Female Genital Mutilation Reconstruction for Plastic Surgeons

A Call to Arms

Takintope Akinbiyi, MD, MSc; Emily Langston; Ivona Percec, MD, PhD

Disclosures

Plast Reconstr Surg Glob Open. 2018;6(11):e1945 

In This Article

Cultural and Historical Background

The primary motivation for the practice of FGM is the belief that it will decrease or eliminate sexual arousal and pleasure, thus protecting the purity of a woman for a husband.[4,5] Making sexual activity less enjoyable for a woman is thought to decrease the risk of her engaging in sexual encounters before or outside of marriage. Motivating factors that contribute to the perpetuation of FGM as a "normal" practice are largely rooted in ancient tradition. Young girls may feel a greater sense of belonging among adult women who have been through the same experience. In some cultures, it is considered a necessary component of childrearing as a rite of passage that purifies a girl by removing her unclean clitoris and labia.[1,6–8] When viewed from within this cultural context, that is by mothers anxious to raise daughters who are socially desirable, it is possible to understand why the custom persists in modern times.[4,6]

FGM is currently carried out in 30 countries across Africa, the Middle East, and Asia, but is practiced predominantly in sub-Saharan Africa.[1,9] As of 2017, over 200 million girls and women have undergone FGM procedures. Although it can be performed at any age, the majority of girls undergo FGM by age 15, and in some cultures the procedure is performed during infancy.[4] In one study of over 2,000 Sudanese women, 96.9% who had undergone FGM had done so by age 6.[10] In Somalia, 98% of women between the ages of 15 and 49 years had undergone FGM.[11] In most cases, the procedure is performed by nonmedical providers such as midwives or other local women considered to have expertise in the procedure.[8] It is therefore typically performed without sterile surgical instruments, a sterile field, or any anesthesia.[1,9,11]

The practice of FGM is frequently misassociated with Islam. However, although the exact origins of female circumcision are unknown, there is growing evidence that its beginnings took place in antiquity well before the birth of Islam.[12] Ancient Egyptian mummies have been discovered that are marked by the signs of female circumcision.[9] In this context, it was restricted to the daughters of priests and rulers and was thus a sign of elevated social status.[13] FGM is also practiced by Christians and Jews in countries where FGM is culturally accepted.[4]

Although the practice of FGM is primarily carried out in Africa, medical providers in Western countries are increasingly encountering FGM victims secondary to the increase in global migration. Women who underwent FGM in their native countries are increasingly seen in Western countries for routine gynecological or obstetrical visits and may require medical treatment for FGM sequelae. In addition, girls and women may remain at risk for undergoing the FGM procedure even after they leave their native countries. In the United States, a 2012 Centers for Disease Control and Prevention (CDC) report cited that over 500,000 girls and women were at risk for undergoing FGM here in the United States based on their country of origin.[14] The practice has been formally banned since 1996 in the United States. However, as of the writing of this article, 26 states still do not currently have legislation in place criminalizing FGM.[15] Tracking its practice here is challenging because the procedure may be carried out in private, nonmedical settings, thereby escaping detection. In addition, girls may be taken back to their home country by family members to have the procedure performed, a practice termed "vacation cutting." As a result, the CDC stated "No reliable sources of data exist on the number of U.S. resident women and girls who have undergone FGM either in the United States or in their country of origin, or on the number of women and girls who undergo the procedure in a given year".[14]

In 2017, Dr. Jumana Nagarwala, an Emergency Medicine physician, and Dr. Fakhruddin Attar, an internal medicine physician, were indicted before a Grand Jury in Detroit for performing FGM on girls in the state of Michigan. The 2 physicians, along with Dr. Attar's wife and practice manager, are alleged to have conspired to perform FGM on two 7-year-old girls. The indictment stated that they may have been performing the procedure at Dr. Attar's clinic since 2005.[16] This represents the first indictment brought under the 1996 Federal anti-FGM law.[17] The 2 girls in question were brought from Minnesota to Michigan to facilitate the procedure suggesting that the motivation to perform FGM is high among some immigrant communities.

Multiple other Western countries are similarly dealing with FGM, both in caring for former victims and by protecting those still at risk. The United Kingdom is now home to an estimated 137,000 victims of FGM. A striking 2.5% of women living in London were victims of FGM. The United Kingdom also has legislation in place making the practice of FGM illegal. However, as of 2016, they also had zero prosecutions under the law, which is startling considering that, on average, a case of FGM is reported every 109 minutes. Many prominent figures, like Lord Smith of Hindhead, have championed the cause.[18,19] However, the frequent involvement of nonmedical practitioners outside of clinical environments means the true numbers at those who have been victimized while in the United Kingdom are unknown, and protecting those at risk is also very challenging.

Despite international recognition of FGM as a violation of human rights and several initiatives promoting education and awareness and implementing improved legal protection, it remains a common practice. Although there is evidence that the incidence is decreasing, globally an estimated 3 million girls and women are still at risk every year.[1,11] In 2013, approximately 89.6% of women aged 15–49 years in Sierra Leone had undergone FGM, down from 91.3% in 2008. A temporary ban on the practice implemented during the Ebola crisis helped drive down the incidence. However, while no recent figures exist, many believe the incidence is rising again due to how deeply ingrained the practice is in the local culture.[20]

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