I FEMALE GENITAL CUTTING

Female genital cutting, also known as female genital mutilation or female circumcision, is genital alteration performed on girls and young women for nontherapeutic reasons. Although opposition to it has increased, the practice is still widespread.

Many different phrases have been used to describe female genital cut­ting. When talking with any woman who has undergone female genital cutting, it is important to determine how she refers to the procedure and adopt that terminology. The intent of this practice is circumcision, the cut­ting of genitals, based on cultural beliefs. The term mutilation emphasizes the degree of damage caused by this practice. It is important to recognize that most women who have undergone female genital cutting do not consider themselves to be mutilated and may be offended by such a sug­gestion.

There is no scientific basis for the practice of female genital cutting. Reasons given by families for the performance of female genital cutting include the following:

• Psychosexual reasons—attenuation of sexual desire in the female, insurance of chastity and virginity before marriage and fidelity within marriage, and increased male sexual pleasure

• Sociologic and cultural reasons—identification with the cultural heritage, initiation of girls into womanhood, social integration, and maintenance of social cohesion; removal of external genitals, which some cultures consider dirty and unsightly

• Myths—enhancement of fertility and promotion of child survival

• Religious reasons—mistaken belief by practitioners that female genital cutting has religious support and is required by the religious scripture

Many forms of female genital cutting are practiced.

Female genital cutting is performed predominantly on girls aged 0-15 years by medically untrained individuals under high-risk, unsterile conditions using crude instruments and no anesthetics. Immediate com­plications may include severe pain, infection (including human immuno­deficiency virus [HIV]), tetanus, shock, hemorrhage, difficulty in passing urine, genital ulceration, injury to adjacent tissue, and death. Long-term complications may include the following:

• Chronic infection of the genital or urinary tracts

• HIV

• Chronic pain

• Keloids and other scarring abnormalities

• Vulvar abscesses

• Fistulae

• Menstrual abnormalities

• Infertility

• Urinary incontinence or voiding difficulty

• Depression, anxiety, and posttraumatic stress disorder

• Sexual dysfunction and dyspareunia

• Obstetric complications

— Prolonged labor

— Cesarean delivery

— Extensive lacerations

— Postpartum hemorrhage

— Fetal asphyxia or death

— Sepsis

The American College of Obstetricians and Gynecologists joins many other organizations (the World Health Organization, United Nations International Children’s Emergency Fund, International Federation of Gynecology and Obstetrics, American Academy of Pediatrics, and the American Medical Association) in opposing all forms of medically unnec­essary surgical modification of the female genitalia. The American College of Obstetricians and Gynecologists further recommends that the issue be addressed by the following:

• Treating patients who have undergone female genital cutting with sensitivity and compassion

• Tailoring obstetric and gynecologic care to the special physical and psychosocial needs of these patients

• Promoting awareness among the public

• Promoting awareness among health care providers

• Developing methods for educating physicians regarding the gyne­cologic and obstetric care of women who have undergone this procedure

Any general health care provider should do the following to address female genital cutting:

• Know the demographics of the local patient population to determine if female genital cutting is a medical issue that is likely to arise.

• Communicate effectively with this patient population with aware­ness and sensitivity.

• Work with interpreters and social workers, as necessary, to address the special needs of immigrants and refugees within this patient population.

• Review with patients the basics of female anatomy and reproductive function.

• Provide health education about female genital cutting and its physi­cal and psychosexual consequences.

• Review with patients any special gynecologic issues, including men­strual, urinary, and sexual functions; family planning; and cancer screening.

• Offer alternatives to vaginal treatments or medications because the patient may not be comfortable with inserting, or may be unable to insert, anything in the vagina.

• Understand techniques for performing a pelvic examination on a woman who has had female genital cutting, including alternative procedures, as necessary:

— Small or narrow speculum

— Single-digit bimanual examination

— Rectal examination to assess pelvic organs

— Ultrasonographic evaluation

Specialized care of the patient who has undergone female genital cutting may include the following:

• Referral to a physician with special interest in pelvic or vaginal reconstructive surgery or a clinician practicing in an area of high prevalence of female genital cutting

• Familiarity with the types of female genital cutting and ensuing complications of each type

• Understanding of surgical therapies available, including the following:

— Excision of cysts

— Revision of introital or urethral scarring

— Defibulation (opening the area that has been surgically closed)

— Repair of Fistulae

— Procedures for correcting vaginal stenosis

• Counseling the patient before and after surgical correction about the new appearance of her anatomy and the expected changes in her urinary, menstrual, and sexual function

• Eliciting the help of social workers and psychiatric professionals

• Communication with policy makers, community groups, and wom­en’s groups about this issue

• Awareness of the current research on female genital cutting and on the safest timing and techniques for repair and reconstruction

Bibliography

American College of Obstetricians and Gynecologists.

Brigham and Women’s Hospital. African Women’s Health Center. Available at: http://www.brighamandwomens.org/Departments_and_Services/obgyn/services/ africanwomenscenter/default.aspx. Retrieved July 31, 2013.

World Health Organization. Eliminating female genital mutilation: an interagency statement UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCHR, UNHCR, UNICEF, UNIFEM, WHO. Geneva: WHO; 2008. Available at: http://whqlibdoc. who.int/publications/2008/9789241596442_eng.pdf. Retrieved September 12, 2013.

World Health Organization. Female genital mutilation. Fact sheet No. 241. Geneva: WHO; 2013. Available at: http://www.who.int/mediacentre/factsheets/fs241/en. Retrieved July 31, 2013.

Resources

Biller-Andorno N, Wild V. The ethics of evidence. Hastings Cent Rep 2012;42:29-30. [PubMed]

Macklin R. Aesthetic enhancement? Or human rights violation? Hastings Cent Rep 2012;42:28-9. [PubMed]

Nour NM. Using facts to moderate the message. Hastings Cent Rep 2012;42:30-1. [PubMed]

Rosenberg LB, Gibson K, Shulman JF. When cultures collide: female genital cutting and U.S. obstetric practice. Obstet Gynecol 2009;113:931-4. [PubMed] [Obstetrics & Gynecology]

Seven things to know about female genital surgeries in Africa. Public Policy Advisory Network on Female Genital Surgeries in Africa. Hastings Cent Rep 2012;42:19-27. [PubMed]

World Health Organization. Female genital mutilation. Available at: http://www. who.int/topics/female_genital_mutilation/en. Retrieved July 31, 2013.