Female Genital Cutting: Confronting Cultural Challenges and Health Complications Across the Lifespan

Miranda A Farage; Kenneth W Miller; Ghebre E Tzeghai; Charles E Azuka; Jack D Sobel; William J Ledger

Disclosures

Women's Health. 2015;11(1):79-94. 

In This Article

Health Consequences

Health complications may vary with the extent of cutting, although only a limited number of studies break out this risk systematically.

Immediate Complications

When cutting is performed with rudimentary techniques and without anesthesia, the immediate complications can include severe pain; hemorrhage from the internal pudental artery or the dorsal artery of the clitoris; damage to the urethra, vulvar vestibule and vaginal walls; urinary retention during the period of healing from Type III cutting (infibulation); bone fractures due to pressure applied to the struggling girl; tetanus from unsterilized instruments; septicemia; shock due to blood loss and death (Table 5).

Long-term Complications

Dermatological Changes. Tissue damage and improper healing occasioned by the rudimentary cutting techniques create several complications. Chronic vulvar pain may result from trapped or unprotected nerve endings. Keloid scars, which are particularly common in people of African descent, result from progressive overgrowth of dense fibrous tissue (collagen) after wound healing.[24] Numerous cases of clitoral or vulvar epidermal inclusion cysts have been reported.[40–43,57–58] Inclusion cysts arise from invagination of the keratinizing epidermis into the dermis, and the cyst is lined with a wall of true epidermis. They are slow-growing, beginning as a painless swelling at the cut site and gradually increasing in size over several years to form a large clitoral or vulvar mass (in one study, 40% were larger than 3.5 × 6.5 cm at an average age of 17).[59] Cysts are socially stigmatizing when they interfere with walking or sitting or are apparent to the spouse. Besides cysts and abnormal scars, two rare complications are neuroma of the clitoris, which also presents as a mass,[24] and vulvar lymphangiactases, which appear as itchy, wart-like papules resulting from damage to the lymphatic tissue.[60] The papules may be superimposed on lichenified tissue due to chronic scratching.

Urological Effects. Damage to the urethra can result from any form of cutting. Slow, painful micturition, dribbling urinary incontinence, urinary retention and recurrent urinary tract infections are common sequelae of infibulation .[44,45]

Menstrual Health & Hygiene. Women who have undergone infibulation suffer high rates of dysmenorrhea due to congestion from obstructed menstrual flow (hematocolpos).[24,46] Often women do not understand the cause of their symptoms, unless they learn about the health complications of FGC through educational efforts or discover relief from symptoms after undergoing defibulation by a healthcare professional.[37]

Limited research exists on menstrual hygiene in these populations. A prospective, examiner-blind clinical trial of disposable sanitary napkins was performed in Abuja, Nigeria among 283 women aged 18–45 years, 20% of whom had undergone Type I FGC.[61] The study compared a locally produced disposable pad and an imported pad designed to trap and keep fluid away from the skin. Mean number of pad changes during the menstrual period ranged from 1.20 to 3.30 per day, depending on flow levels. The imported pad was preferred for lack of soreness or tenderness and for not feeling wet during wear. Neither product was associated with adverse effects.

A hospital-based, case–control study of cervical cancer in Mali, which examined women who had undergone FGC (95.1% of cases and 92.8% of controls), found that lack of care in cleaning the genitalia was associated with a 5.6-fold increased risk of invasive cervical cancer.[34] Use of commercial sanitary napkins or tampons was virtually nonexistent in the population. Reusing homemade sanitary napkins was almost exclusively restricted to cancer cases, resulting in a 46-fold odds ratio for cervical cancer associated with this practice when adjusted for age, availability of a toilet inside the home, parity and human papillomavirus serostatus.[34] Malian women often report repeated use of menstrual pads that are not always clean, possibly due to lack of access to tap water. Whether FGC contributes to the excess cervical cancer risk in Malian women by impeding adequate menstrual hygiene cannot be ascertained from this study. Poor menstrual hygiene and the rewashing of rags for menstrual protection have been linked to genital infections in other resource-poor countries.[62] For example, poor genital hygiene was associated with cervical cancer in rural China, while sanitary napkin use was protective.[63]

Obstetric & Perinatal Complications. FGC is associated with adverse obstetric and perinatal outcomes and the excess risk depends on the severity of cutting. A large, prospective collaborative study sponsored by the WHO in 2006 examined 28,393 patients at 28 obstetric centers in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan.[48] Cut women were at higher risk for caesarian section, postpartum hemorrhage, extended maternal hospital stay, infant resuscitation, stillbirth or early neonatal death and low birth weight. The excess risk rose with the extent of cutting: women with Type III FGC had a 69% higher risk of postpartum hemorrhage, a 98% higher risk of extended hospital stay, a 66% excess risk of requiring infant resuscitation and a 55% excess risk of stillbirth or early neonatal death.[48] Parity did not significantly affect these relative risks. FGC was estimated to lead to an extra one to two perinatal deaths per 100 deliveries.

Numerous studies have been performed in various locations and utilizing different approaches (case series, case–control studies and cross-sectional surveys, among others) A recent meta-analysis of 28 comparative studies, involving almost 3 million women, provides considerable supporting but not conclusive evidence that FGC is associated with obstetric complications.[49] The analysis found that cut women were 3.3-times more likely to experience difficult or prolonged labor and twice as likely to experience obstetric hemorrhage. Vaginal stenosis and obstruction around the introitus associated with more invasive forms of FGC could contribute to prolonged labor; the inelasticity of vulvovaginal scar tissue could contribute to the increased risk of perineal tears and hemorrhage.

