Abstract and Introduction
Female genital cutting affects over 140 million women worldwide. Prevalent in certain countries of Africa and the Middle East, the practice continues among immigrants to industrialized countries. Female genital cutting is a deeply rooted tradition that confers honor on a woman and her family, yet also a traumatic experience that creates significant dermatological, gynecological, obstetric and infectious disease complications. Little is known about postmenopausal health in cut women. The international community views this practice as a human rights violation. In addition to genital health complications, the medical community must confront an understudied concern of what happens as this population ages. These challenges must be addressed to provide optimal care to women affected by female genital cutting.
Female genital cutting (FGC) comprises all procedures that involve partial or total removal of the external female genitalia, or injury to the female genital organs, for cultural or nontherapeutic reasons. The WHO estimates that over 140 million women and girls worldwide have been subjected to this practice and that each year about 3 million more girls are at risk for some form of genital cutting. It occurs at high rates in 28 countries in Africa and to some degree in certain countries of the Middle East and Asia (Yemen, Oman, Saudi Arabia, United Arab Emirates, Bahrain, northern Iraq, Malaysia, Indonesia, Pakistan, India and southern Israel). The WHO defines four main categories of FGC (Figure 1):
Anatomical perspective on some major forms of female genital cutting. Blue color represents excised portion of the anatomy. Due to rudimentary cutting techniques, variants of lesser or greater severity may be observed (see Table 1). (A) Type I: full clitoridectomy. (B) Major Type II variants: removal of the clitoris and partial removal of the labia minora; removal of the labia minora only; total excision of the clitoris and labia minora (red lines indicate where cut edges of the labia majora may be created in the progression to Type III). (C) Type III: infibulation achieved by excision of the external genitalia and apposition of the cut edges of the labia majora.
Type I: excision of the prepuce with partial or total excision of the clitoris (clitoridectomy);
Type II: excision of the clitoris with partial or total excision of the labia (clitoridectomy and/or labial excision; types of FGC that involve cutting of the clitoris are known in some places as the Sunna form);
Type III: excision of part or all of the external genitalia and narrowing and covering the vaginal opening by joining and fusing the raw edges of the labia with stitches or glue, leaving a small opening for the flow of urine and menses (infibulation, also known as the Pharaonic form);
Type IV: includes other forms of nontherapeutic genital alteration such as pricking, piercing, incising the clitoris or labia; stretching the clitoris or labia; cauterizing the clitoris and surrounding tissue; scraping the vulvar vestibule; cutting the vagina; and introducing caustic substances, poultices or herbs into the vagina to create tightening or narrowing of the vaginal vault.
Because cutting often involves rudimentary techniques, the WHO describes subsets of these categories to approximate the range of possible outcomes (Table 1).
Growing numbers of immigrants from countries where this practice is common have settled in North America, Western Europe, Australia and New Zealand, bringing the practice with them. Global authoritative bodies, which have declared the procedure a violation of bodily integrity and human rights, use the term, female genital mutilation. Because women from affected regions may not view themselves as having been mutilated, this review uses the neutral term, 'female genital cutting'. The authors have a particular interest in how FGC affects a woman's quotidian quality life, from everyday menstrual health and hygiene, to sexual health, pregnancy, childbirth, and postmenopausal challenges. This review describes the cultural determinants of the practice, its impact on health and wellbeing, and areas where further research is needed. Limited research exists on the prevalence and consequences of FGC within immigrant communities to the developed world, perhaps because practice is illegal in many immigrant-receiving communities. The goal of this review is to highlight the health and emotional concerns of these women with sensitivity so that we can improve their quality of life.
Women's Health. 2015;11(1):79-94. © 2015 Future Medicine Ltd.