Female Genital Mutilation

Female genital mutilation encompasses a varied group of operations. Although the procedure is unfamiliar to Western health care professionals, there is an increasing need for information about these procedures, because of an increasing number of immigrant women who have been circumcised and who require obstetrical and gynaecological services. An historical perspective is supplied. The types of procedures, as well as peri-operative, long-term gynaecological, and obstetric complications are discussed. Suggestions are made for the management of these patients. Some restorative techniques are reviewed in the context of a clinical case presentation. Some of the cultural and sociological rationalizations for the procedure are reviewed along with examination of the methods used to eliminate the practice of female circumcision in Canada and elsewhere.     

Late Complications of Childhood Female Genital Mutilation

BackgroundCanada’s immigrants are increasingly from non-English-speaking countries with different medical issues. Female genital mutilation (FGM) is a procedure performed for non-medical reasons that is not traditionally encountered in Canada and that has serious health implications for women.CaseA 36-year-old woman, who underwent FGM at the age of four, presented to our colposcopy unit with increasing swelling of the vulva. Examination revealed a large cystic mass in the midline of the vulva, and MRI identified two well-defined cystic lesions. The mass was excised, and histologic examination confirmed an epidermal inclusion cyst.ConclusionAn epidermal inclusion cyst can develop as a long-term consequence of FGM. Although it grows slowly and usually without symptoms, it may require excision because of inflammation, secondary infection, or, in rare cases, malignancy developing within the cyst.     

Female Genital Mutilation and Childbirth: A Case Report

ABSTRACT: Over 80 million women in more than 30 countries have undergone female genital mutilation, also called female circumcision, according to World Health Organization estimates. Over the past decade 70,000 Somalians have become residents in Canada, 50,000 of whom live in Toronto, Ontario. Many of the women are of childbearing age, and 99.5 percent of women in Somalia are reported to have been genitally mutilated. Canadian medical organizations have published position statements prohibiting the practice. This case report describes the pregnancy and childbirth of a Somalian woman with the infibulation type of procedure. When perinatal health professionals are aware of and sensitive to the cultural and medical implications and sequelae of female genital mutilation, they will give better care to affected women.     

Key points for abolishing Female Genital Mutilation from the perspective of the men involved

Introductionfemale Genital Mutilation is internationally considered an affront on human rights and an act of violence against women and young girls. Furthermore, it hierarchises and perpetuates inequality and denies the right to bodily and psychosocial integrity of women and young girls.Aimsto detect the key points for the abolition of Female Genital Mutilation as well as the necessary resources for its eradication.Material and Methoda qualitative methodology with an ethnonursing perspective, via semi-structured interviews, held both individually and in groups, in 21 men familiar with Female Genital Mutilation.Findingsthrough the voices of men familiar with this tradition, five key points are presented for its gradual eradication: sensitisation and awareness building, team action, abolition-promoting media, focusing action on rural areas and applying educational means before punitive ones.Conclusion and practical implicationsawareness-raising via the combined efforts of families, communities and governments, together with the promotion of health education programmes in demonstrating the complications derived from this practice, play a vital part in eradicating Female Genital Mutilation.     

