Female genital mutilation

It is important to identify girls at risk say Dr Makeba Roach and Dr Comfort Momoh MBE.

Circumcised woman prior to surgery to reopen her vaginal passageway (Photograph: SPL)
Circumcised woman prior to surgery to reopen her vaginal passageway (Photograph: SPL)

Community healthcare providers may be the first point of contact for many women affected by female genital mutilation (FGM) and staff must care for these women sensitively and professionally.

Prevalence
Between 100 and 140 million women worldwide have undergone FGM, with a further three million at risk annually.1 FGM is practised in 28 countries across Africa, the Middle East and Asia, and is now increasingly being seen in western migrant-receiving countries.

Estimates of UK prevalence suggest that almost 66,000 women who had undergone FGM were living in England and Wales in 2001; this figure is likely to have increased significantly since then in light of increasing migration to the UK.2 The WHO describes four types of FGM (see box below).

WHO Classification of FGM1

Type 1 (clitoridectomy): Partial or total removal of the clitoris and/or the prepuce.

Type 2 (excision): Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora.

Type 3 (infibulation): Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris.

Type 4 (unclassified): All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterisation.

 

Complications
Following the initial FGM procedure, key events throughout women's lives present further opportunities for physical and psychological complications. Obstetric complications can include prolonged/obstructed labour, fetal distress, perineal tears, postpartum haemorrhage, stillbirth, and antenatal and postnatal wound infection.

The procedure can also lead to gynaecological complications, such as keloid scarring, abscess formation, rectovaginal or vesicovaginal fistula formation, vaginal atresia, dysmenorrhoea, oligomenorrhoea, pelvic infection, inclusion cysts, and partial or complete labial fusion.

Psychosexual problems including fear and anxiety around sexual intercourse, vaginismus, anorgasmia and marital breakdown can also occur. Urinary problems, including urethral stricture, urinary retention and dysuria, are also common.

Immediate complications include haemorrhage, shock, anaemia and fractures or dislocations from being restrained.

In some groups that practise type 3 FGM, it is customary on a woman's wedding night for her husband to cut her open with a knife to consummate the marriage. Traditional practitioners may 'open' a woman before childbirth and close her afterwards.

A 2006 prospective study3 of more than 28,000 women from six African countries showed that deliveries to women who have undergone FGM are more likely to be complicated by caesarean section, postpartum haemorrhage, episiotomy, extended maternal hospital stay, resuscitation of the infant and inpatient perinatal death.

FGM in the UK
FGM is outlawed in the UK; recent years have seen increased co-operation between the government, health and education authorities and police to raise the profile of FGM in the UK.

The government launched comprehensive multi-agency practice guidelines in February 2011, and several local safeguarding children boards have issued specific safeguarding guidelines.4

In addition to guidelines available from the Royal Colleges, the BMA has updated its guidance on FGM, informing doctors what to do next if they suspect a patient may be at risk.5

Health services
Nationwide there are 15 FGM clinics run by midwifery and medical FGM specialists. They provide advice and support to patients, and offer 'deinfibulation', a surgical procedure to reverse the anatomical changes of type 3 FGM, allowing more comfortable sexual intercourse and reducing physical and obstetric complications.

Women present to FGM clinics either for deinfibulation because they are pregnant and afraid of childbirth, or have an upcoming marriage, recurrent UTIs, dyspareunia or dysmenorrhoea. They may also present for advice and support regarding antenatal care, postnatal care or recurrent flashbacks.

Deinfibulation can be done in clinic under local anaesthetic, with counselling and follow-up. Deinfibulation is ideally performed before pregnancy; alternatively it can be done after 20 weeks' gestation, giving time for healing before birth. Before 20 weeks there is a risk of causing further psychological trauma if women have a miscarriage.

Although FGM clinics are making an impact in some urban areas, female asylum seekers and refugees with complex health needs may be dispersed to rural areas where there is little awareness of FGM.

In response to calls for all health professionals to undergo specific FGM training, an accredited course in FGM management for midwives, nurses and health visitors has been running for three years at King's College London.

Healthcare staff have a safeguarding duty towards girls who may be at risk of undergoing FGM in the future. FGM differs from other forms of child abuse in that it is usually a one-off act, and parents believe they are acting in the best interests of the child.5 It is important to refer to the police and social services quickly if there are suspicions a child may be at risk.4,5

Features that suggest a girl might be at risk of FGM include belonging to a community known to practise FGM, an upcoming holiday to her country of origin or another country where FGM is prevalent, or a female born to a woman who has undergone FGM. A girl may already have undergone FGM if she has had prolonged absences from school, is spending a long time outside the classroom with menstrual or bladder problems, if she has withdrawal or behaviour changes or is repeatedly being excused from physical exercise lessons.

Current controversies
Medicalisation of FGM occurs when health professionals perform FGM in a public or private setting.

Worldwide, practising communities are asking healthcare providers to perform FGM, hoping to reduce the associated health risks. UN agencies argue that medicalisation falsely bestows a degree of legitimacy on FGM, and is more likely to institutionalise it than encourage abandonment.

Community health professionals must consider their position on these matters and stay updated with UK law and clinical guidelines. We must not be afraid to ask women from practising countries about FGM, and should consider it as a possibility even in second and third generation women and girls.

  • Dr Roach MBBS, BSc is currently doing an MSc in public health at the London School of Hygiene and Tropical Medicine. Dr Momoh MBE, MA is a specialist FGM midwife at Guy's & St Thomas' Hospital, London
References
1. WHO (2008). Eliminating female genital mutilation: an interagency statement. http://whqlibdoc.who.int/publications/2008/9789241596442_eng.pdf

2. FORWARD, in collaboration with the London School of Hygiene and Tropical Medicine and the Department of Midwifery, City University (2007). A statistical study to estimate the prevalence of female genital mutilation in England and Wales.

3. WHO Study Group on Female Genital Mutilation and Obstetric Outcome. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006 367: 1835-41.

4. London Safeguarding Children Board (2007). Safeguarding children at risk of abuse through female genital mutilation. Available at www.londonscb.gov.uk/fgm/

5. British Medical Association. Female genital mutilation: Caring for patients and safeguarding children. BMA 2011, London.

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