Female Genital Mutilation

Female genital mutilation is a widespread traditional practice. More than 230 million girls and women alive today have undergone female genital mutilation in 30 countries worldwide (1). It is especially prevalent in some areas and cultures in Africa (usually northern or central Africa and extending into the Horn of Africa). It is also performed in some parts of the Middle East and in other areas of the world (eg, in diaspora communities worldwide due to migration). In cultures where it is practiced, it is often regarded as providing benefits regarding female hygiene, fertility, and chastity and male sexual pleasure and may be considered a prerequisite for marriageability. Female genital mutilation may be decreasing due to the influence of religious leaders who have discouraged the practice and growing opposition in some communities. This is especially true among younger cohorts and in urban areas, although the pace and extent of decline vary regionally (2).

The practice has many potential complications and no health benefits.

The age at which mutilation is performed varies significantly by location (3). In approximately half of countries with available data, most girls undergo the procedure before the age of 5, while in other settings, the procedure is more commonly performed up to age 12, or even during adolescence. Mutilation is typically done without anesthesia.

There are 4 main types of female genital mutilation defined by the World Health Organization (WHO) (1):

• Type I: Clitoridectomy—Partial or total removal of the clitoral glans (visible part of the clitoris) and/or the prepuce (the fold of skin surrounding the clitoris)

• Type II: Excision—Partial or total removal of the clitoral glans and the labia minora, with or without removal of the labia majora

• Type III: Infibulation—Narrowing of the vaginal opening by cutting and repositioning the labia minora or labia majora, sometimes through stitching, with or without removal of the clitoral prepuce/clitoral hood and glans

• Type IV: Other—All other harmful procedures done to the female genitals for nonmedical purposes (such as pricking, piercing, carving [incising], scraping, and cauterizing the genital area)

The potential sequelae of genital mutilation include immediate operative or postoperative bleeding and infection (including tetanus) (3). Menstrual difficulties (eg, dysmenorrhea, heavy or irregular menstrual bleeding) may result. For women who have undergone infibulation (Type III genital mutilation), recurrent urinary and/or gynecologic infection and scarring are possible. Women may develop chronic vulvar pain and may experience pain or lower genital tract lacerations with sexual intercourse. Women who become pregnant after female genital mutilation may have significant perineal lacerations or hemorrhage during childbirth. Psychological sequelae may be severe.

Medical care for women who have undergone infibulation includes using a culturally sensitive approach and sometimes a deinfibulation procedure (4), preferably prior to initiating sexual activity or antenatally prior to vaginal delivery. Women should be referred to a specialist experienced with this care.