Clitoral Reconstruction after Female Genital Mutilation/Cutting: Case Studies

IntroductionClitoral reconstruction following female genital mutilation/cutting (FGM/C) is a new surgical technique reported to be a feasible and effective strategy to reduce clitoral pain, improve sexual pleasure, and restore a vulvar appearance similar to uncircumcised women. However, data on safety, care offered, and evaluation of sexual and pain outcomes are still limited.AimsThis study aims to present the care offered and clinical outcomes of two women who received multidisciplinary care, including psychosexual treatment, with clitoral reconstruction. We report their long‐term outcomes, and the histology of the removed periclitoral fibrosis.MethodsWe report the cases of two women with FGM/C types II and III who requested clitoral reconstruction for different reasons. One woman hoped to improve her chronic vulvar pain, as well as improve her sexual response. The other woman requested surgery due to a desire to reverse a procedure that was performed without her consent, and a wish to have a genital appearance similar to non infibulated women. They both underwent psychosexual evaluation and therapy and surgery. The histology of the periclitoral fibrosis removed during surgery was analyzed.ResultsAt 1‐year postoperatively, the first woman reported complete disappearance of vulvar pain and improved sexual pleasure, including orgasm. Our second patient also described improved sexuality at 1‐year follow‐up (increased sexual desire, lubrication, vulvar pleasure, and sensitiveness), which she attributed to a better self body image and confidence. Both women reported feeling satisfied, happy, and more beautiful.ConclusionWe show a positive outcome in pain reduction and improved sexual function, self body image, and gender after psychosexual therapy and clitoral reconstruction. More evidence is needed about clitoral reconstruction to develop guidelines on best practices. Until research is conducted that rigorously evaluates clitoral reconstruction for its impact on pain and sexuality, we advise always offering a multidisciplinary care, including sexual therapy before and after the surgery. Abdulcadir J, Rodriguez MI, Petignat P, and Say L. Clitoral reconstruction after female genital mutilation/cutting: Case studies. J Sex Med 2015;12:274–281.     

Epidemiology,Regional Characteristics,Knowledge, and Attitude Toward Female Genital Mutilation/Cutting in Southern Iran

IntroductionFemale genital mutilation/cutting (FGM/C), also known as female circumcision, is an ancient traditional procedure that involves partial or total removal of the female external genitalia for nonmedical reasons. Although it is well described in African and some Arabic countries, data from Iran are scarce.AimTo describe the epidemiology, regional characteristics, knowledge, and attitude toward FGM/C in Southern Iran.MethodsThis cross‐sectional study was conducted during a 36‐month period from 2010 to 2013 in Hormozgan, a southern province of Iran near the Persian Gulf. We included 780 women in six major rural areas of the province who referred to healthcare centers for vaccination, midwifery, or family planning services. All participants underwent complete pelvic examination to determine the type of FGM. The questionnaire consisted of several sections such as demographic and baseline characteristics, and two self‐report sections addressing the knowledge and attitude toward FGM/C and its complications. Baseline sociodemographic characteristics including age, educational level, marital status, religion, and nationality were the independent variables.ResultsAmong the participants, 535 (68.5%) had undergone FGM/C. FGM/C was associated with higher age (P = 0.002), Afghan nationality (P = 0.003), Sunni Islam as religion (P = 0.019), illiteracy (P < 0.001), and family history of FGM/C in mother (P < 0.001), sister (P < 0.001), and grandmother (P < 0.001). Ancient traditions in the area (57.1%) were mentioned as the most important factor leading to FMG/C. Urinary tract infection was the most common reported complication (60.4%).ConclusionFGM/C is a common practice in rural areas of Southern Iran. It is associated with increased age, illiteracy, Sunni Islam religion, Afghan nationality, and positive family history. Lack of knowledge toward FGM/C is the main cause of its high prevalence and continuation in the area. Dehghankhalili M, Fallahi S, Mahmudi F, Ghaffarpasand F, Shahrzad ME, Taghavi M, and Fereydooni Asl M. Epidemiology, regional characteristics, knowledge, and attitude toward female genital mutilation/cutting in Southern Iran. J Sex Med 2015;12:1577–1583.     

Type I Female Genital Mutilation: A Cause of Completely Closed Vagina

IntroductionFemale genital mutilation (FGM) ranges in severity from a nick of the clitoris to partial or total removal of the external genitalia. Sexual complications after FGM include sexual dysfunction, difficult intercourse, and dyspareunia.AimWe report a case of Type I FGM presenting as complete vaginal closure and urinary retention.MethodsA 16‐year‐old adolescent was referred for obliterated vagina and urinary retention. She had recurrent urinary tract infections, difficulty in voiding, and cyclic hematuria. At the age of 1 year she had been taken by her mother to a pediatric surgeon to have a Type I FGM procedure. On examination, the urethral meatus and vaginal orifices were completely closed by the FGM scar. She underwent uneventful surgical opening of the vagina.ResultsA normal vaginal orifice was created and normal flow of urine and menses occurred.ConclusionType I FGM can present as complete vaginal closure and urinary retention. Proper diagnosis and treatment are of paramount importance. Rouzi AA, Sahly N, Alhachim E, and Abduljabbar H. Type I female genital mutilation: A cause of completely closed vagina. J Sex Med 2014;11:2351–2353.     

