Female genital cutting

INTRODUCTION — 

Female genital cutting (FGC), also known as female circumcision or female genital mutilation (FGM), is a culturally determined practice, predominantly performed in parts of Africa and Asia and affecting more than 200 million females worldwide [1-3]. In 2012, the United Nations General Assembly passed a resolution to advise the elimination of FGC [4,5].

Immigration patterns have caused clinicians throughout the world to increasingly encounter individuals who have experienced this practice [6,7]. It is imperative that these providers understand the health and social issues related to FGC so that they can manage the immediate and long-term complications of the procedure.

The role of the clinician in the care of patients who have undergone an FGC procedure will be reviewed here.

CLASSIFICATION — 

FGC refers to the manipulation or removal of external genital organs in females. The World Health Organization (WHO) classifies FGM into four types of procedures (figure 1) [3]:

●Type I (also referred to as clitoridectomy) consists of excision of the prepuce, with or without excision of part or all of the clitoris.

●Type II (also referred to as excision) involves clitoridectomy and partial or total excision of the labia minora and majora.

●Type III (also referred to as infibulation) includes removing part or all of the external genitalia and reapproximation of the remnant labia majora, leaving a small neo-introitus.

●Type IV includes any other injury to the female genital organs (eg, pricking, piercing, incising, scraping, and cauterizing).

ORIGINS AND RATIONALE — 

The origins of FGC are unknown, but theories as to its origins date back to ancient Egypt, pre-Islamic Arabia, ancient Rome, and Tsarist Russia [8-10]. In the modern era, this practice has come to represent an important rite of passage for young females into adulthood within some cultures. It is thought by some to be a religious custom, but no religion condones it. It is reinforced by customary beliefs that it maintains a female's chastity, preserves fertility, ensures marriageability, improves hygiene, and enhances sexual pleasure for males.

In Europe and the United States, removal of the clitoris or prepuce was occasionally performed up until the 1930s to treat clitoral enlargement, redundancy, hysteria, erotomania, and individuals identified as lesbians [11].

Most of the time, FGC is done with the intention to provide benefit, not cause harm. Parents initiate this procedure with the aim of helping their daughters. Being a wife and a mother is a female's livelihood in these societies; thus, not circumcising one's daughter is equivalent to condemning them to a life of isolation. Infibulation safeguards their sexual abstinence and ensures their eligibility for marriage, thereby protecting their future.

EPIDEMIOLOGY — 

As of 2023, the United Nations Children's Fund (UNICEF) found that FGC has been performed in at least 200 million females in the 31 countries in Africa and the Middle East where the procedure is mainly practiced [12,13]. In some countries, such as Somalia, Guinea, and Djibouti, the practice is almost universal [12].

While there has been an overall decline in the prevalence of FGC over the past three decades, especially in younger females, the majority of FGC is performed before age 14 years [14].

PROCEDURE — 

In some places, females are cut during a celebration in which the individual receives gifts of money, gold, and clothes. Invited families and friends often bring food and music to the festivities. In other regions, however, females are abducted in the middle of the night to be cut.

Non-medically trained operators usually perform FGC. Anesthesia and antibiotics are rarely administered. The instruments used may be old, rusty knives, razors, scissors, or heated pebbles, which are rarely washed between procedures. Hemostasis is assured by catgut sutures, thorns, or homemade adhesive concoctions such as sugar, egg, or animal excrement. The individual's legs are bound around the ankles and thighs for approximately one week after the procedure, and they are kept in bed.

However, some procedures are done under sterile conditions with appropriate instruments. An anesthetic may be administered when the procedure is performed in major cities.

COMPLICATIONS — 

There are both short- and long-term complications related to this procedure. However, health care providers should be mindful that not all individuals suffer complications and that their patient's health care concerns may or may not be related to FGC.

Periprocedural — Periprocedural complications include bleeding, infection, urethral injury, and fractures (table 1) [15]. Lack of anesthesia, struggles of a child held forcibly in the lithotomy position, inexperience of the operator, and lack of surgical precision often contribute to these complications.

Long-term gynecologic issues — The most common long-term complications are dysmenorrhea, dyspareunia, and chronic vaginal infections (table 2). Females who have undergone type II or III FGC (figure 1) tend to suffer more long-term complications than those who have undergone type I or IV.

●Urinary – Urinary complications, including meatal obstructions and urinary strictures, can develop if the urethral meatus was inadvertently injured [16]. Affected individuals may complain of straining, urinary retention, or a slow urinary stream. An infibulated scar can also result in the urine becoming stagnant, thereby facilitating the ascent of bacteria into the urethra. Infibulated individuals are thus at higher risk for meatitis, urinary stones, and chronic urinary tract infections [17,18].