Rates of maternal morbidity and mortality are higher in countries that practice FGC compared with more developed regions, with hemorrhage being the leading cause of maternal mortality.[64] Countries in which the majority of women undergo the most extensive forms of FGC, such as Somalia and Djibouti, have a higher maternal death rate (>700 per 100,000 live births) than countries with a much lower prevalence of FGC but similar midwifery practices, such a Kenya and Tanzania (<500 per 100,000 live births).[14]

Some excess risk of prolonged labor or postpartum hemorrhage may persist among immigrants to developed countries. Studies dating to the initial time period of Somali immigration to the USA and Europe suggested that immigrant women were at higher risk for perineal laceration and postpartum hemorrhage,[65–67] perhaps due to challenges in communicating effectively with immigrant patients and their resistance to western obstetrical interventions.[31] However, other investigations of immigrant women with FGC receiving modern obstetric care in Saudi Arabia, Israel and Western Europe have found no difference in rates of prolonged labor or other perinatal complications.[68–70] In developed countries, it has become more common to offer the patient anterior episiotomy during labor and not reinfibulate after delivery.

Obstetric fistulas, a potential complication of FGC, result from necrosis of urogenital structures when compressed between the fetal head and the mother's pelvis during obstructed labor. Urinary incontinence results from sloughing of the posterior wall of the bladder or urethra and fecal incontinence from pressure necrosis of the posterior vaginal wall and neighboring rectum. These consequences are devastating to the woman, both physically and socially. Several case reports involve women who have undergone Type III FGC or caustic narrowing of the vagina .[50,51] However, a recent study in Ethiopia found that Types I and II FGC were not independent causative factors in development of vesicovaginal fistula from obstructed labor.[52] The high rate of obstetric fistulas in countries where FGC is prevalent could also be related to risk factors such as early marriage when pelvic growth is incompletely coupled with the lack of emergency care.

Sexual Health. Studies of the sexual health of women who have undergone FGC vary in location, methodology, quality and in the types of cutting represented, making broad conclusions difficult. A systematic meta-analysis of 17 comparative surveys of cut and uncut women, comprising a total of 12,755 participants, concluded that the evidence base was insufficient to draw conclusions about the psychological and social consequences of FGC.[47] The analysis suggested that cut women are more likely to experience pain during intercourse, reduced sexual satisfaction and reduced sexual desire, but the quality of the evidence was judged too low to conclude a causal relationship to FGC.

Blood-borne & Sexually Transmitted Infections. Wound infections and sepsis can develop due to unsterile conditions employed when girls are cut, and group cutting with the same instrument may increase the risk of transmitting blood-borne diseases such as hepatitis B and HIV. Among pregnant women in Yemen, for example, being cut was significantly associated with seropositivity for hepatitis B antigen.[71] Cut women with Type II FGC in rural Gambia had a 66% higher risk of bacterial vaginosis, which the investigators speculated might be related to removal of the labia minora.[33] Cut women also had a 4.7-fold higher prevalence of herpes simplex-2 infection,[33] an epidemiologic risk factor for HIV throughout Africa.[53] Analysis of demographic variables among 3167 Kenyan women aged 15–49 suggests that FGC is indirectly associated with HIV risk through associated practices in adulthood.[54] Specifically, cut women are 1.72-times more likely than uncut women to have older partners (perhaps through arranged marriage) and women with older partners are 2.65-times more likely than women with younger partners to test positive for HIV; moreover, cut women have 1.94-times higher odds than uncut women of initiating sexual intercourse before they are 20, and women who experience their sexual debut before age 20 have 1.73-times higher odds of testing positive for HIV. However, a study of 379 clinic patients in Tanzania found no association of FGC with hepatitis B, HIV or reproductive tract infections.[6]

Psychological Impact. Human rights advocacy groups and women's health centers that serve immigrant women affected by FGC obtain poignant testimony of the psychological trauma they endure.[37,72–73] Evidence of post-traumatic stress disorder has been observed in subsets of women in their home countries and among immigrants to the West.[55,74] Not all women process their experience in the same way; it is colored by the meaning they create of this tradition and their own adaptive styles.

Postmenopausal Health. Vulvovaginal atrophy is a natural consequence of hypoestrogenism following the menopausal transition (reviewed in[75]). It is a growing women's health concern as the population of the industrialized world ages. In the intact woman, the labia atrophy and lose elasticity, the introitus narrows and the clitoral hood may become phimotic. The vagina becomes shorter and narrower and loses the typical folds (rugae); the vaginal epithelium is more friable and prone to friction-induced bleeding. Vaginal pH rises above 4.5, increasing susceptibility to infection. Atrophic symptoms in the intact woman include vaginal dryness, itching or burning, painful intercourse, increased urinary frequency, dysuria and nocturia.

However, in the less developed countries of Africa, the risks of HIV infection, maternal mortality and limited access to healthcare reduce life expectancies to some of the lowest levels globally. Life expectancy for women in Tanzania, for example, is 53 years, and FGC is a risk factor for early death.[76] African immigrants to the USA are less likely to be over age 65 years than the native or foreign born population; two-thirds of African-born immigrants are under age 45 years.[28,30] No systematic studies are available on postmenopausal urogenital health in women who have undergone FGC and their needs are unaddressed. Health professionals in the developed world who serve immigrant communities must examine the sequelae of aging in cut women, raise awareness and address the impact of FGC on postmenopausal health and quality of life.

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