Expert Opinion: Female Genital Mutilation

Female genital mutilation (FGM) is an ancient tradition steeped in a multitude of cultures. The practice involves the unconsented restraint of minors in order to nick, excise or infibulate their genitalia (WHO, 2008). FGM is usually performed by untrained personnel in unsterile environments, exposing these girls to a lifetime of potential complications. These include dyspareunia/apareunia, dysmenorrhea, pelvic pain, recurrent urinary tract infections, prolonged labor, increased perineal trauma, and psychiatric complications. The continuation of FGM is fueled by numerous socio-cultural pressures including initiation into womanhood, religious beliefs, aesthetic appeal, and as a means of suppressing sexual desires. Despite the medical complications of FGM and increasing legal ramifications, FGM prevalence rates have only marginally declined over the past two decades. The United Nations International Children’s Emergency Fund (UNICEF) estimates that over 200 million girls and women alive today have undergone FGM (WHO, 2008). Although FGM is practiced across many cultures, the highest prevalence remains in Sub Saharan African communities, with 11 countries in the region having prevalence rates greater than 70% (WHO, 2008). Due to the rise in global migration, the issue of FGM is becoming more and more prevalent in societies previously naïve to the practice.

From a regulation standpoint, FGM is illegal and constitutes criminal assault (WHO, 2008). This includes the practice of re-infibulation which cannot be performed under any circumstance. Similarly, it is illegal to arrange or assist in arranging for an individual to go overseas for the purpose of FGM. The role of healthcare professionals in detecting and appropriately managing FGM is paramount in breaking the cycle. An important aspect of managing FGM is to appreciate the deep-rooted socio-cultural pressures fueling the practice. In societies where FGM is a social norm, the practice is self-perpetuating secondary to a desire to conform to this behavioral rule. Individuals and families alike fear marginalization and loss of social status if they were to abandon the practice. Thus, any blame towards the patient or their culture does not aid the process of abandonment or management of the individual.

FGM is ideally managed in specialized, self-referral clinics in areas easily accessible to patients. These clinics should offer a streamlined hub of access to culturally appropriate liaison officers, interpreters, psychiatric services, social workers, and healthcare professionals. Patients with FGM often hail from low socio-economic backgrounds and thus are less likely to present for care. This opportune moment should thus be utilized to ensure that the patient’s general wellbeing is addressed with a particular emphasis on mental health. The legal aspects of FGM should be made clear to the patient. Reporting to the police and social services is only mandatory if the patient is under age, the FGM was recently performed (as per clinical findings), or if the patient voices intent for performing the practice (most relevant in the antenatal context with a female fetus). De-infibulation is a minor surgical procedure to divide the scar tissue sealing the vaginal introitus in cases of infibulation. There are no randomized controlled trials looking at patient outcomes with de-infibulation, but it remains the mainstay for managing infibulation. Ensure the patient is adequately consented and understands the indication for the procedure. If the patient is pregnant then ideally de-infibulation should be performed in the 2^nd trimester but can be done intra-partum as well. The patient should be made aware that re-infibulation will not be performed later on.

In most cases, de-infibulation can be performed under local anesthesia but for some women psychological distress may warrant general anesthesia. Infiltrate the infibulation scar tissue using 1% xylocaine at the midline of the vaginal introitus. An in-dwelling catheter can be inserted to help delineate the external urethral meatus if the infibulation extends adjacent to it. Gently insert two fingers or surgical forceps past the introitus behind the scar tissue to avoid inadvertent tissue damage. Then, using either a scalpel or scissors, incise the infibulation scar tissue to allow visualization of the external urethral meatus. It is important to avoid the buried clitoris or clitoral stump as this can cause significant bleeding. Finally, using 3-0 vicryl rapide apply a hemostatic running suture to oversew the raw vulval edges bilaterally (NZ FGM Education Programme, 2009).

FGM is a multi-faceted, socially taboo topic with a range of complications. If addressed with understanding, in a culturally appropriate and timely manner, then the complications can be suitably managed and steps taken towards abandoning the practice.

REFERENCES

World Health Organization: Office of the High Commissioner For Human Rights, Joint United Nations Programme on HIV/AIDS, United Nations Development Pro- gramme, et al. 2008. Eliminating female genital mutilation: an interagency statement. Geneva. Website: https://apps.who.int/iris/bitstream/handle/10665/43839/9789241596442_eng.pdf;jsessionid=D71499CA7DEA3497540BAC214EDD2CF3?sequence=1

Female genital mutilation clinical care. Deinfibulation guidelines (2009). FGM Education Programme for the New Zealand Ministry of Health. Website: https://fgm.co.nz/wp-content/uploads/2019/10/fgm-deinfibulation-guidelines-2009.pdf