Female Genital Mutilation - Global Library Of Women's Medicine

22Female Genital MutilationHassan Azadeh and Moustapha TouréINTRODUCTIONDefinitionThe World Health Organization (WHO) (2000)defines female genital mutilation (FGM) as ‘procedures involving partial or total removal of theexternal female genitalia or other injury to thefemale genital organs whether for cultural, religiousor other non-therapeutic reason’.Scope of the problemThe prevalence of FGM is illustrated in Figure 11.Female circumcision or genital mutilation is stillwidely practiced in over 30 countries in the world.WHO estimates that over 120 million women havebeen circumcised and several thousand more arecircumcised each day. Due to population movements women and girls living in western nationsbut originating from cultures where FGM is practiced are also at risk. The practice has become anissue for most healthcare providers, particularlymidwives and obstetricians who may, however, notbe aware of the consequences. All health workerswho are involved in caring for the mutilatedpatient have an important role to play: theymust recognize the sensitive nature and complexity of the issues related to FGM, and shouldhave knowledge on the possible complications inchildbirth. Caregivers should avoid becomingjudgmental or punitive.In this chapter, we will explain the problemssurrounding female circumcision/genital mutilation particularly the sexual problems and thepossible serious gynecological and obstetriccomplications.Figure 1 Prevalence of female genital mutilation inAfrica. Source: index.htmHistory and practiceFemale sexuality has been repressed in a variety ofways in all parts of the world throughout history upto the present time. Female slaves in ancient Romehad one or more rings put through their labia toprevent them from becoming pregnant. Chastitybelts were brought to Europe by the crusaders during the 12th century. The burning of women aswitches in Europe, foot binding in China andwidow burning in India all contributed to theoppression of women. In the 19th century the removal of the clitoris was performed as a surgicalremedy against masturbation in Europe and in theUSA. FGM may be viewed upon as one of the275

GYNECOLOGY FOR LESS-RESOURCED LOCATIONS Type III: excision of part or all of the externalgenitalia and stitching/narrowing of the vaginalopening, or infibulation (may be known aspharaonic circumcision of infibulation). Type IV: pricking, piercing or incising of theclitoris and/or labia; stretching of the clitorisand/or labia; cauterization by burning of theclitoris and surrounding tissue; scraping of tissuesurrounding the vaginal orifice (angurya cuts) orcutting of the vagina (gishiri cuts); introductionof corrosive substances or herbs into the vaginato cause bleeding, or for the purpose of tightening or narrowing it – and any other procedurethat falls under the definition given above.extreme forms of female oppression seen acrosscenturies. FGM is found across many African countries (Figure 1) and some countries in Asia and theMiddle East such as Malaysia, Indonesia and theUnited Arab Emirates2. It is traditional in manydifferent groups and faiths, including Christians andMuslims. Although there is no clear obligatorystatement in the Qur’an for this practice, it is stillcarried out in the name of religion, although thepractice is not exclusive to Muslims.The age at which FGM is carried out differsfrom area to area. It varies from a few days’ old baby(e.g. Mali, the Jewish Flashas in Ethiopia and theNomads of the Sudan) to about 7 years old (as inEgypt and many countries of Central Africa), or toadolescents (among the Ibo of Nigeria) where excision takes place shortly before marriage or beforethe first child (as among the Ahols in mid-WesternNigeria). Most experts agree, however, that the ageof mutilation is becoming younger and has less andless to do with initiation into adulthood.Most frequently, FGM is performed by anold woman of the village (known as ‘NoumouMousso’ in Mali, ‘Gadda’ in Somalia) or traditionalbirth attendants (called Daya in Egypt and theSudan). In northern Nigeria and in Egyptianvillages barbers carry out the task and on rare occasions it is done by the mother herself. Anestheticsare never used and the child is usually held downeither by one or several village women. Herb mixtures, earth, cow dung or ashes are rubbed intothe wound to stop bleeding. The instruments arecrude and include kitchen knives, razor blades andpieces of glass. Needles, thorns, catgut or thread areused to stitch the wound. There is no attempt atasepsis.FGM is practiced on thousands or hundreds ofthousands of newborn and small girls worldwide.These girls have the most awful experiences andthe degree of post-traumatic stress will never befully assessed in most individuals.Cultural issuesSeveral theories exist about its origin: To control women’s sexuality or an attempt toobtain control of women’s magic power. Toguarantee virginity until marriage. The excisionof the clitoris would decrease sexual desire andpleasure of the women before marriage. To ensure a secure future for a female child in asociety ‘that requires infibulated wives, and sincea girl has no other choice in life but to marry,she must undergo the operation’. As a protection against rape for young girls whotake the animals out to pasture. For hygienic and esthetic reasons because awoman’s genitalia were considered unclean andunsightly. As a religious ritual in some countries. TheMossi in Burkina Faso believe that contactbetween the clitoris and child’s head duringdelivery can result in the death of the child. Inother cases it is believed that removal of theclitoris promotes fecundity.Continuation of the practiceForms of female genital mutilation3Why does the practice continue when the personal,psychological and heath complications are sosevere? A study in 1984 of 300 women in SierraLeone found that of the 90% who were circumcised the reasons cited were tradition (85.6%), tobelong to a group (35%), religion (17%), protectionof virginity (3.7%), to please husband (0.7%) and tomaintain good health (0.3%). Haga Sasso a SierraLeone woman who practices FGM in a villageFigure 2 illustrates the types of FGM4: Type I: excision of the prepuce (a retractablepiece of skin covering part of the clitoris), withor without excision of parts or all of the clitoris. Type II: excision of the clitoris with partial ortotal excision of the labia minora (may be knownas sunna circumcision).276

