WHO definition of FGM
“Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.”
FGM is recognized internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of girls. The practice also violates a female’s rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.
- FGM includes procedures that intentionally alters or cause injury to the female genital organs for non-medical reasons.
- FGM has no health benefits for girls and women.
- It causes severe bleeding, problems urinating, and later cysts, infections, as well as complications in childbirth and increased risk of newborn deaths.
- More than 200 million girls and women alive today have been cut in 30 countries in Africa, the Middle East and Asia where FGM is concentrated.
- FGM is mostly carried out on young girls between infancy and age 15.
- FGM is a violation of the human rights of girls and women.
Not all women/girls know that they have had FGM. If a girl was cut when she was a baby she may have no idea that she has FGM. A Midwife or Doctor may identify FGM during childbirth and may be the first person who has ever told her that she has FGM. Clinicians need to be sensitive and non-judgemental when talking to women/girls about FGM
FGM – the different Types
Female genital mutilation is classified into 4 major types. It may sometimes be difficult to diagnose the different Types due to
Type 1: Often referred to as clitoridectomy
This is the partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals), and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
This practice is extremely painful and distressing, damages sexually sensitive skin & is an infection risk. It is sometimes called “Sunna/sunnah” which means ‘tradition’ or ‘the way of the prophet’ in Arabic. Some people believe that Sunna is just a small prick to the clitoral hood or is “just a bleed”.
There is some evidence that people think that Type 1 FGM may cause less physical harm. Please consider that with Type 1 FGM a girl will have been held down, be bleeding and in pain during and after the procedure. There may have been no anaesthetic used and it may have been carried out by a trusted family member, or a trusted family member may be present and have been assisting during the procedure.
The psychological trauma may be just as severe as with other types of FGM.
Type 1 may produce scar tissue, anterior to the vaginal opening, which can result in a higher chance of tearing and bleeding during labour.
Cutting the clitoris and/or clitoral hood may result in long term chronic pain or an inability to enjoy sexual pleasure. If a child is struggling there may also be damage to the urinary meatus. If a blood vessel is cut this could result in death of the child. If equipment being used is not sterilized the girl could catch tetanus, hepatitis, HIV or other infection.
Type 2: Often referred to as excision
This is the partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without excision of the labia majora (the outer folds of skin of the vulva).
This type is also sometimes called Sunna in some communities.
Top tips for diagnosing Type 2 :
- If a woman has Type 2 FGM the vaginal opening and the urinary meatus will be clearly visualized . The size of the introitus will appear to be comfortable/adeqaute for sexual penetration.
- Type 2 will produce some scar tissue, anterior to the vaginal opening, which can result in a higher chance of tearing and bleeding during labour. Some women have had part or all of their labia removed.
- Type 2 may also result in long term chronic pain, damage to the urinary meatus and/or urethra itself, and may make sexual intercourse uncomfortable or painful.
Type 3: Often referred to as infibulation or pharaonic circumicision
This is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris (clitoridectomy).
The girl is left with a new introitus through which she must pass menstrual blood, urine, have sexual intercourse and give birth.
Top Tips for diagnosing a Type 3:
- The vaginal opening AND the urinary meatus cannot be visualized easlily.
- Vaginal examination will be difficult as will the insertion of a urinary catheter.
- The size of the introitus will appear inadequate for comfortable sexual penetration.
- The woman gives a clear history of previous deinfibulation.
Woman with Type 3 FGM, especially pregnant ones, should be consented for antenatal or intrapartum deinfibulation.
De-infibulation is the process of cutting open a woman who has been infibulated to facilitate intercourse and/or childbirthcan and can be done under local, spinal or general anaesthetic. A woman may request deinfibulation because she is suffering problems caused by FGM; e.g. because they are unable to undergo a cervical smear or because of recurrent infections. Some women present for deinfibulation when they are about to get married or have just got married (prior to sexual intercourse).
For pregnant women de-infibulation may be performed antenatally, in the first stage of labour or at the time of delivery and can usually be performed under local anaesthetic in a delivery suite room. It can also be performed perioperatively after caesarean section.
Many women will call this a “reversal” procedure. Of course we cannot put back what has been removed so it is not a true reversal of what was done to her as a child.
Some women may have been ‘opened’ by their husband by repeated sexual penetration. These women may still require a further deinfibulation procedure because, for women who have been “opened” in this way, often sexual intercourse remains very painful and the introitus is still not adequate for childbirth.
If a woman is deinfibulated she should be counselled properly beforehand with regard to the change in the way her genitals will look and feel. It may be a shock for a woman to come to terms with the way her genitalia look after deinfibulation.
