This is by a Muslim doctor a graduate from harvard!
Female circumcision and genital cutting
Nawal M Nour, MD, MPH
UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.1 is current through December 2006; this topic was last changed on June*30,*2006. The next version of UpToDate (15.2) will be released in June 2007.
INTRODUCTION — Female genital cutting (FGC), also known as female circumcision or genital mutilation, is a culturally determined practice, predominantly performed in parts of Africa and Asia and affecting more than 130 million women and girls worldwide [1]. Recent immigration patterns have caused obstetricians and gynecologists throughout the world to increasingly encounter women who have experienced this practice. It is imperative that these providers understand the health and social issues related to FGC so that they can manage the immediate and long-term complications of the procedure.
TYPES — FGC refers to the manipulation or removal of external genital organs in girls and women. The World Health Organization classified FGC into four types of procedures. Type I consists of excision of the prepuce, with or without excision of part of all of the clitoris. Type II involves clitoridectomy and partial or total excision of the labia minora. Type III, or infibulation, includes removing part or all of the external genitalia and reapproximation of the remnant labia majora, leaving a small neointroitus. Type IV involves other forms of injuries to the genital region including pricking, piercing, stretching, burning, scraping or any other manipulation of external genitalia [1,2].
ORIGINS AND RATIONALE — The origins of FGC are unknown, but theories as to its origins date back to ancient Egypt, pre-Islamic Arabia, ancient Rome, and Tsarist Russia [3-5]. More recently, this practice has come to represent an important rite of passage for girls into womanhood within some cultures. It is thought by some to be a religious custom, but no religion condones it. It is reinforced by customary beliefs that it maintains a girl's chastity, preserves fertility, ensures marriageability, improves hygiene, and enhances sexual pleasure for men.
In Europe and the United States, removal of the clitoris or prepuce was occasionally performed to treat clitoral enlargement, redundancy, hysteria, lesbianism, and erotomania up until the 1930s [6].
Most of the time, circumcision is done out of love. Parents initiate this procedure for their daughters, not to them. Being a wife and a mother is a woman's livelihood in these societies; thus not circumcising one's daughter is equivalent to condemning her to a life of isolation. Infibulation safeguards her virginity, preserves her chastity, and ensures her eligibility for marriage, thereby protecting her future.
Many women who have undergone FGC do not consider themselves to be mutilated. They do not believe that they are being selectively tortured because the majority of women in their community have gone through this ritual. Those who immigrate to the United States from refugee camps may be surprised to learn that most women here are not circumcised. Therefore, these women can be offended if they are referred to as having undergone genital mutilation. Instead, it is better to use the term circumcision, genital cutting, or the exact word they use in their language. Women who have undergone FGC have voiced concern that health care providers are not sensitive when broaching this subject and sometimes must be educated about this practice by the patient herself.
PROCEDURE — Circumcision is performed between the ages of 5 and 12, in some places during a celebration in which the girl receives gifts of money, gold, and clothes. Invited families and friends often bring food and music to the festivities. In other regions, however, girls are abducted in the middle of the night to be circumcised.
Nonmedically trained operators usually perform FGC. Anesthesia and antibiotics are rarely administered. The instruments used are old, rusty knives, razors, scissors, or heated pebbles, which are rarely washed between procedures. Hemostasis is assured by catgut sutures, thorns, or homemade adhesive concoctions such as sugar, egg, or animal excrement. The girl's legs are bound around the ankles and thighs for approximately one week after the procedure, and she is kept in bed. However, the circumcision can be done under more sterile conditions and an anesthetic may be administered when performed in major cities.
COMPLICATIONS AND OUTCOME — There are both short and long-term complications related to this procedure. However, health care providers should be aware that circumcised women present with a variety of complaints and their circumcision is not necessarily the problem. It is also important to stress that not all women suffer complications.
Periprocedural complications — Surgical precision can be compromised by lack of anesthesia, the struggles of the child held forcibly in the lithotomy position, and the experience of the operator. Success is often dependent upon chance, rather than accuracy. Early post-procedure complications thus include hemorrhage, infection, oliguria, and sepsis (show table 1) [7].
Long-term gynecological issues — Women who have undergone type II or III FGC tend to suffer more long-term complications than those who have undergone type I or IV. The most common long-term complications are dysmenorrhea, dyspareunia, and chronic vaginal infections. Other complications are related to voiding (show table 2) [8]. Meatal obstructions and urinary strictures could develop if the urethral meatus was inadvertently injured. Affected women complain of straining, urinary retention, or a slow urinary stream. An infibulated scar can also result in the urine becoming stagnant, thereby facilitating the ascent of bacteria into the urethra. Infibulated women are thus at higher risk for meatitis, urinary stones, and chronic urinary tract infections [9,10]. Other complications from scarring include fibrosis, keloids, sebaceous cysts, vulvar abscesses, and partial or total fusion of the labia minora or majora. The latter complication can lead to hematometra or hematocolpos. In addition, a small neointroitus may cause vaginismus, chronic vaginal infection, and neuromas [11,12]. The infertility rate is higher in circumcised women compared to the general population (25 to 30 versus 8 to 14 percent) [13]. The frequency of infertility appears to correlate with the anatomical extent of FGC [14]. Introital and vaginal stenosis create a physical barrier; thus, couples may attempt coitus for months before completing penetration [15]. Failure to succeed and persistent dyspareunia can lead to apareunia [16]. Infertility may also be related to tubal damage from ascending infection related to the procedure. Sexual satisfaction has been difficult to ascertain because of the sensitive nature of the topic. One survey that interviewed circumcised women reported they were able to achieve orgasm [17]. However, a study of 1836 circumcised Nigerian women found that the procedure (type 1 and II) did not attenuate sexual feelings or frequency of intercourse and was associated with a higher prevalence of abnormal vaginal discharge and pelvic pain [18]. Another study also showed that those who had undergone type III infibulation were significantly affected in terms of sex drive, arousal and orgasm when compared with those who had undergone a type I procedure [19].
