Caring for Women who have Experienced Female Genital Cutting

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Video Description

Health care practitioners have identified being underprepared to care for women who have experienced female genital mutilation or cutting (FGM or FGC).

The objective of this video is to provide the health care practioner with considerations for terminology use, overview of health consequences of FGM or FGC, and an approach to the vulvar exam.

The World Health Organization (WHO) classification of Female Genital Mutilation is reviewed and a brief summary of the procedure of defibulation is discussed.

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North York General Hospital & Geneva University Hospital

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What is Female Genital Cutting?

Female Genital Cutting (FGC), also known as Female Genital Mutilation (FGM) or Female Circumcision, refers to all procedures involving partial or total removal of the external female genitalia or other injuries to the female genital organs for non-medical reasons. It’s a practice with deep cultural roots in many communities, and it is performed for various reasons within different societal contexts. However, it’s important to note that FGC is internationally recognized as a human rights violation.

FGC is prevalent in parts of Africa, the Middle East, and Asia. It also occurs in some communities in North America, Europe, and Australia among immigrants from countries where the practice is common. The reasons behind FGC vary greatly between communities and include a mix of sociocultural factors. Among them are rites of passage, social norms that equate purity and modesty with a lack of sexual desire, and beliefs about what is considered proper sexual behavior.

What are the risks of Female Genital Cutting?

FGC has no health benefits and can lead to a range of potential health problems, including severe pain, bleeding, infection, complications in childbirth, mental health problems, and, in some cases, death. These risks underscore the severity of FGC’s impact on the physical, sexual, and psychological health of women and girls, further emphasizing the need for continued global efforts to end this practice.

Video Transcript: Caring for Women who have Experienced Female Genital Cutting

Caring for women who have experienced female genital cutting. The objectives of this video are to review terminology in the WHO classification, provide an approach to vulva examination, review health consequences, and considerations for the procedure of defibulation.

Data has shown that healthcare practitioners have challenges in providing quality care to women that have experienced female genital cutting. They’re often underprepared to assess and manage complications, lack technical skills to provide procedures such as defibulation, and face communication challenges.

Additionally, women that have experienced female genital cutting have expressed concerns with the quality of care they’ve received.

Female genital cutting is the ritual removal or injury to any part of the female genitals for non-medical reasons. The words we use matter.

There is no international consensus on terminology. Female circumcision is problematic because it equates the practice with male circumcision. Female genital mutilation is an advocacy term, however, can be considered judgmental and stigmatising. As medical practitioners we should use the term female genital cutting as it is medically correct, neutral, and culturally sensitive.

FGC is a complex global public health issue. It’s considered to be a harmful practice, a violation of human rights and the rights of a child. It is also a form of gender-based violence.

The WHO estimates that over 200 million women and girls have experienced FGC, and 3 million girls are at risk each year. The practice is known to occur in over 40 countries with the highest prevalence in Somalia, Sudan, Egypt, Eritrea, Djibouti and Guinea.

It is often misunderstood, even by healthcare practitioners, that the entirety of the clitoris is removed with female genital cutting. This is a misconception. The clitoris is a multiplanar structure that surrounds the urethrovaginal complex interior laterally. It is centrally attached to the urethra and vagina.

The main components include the clitoral glands, body or corpora, the crura and the vestibular bulbs. The external components are the clitoral hood which connects to the labia minora via the frenulum, also known as the prepuce. It drapes over the clitoral glands. It’s these two components plus the clitoral body that are often cut.

The World Health Organization has classified FGC into four types, with subcategories. Briefly summarized they are, Type I A partial or total removal of the clitoral hood. Type I B, the clitoral hood plus the clitoral glands. Of note, when the WHO refers to clitoral glands excision, it can also include partial excision of the clitoral body.

Type II A partial or total removal of the labia minora only. Type II B includes the labia menorah, clitoral glands and sometimes the clitoral hood. Whereas Type II C includes the clitoral glands, labia minora and labia majora, as well as sometimes the clitoral hood.

Type III is infibulation, where the labia minora, labia majora are cut, and appositioned, narrowing the vaginal opening.

 Type IV is all other harmful procedures such as pricking, incising, scraping or cauterisation. They may have a normal appearing vulvar examination, however, have a significant history of a harmful genital procedure.

A simplified approach to the classification would be to observe if the clitoral glands has been cut. This could be any type. If the clitoral hood has only been cut, it’s a Type I. If the labia minora or majora have been cut it as a Type II. And if there’s infibulation, this is Type III.

FGC can alter the health trajectory of a woman’s lifetime. Consequences can be experienced in multiple spheres of health and wellness.

Immediate consequences can include severe pain, bleeding haemorrhage, shock, infection, broken limbs, and even death.

 Sexual function can be impacted in terms of lack of sensation, dyspareunia, diminished arousal or desire, and anorgasmia. The psychological impacts can be significant and influence one’s identity, belonging, and body image. There’s also increased rates of anxiety, depression and post-traumatic stress disorder.

Obstetrical consequences can include prolonged labour, increased perineal tearing, increased need for interventions such as episiotomy, instrumental delivery, and caesarean section.

 Long term complications include chronic pain, dysmenorrhea, genital tract infections, infertility, and difficulty with gynaecological procedures and screening. It can have keloid scarring, recurrent vulvar abscess, and epidermoid cyst formation.

Medical history taking should be done in a respectful, culturally sensitive and non-judgmental manner. Use a person-centred approach that focuses on her lived experience of cutting and how it has impacted her physically, mentally and socially.

It’s important for the practitioner to understand that the experience of cutting can be highly diverse. The range of impact is on a wide spectrum and can change throughout one’s lifetime.

Example questions could include, what do you remember about being cut and how has this impacted you?

Documentation is important to alert other healthcare providers and avoid unnecessary examinations. Use a diagram not only for your medical records, but as a teaching tool for your patient to explain their vulvar anatomy. Use the WHO classification system. If it’s unclear, describe the anatomical structures that have been removed or injured.

In the setting of Type III with infibulation the process of defibulation can be used to open the midline vulvar scar. Indications include personal choice to improve urinary menstrual outflow, to decrease genitourinary tract infections and cyst formation to permit vaginal penetration and decreased dyspareunia and permit vaginal delivery and decrease obstetrical intervention.

Defibulation is a simple procedure however the complexity lies in preoperative counselling and expectation setting. Considerations include, it’s not only an anatomical and physiological change, it can alter body image and represent a cultural shift, especially around marriage eligibility.

Discuss alterations in vaginal discharge, urine stream, and menstruation flow. Review clitoral anatomy and the possibility the clitoral glands may be found intact under the scar.

Agree on the amount of opening. For example, some women prefer partial defibulation.

Develop an anaesthetic plan. Defibulation can be done under a local spinal or general anaesthetic. Operative and postoperative pain can trigger post-traumatic stress disorder symptoms and therefore discussion of this possibility is important in ensuring the availability of psychological support.

Steps to the procedure can include, marking a line of the planned incision to avoid asymmetry, assessing for underlying adhesions, which can be done by placing a finger beneath the scar.

Gently place a Kelly clamp beneath the scar to retract the tissue forward to help protect the urethral meatus and clitoral glands. Move slowly from inferior to superior, observing for the anatomical landmarks.

Here you can appreciate the newly exposed glands as well as the defibulated labia. To reapproximate the neo labia use interrupted 4O absorbable monofilament suture.

For further reference, see these additional resources.