A woman/girl should be counselled regarding the fact that her urinary flow may be faster and may appear to “spray” over a wider area. She may need to sit differently on the toilet. She should also be reassured that her menstrual blood flow may appear to be much more voluminous but actually the body is producing the “normal” amount of blood but because the blood is not clotting it does not get stuck behind the scar tissue.
The FGM National Clinical Group have produced a video (Resource Film) of a deinfibulation. Please click here if you would like to view it. Warning – this shows graphic images.
Please note – It is always good practice to oversew the edges when deinfibulating. The edges should not be left unsutured as the skin is very likely to fuse back together. This will also avoid further bleeding and reduce the risk of infection. The latest research recommends using continuous sutures where possible (rather than interrupted sutures) – as this will mean less suture material and reduce the risk of thin bridges of skin fusing.
Why choose antenatal deinfibulation?
- We would recommend that women choose to be opened before going into labour so that a specialist can open the scar tissue rather than whoever happens to be available on labour ward when she goes into labour. It is not an emergency and will be done by an expert with lots of experience who can take their time to make sure that the woman is not in discomfort and there is plenty of time to heal before the baby is born.
- During labour, if a woman has an intact Type 3, it may be difficult or impossible to do a vaginal examination, insert a urinary catheter, place a fetal scalp electrode, or insert a pessary for induction etc.
- If a woman has an intact Type 3 FGM she may be more likely to have urinary tract infections and/or thrush infections during your pregnancy
- If the woman has a precipitated labour and gives birth before arriving at the hospital she is at greater risk of tearing and bleeding and the baby may become distressed if the exit route is too small and the birth becomes obstructed.
- The anterior incision is more likely to extend if it has not had time to heal before the birth.
Reinfibulation is the re-closing of a woman who has Type 3 FGM. This may be carried out after childbirth in some parts of the world. This is illegal in the U.K.
What is the role of clitoral reconstruction?
- Clitoral reconstruction should not be performed because current evidence suggests unacceptable complication rates without conclusive evidence of benefit.” [ROCG page 4]
Type 4: This includes all other harmful procedures
Type 4 FGM can include pricking, piercing, incising, scraping (angurya cuts), or gishiri cuts to the vagina and surrounding tissue or cauterizing the genital area.
Sometimes Type 4 (if a small prick to the clitoral hood) is not visible to the naked eye.
A young girl may remember being held down, bleeding and being in pain – so even if you cannot see any scars – listen to the history that she is giving you .
Diagnosing the different Types of FGM
Many women do not know what Type of FGM they have had as they may not be knowledgeable about genital anatomy and are most likely to have been cut when very young.
A woman may say that she has had “sunna”, but upon genital assessment she may be found to have had Type 3. This is because it is possible that when the labia were removed subsequently the edges fused together so the woman may tell you that she was not “stitched up” but actually she does have Type 3.
If a woman was cut as a child she may have no memory of what her genitalia were like prior to the FGM. Therefore she may not realise that the health problems that she is suffering (such as frequent thrush or urine infections or painful sexual intercourse) are a consequence of being cut. She may believe that these problems are common or ‘normal’ for all woman.
If the woman consents, and you have the expertise to identify the different Types, it may be beneficial to do a genital examination to be able to explain to the woman her anatomy and in detail show her (perhaps using a mirror) what tissue/skin has been removed and how this may affect her physically.
Sometimes even experienced FGM specialists can find it difficult to diagnose the Type of FGM that a woman has, as the genital appearance may not fit neatly into one specific category. If you are not sure what Type the woman has then alternatively, describe what you see. For example. Some evident scarring of the prepuce, and 2cms of labia on the right side appears to be missing.
Who is affected by FGM?
The World Health Organisation has estimated that :
“More than 200 million girls and women alive today have undergone female genital mutilation in the countries where the practice is concentrated. Furthermore, there are an estimated 3 million girls at risk of undergoing female genital mutilation every year. The majority of girls are cut before they turn 15 years old”.
Female genital mutilation has been documented in 30 countries, mainly in Africa, as well as in the Middle East and Asia. Some forms of FGM have also been reported in other countries, including among certain ethnic groups in South America. Moreover, growing migration has increased the number of girls and women living outside their country of origin who have undergone FGM or who may be at risk of being subjected to the practice in Europe, Australia and North America.
The prevalence of FGM has been estimated from large-scale, national surveys asking women aged 15–49 years if they have themselves or their daughters have been cut. Considerable variations have been found between the countries, with prevalence rates over 80% in eight countries. Moreover, the prevalence varies among regions within countries, with ethnicity being the most influential factor.
