Female genital cutting

INTRODUCTION — Female genital cutting (FGC), also known as female circumcision or genital mutilation, is a culturally determined practice, predominantly performed in parts of Africa and Asia and affecting more than 125 million females worldwide [1,2]. Immigration patterns have caused clinicians throughout the world to increasingly encounter individuals who have experienced this practice [3,4]. 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) classified FGC into four types of procedures.

●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 neointroitus.

●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 [5-7]. 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 2013, the United Nations General Assembly passed a resolution to advise the elimination of FGC [8,9].

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 [10].

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.

Many individuals who have undergone FGC do not consider themselves to be mutilated. They do not believe that they are being selectively tortured because the majority of females in their community have 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.

EPIDEMIOLOGY — As of 2021, 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 [11,12]. There has been an overall decline in the prevalence of FGC over the past three decades, especially in younger females. In this report, the prevalence for females ages 45 to 49 years compared with females ages 15 to 19 years was 54 percent and 36 percent, respectively.

PROCEDURE — Females are cut between the ages of 5 and 12; in some places 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.

Nonmedically 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 AND OUTCOME — There are both short and long-term complications related to this procedure. However, health care providers should be aware that individuals with FGC present with a variety of complaints and FGC is not necessarily the problem. It is also important to stress that not all individuals suffer complications.

Periprocedural complications — Surgical precision can be compromised by lack of anesthesia, the struggles of the child held forcibly in the lithotomy position, and the experience of the operator. Success is often dependent upon chance, rather than accuracy. Early postprocedure complications thus include hemorrhage, infection, oliguria, and sepsis (table 1) [13].

Long-term gynecologic issues — Females who have undergone type II or III FGC tend to suffer more long-term complications than those who have undergone type I or IV.

●The most common long-term complications are dysmenorrhea, dyspareunia, and chronic vaginal infections. Other complications are related to voiding (table 2) [14]. Meatal obstructions and urinary strictures could develop if the urethral meatus was inadvertently injured. Affected individuals 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 [15,16].

●Other complications from scarring include fibrosis, keloids, sebaceous (epidermal) cysts, vulvar abscesses, and partial or total fusion of the labia minora or majora. The latter complication can lead to hematometra or hematocolpos. In addition, a small neointroitus may cause vaginismus, chronic vaginal infection, and neuromas [17,18]. (See "Vulvar abscess".)

●The infertility rate is higher in females with FGC compared with the general population (25 to 30 versus 8 to 14 percent) [19]. The frequency of infertility appears to correlate with the anatomical extent of FGC [20]. Introital and vaginal stenosis create a physical barrier; thus, couples may attempt coitus for months before completing penetration [21]. Failure to succeed and persistent dyspareunia can lead to apareunia [22]. Infertility may also be related to tubal damage from ascending infection related to the procedure.

●Sexual satisfaction has been difficult to ascertain because of the sensitive nature of the topic [23]. One survey that interviewed individuals with FGC reported they were able to achieve orgasm [24]. However, a study of 1836 Nigerian females with FGC found that the procedure (type 1 and II) did not attenuate sexual feelings or frequency of intercourse and was associated with a higher prevalence of abnormal vaginal discharge and pelvic pain [25]. Another study also showed that those who had undergone type III infibulation were significantly affected in terms of sex drive, arousal, and orgasm when compared with those who had undergone a type I procedure [26].

Obstetric issues

Monitoring labor — Progress of labor is typically monitored using serial cervical examinations. Performing a pelvic examination on an infibulated patient can be challenging. The narrow neointroitus can make a bimanual examination difficult, if not impossible. Obstetricians face the dilemma of either defibulating the patient early in labor or monitoring the labor via rectal examination. Neither of these is an optimum solution: early defibulation (reversal of infibulation) would require a very 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 delivery. Other challenges include difficulties placing a fetal scalp electrode, intrauterine pressure catheter, or Foley catheter and performing fetal scalp pH.

The infibulated scar can prolong only the second stage of labor, probably because the scar may obstruct crowning and delivery [27]. A defibulation procedure during the second trimester is strongly recommended to prevent this problem [28].

Pregnancy outcome — A World Health Organization (WHO) study group compared obstetric outcomes of patients with and without FGC (n = 7171 no FGC, 6856 FGC 1, 7771 FGC II, 6595 FGC III) [29]. Patients with FGC II and III, but not FGC I, were at significantly higher risk of cesarean delivery, postpartum hemorrhage, and extended maternal hospital stay, and their infants were at significantly higher risk of requiring resuscitation and of dying in the hospital than patients without FGC. The risks were higher in patients with FGC III than FGC II. Nulliparous and parous patients with FGC I, II, and III had higher rates of episiotomy and perineal tears than patients without FGC.

DEFIBULATION COUNSELING AND PROCEDURE — Individuals seek defibulation because they are pregnant or planning pregnancy, or because of apareunia/dyspareunia, dysmenorrhea, or difficulty urinating [30].

The optimum time to defibulate a patient is prior to coitus to prevent dyspareunia or prior to pregnancy to prevent obstetric complications. What is medically beneficial to the patient, however, may not necessarily be the best time for them. As discussed 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 be performed during pregnancy. A patient may require multiple prenatal visits before they finally consents to the procedure [28]. Counseling them about the risks of delivery with an infibulated scar is critical; the risks (eg, bleeding, infection, scar formation, preterm labor) and benefits of defibulation must also be reviewed and they should be aware that their urinary stream will feel different (increased).

Surgery during the second trimester under regional anesthesia decreases both obstetric and fetal risks. General anesthesia is an alternative, but local anesthesia is not a good choice because patients sometimes develop flashbacks from the day they underwent FGC.

Positive outcomes have been reported following defibulation or reconstructive surgery following genital cutting. As an example, a prospective study of 2938 patients with type II or III FGC who underwent mobilization of the clitoral stump reported that complications occurred in 5 percent of patients. Among the 866 patients who completed a one-year postoperative assessment, 97 percent had no change or an improvement in sexual pain and clitoral pleasure. In addition, a series of 32 patients who underwent defibulation reported that all of the patients and their husbands were satisfied with the results [30].

Technique — The infibulated scar is a flap obstructing the introitus and urethra that must be excised. The steps in the procedure are as follows [30]:

●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).

Postoperatively, instruct the patient to take sitz baths twice each day. Lidocaine cream (2 percent) can be applied after the sitz bath. Opioid analgesics taken as needed for one or two days is usually adequate for postoperative pain control [31].

A treatment technique using carbon dioxide laser surgery has also been described [32].

REINFIBULATION — Some patients who have just given birth will request immediate reinfibulation. The procedure may create the long-term complications previously mentioned and should be strongly discouraged. The patient may only feel 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 as a federal crime, so it may be performed with absorbable sutures in a running fashion if a patient strongly insists upon the procedure [33].

SUMMARY AND RECOMMENDATIONS

●There are four types of female genital cutting (FGC). (See 'Classification' above.)

●The number of African immigrants and refugees coming to American and European countries is increasing, bringing renewed interest in unique cultural traditions. The most important aspect of caring for individuals who have undergone FGC is to develop a trusting relationship. Obstetrician-gynecologists 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 'Origins and rationale' above.)

●Potential 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, coitus, and vaginal delivery. (See 'Complications and outcome' above.)

●We suggest defibulation prior to coitus to prevent dyspareunia or prior to pregnancy to prevent problems with vaginal delivery (Grade 2C). (See 'Defibulation counseling and procedure' above.)