Female Genital Cutting: Epidemiology, Consequences, and Female Empowerment as a Means of Cultural Change

Martin Donohoe, MD, FACP

Disclosures

November 06, 2006

Introduction

The preceding articles in this series discussed historical and contemporary ideals of beauty and methods of body modification.[1,2] This content is focused on female genital cutting (FGC), a form of body modification common in many parts of the developing world, and outlawed in most parts of the developed world.

FGC is also referred to as female genital mutilation and female circumcision. The term mutilation, when used with patients, can further damage the self-esteem of those affected. Additionally, its pejorative tone may make it more difficult for public health advocates to obtain allies for their quest to eliminate the procedure.

The term circumcision evokes analogies to male circumcision, a procedure that involves far less alteration in structure and function of the male genital organ. For example, the male equivalent of clitoridectomy would be penectomy, or removal of the entire penis. Furthermore, male circumcision carries multiple personal and public health benefits, and when carried out in the neonatal period is very cost-effective.[3] Circumcision reduces the risk for HIV, chancroid, syphilis, neonatal urinary tract infection, penile and cervical cancers, and possibly herpes simplex virus II.[4,5,6] Current evidence suggests that some cells found in the male foreskin are especially vulnerable to infection with HIV,[7] and that routine circumcision of all men in Africa, for instance, could prevent 2 million new HIV infections and avert 300,000 deaths over the next 10 years.[8,9,10] After 20 years, 3.7 million new HIV infections would be prevented and 2.7 million deaths averted.[10]

FGC was practiced as early as 450 BCE and was widely performed throughout ancient Egypt and in many other societies and cultures.[11] Clitoridectomy, as well as hysterectomy and oophorectomy, were used in the United States and Great Britain from the early 1800s to the mid-1950s as treatments for such diverse "disorders" as masturbation, lesbianism, falling of the womb, floating womb, hysteria, emaciation, debility, nymphomania, melancholia, insanity, and seizures.[11,12] The father of modern gynecology, J. Marion Sims, advocated the procedure.[13] Sigmund Freud once opined that "elimination of clitoral sexuality is a necessary precondition for the development of femininity."[14] The last known medical female "circumcision" in the United States took place in Kentucky in 1952, although some cultures within the United States continue the practice today outside of the medical system.[13]

Over 130 million women worldwide have undergone FGC.[15] Prevalence of FGC ranges from 80% to 100% in Egypt, Somalia, Ethiopia, Eritrea, and Sudan; from 51% to 79% in Mali, Chad, and Liberia; 50% in Nigeria and Kenya; and 20% or less in Senegal, Tanzania, Zaire, and Uganda.[16] More than 168,000 women in the United States have either undergone or are at risk for undergoing this procedure. An estimated 20,000 African refugees enter the United States each year, 80% from countries where FGC is a common practice. Immigration of affected refugees to Europe is also increasingly common.[15]

Reasons given for FGC include the psychosexual (maintenance of chastity and virginity before marriage, fidelity during marriage, and promotion of "morally appropriate fertility"); the sociologic (initiation into womanhood, maintenance of cultural heritage and social cohesion, and protection against spells); the hygienic and aesthetic, and outright myths (the clitoris is dangerous and can damage a penis).[11,17] Use is found among all races and many religions, including Islam, Coptic Christianity, Catholicism, and Protestantism.[14] Contrary to popular belief, FGC predates Islam and is not condoned by that religion.[18] It occurs among all socioeconomic groups, although daughters of urban and educated women may be less likely than others to undergo FGC.[19] Many women perpetuate the practice and insist that it be done to their daughters, often out of a desire to pass on the most intimate aspects of their self-perception and feelings of gender and social identity.[17]

FGC operations are most commonly carried out on young girls between the ages of 4 and 12 years; physicians perform about 12% of procedures.[20,21,22] Some procedures involve celebrations and the exchange of gifts and money. Others take place in secret and may involve kidnapping. Cutting is often done under nonsterile conditions and without anesthesia or pain medication other than, perhaps, local salves.

The types of FGC are:

  • Type I: excision of the prepuce, with or without excision of part or all of the clitoris;

  • Type II: excision of the clitoris with partial or total excision of the labia minora;

  • 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 and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue;

  • Scraping of tissue surrounding the vaginal orifice or cutting of the vagina;

  • Introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it; and

  • Any other procedure that injures the female genital organs.[23]

Types I through III are most common. Reliability of a self-reported form of FGC is low, and examination is necessary to determine the extent of cutting.[24]

The more extreme forms of FGC constitute a surgical "chastity belt." Deinfibulation, or cutting open the sewn labia, is often performed multiple times, such as when the women's husband returns from work in another village or in the gold or diamond mines (M. Donohoe, unpublished data), and prior to childbirth. Deinfibulation is typically followed by reinfibulation.

Immediate complications of FGC include severe pain, cellulitis, sepsis, urinary retention, hemorrhage, shock, and even death. Long-term complications, seen predominantly in women who have undergone type III procedures, include cysts, abscesses, keloids, recurrent infections, dyspareunia, and dysmenorrhea due to the infibulated scar overlying the vaginal introitus.[21,22] Neuromas, which can cause sharp, excruciating pain, are rare. Decreased sexual responsiveness is understandably common, and some women suffer infertility, but there is no increased risk for sexually transmitted infections.[21,25]

Women with FGC are significantly more likely than those without FGC to have adverse obstetrical outcomes, including prolonged or obstructed labor, obstetric fistulas, caesarean section, postpartum hemorrhage, extended maternal hospital stay, infant resuscitation, stillbirth or early neonatal death, and low birthweight.[19,26] Risks are higher with more extensive FGC. FGC leads to an extra 1-2 perinatal deaths per 100 deliveries, likely secondary to unattended or inappropriately treated obstructed labor caused by vulvar scarring.[19,23] Fetal complications are rarely seen in developed nations.[15]

Psychiatric sequelae of FGC include shame, fear, depression, posttraumatic stress disorder, and memory problems.[21,27] Male complications resulting from FGC include difficulty in penetration, wounds and infections on the penis, and psychological problems.[28]

Deinfibulation, with surgical reconstruction of the infibulated scar, is performed by making an anterior incision on the scar and creating 2 neo-labia majora. Such deinfibulation reduces the incidence of some long-term complications.[22]

However, a clitoris, with its multiple sensory nerves, cannot be reconstructed.