The type of procedure performed also varies, mainly with ethnicity. Current estimates (from surveys of women older than 15 years old) indicate that around 90% of FGM cases include either Types I (mainly clitoridectomy), II (excision) or IV (“nicking” without flesh removed), and about 10% (over 8 million women) are Type III (infibulation). Infibulation, which is the most severe form of FGM, is mostly practiced in the north-eastern region of Africa: Djibouti, Eritrea, Ethiopia, Somalia, and Sudan. In West-Africa (Guinea, Mali, Burkina Faso, etc.), the tendency is to remove flesh (clitoridectomy and/or excision) without sewing the labia minora and/or majora together.”
(Reference from WHO web pages, 2018)
Why is FGM carried out?
FGM is usually carried out by traditional circumcisers, traditional birth attendants or healthcare professionals.
Anaesthetic is rarely used and the child is often held down by a number of women, usually relatives. Special knives, scissors, razors, sharp stones or pieces of glass are often used. For Type 3 the wound may be held together with thorns and the girls’ legs may be bound together until the wound is healed.
18% of all FGM is performed by health care professionals, who are violating the fundamental medical ethics to “do no harm”. For example, in Egypt it is common for FGM to be performed by doctors in hospital settings.
We have met several women who were born in the U.K. and who were taken on holiday by their parents. Whilst on holiday their mother (and/or father) went shopping and the daughters remember being taken and cut by their grandmother or aunty.
In the U.K. a parent has a legal duty to protect and safeguard their daughters. It it important to explain to parents that if they go on holiday to a country where their daughter gets cuts even if carried out by extended family against their wishes, they can be prosecuted by the law for FAILING TO PROTECT their daughter. If you have concerns you should speak to a safeguarding expert. FGM PROTECTION ORDERS can help protect girls.
The reasons why FGM is practiced are complex and include:
Control of women’s sexual desire, ensuring marital fidelity and preserving virginity. These form part of the social pressure to conform and may be seen as part of a woman’s cultural identity and heritage.
One myth used to justify FGM is that FGM will enhance the girl’s femininity, and it is often seen as a means of ensuring female docility and obedience. It is possible that the trauma of mutilation may have this effect on a girl’s personality.
In some communities there is a belief that female genitalia are unsightly and dirty, and therefore FGM is more hygienic. The removal of the clitoris and labia are viewed by some as the “male parts” of a woman’s body and girls are told that the clitoris will continue to grow if it is not removed.
In some FGM-practicing societies, un-mutilated women are regarded as unclean and are not allowed to handle food and water.
As a result of peer pressure girls themselves may want to undergo FGM
FGM is a form of Honour and Gender based violence. It may be practised to mark the transition to womanhood and to ensure marriageability.
If mutilation is part of an initiation rite, then it is accompanied by explicit teaching about the woman’s role in her society.
There is a mistaken belief that FGM is a religious obligation. Even though the practice can be found among Christians, Jews and Muslims, none of the holy texts of any of these religions prescribes female genital mutilation and the practice pre-dates both Christianity and Islam.
FGM is a taboo subject and is not easily discussed amongst family members.
This vignette of campaigner, Leyla Hussein, talking to her mother about FGM highlights this.
Potential Health Consequences
The most common short term complications are:
- Severe pain and shock
- Urine retention
- Injury to adjacent tissue
- Tetanus, HIV, Hep B/C
- Fracture or dislocated limbs as a result of being restrained
- The procedure can result in death through severe bleeding leading to haemorrhagic shock, neurogenic shock as a result of pain and trauma, and overwhelming infection and septicaemia
The most common Long Term Complications are:
- Difficulty passing urine and chronic urinary tract infections. Possible renal failure.
- Difficulties with menstruation and painful periods. Possible hysterectomy.
- Sexual dysfunction & lack of sexual pleasure
- Acute and chronic pelvic infections which can lead to Infertility
- Infertility in rare cases may be due to failure of penetration because of tight vaginal opening.
- Clitoral tissue may be trapped in fibrous tissue of scar following clitoridectomy and cause sharp pain over the fibrous swelling. Intercourse or even friction of underwear can cause pain.
- Infibulation cysts which are either dermoid cysts caused by a fold of skin becoming embedded in the scar or sebaceous cyst caused by a blockage of the sebaceous gland duct are common with all forms of FGM.
- This cyst may be the size of a pea or even a grapefruit. Cysts may frequently become infected. Great care should be taken when removing the cyst not to further damage the sensitive tissue or injure the blood or nerve supply of the area.
