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 230 million females worldwide [1-3]. In 2012, the United Nations General Assembly passed a resolution to advise the elimination of FGC [4,5], and in 2024, through the United Nations Sustainable Developmental Goals Report, the global community committed to end FGC by 2030 [6]. Although progress has been made in several countries, meeting this goal requires this practice to decrease almost 30-fold faster than that seen in the last decade [3].

Immigration patterns have caused clinicians throughout the world to increasingly encounter individuals who have experienced this practice [7,8]. 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) [2]:

●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 [9-11].

In the modern era, this practice has come to represent an important rite of passage for young females into adulthood within some cultures. While it is thought by some to be a religious custom, no religion condones it, and the World Health Organization (WHO) declares FGC a violation of human rights [12]. Rather, FGC 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 many instances, FGC is done with the intention to provide perceived benefit, not cause harm; adherence to cultural or religious practice or social acceptance is the motivation.

EPIDEMIOLOGY — 

As of 2024, the United Nations Children's Fund (UNICEF) found that FGC has been performed in at least 230 million females in 31 countries in Africa and the Middle East where the procedure is mainly practiced [3,13]. Despite a decrease in the practice in some countries, this represents a 15 percent increase (or 30 million additional cases) compared with data released eight years prior. In some countries, such as Somalia, Guinea, and Djibouti, the practice is almost universal.

The majority of FGC is performed between the ages of 5 and 14 years [14].

PROCEDURE — 

The performance of FGC varies greatly. In some cultures, females are cut during a celebration with invited family and friends. The individual receives gifts of money, gold, and clothes. In other regions, however, females are abducted in the middle of the night to be cut. Consent is rarely obtained, if at all, even for older children.

FGC is often performed by non-medically trained operators, generally without the use of anesthesia or antibiotics. Sterile surgical technique is rare in these circumstances, and the instruments used may be old, rusty knives, razors, scissors, or heated pebbles, which may not be washed between procedures. Hemostasis may be maintained by catgut sutures, thorns, or homemade adhesive remedies such as sugar, egg, or animal excrement. After the procedure, the individual's legs may be bound around the ankles and thighs for approximately one week and they are kept in bed.

In other regions, health care providers perform the procedure under sterile conditions with appropriate anesthetics and instruments.

COMPLICATIONS — 

There are both short- and long-term complications related to FGC. 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 (both upper and lower genital tract), urethral injury, and death (table 1) [15]. Lack of anesthesia combined with struggles of a child held forcibly in the lithotomy position, can lead to fracture of the clavicle, humerus, or femur. Inexperience of the operator, lack of surgical precision, and lack of sterile surgical technique 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 keloids, sebaceous (epidermal) cysts, clitoral neuromas, vulvar abscesses, or vulvar lymphangiectasias. Partial or total fusion of the labia minora or majora can lead to hematometra or hematocolpos. In addition, a small neo-introitus may cause dyspareunia or chronic pain with secondary vaginismus or chronic vaginal infection [19-21].

●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 — Ideally, prepregnancy or antepartum counseling will prevent the need for unplanned intrapartum procedures and potential complications in patients with FGC.

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. If an examination is possible but painful, early regional anesthesia may be indicated.

Defibulation (reversal of infibulation) early in labor (see 'Defibulation' below) or rectal examination for evaluation of labor progress may be a difficult choice for the delivering health professional who may not be familiar with either procedure. Additionally, neither of these is an optimum solution: early defibulation requires an early epidural and irritation of the incision with every cervical assessment, which may increase infection rates, while rectal examination of the cervix is uncomfortable and less accurate in inexperienced hands. Other challenges include difficulties placing a fetal scalp electrode, intrauterine pressure catheter, or Foley catheter, and performing fetal scalp pH (if indicated).

The infibulated scar can also prolong the second stage of labor, probably because the scar can obstruct crowning and delivery [29]. In either stage of labor, cesarean birth may be performed prematurely.

If a defibulation procedure is warranted and desired by the patient, intervention prior to pregnancy or in the second trimester is strongly recommended (see 'Timing' below) For those who do not wish to have a defibulation procedure, cesarean birth may be considered.