432 Somali Women's Birth Experiences in Canada after Earlier Female Genital Mutilation

Background: Women with previous female genital mutilation (sometimes referred to as circumcision) are migrating, with increasing frequency, to countries where this practice is uncommon. Many health care professionals in these countries lack experience in assisting women with female genital mutilation during pregnancy and birth, and they are usually untrained in this aspect of care. Somali women who customarily practice the most extensive form of female mutilation, who were resident in Ontario and had recently given birth to a baby in Canada, were surveyed to explore their perceptions of perinatal care and their earlier genital mutilation experiences. Method: Interviews of 432 Somali women with previous female genital mutilation, who had given birth to a baby in Canada in the past five years, were conducted at their homes by a Somali woman interviewer. Results: Findings suggested that women's needs are not always adequately met during their pregnancy and birth care. Women reported unhappiness with both clinical practice and quality of care. Conclusions: Changes in clinical obstetric practice are necessary to incorporate women's perceptions and needs, to use fewer interventions, and to demonstrate greater sensitivity for cross‐cultural practices and more respectful treatment than is currently available in the present system of care.     

Female Genital Mutilation: When a Cultural Practice Generates Clinical and Ethical Dilemmas

Female genital mutilation (FGM) is of growing concern to health care providers in the United States and Canada as more women from countries where the procedure is practiced emigrate to North America. An introduction to the demographics of FGM, including prevalence rates, is a necessary antecedent for understanding the cultural rationales for this widespread practice. Considering the health consequences of this practice promotes questions about legal and ethical aspects of care as North Americans approach FGM from their own individual cultural frameworks.     

Pleasure and orgasm in women with Female Genital Mutilation/Cutting (FGM/C)

IntroductionFemale genital mutilation/cutting (FGM/C) violates human rights. FGM/C women's sexuality is not well known and often it is neglected by gynecologists, urologists, and sexologists. In mutilated/cut women, some fundamental structures for orgasm have not been excised.AimThe aim of this report is to describe and analyze the results of four investigations on sexual functioning in different groups of cut women.Main Outcome MeasureInstruments: semistructured interviews and the Female Sexual Function Index (FSFI).MethodsSample: 137 adult women affected by different types of FGM/C; 58 young FGM/C ladies living in the West; 57 infibulated women; 15 infibulated women after the operation of defibulation.ResultsThe group of 137 women, affected by different types of FGM/C, reported orgasm in almost 86%, always 69.23%; 58 mutilated young women reported orgasm in 91.43%, always 8.57%; after defibulation 14 out of 15 infibulated women reported orgasm; the group of 57 infibulated women investigated with the FSFI questionnaire showed significant differences between group of study and an equivalent group of control in desire, arousal, orgasm, and satisfaction with mean scores higher in the group of mutilated women. No significant differences were observed between the two groups in lubrication and pain.ConclusionEmbryology, anatomy, and physiology of female erectile organs are neglected in specialist textbooks. In infibulated women, some erectile structures fundamental for orgasm have not been excised. Cultural influence can change the perception of pleasure, as well as social acceptance. Every woman has the right to have sexual health and to feel sexual pleasure for full psychophysical well-being of the person. In accordance with other research, the present study reports that FGM/C women can also have the possibility of reaching an orgasm. Therefore, FGM/C women with sexual dysfunctions can and must be cured; they have the right to have an appropriate sexual therapy. Catania L, Abdulcadir O, Puppo V, Baldaro Verde J, Abdulcadir J, and Abdulcadir D. Pleasure and orgasm in women with female genital mutilation/cutting (FGM/C).     