- There is also a risk of tetanus, HIV, Hepatitis C/B from sharing of unsterile equipment when carrying out FGM
The most common obstetric complications are:
- Scarring & stricture of the vaginal canal resulting in increased risk of perineal trauma / tears / fistulae
- FGM may not be identified antenatally therefore if the woman has Type 3, an emergency deinfibulation may be required during the second stage of labour. Possible obstructed labour (less likely in the U.K. as rapid access to caesarean section if required)
- Psychological trauma, flash backs
- Difficulty with vaginal examination/inserting urinary catheter/applying fetal scalp electrode
- Increased risk of caesarean section, post partum haemorrhage, , longer maternal stay in hospital, foetal asphyxia/anoxia
[FGM and obstetric outcomes WHO collaborative prospective study in six African Countries, 2006, the Lancet, 367:1835-1841]
The most common psychological and mental health consequences
- FGM is extremely traumatic and can have lifelong consequences for psychological and mental health. Young women who have suffered FGM report feelings of betrayal by parents, incompleteness, regret and anger.
- FGM can cause mental health problems, drug and alcohol dependency and research in African communities show that women who have had FGM have the same level of PTSD as adults who were subjected to other forms of abuse in childhood.
- The fact that FGM is “embedded” in culture does not protect survivors from developing PTSD
- Women may not link having had FGM to the problems they are experiencing.
- Mental health Symptoms might include:-
- Flashbacks (maybe triggered during labour)
- Sleep disturbances & nightmares
- Panic attacks
- Sexual dysfunction
- Depression & anxiety
Women in a study in Senegal who had undergone FGM reported feelings of intense fear, horror, helplessness and severe pain at the time of the cutting.
80% of the women reported they continued to suffer from intrusive re-experiencing of their cutting.
A UK pilot project (NESTAC) providing psychological support to women reported that those who had FGM experience long-lasting emotional damage and had difficulty living in silence.
Top tips for when caring for women/girls who have had FGM
Possible opening questions:
I notice that you come from a country where some communities practice FGM. Do you know what FGM is?
Have you had circumcision or been cut when you were a young girl or baby?
Ask the women if they are happy to look at line drawings of the different types.
If they consent, talk to them about their anatomy.
- There is evidence from the WHO that people believe that there are less severe types of FGM. The risk is that perpetrators stop practising Type 3 but continue to practice the other types.
- Take time to explain that Type 1 FGM is when part or all of the clitoris or clitoral hood has been removed.
- Ask them if they know what the clitoris is. Explain that there are many nerve endings and blood vessels in the clitoris which help to make this a very sensitive part of the bod. Explain, that the clitoris is one part of the body that is involved in ensuring that women enjoy sexual intercourse and that this is one of our human rights.
- Explain that even a small cut to the clitoris can result in pain, bleeding, infection (such as HIV or Hepatitis). If the child is struggling the circumciser may damage the urine hole and this may cause long term pain for the woman.
- Many women also suffer from psychological trauma from FGM, irrespective of what type she has.
- In Type 2 FGM some or all of the labia minor have been removed. The labia are there to protect the urine hole and vaginal opening to help prevent bacterial and fungal infections.
Discuss the health complications in detail to ensure that the woman understands that her health problems are caused by FGM and are not “normal” and that women who are not circumcised do not suffer with the same problems. Reassure her that even if part of the clitoris has been removed she may still be able to enjoy sexual intercourse
“Healthcare professionals should be vigilant and aware of the clinical signs and symptoms of recent FGM, which include pain, haemorrhage, infection and urinary retention.
By far the majority of FGM cases seen in the U.K. are historic. Examination findings should be accurately recorded in the clinical records.
Some type 4 FGM, where a small incision or cut is made adjacent to or on the clitoris, can leave few, if any, visible signs when healed” [ROCG guidelines, page 3]
Behrendt, A. & Moritz, S. (2005). Post-traumatic stress disorder and memory problems after female genital mutilation. American Journal of Psychiatry, 162 (5), 1000–1002.CrossRef | PubMed | Web of Science® Times Cited: 34
Voices of the Community: Exploring Female Genital Mutilation in the African Community across Greater Manchester
- (International Journal of Mental health Nursing (Feb. 2014) http://onlinelibrary.wiley.com/doi/10.1111/inm.12060/full &
- Journal of Reproductive and Infant Psychology (October, 2014)
The WHO published guidelines in May 2016 to help health workers provide better care to the 200 million girls and women worldwide living with FGM. The recommendations focus on preventing and treating obstetric complications; treatment for depression and anxiety disorders; attention to female sexual health such as counselling, and the provision of information and education.
“WHO guidelines on the management of health complications from FGM”
Survivors account of when they were cut and the impact of FGM on their lives (sensitive nature of content may be distressing).
RCM position paper (2015)
RCOG Green top guidelines (2015)
List of traditional and local terms for FGM
Different communities have different names for FGM and it is important to familiarise oneself with the local terms