Female Genital Mutilation(a)(c)(b)(d)Figure 2 Different types of female genital mutilation (FGM). (a) Type I FGM; (b) type II FGM; (c) type III FGM; (d)type IV FGM. Source: Touré, M. Excision et Santé de la Femme. Conakry, Guinea: Editions Ganndal. ISBN: 2–913326–49–8Acute complicationsexplains ‘If the women of our village stop this practice, life will be meaningless to us all. It is our culture, and nobody has the right to take it away fromus’.WHO has taken a stand against genital mutilation but has acknowledged that in the Africancountries where female circumcision is practiced,attempts to outlaw this have met with strong opposition from both men and women and an insistencethat westerners should not interfere with the cultural practices of another nation.These may include the immediate ones such asshock due to pain, infection or severe hemorrhage. Acute infection with tetanus and generalized septicemia is a frequent problem due tothe conditions in which FGM is carried out.Abscess, urinary retention and damage to theurethra or anus may occur. The mortality rate ofgirls as a result of bleeding after FGM is unknownbecause these deaths are rarely reported to thehealth information system and are usually keptsecret.HEALTH COMPLICATIONSHealth complications of FGM for women andchildren are serious, many and varied. They arephysical, psychological and social. They are acute orchronic. There is a broad range of complicationsdue to genital mutilation which women can sufferfrom during their entire life:Chronic complicationsThese include chronic urinary retention, obstruction to menstrual flow and consequences of infection can lead to the following frequent occurringcomplications:277

GYNECOLOGY FOR LESS-RESOURCED LOCATIONS Chronic urinary tract infections (UTI).Chronic pelvic pain.Infertility.Keloid scar – sometimes extensive keloid is seen(Figure 3).Psychological trauma: infibulated women sufferconsiderable trauma during actual or attemptedsexual penetration. Full sexual intercourse maytake some weeks to achieve.Difficulties in childbirth: especially after excisiontype III (infibulation) the child may be retainedin the vagina (Figure 4). The presenting partcan compress the bladder and the rectum dueto the fetus being retained in the vaginathrough infibulation itself or scar tissue oftype I and II FGM. If the situation lasts formany hours, tissue necrosis of bladder andrectum will develop which will lead to a vesicovaginal (VVF) or recto-vaginal fistula (RVF)once the necrotic tissue falls off (for moreinformation about fistula see Chapter 21). Inmost cases the fetus will die (Figure 5) andthe mother, if she survives may suffer fromserious injuries (Figure 6) and become a socialoutcast due to the permanent stench of urine.FGM and the resulting scar tissue causes rigidityof vaginal tissue. At childbirth the level ofelasticity of the vagina cannot be expected to benormal due to scarring. In the absence of surgicalinterventions severe tears of the vaginal wallor perineum can arise with the risk of majorbleeding.Loss of sexual function: sexual pleasure andorgasm is diminished or absent. Dyspareunia(pain during intercourse) and trauma can lead tovaginismus and other sexual problems.Psychological implications: disorders such asinsomnia, nightmares, mood disorders, difficulty concentrating, depression, chronicanxiety have been reported. One can assume that these problems have a high incidenceamong women suffering from FGM but thereare hardly any statistics or studies availableon this issue. In addition many victims arenot even aware of the fact that their symptomsare related to FGM as the procedure is considered as normal in their setting and theycan’t compare their health problems with someone who has not undergone FGM. Manywomen or girls can’t express their pain and sufferin silence.Figure 3 Excessive keloid after female genital mutilation. Source: TouréFigure 4 Obstructed labor due to female genitalmutilation. Source: TouréFigure 5 Stillborn baby due to obstructed labor causedby female genital mutilation. Source: TouréLess common complications Abscesses: collection of pus in wound cavitiesafter excision. These abscesses may prevent sexualintercourse and are very painful (Figure 7).278

Female Genital MutilationFigure 6 Maternal injuries after female genital mutilationand attempt of vaginal delivery. Source: TouréFigure 8 Clitoral neurinoma. Source: TouréFigure 7 Abscess of the introitus. Source: Touré Clitoral neurinoma: nerve endings in the clitoris, can be caught in the scar tissue, causing excruciating pain on the slightest touch (Figure 8). Menstrual difficulties: in case of closure of theintroitus (infibulation) a hematocolpos (accumulation of menstrual blood in the vagina) orhematometra (accumulation of blood in theuterus) can develop which can cause an abdominal swelling and be mistaken for a pregnancyand may lead to infertility (Figure 9).Figure 9 Tapping of a hematocolpos or hematometra.Source: TouréDifficulties in the provision of gynecologicalcare to victims of female genital mutilationThe vaginal opening is very small in cases of primary classical or secondary type II infibulation(Figure 10). A normal gynecological examination is279