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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.
- Over 140 million girls and women worldwide have undergone FGM.
- FGM is practised in more than 29 countries across Africa, parts of the Middle East, Southeast Asia and countries where migrants from FGM-affected communities live.
- It has been estimated that around 137,000 girls and women are living in the UK with the consequences of FGM.
- Around 60,000 girls aged under 15 are at risk of FGM in the UK.
Types of female genital mutilation
FGM is classified into four major types:
- 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.
FGM is usually carried out between the ages of 5 and 8, but it may be performed at any time from birth to delivery of the first baby. 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.
This procedure has many complications, including sepsis and death. Procedure-related mortality has been estimated at 2.3% in one country in Africa.
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.
A government declaration to end the practice in the UK and around the world was announced in February 2014.To demonstrate this commitment, several measures were announced; these included £100,000 to fund community engagement within the UK, and £35m to support work in Africa, which is the biggest ever international contribution.
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..
As of 31st October 2015, cases of FGM in girls under the age of 18 should be reported to the police.
Data collection on these women in the UK is very important.However, how these requirements for data collection will contribute is unclear. 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.
Management of women
Mutlidisciplinary care is needed for these women. Psychological and educational input for these women is very important.Women can have negative psychosexual and health consequences that need specific care.
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.
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.
The Female Genital Mutilation Act 2003 came into force on 3 March 2004.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.
Further reading and references
FORWARD; Foundation for Women's Health, Research and Development
Female Genital Mutilation and its Management; Royal College of Obstetricians and Gynaecologists Green top guideline (July 2015)
Farage MA, Miller KW, Tzeghai GE, et al; Female genital cutting: confronting cultural challenges and health complications across the lifespan. Womens Health (Lond Engl). 2015 Jan11(1):79-94. doi: 10.2217/whe.14.63.
Creighton SM, Liao LM; Tackling female genital mutilation in the UK. BMJ. 2013 Dec 4347:f7150. doi: 10.1136/bmj.f7150.
Female genital mutilation and its management; Royal College of Obstetricians and Gynaecologists (May 2009)
Erskine K; Collecting data on female genital mutilation. BMJ. 2014 May 13348:g3222. doi: 10.1136/bmj.g3222.
New government measures to end FGM; Home Office, 2014
FGM mandatory reporting duty; Dept of Health and NHS England, 2015
Tackling FGM in the UK. Intercollegiate recommendations for identifying, recording and reporting; Royal College of Midwives, 2013
Liao LM, Elliott C, Ahmed F, et al; Adult recall of childhood female genital cutting and perceptions of its effects: a pilot study for service improvement and research feasibility. J Obstet Gynaecol. 2013 Apr33(3):292-5. doi: 10.3109/01443615.2012.758695.
Abdulcadir J, Rodriguez M, Say L; Research gaps in the care of women with female genital mutilation: an analysis. BJOG. 2014 Dec 17. doi: 10.1111/1471-0528.13217.
Dyer C; More doctors should be trained in identifying female genital mutilation in children, says judge. BMJ. 2015 Jan 18350:h273. doi: 10.1136/bmj.h273.