][8][10][21]}.

Painful Sexual Intercourse: Type III FGM must be opened to allow for sexual intercourse, either by defibulation or by penetration. This can lead to sensitivity and pain when sexual intercourse is first initiated, and can last for several weeks, barring other complications. FGM can also lead to pain and discomfort for the male partner during sexual intercourse^{[1][9][8][21]}.

Infertility: The increase in infertility is attributed most directly to the cutting and removal of the labia majora. There is a strong correlation between the amount of flesh removed and the increased risk of infections that can lead to infertility^[1][9].

References

1. ↑ ^{1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 1.36 1.37 1.38 1.39} (PDF) Eliminating Female Genital Mutilation - An interagency statement OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, WHO, Department of Reproductive Health and Research (RHR), World Health Organization, 2008.
2. ↑ Bailey RC, Moses S,Parker CB,Agot K,Maclean I,Krieger JN (2007). Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet, 369:643−656.
3. ↑ WHO, UNAIDS (2007). New data on male circumcision and HIV prevention: policy and programme implications. WHO/UNAIDS Technical Consultation, Montreux, 6−8 March 2007. Conclusions and Recommendations. Geneva, World Health Organization.
4. ↑ ^{4.0 4.1} Malmström M (2007). Bearing the pain as a woman or becoming ruined for life? Changing views of the meaning and morality of pain and suffering among the popular classes of Cairo. Paper presented at 4th FOKO conference (Nordic Network for Research on FGM), Hansaari, Finland 7−8 September 2007.
5. ↑ ^{5.0 5.1 5.2 5.3} Dare FO, Oboro VO, Fadiora SO, Orji EO, Sule-Odu AO, Olabode TO (2004). Female genital mutilation: an analysis of 522 cases in South-Western Nigeria. Journal of Obstetrics and Gynaecology, 24:281−283
6. ↑ ^{6.0 6.1 6.2} Johansen REB (2002). Pain as a counterpoint to culture: towards an analysisof pain associated with infibulation among Somali immigrants in Norway. Medical Anthropology Quarterly, 16:312−340.
7. ↑ ^{7.0 7.1 7.2 7.3 7.4 7.5} Agugua NE, Egwuatu VE (1982). Female circumcision: management of urinary complications. Journal of Tropical Pediatrics, 28:248−252.
8. ↑ ^{8.0 8.1 8.2 8.3 8.4 8.5} Dirie MA, Lindmark G (1992). The risk of medical complications after female circumcision. East African Medical Journal, 69:479−482.
9. ↑ ^{9.0 9.1 9.2 9.3 9.4 9.5} Almroth L, Bedri HA, Elmusharaf S, Satti A, Idris T, Hashim MS (2005a). Urogenital complications among girls with genital mutilation: A hospital based study in Khartoum. African Journal of Reproductive Health, 9:127–133.
10. ↑ ^{10.0 10.1 10.2 10.3} Chalmers B, Hashi KO (2000). 432 Somali women’s birth experiences in Canada after earlier female genital mutilation. Birth, 27:227−234.
11. ↑ ^{11.0 11.1 11.2} Morison L, Scherf C, Ekpo G, Paine K, West B, Coleman R, Walraven G (2001). The long-term reproductive health consequences of female genital cutting in rural Gambia: a community-based survey. Tropical Medicine and International Health, 6:643−653.
12. ↑ ^{12.0 12.1 12.2} . Klouman E, Manongi R, Klepp KI (2005). Self-reported and observed female genital cutting in rural Tanzania: associated demographic factors, HIV and sexually transmitted infections. Tropical Medicine and International Health, 10:105−115.
13. ↑ Mohamud OA (1991). Female circumcision and child mortality in urban Somalia. Genus, 47:203−223.
14. ↑ ^{14.0 14.1} Johansen REB (2006b). Experiences and perceptions of pain, sexuality and childbirth. A study of female genital cutting among Somalis in Norwegian exile, and their health care providers. Dissertation. University of Oslo, Faculty of medicine.
15. ↑ Fernandez-Aguilaret S, Noel JC (2003). Neuroma of the clitoris after female genital cutting. Obstetrics and Gynecology, 101:1053−1054.
16. ↑ ^{16.0 16.1 16.2 16.3} Okonofua FE, Larsen U, Oronsaye F, Snow RC, Slanger TE (2002). The association between female genital cutting and correlates of sexual and gynaecological morbidity in Edo State, Nigeria. British Journal of Obstetrics and Gynaecology, 109:1089−1096.
17. ↑ ^{17.0 17.1} WHO Study Group on Female Genital Mutilation and Obstetric Outcome (2006). Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet, 367:1835−1841.
18. ↑ ^{18.0 18.1} Vangen S, Stoltenberg C, Johansen REB, Sundby J, Stray- Pedersen B (2002).Perinatal complications among ethnic Somalis in Norway. Acta Obstetrics et Gyneco- logica Scandinavica, 81:317−322.
19. ↑ Berggren V, Abdel Salam G, Bergstrom S, Johansson E, Edberg AK (2004). An explorative study of Sudanese midwives’ motives, perceptions and experiences of re-infibulation after birth. Midwifery, 20:299−311.
20. ↑ Berggren V, Yagoub AE, Satti AM, Khalifa MA, Aziz FA, Bergstrom S (2006). Postpartum tightening operations on two delivering wards in Sudan. British Journal of Midwifery, 14:1−4.
21. ↑ ^{21.0 21.1 21.2} Nour NM, Michels KB, Bryant AE (2006). Defibulation to treat female genital cutting. Effect on symptoms and sexual function. Obstetrics and Gynecology, 108:55−60.