Female Circumcision

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Chapter 71 Female Circumcision

INTRODUCTION

Description: Female circumcision is removal of part or all of the external genitalia including the labia majora, labia minora, the clitoris, or all three. Female circumcision (female genital mutilation, infibulation) is generally performed as a ritual process, often without benefit of anesthesia and frequently under unsterile conditions. The resulting scarring may preclude intromission. The amount and location of tissue removed determine the type of infibulation:

• Type I—excision of the prepuce, with or without excision of part or the entire clitoris
• Type II—excision of the clitoris with partial or total excision of the labia minora (most common form)
• Type III—excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation)
• Type IV—pricking, piercing, or incising of the clitoris, labia, or both; stretching of the clitoris, labia, or both; cauterization by burning of the clitoris and surrounding tissue

Other forms of female genital mutilation include the following:

• Scraping of the tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts)
• Introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it
• Any other procedure that falls under the definition given previously

Prevalence: Approximately 168,000 women in the United States, approximately 96% of women in some African countries (e.g., Somalia). (Amnesty International estimates that it is performed on more than 130 million women worldwide.)
Predominant Age: Majority performed during early teens.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Performed as part of ritual or religious beliefs, generally without the permission and often without the cooperation of the young girl herself.
Risk Factors: Most common in some African and Southeast Asian cultures.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Significant scarring and deformity of the external genital structures, often to the point of complete obliteration of vaginal introitus (varies with the type and extent of the procedure performed)
• Obstruction may be sufficient to result in amenorrhea or dysmenorrhea
• Dyspareunia
• Orgasmic dysfunction
• Libidinal dysfunction
• Obstruction or hindrance to vaginal delivery

DIAGNOSTIC APPROACH

Differential Diagnosis

• Childhood burn injuries
• Intersex condition
• Imperforate hymen

Associated Conditions: Dyspareunia, libidinal dysfunction, and orgasmic dysfunction.

Workup and Evaluation

Laboratory: No evaluation indicated.
Imaging: No imaging indicated.
Special Tests: None indicated.
Diagnostic Procedures: History and physical examination.

Pathologic Findings

Absent or grossly scarred and deformed external genital tissues.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, support, and culturally sensitive education.
Specific Measures: Surgical opening of fused or scarred genital tissue may be necessary to allow for menstrual hygiene and sexual function. An anterior episiotomy, with or without subsequent repair, may be required at the time of childbirth (see the following).
Diet: No specific dietary changes indicated.
Activity: No restriction.
Patient Education: Culturally sensitive discussion of female anatomy, sexuality, and menstrual hygiene.

Drug(s) of Choice

None.

FOLLOW-UP

Patient Monitoring: Normal health maintenance. (Cervical samples for cytologic examination may be difficult to obtain in patients with extensive scarring until or unless surgical revision is performed.)
Prevention/Avoidance: Education of parents of young girls in cultures at risk for the procedure.
Possible Complications: Acutely (at the time of the procedure)—bleeding and infection (including tetanus), urinary retention, pain. Long term—sexual dysfunction, difficulty with menstrual hygiene, recurrent vaginal or urinary tract infections, retrograde menstruation, hematocolpos, chronic pelvic inflammatory disease.
Expected Outcome: Sexual sequelae are often lifelong despite surgical revision (especially when clitoridectomy has been performed).

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy, but presence may complicate conception and delivery. Delivery may require an anterior episiotomy with attendant increased risk of bleeding. (Subsequent repair of the episiotomy is illegal in some locations such as the United Kingdom and others because this amounts to reinfibulation.)

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ICD-9-CM Codes: 624.4 (Old laceration or scarring of the vulva).

REFERENCES

Level II

Elmusharaf S, Elhadi N, Almroth L. Reliability of self reported form of female genital mutilation and WHO classification: cross sectional study. BMJ. 2006;333:124. Epub 2006 Jun 27

WHO study group on female genital mutilation and obstetric outcome, Banks E, Meirik O, Farley T, et al. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet. 2006;367:1835.

Level III

Adams KM, Gardiner LD, Assefi N. Healthcare challenges from the developing world: post-immigration refugee medicine. BMJ. 2004;328:1548.

Aziz FA. Gynecologic and obstetric complications of female circumcision. J Gynaecol Obstet. 1980;17:560.

Baker CA, Gilson GJ, Vill MD, Curet LB. Female circumcision: obstetric issues. Am J Obstet Gynecol. 1993;169:1616.

Council on Scientific Affairs, American Medical Association. Female genital mutilation. JAMA. 1995;274:1714.

Cuntner LP. Female genital mutilation. Obstet Gynecol Surv. 1985;40:437.

Khaled K, Vause S. Genital mutilation: a continued abuse. Br J Obstet Gynaecol. 1996;103:86.

Lentz GM. Rape, incest, and domestic violence. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:207.

Toubia N. Female circumcision as a public health issue. N Engl J Med. 1994;331:712.

World Health Organization. Female genital mutilation. Fact sheet 241. Available at: http://www.who.int/mediacentre/factsheets/fs241/en/l, 2000. Accessed June 7, 2007.

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