Female Genital Cutting (FGC)

OVERVIEW

Prevalence: Affects an estimated 168,000 women in the United States, and more than 96% of women in some African countries (for example, Somalia).

Definition: The partial or complete removal of the labia majora, labia minora, and/or clitoris. Female genital cutting (the removal of female genital tissue) is most often performed for religious or cultural reasons, typically without anesthesia and under non-sterile conditions.

The resulting scarring can make intercourse impossible. The location and amount of tissue removed determines the type of infibulation:

• Type I — Removal of all or part of the clitoris, along with the overlying skin
• Type II — Removal of the clitoris together with part or all of the labia majora
• Type III — Excision and stitching of all or part of the external genital structures (narrowing the vaginal opening — infibulation)
• Type IV — Removal of part of the clitoris and/or labial tissue, with cauterization and closure of the remaining tissue and surrounding area

Other procedures performed on the external genitalia include:

Cutting and removing tissue around the vaginal opening in sections (angurya cuts), or making a surgical incision into the vagina (gishiri cutting). Placing corrosive substances or certain plants/herbs into the vaginal opening to cause tissue tightening or bleeding. Any other procedure that could be used for the purposes described above.

Most Common Age: A large proportion occurs during early girlhood (about 48,000 are under 18 years old).

Genetics: There is no genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: An elective practice performed for traditional or religious reasons, generally on young girls without their consent and often without informed agreement.

Risk Factors: Most prevalent in certain African countries and in parts of the Middle East and Asia.

CLINICAL FEATURES

Findings and Symptoms: Prominent scarring and deformity of the external genital structures, frequently with complete obstruction of the vaginal opening (which can vary depending on the technique used and the extent of tissue removed).

• Obstruction may cause amenorrhea or dysmenorrhea
• Dyspareunia (painful intercourse)
• Orgasmic dysfunction
• Libido dysfunction

DIAGNOSTIC APPROACH

Differential Diagnosis:

• Childhood burns
• Intersex conditions
• Imperforate hymen

Associated Conditions: Dyspareunia, libido dysfunction, and orgasmic disorders.

Evaluation and Assessment

• Laboratory: No evaluation required.
• Imaging: No imaging required.
• Special Tests: None.

Diagnostic Procedures:

• Patient history and physical examination.
• Pathological findings.
• Deformed external genital tissue and gross scar formation, or absence of external genital organs.

MANAGEMENT AND TREATMENT

Non-Pharmacological

• General Measures: Assessment, support, and culturally sensitive counseling.
• Specific Measures: Surgical release of scarring or adhesions in the genital tissue may be needed for sexual function or menstrual hygiene.
• An anterior episiotomy, with or without repair, may be required during childbirth.
• Diet: No special dietary adjustment needed.
• Activity: No restriction needed.

Medication: None.

FOLLOW-UP

Patient Monitoring: Routine health check-ups are recommended (cervical sampling for cytological evaluation may be difficult due to scarring; surgical revision may be needed).

Prevention: Families should be educated about the risks of performing this practice on young girls.

Regardless of the religious or cultural justification given, such practices have no basis in science and represent a serious assault on women's freedom and wellbeing.

Anyone who believes such practices are necessary, or who performs them, should — from a clinical standpoint — be regarded as requiring care themselves, rather than as acting within any legitimate professional standard.