●Scarring – Complications from scarring include fibrosis, keloids, sebaceous (epidermal) cysts, clitoral neuromas, vulvar abscesses, vulvar lymphangiectasias, and partial or total fusion of the labia minora or majora [19-21]. The latter complication can lead to hematometra or hematocolpos. In addition, a small neo-introitus may cause vaginismus and chronic vaginal infection.

●Infertility – Infertility rates are higher in females with FGC compared with the general population (25 to 30 versus 8 to 14 percent) [22]. The frequency of infertility appears to correlate with the anatomical extent of FGC [23]. Introital and vaginal stenosis create a physical barrier; thus, couples may attempt coitus for months before completing penetration [24]. Failure to succeed and persistent dyspareunia can lead to apareunia [25]. Infertility may also be related to tubal damage from ascending infection related to the procedure. (See "Pelvic inflammatory disease: Long-term complications", section on 'Infertility'.)

●Sexual dysfunction – Sexual satisfaction has been difficult to ascertain because of the sensitive nature of the topic [26]. In one cross-sectional study of 1836 Nigerian females, type I and II FGC was not associated with attenuation of sexual feelings or frequency of intercourse but was associated with a higher prevalence of abnormal vaginal discharge and pelvic pain [27]. In a subsequent study evaluating the effects of FGC on sexual dysfunction, those who had undergone type III infibulation (30 individuals) compared with those who had undergone a type I procedure (30 individuals) had lower scores on questionnaires evaluating sexual desire, arousal, and orgasm [28].

OBSTETRIC ISSUES

Monitoring labor — Performing cervical examinations on an infibulated patient in labor can be challenging. The narrow neo-introitus can make a bimanual examination difficult, if not impossible. Obstetricians face the dilemma of either defibulating (reversal of infibulation) the patient early in labor or monitoring the labor via rectal examination. Neither of these is an optimum solution: early defibulation requires an early epidural and irritation of the incision with every cervical assessment, while rectal examination of the cervix is uncomfortable, and most obstetricians have no experience using this technique in labor. However, inaccurate cervical assessment is also problematic because latent phase of labor may be falsely diagnosed as active labor and lead to an unnecessary cesarean birth. Other challenges include difficulties placing a fetal scalp electrode, intrauterine pressure catheter, or Foley catheter and performing fetal scalp pH.

The infibulated scar can also prolong the second stage of labor, probably because the scar can obstruct crowning and delivery [29]. Thus, a defibulation procedure prior to pregnancy or in the second trimester is strongly recommended to prevent this problem. (See 'Timing' below.)

Pregnancy outcomes — Adverse pregnancy outcomes appear to higher for patients with FGC, especially those with types II and III.

In a World Health Organization (WHO) prospective study group evaluating obstetric outcomes after FGC, those with type II and III FGC (14,366 patients) compared with those without FGC (7171 patients), had higher rates of [30]:

●Cesarean birth (adjusted relative risk [aRR] 1.29 and 1.31, respectively)

●Postpartum hemorrhage (aRR 1.21 and 1.69, respectively)

●Extended maternal hospitalization (aRR 1.51 and 1.98, respectively)

●Infants requiring resuscitation (aRR 1.28 and 1.66, respectively)

●Infants dying in the hospital (aRR 1.32 and 1.55, respectively)

Rates of adverse outcomes were similar for those with type I FGC (6856 patients) compared with uncut patients. All patients (both nulliparous and parous) with FGC (types I, II, and III) had higher rates of episiotomy and perineal tears compared with patients without FGC.

CARING FOR PATIENTS WITH FGC — 

Many individuals who have undergone FGC do not consider themselves to be mutilated. They do not believe that they are being selectively tortured because many females in their community have also gone through this ritual. Those who immigrate to the United States and Europe may be surprised to learn that most females in these regions have not undergone FGC. Therefore, these individuals can be offended if they are referred to as having undergone genital mutilation. Instead, it is better to use the term genital cutting, circumcision, or the exact word they use in their language. Individuals who have undergone FGC have voiced concern that health care providers are not sensitive when broaching this subject and sometimes must be educated about this practice by the patient themself.

The most important aspect of caring for individuals who have undergone FGC is to develop a trusting relationship. Clinicians should move beyond the scar and address the patient's health needs (eg, reproductive health, cervical cancer screening, menopause management). Cultural awareness and sensitivity regarding the procedure are crucial.

DEFIBULATION

Counseling — Individuals seek defibulation because they are pregnant or planning pregnancy, or because of apareunia/dyspareunia, dysmenorrhea, or difficulty urinating [31]. Counseling includes the risks of delivery with an infibulated scar (eg, bleeding, infection, scar formation, cesarean birth) and benefits of defibulation. Patients should also be counseled that their urinary stream will feel different (increased).

Timing — The optimum time to defibulate a patient is prior to coitus to prevent dyspareunia or prior to pregnancy to prevent obstetric complications (see 'Obstetric issues' above). What is medically beneficial to the patient, however, may not necessarily be the best time for them. As discussed above (see 'Origins and rationale' above), one of the reasons for FGC is to ensure sexual abstinence. Therefore, these patients may prefer to marry and prove they have never had vaginal penetration prior to defibulation.