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 — 

Individuals who have undergone FGC need an open, culturally sensitive, and trusting relationship with their health care providers. Clinicians should see beyond the scar and address the patient's health needs (eg, reproductive health, cervical cancer screening, menopause management). Women's health care providers should approach these individuals using the principles of trauma-informed care (see "Trauma-informed care in adults"). Depending on the type and the way in which the FGC was performed, gynecologic care may be difficult both physically and emotionally.

Importantly, patients who have undergone FGC may not see FGC in the same way as health care providers from different cultures. Many have come from areas where most 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 and do not consider themselves to be mutilated. 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.

As many clinicians will have little or no experience in caring for patients with FGC, consultation with colleagues more familiar with managing these challenging situations is encouraged.

DEFIBULATION

Counseling — Individuals may 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. Postoperative changes, such as a stronger urinary stream, should be discussed. Those who have undergone complete or partial clitorectomy should be counseled about orgasm and sexual outcomes. Similarly, individuals with dyspareunia or chronic pain should be counseled that defibulation alone may not fully address their problem and secondary conditions, such as dryness, vaginismus, or vulvodynia may also have to be addressed. As appropriate, individual, couples, or sexual counseling should also be considered. (See "Overview of sexual dysfunction in females: Management", section on 'Couples therapy and sex therapy'.)

Timing — The optimum time to defibulate a patient is prior to the initiation of coitus in an attempt to prevent dyspareunia or prior to pregnancy to prevent obstetric complications (see 'Obstetric issues' above); however, shared decision-making with clear outlines of risks and benefits should be discussed, and timing of the procedure should be the patient's choice. As FGC may be to ensure sexual abstinence, culturally, an individual may prefer to marry prior to defibulation. If appropriate, and the patient consents, her partner may be included in the counseling process.

Defibulation can also be performed during pregnancy. Ongoing discussions, accurate counseling, and multiple prenatal visits may be required prior to a patient consenting or declining the procedure [32]. When performed during pregnancy, surgery is typically performed in the second trimester under regional anesthesia or general anesthesia. Local anesthesia is generally not recommended, especially if they have had a traumatic experience during the FGC procedure. If a patient declines defibulation, counseling concerning risks and benefits of vaginal versus caesarean birth should be undertaken.

Defibulation technique — The infibulated scar is a flap obstructing the introitus and urethra that must be excised. The steps in the procedure are as follows (as FGC varies in type and extent, the following procedure may need to be adapted to the individual's anatomy) [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, pain relief can be obtained using sitz baths twice daily with Lidocaine cream (2%) applied afterwards. Surgeons may also utilize intraoperative nerve blocks for postoperative pain relief. Oral analgesics taken as needed for up to one week are usually adequate for postoperative pain control [34,35].

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 [36]. Among the 866 patients who completed a one-year postoperative assessment, almost all (97 percent) reported an improvement, or at least no worsening, 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 will request reinfibulation after having the scar disrupted during vaginal birth [37]. For such patients, a thorough discussion of the risks of this procedure should be undertaken (see 'Complications' above) consideration should include future pregnancy desires.

If the patient continues to desire reinfibulation, the request should be respected. For such patients, we use absorbable sutures in a running fashion.

Health care providers should be aware of relevant federal and state regulations criminalizing performing or assisting in FGM. These laws emphasize protecting minors and recognize FGM as a human rights issue and a form of gender-based violence. Unlike in some European nations, however, in the United States, reinfibulation after birth is not included in these regulations [38].

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, and in 2024, through the United Nations Sustainable Developmental Goals Report, the global community committed to end FGC by 2030. (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, fractures, and death (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, 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 – Individuals who have undergone FGC need an open, culturally sensitive, and trusting relationship with their health care providers. Clinicians should see beyond the scar and address the patient's health needs (eg, reproductive health, cervical cancer screening, menopause management). Women's health care providers should approach these individuals using the principles of trauma-informed care. Depending on the type and the way in which the FGC was performed, gynecologic care may be difficult both physically and emotionally. (See 'Caring for patients with FGC' above and "Trauma-informed care in adults".)

●Defibulation – For most patients, we suggest defibulation (Grade 2C). The optimum time to defibulate a patient is prior to initial coitus (to prevent dyspareunia) or prior to pregnancy (to prevent obstetric complications). However, shared decision-making with clear outlines of risks and benefits should be discussed with the patient and timing of the procedure should be the patient’s choice. (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.)