Categories, Description and Complications of FGM

Categories

The World Health Organization (WHO, 1997) defined female genital mutilation (FGM) as all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons. Note that the male equivalent, of even the least severe form of female genital cutting, would be complete amputation of the entire head of the penis. The World Health Organization has classified FGM into four types:

Type I: Excision of the prepuce (less common), with or without excision of part or all of the clitoris (more common).

Type II: Excision of the clitoris with partial or total excision of the labia minora (clitoridectomy).

Type III: Excision of part or all of external genitalia and stitching/narrowing of the vaginal opening (infibulation).

Type IV: Unclassified: includes pricking, piercing or incising of clitoris and/or labia; stretching of clitoris and/or labia, and cauterization by burning of clitoris and surrounding tissue.

Description

Female Genital Mutilation (FGM) has been practiced for several thousand years in almost 30 African and Middle Eastern nations and, to a lesser extent, in parts of Asia.

FGM varies in degree, ranging from cuts around the clitoris (rare), to (more commonly) the entire removal of the clitoris, the removal of the clitoris and labia minora, or the removal of the clitoris and entire labias, with the resulting wound stitched shut. In this last form, infibulation, the opening left is generally no larger than a match head, leaving an insufficient opening for the passage of urine and menses. FGM is often performed in unsterile surroundings with the girl forcibly restrained and cut with rudimentary instruments (razor blade, knife, glass, etc); it is sometimes performed in a medicalized setting.

The age at which a girl is subjected to FGM ranges from seven days old to young adulthood. It is most commonly performed between 2 and 15 years of age. Note that clitoridectomy was practiced as treatment for psychological disorders, mental illness and hysteria in the United States and Europe as late as the 1950's. It has increasingly become prevalent in western countries, especially, for example, in the U.K., where it takes the form of extreme rituals performed on members of populations not previously subjected to it, and as traditional rites imposed by immigrants on immigrant females from practicing cultures.

Complications

Immediate Complications

Agonizing pain due to lack of anesthesia;

Hemorrhage: Amputation of the clitoris involves cutting across the clitoral artery, which has a strong flow and high pressure. Cutting across the internal pudendal artery can cause serious bleeding. Hemorrhage may also occur after the first week as a result of sloughing of the clot over the artery, usually because of infection. If bleeding is very severe and uncontrolled, it can result in death;

Shock because of the sudden blood loss and/or the unexpected and agonizing pain;

Tetanus can occur due to the use of not sterilized equipment and lack of tetanus toxo´d injection;

Trauma to the adjacent structures (urethra, bladder, anal sphincter, vaginal walls and Bartholin's gland);

Acute urinary retention occurs nearly always because of 1) the pain and burning sensation of urine on the raw wound; 2) damage to the urethra and its surrounding tissue; 3) labial adhesion or nearly complete closure of the vaginal orifice, as in infibulation;

Wound infection and urinary infection due to urine retention, the use of non-sterilized equipment and the application of local dressings of animal feces and ashes. The infecting organisms may ascend through the short urethra into the bladder, and the kidneys;

Fever and septicemia;

Group circumcisions using unclean cutting instruments are common, and can spread HIV infection;

Fractures of the clavicle, femur, or humerus due to strong pressure applied to the struggling girl;

Eventually death can occur due to hemorrhagic or septic shock, tetanus and lack of availability of medical services or delay in seeking help.

Intermediate Complications

Delay in wound healing due to infection, malnutrition and anemia;

Anemia due to profuse bleeding;

Pelvic infection: infection of uterus and vagina ascending from the genital wound and necrotising fasciitis;

Irregular bleeding and vaginal discharge;

Dysmenorrhoa due to pelvic infection, or due to the obstruction of the vaginal orifice (as in infibulation);

Vulvar dermoid cysts and abscesses are a frequent complication;

Formation of a keloid scar because of slow and incomplete healing of the wound, and infection after the operation leading to production of excessive connective tissue in the scar;

Dyspareunia due to the tight vaginal opening, to pelvic infection or to vaginismus;

In case of infibulation, it may be necessary to cut the bridge of skin created by the labia majora before coitus. In one study surgery was needed in 23 percent before penetration could occur.

Late Complications

Haematocolpos is estimated at 2 - 3.5 percent in Sudan and Somalia (Dirie MA, Lindmark G, 1992), due to closure of the vaginal opening by the scar tissue. The menstrual blood accumulates over many months in the vagina and uterus. It appears as a bluish, bulging membrane on vaginal examination;

Infertility because of chronic pelvic infection blocking both Fallopian tubes -undiagnosed and untreated until it is too late. Recurrent infections can also cause miscarriages;

Recurrent or chronic urinary tract infections due to stasis of urine in the bladder and behind scar tissue;

Difficulty in urinating because of damaged urethral opening or scarring over the urethral opening, or inability to completely evacuate the bladder when urinating;

Calculus/stone formation in bladder and in vagina because of stasis of urine and urinary infection;

Urinary incontinence as a complication of an over-distended bladder and recurrent urinary infections. Vesico-vaginal fistula result in a distressing condition of urinary incontinence, for which women are often ostracized from their community;

Anal incontinence and anal fissure due to rectal intercourse when vaginal intercourse is not possible;

Transmission of HIV because of bleeding during unprotected intercourse and because of anal intercourse.

Obstetrical Complications

Prolongation of the second stage of labor because of scar or soft tissue dystocia;

Perineal lacerations because of loss of natural compliance of the tissues;

Haemorrhage, leading to shock and death because of tearing of the scar tissue;

Vesico-vaginal or recto-vaginal fistula: obstructed labor can cause necrosis of the vaginal wall, due to constant pressure of baby's head on posterior wall of the urinary bladder and anterior wall of the rectum;

Difficulty in performing a good pelvic examination in infibulated women, resulting in the inability to effectively monitor the progress of labor;

Repetition of deinfibulation and reinfibulation: leaves extensive scarring which is often unstable;

Unnecessary caesarean sections where doctors are not familiar with FGM. Resort to caesarean section for fear of handling the infibulation scar adds the risks of general anaesthesia and major surgery.

Prolonged, obstructed labor and lack of oxygen during the second phase of labor can result in stillbirths or children with cerebral palsy;

Increased risk of HIV transmission in infibulated women: Excessive blood loss at delivery in infibulated women might expose the child (and staff) to HIV infections.

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