Defibulation can also be performed during pregnancy. A patient may require multiple prenatal visits before they finally consent to the procedure [32]. When performed in pregnancy, surgery is typically performed in the second trimester under regional anesthesia. General anesthesia is an alternative, but local anesthesia alone is typically not a good choice because patients may develop flashbacks from the day they underwent FGC.

Technique — The infibulated scar is a flap obstructing the introitus and urethra that must be excised. The steps in the procedure are as follows [31]:

●Place regional or general analgesics and long-acting local anesthesia.

●Insert a Kelly clamp under the scar to delineate its length (picture 1).

●Palpate anteriorly to assess whether the clitoris is buried under the scar.

●Place two Allis clamps along the infibulated scar.

●Make an anterior incision between the two Allis clamps with Mayo scissors, being certain not to cut into a buried clitoris (picture 2 and picture 3). The goal is to view the introitus and urethra easily (picture 4). There is no need to incise too anteriorly towards the clitoral region.

●Place (4-0) subcuticular sutures on each side (picture 5 and picture 6).

A treatment technique using carbon dioxide laser surgery has also been described [33].

Postoperative care — Postoperatively, instruct the patient to take sitz baths twice daily. Lidocaine cream (2%) can be applied after the sitz bath. Oral analgesics taken as needed for one or two days is usually adequate for postoperative pain control [34].

Outcomes — Positive outcomes have been reported following defibulation or reconstructive surgery following genital cutting. In a prospective study of 2938 patients with type II or III FGC who underwent mobilization of the clitoral stump, complications (eg, hematoma, wound separation, fever) occurred in 5 percent of patients [35]. Among the 866 patients who completed a one-year postoperative assessment, 97 percent had either no change or an improvement in sexual pain and clitoral pleasure. In another series of 32 patients who underwent defibulation, all patients were satisfied with the results [31].

ROLE OF REINFIBULATION — 

Some patients who have just given birth will request immediate reinfibulation. The procedure may create the long-term complications previously mentioned (see 'Complications' above and 'Obstetric issues' above) and should be strongly discouraged. However, if the patient only feels comfortable being infibulated, their request should be respected.

The United States passed a law in March 1997 that made performing any medically unnecessary surgery on the genitalia of a female younger than 18 years of age a federal crime. However, reinfibulation was not included in this law.

When reinfibulation is performed in a patient who strongly insists upon the procedure, absorbable sutures are placed in a running fashion [36].

SUMMARY AND RECOMMENDATIONS

●Clinical significance – Female genital cutting (FGC), also known as female circumcision or female genital mutilation (FGM), is a culturally determined practice, predominantly performed in parts of Africa and Asia. In 2012, the United Nations General Assembly passed a resolution to advise the elimination of FGC. (See 'Introduction' above.)

●Classification – There are four types of FGC/FGM (figure 1). (See 'Classification' above.)

●Complications

•Periprocedural complications – Periprocedural complications include bleeding, infection, urethral injury, and fractures (table 1) [15]. (See 'Periprocedural' above.)

•Long-term gynecologic issues – Potential long-term problems after FGC include dysmenorrhea, dyspareunia, chronic vaginal and bladder infections, voiding difficulties, fibrosis, keloids, sebaceous cysts, vulvar abscesses, infertility, and difficulty with pelvic examinations and coitus (table 2). (See 'Long-term gynecologic issues' above.)

•Obstetric issues – In labor, the infibulated scar can make it challenging to perform cervical examinations; place a fetal scalp electrode, intrauterine pressure catheter, or Foley catheter; or perform fetal scalp pH. The infibulated scar can also prolong the second stage of labor. (See 'Obstetric issues' above.)

●Caring for patients – The most important aspect of caring for individuals who have undergone FGC is to develop a trusting relationship. Clinicians should move beyond the scar and address the patient's health needs (eg, reproductive health, cervical cancer screening, menopause management). Cultural awareness and sensitivity regarding the procedure are crucial. (See 'Caring for patients with FGC' above.)

●Defibulation – For most patients, we suggest defibulation (Grade 2C). The optimum time to defibulate a patient is prior to coitus (to prevent dyspareunia) or prior to pregnancy (to prevent obstetric complications). However, what is medically beneficial to the patient may not necessarily be the best time for them. As one of the reasons for FGC is to ensure sexual abstinence, some patients may prefer to marry and prove they have never had vaginal penetration prior to defibulation. (See 'Defibulation' above.)

●Role of reinfibulation – For most patients, we suggest against immediate reinfibulation after vaginal birth (Grade 2C). Reinfibulation may create long-term complications. However, if the patient only feels comfortable being infibulated, their request should be respected. (See 'Role of reinfibulation' above.)