Female genital mutilation

What is female genital mutilation?

Female genital mutilation (FGM) used to be known as 'female circumcision' and is widely practised throughout Africa and the Middle East. The term 'female circumcision' is inappropriate, as it is not simply removal of the clitoral prepuce but a rather gross procedure often involving clitoridectomy and with no degree of precision or skill. The term 'female genital mutilation' is more appropriate and is now in common use.

The World Health Organization (WHO) defines it as '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 done for many reasons; there is no single religious basis. In some cultures a woman who has not undergone the procedure may be thought unmarriageable. Female genital cutting is a deeply rooted tradition that confers honour on a woman and her family, yet also a traumatic experience that creates significant dermatological, gynaecological, obstetric and infectious disease complications.

How common is female genital mutilation? (Incidence)¹

More than 200 million girls and women alive today have undergone female genital mutilation (FGM) in 30 countries in Africa, the Middle East and Asia where FGM is practiced. FGM is mostly carried out on young girls between infancy and age 15.²

It is a traditional cultural practice in 29 African countries. Outside of Africa, FGM is also practised in Yemen, Iraqi Kurdistan and parts of Indonesia and Malaysia. Far smaller numbers have been recorded in India, Pakistan, Sri Lanka, the United Arab Emirates, Oman, Peru and Colombia.

It has been estimated that 137,000 women and girls in England and Wales, born in countries where FGM is traditionally practised, have undergone FGM, including 10,000 girls aged under 15 years.

Types of female genital mutilation

FGM is classified by the WHO as follows:³

• Type 1 - clitoridectomy: partial or total removal of the clitoris and, in very rare cases, only the prepuce.

• Type 2 - excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora.

• Type 3 - infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris.

• Type 4 - other: all other harmful procedures to the female genitalia for non-medical purposes - eg, pricking, piercing, incising, scraping and cauterising the genital area.

Procedure

The procedure is traditionally carried out by an older woman with no medical training. Anaesthetics and antiseptics are not generally used and the practice is usually carried out using basic tools such as knives, scissors, scalpels, pieces of glass and razor blades. Often iodine or a mixture of herbs is placed on the wound to tighten the vagina and stop the bleeding.

Complications of female genital mutilation

This procedure has many complications, including sepsis and death. Procedure-related mortality has been estimated at 2.3% in one country in Africa.⁴

As well as the immediate risk, long-term complications may include:

• Extensive damage of the external reproductive system.

• Uterine, vaginal and pelvic infections.

• Cysts and neuromas.

• Increased risk of vesico-vaginal fistula.

• Complications in pregnancy and childbirth.

• Psychological damage.

• Sexual dysfunction.

• Difficulties in menstruation.

In women with type 3 mutilation, the introitus may be too narrow for childbirth, and the tissues that have sealed together need to be separated. This is termed deinfibulation.

NHS action regarding female genital mutilation

Knowledge of FGM is important because doctors in this country may have to treat women who have been mutilated in this way. The guideline on FGM from the Royal College of Obstetricians and Gynaecologists (RCOG) recommends that every pregnant woman should be asked if she has been cut.¹

A government declaration to end the practice in the UK and around the world was announced in February 2014.⁵

All acute NHS hospitals are now required to record FGM and report the data centrally. NHS hospitals have to record:

• If a patient has had FGM.

• If there is a family history of FGM.

• If an FGM-related procedure has been carried out on a woman.

Women attending maternity, family planning, gynaecology, and urology clinics (among others) should be asked routinely about the practice of FGM.⁴

As of 31st October 2015, cases of FGM in girls under the age of 18 should be reported to the police.⁶

Data collection on these women in the UK is very important.⁷ Healthcare professionals are asked to record the grade of mutilation, which cannot be done without a genital assessment. It may be intrusive to insist on genital examination for all women from communities that practise cutting, regardless of their symptoms, and many healthcare staff are unlikely to feel confident in making such an assessment.⁸

Management of women

Multidisciplinary care is needed for these women. Psychological and educational input for these women is very important.⁹ Women can have negative psychosexual and health consequences that need specific care.¹⁰ Reconstructive surgery for women who suffer sexual consequences from FGM is feasible.¹¹

Antenatally, women who have been cut should be assessed and, if necessary, offered deinfibulation before the birth. Women (and men) need to be supported to ensure that they realise that the practice is a crime, and that their daughters should not suffer.⁸

More medical knowledge of FGM is needed, particularly paediatric, and understanding of FGM classification is important. Examinations of women and girls should be planned carefully, with referral to a specialist FGM clinic if possible.¹²

The Female Genital Mutilation Act 2003 came into force on 3 March 2004.¹³ It replaced the 1985 Act and makes it an offence for the first time for UK nationals or permanent UK residents to carry out FGM abroad, or to aid, abet, counsel or procure the carrying out of FGM abroad, even in countries where the practice is legal. A person found guilty of an offence under the Act is liable for a prison sentence of up to 14 years.

FGM is an abuse of human rights and is also a child protection issue.¹