Obstetrical issues
**Monitoring labor — Progress of labor is typically monitored using serial cervical examinations. Performing a pelvic exam on an infibulated woman can be challenging. The narrow neointroitus can make a bimanual exam difficult, if not impossible. Obstetricians face the dilemma of either defibulating the woman early in labor or monitoring the labor via rectal exam. Neither of these is an optimum solution: early defibulation would require a very early epidural and irritation of the incision with every cervical assessment, while rectal examination of the cervix is uncomfortable and most obstetricians have no experience using this technique in labor. However, inaccurate cervical assessment is also problematic because latent phase of labor may be falsely diagnosed as active labor and lead to an unnecessary cesarean delivery. Other challenges include difficulties placing a fetal scalp electrode, intrauterine pressure catheter, or Foley catheter and performing fetal scalp pH.
The infibulated scar can prolong only the second stage of labor, probably because the scar may obstruct crowning and delivery [20]. A defibulation procedure during the second trimester is strongly recommended to prevent this problem [21].
**Pregnancy outcome — A WHO study group compared obstetrical outcomes of women with and without FGC (n=7171 no FGC, 6856 FGC 1, 7771 FGC II, 6595 FGC III) [22]. Women with FGC II and III, but not FGC I, were at significantly higher risk of cesarean delivery, postpartum hemorrhage, and extended maternal hospital stay, and their infants were at significantly higher risk of requiring resuscitation and of dying in the hospital than women without FGC. The risks were higher in women with FGC III than FGC II. Nulliparous and parous women with FGC I, II, and III had higher rates of episiotomy and perineal tears than women without FGC.
DEFIBULATION COUNSELING AND PROCEDURE — Women seek defibulation because they are pregnant or planning pregnancy, or because of apareunia/dyspareunia, dysmenorrhea, or difficulty urinating [23].
The optimum time to defibulate a woman is prior to coitus to prevent dyspareunia or prior to pregnancy to prevent obstetric complications. What is medically beneficial to the woman, however, may not necessarily be the best time for her. As discussed above, one of the reasons for female circumcision is to ensure virginity. Therefore, these women may prefer to marry and prove their virginal status prior to defibulation.
Defibulation can be performed during pregnancy. A woman may require multiple prenatal visits before she finally consents to the procedure [21]. Counseling her about the risks of delivery with an infibulated scar is critical; the risks (eg, bleeding, infection, scar formation, preterm labor) and benefits of defibulation must also be reviewed and she should be aware that her urinary stream will feel different (increased).
Surgery during the second trimester under regional anesthesia decreases both obstetrical and fetal risks. General anesthesia is an alternative, but local anesthesia is not a good choice because women sometimes develop flashbacks from their circumcision.
One series of 32 patients who underwent defibulation reported that all of the women and their husbands were satisfied with the results [23].
Technique — The infibulated scar is a flap obstructing the introitus and urethra that must be excised. The steps in the procedure are as follows [23]: Place regional or general analgesics and long-acting local anesthesia. Insert a Kelly clamp under the scar to delineate its length (show picture 1). Palpate anteriorly to assess whether the clitoris is buried under the scar). Place two Allis clamps along the infibulated scar Make an anterior incision between the two Allis clamps with Mayo scissors, being certain not to cut into a buried clitoris (show picture 2A-2B). The goal is to view the introitus and urethra easily (show picture 3). There is no need to incise too anteriorly towards the clitoral region. Place (4.0) subcuticular sutures on each side (show picture 4 and show picture 5).
Postoperatively, instruct the patient to take sitz baths twice each day. Lidocaine cream (2 percent) can be applied after the sitz bath. Opioid analgesics taken as needed for one or two days is usually adequate for postoperative pain control [24].
A treatment technique using carbon dioxide laser surgery has also been described [25].
REINFIBULATION — Some women who have just given birth will request immediate reinfibulation. The procedure may create the long-term complications previously mentioned and should be strongly discouraged. The woman may only feel comfortable being infibulated; her request should be respected. The United States passed a law in March 1997 that made performing any medically unnecessary surgery on the genitalia of a girl younger than 18 years of age a federal crime. However, reinfibulation was not included as a federal crime, so it may be performed with absorbable sutures in a running fashion if a woman strongly insists upon the procedure [26].
SUMMARY AND RECOMMENDATIONS There are four types of female genital cutting. (See "Types" above). The number of African immigrants and refugees coming into the United States is increasing, bringing renewed interest in unique cultural traditions [27]. The most important aspect of caring for circumcised women is to develop a trusting relationship. Obstetrician-gynecologists should move beyond the scar and address the woman's health needs, such as pregnancy tests, annual Papanicolaou smears, mammograms, and hormone replacement therapy recommendations. Cultural awareness and sensitivity regarding the procedure are crucial. (See "Origins and rationale" above). Potential problems after female genital cutting include dysmenorrhea, dyspareunia, chronic vaginal and bladder infections, voiding difficulties, fibrosis, keloids, sebaceous cysts, vulvar abscesses, infertility, and difficulty with pelvic examinations, coitus, and vaginal delivery. (See "Complications and outcome" above). We suggest defibulation prior to coitus to prevent dyspareunia or prior to pregnancy to prevent problems with vaginal delivery (Grade 2C). (See "Defibulation counseling and procedure" above).
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