Reconstructive Surgery for Female Genital Mutilation Starts Sexual Functioning in Sudanese Woman: A Case Report

IntroductionFemale genital mutilation (FGM) involves the partial or complete removal of the external female genitalia and/or other injury to the female genital organs whether for cultural or other nontherapeutic reasons.AimsThe study aims to describe the method of and findings from reconstructive surgery for FGM victims.MethodsWe present a case of a 24-year-old Sudanese female, who had undergone ritual FGM type III as a young girl. She had suffered from a large, vulval mass for the last 6 years and came to the clinic because of apareunia. We performed mass excision and reconstructive surgery of the mutilated genital tissue.ResultsThe giant mass was successfully removed. Remaining genital tissues were approximated and sutured, with hemostasis assured for the reconstructed organs on each side.ConclusionReconstructive surgery for women who suffer sexual consequences from FGM is feasible, with a high degree of client acceptance and satisfaction. It restores some of women's natural genital anatomy, and offers the potential for improved female sexuality. Fazari ABE, Berg RC, Mohammed WA, Gailii EB, and Elmusharaf K. Reconstructive surgery for female genital mutilation starts sexual functioning in S udanese woman: A case report. J Sex Med 2013;10:2861–2865.     

Reasons for and Experiences With Surgical Interventions for Female Genital Mutilation/Cutting (FGM/C): A Systematic Review

BackgroundBecause female genital mutilation/cutting (FGM/C) leads to changes in normal genital anatomy and functionality, women are increasingly seeking surgical interventions for their FGM/C-related concerns.AimTo conduct a systematic review of empirical quantitative and qualitative research on interventions for women with FGM/C-related complications.MethodsWe conducted systematic searches up to May 2016 in 16 databases to obtain references from different disciplines. We accepted all study designs consisting of girls and women who had been subjected to FGM/C and that examined a reparative intervention for a FGM/C-related concern. We screened the titles, abstracts, and full texts of retrieved records for relevance. Then, we assessed the methodologic quality of the included studies and extracted and synthesized the study data.OutcomesAll outcomes were included.ResultsOf 3,726 retrieved references, 71 studies including 7,291 women were eligible for inclusion. We identified three different types of surgical intervention: defibulation or surgical separation of fused labia, excision of a cyst with or without some form of reconstruction, and clitoral or clitoral-labial reconstruction. Reasons for seeking surgical interventions consisted of functional complaints, sexual aspirations, esthetic aspirations, and identity recovery. The most common reasons for defibulation were a desire for improved sexual pleasure, vaginal appearance, and functioning. For cyst excision, cystic swelling was the main reason for seeking excision; for reconstruction, the main reason was to recover identity. Data on women's experiences with a surgical intervention are sparse, but we found that women reported easier births after defibulation. Our findings also suggested that most women were satisfied with defibulation (overall satisfaction = 50–100%), typically because of improvements in their sexual lives. Conversely, the results suggested that defibulation had low social acceptance and that the procedure created distress in some women who disliked the new appearance of their genitalia. Most women were satisfied with clitoral reconstruction, but approximately one third were dissatisfied with or perceived a worsening in the esthetic look.Clinical TranslationThe information health care professionals give to women who seek surgical interventions for FGM/C should detail the intervention options available and what women can realistically expect from such interventions.Strengths and LimitationsThe systematic review was conducted in accordance with guidelines, but there is a slight possibility that studies were missed.ConclusionThere are some data on women's motivations for surgery for FGM/C-related concerns, but little is known about whether women are satisfied with the surgery, and experiences appear mixed.Berg RC, Taraldsen S, Said MA, et al. Reasons for and Experiences With Surgical Interventions for Female Genital Mutilation/Cutting (FGM/C): A Systematic Review. J Sex Med 2017;14:977–990.