Physicians managing those who have undergone genital cutting need to be sensitive to cultural identity issues and aware of the availability of reconstructive deinfibulation procedures.[20] Physicians are not obligated to, and in fact should not, reinfibulate patients who have been deinfibulated for labor and delivery. This is in keeping with ethical precepts that counsel physicians to avoid causing physical, social, and emotional harm to their patients.[29]

Hymen reconstruction. As many as 2% of Guatemalan women have undergone a unique form of FGC involving hymen reconstruction locally known as "intimate surgery." [30] The procedure is costly (up to US $1000), usually carried out by poorly trained medical practitioners and without adequate informed consent, and often leads to infections, hemorrhage, incontinence, fistulas, and extreme dyspareunia.

Guatemala has dismal reproductive healthcare, with high levels of maternal and infant mortality and low levels of knowledge about (and use of) contraception. This situation is a consequence of a conservative government; a powerful, vocal, and authoritative Catholic Church; and cuts in US family planning aid, resulting from the political ideology of the current administration.[31,32]

The expectation that girls will be virgins at the time of marriage (which sometimes requires blood evidence for confirmation on the wedding night) has led to an increase in anal sex and, for women who have lost their virginity, desperation sufficient to lead them to undergo hymen reconstruction to avoid rejection by their communities and the economic hardships that such rejection and the single life entail. Despite strong opposition from the president and the Catholic Church, the Guatemalan legislature recently passed a law designed to strengthen family planning programs, which will hopefully help to decrease the practice of hymen reconstruction.[33]

Love surgery. Dr. James Burt was an Ohio gynecologist who subjected hundreds of women in the late 20th century to a procedure he called the "Surgery of Love." This "operation" involved removing the skin around the clitoris and "reshaping" the vagina.[34] Despite Burt's claims that his procedure would enhance sexual pleasure, many of his victims suffered complications such as infections and decreased sexual responsiveness. Burt practiced for decades, published a book about his procedure, and benefited from the unwillingness of the local medical community to report and condemn the procedure. Only after a number of patients brought lawsuits against him was he forced to give up his license.[35]

FGC has been illegal in the United States since 1997,[15] and is also outlawed in Canada, Australia, the United Kingdom, France, many other European countries, and in much of sub-Saharan Africa, where penalties for cutters range from a minimum of 6 months to a maximum of life in prison.[36] Immigrant women who fear that they are likely to face a forced operation upon return to their countries of origin have successfully petitioned for political asylum. FGC has been condemned by the World Health Organization, the United Nations, the World Medical Association, the International Federation of Gynecology and Obstetrics, the American Medical Association, and the American Academy of Pediatrics.[11,20,37]

Cutting of children is internationally recognized as gender-specific child abuse, child exploitation, and torture.[11] It is a violation of the United Nations Convention on the Rights of the Child (which all countries except the United States and Somalia have ratified).[14,19] Furthermore, a long history of case law in the United States upholds the right of the state to intervene when parents endanger the physical or mental well-being of their children.[38]

Although some have argued that opposition to FGC smacks of ethnocentrism and cultural imperialism, moral norms, feminist philosophy, and a rethinking of institutionalized practices from the viewpoint of the oppressed masses (as opposed to the powerful few) has led to a consensus that FGC constitutes the subjugation of female sexuality and bodily integrity, and represents a form of physical and psychological abuse.[38,39] FGC represents the cultural control of women's libido, sexuality, and reproductive capabilities.

Historical abuses once considered cultural have been abolished in many parts of the world, such as denial of life-saving treatment for children on the basis of religious beliefs, child labor, polygamy, slavery, head hunting, and cannibalism.[11,38] In India, child marriages were outlawed in 1929, and measures have been taken to prevent sati, the self-immolation of wives on the funeral pyres of their deceased husbands. China outlawed foot binding in 1949.[11] Current opposition to the international sex trade and to prenatal sex selection and infanticide in China is also based on moral arguments relevant to women's rights.

FGC can be reduced through increased education and cultural empowerment of women, more effective enforcement of existing prohibitions, equitable economic development involving reductions in poverty, enhanced legal and political representation of women, and the substitution of culturally acceptable alternative rites of passage.[40,41] Similar reacculturation successfully altered lay and medical conceptions of hysteria in the United States and led to the elimination of FGC and hysterectomies for women diagnosed with this "affliction."[13] Medical schools, residency programs, and schools of public health should improve their teaching about FGC in particular and the relationship between women's health and human rights in general.[25,42,43]

Public health interventions to reduce FGC should be nondirective, culture-specific, multifaceted, and involve members of the involved communities, including traditional healers.[16] The norm of damage to young girls should be replaced with a norm of strengthening them through improved education, employment, and healthcare with the support of other women in the community.[35] With successful interventions, over time a critical mass of parents who have not undergone FGC will be reached within a community, levels of FGC will fall dramatically, and males will be more likely to prefer women who have not been cut.[28]

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