FGM -Female Genital Mutilation

International Day of Zero Tolerance for Female Genital Mutilation Feb. 6

It is estimated that over 200 million women/girls have undergone female genital mutilation. The overwhelming majority are in African nations, particularly the region of Sudan, Djibouti, Egypt.

FGM has been banned by the three Abrahmaic faiths and by numerous forms of legistlation worldwide. Here I summarize the detrimental health effects of FGM, and the long term consequences.

Background:

FGM is the "cutting" or removal of all or part of the female clitoris. The clitoris is the main pathway and concentration point for nerves and erectile tissue. All types of FGM/C even minimal cutting or nicking or pricking of the clitoris, interrupts this natural pathway and leading to a difficulty in achieving orgasm, which is the peak of sexual pleasure. The clitoris is a natural “hood” above the urethral opening (the opening that releases urine) that protects this area from bacteria or other diseases and trauma during intercourse.

Its natural protective function is damaged in FGM/C/C of all types.

Medical Complications:

1. Sexual Complications:

   1. During sexual intercourse FGM/C leads to bleeding. This is because the area that has been cut is replaced by scar tissue that is thinner, weaker, and leads to weaker vessels that bleed and tear easily during or after intercourse.

   2. Painful intercourse (dyspareunia): The narrowing of the vulval opening by either reactive scarring from the cut or by the intentional narrowing performed in FGM/C, leads to difficulty in penetration and pain.

c. Vulvar pain: damage to the ends of the nerves present in the sensitive area of the clitoris/labia leads to hypersensitive nerve pathways and sharp pain, extending to other areas of the vulva.

d. Urinary incontinence: Pressure on the exposed urethral opening leads to inadvertent loss of urine during sexual relations, which can be distressing and embarrassing for the woman.

e. Husbands/ partners: the penis can often become injured due to the excessive scarring or narrow opening caused by FGM/C, up to 15% of males complain of erectile dysfunction and other sexual disorders.

f. The lack of sexual pleasure can cause anxiety between couples since the woman will often avoid sexual intercourse for fear of pain and bleeding, and men may avoid it for fear of causing her discomfort, or for fear of his own discomfort. There is an increased rate of divorce in couples where women have undergone FGM/C, with sexual displeasure cited as a common factor.

2. Repeated Urinary Infections and Menstrual Difficulties: 

a. Retention of urine: nearly 30% of women who have undergone FGM/C complain of urinary difficulties. For some, urination takes almost 15 minutes to complete because of the scarring. For fear of pain some women will try to retain the urine, which can lead to urinary retention.

b. Repeated infections and scarring at the urethral meatus also lead to urinary retention, and even renal failure.

c. Urinary fistulas: One of the worst urinary complications of FGM/C happens during pregnancy, when the head of the baby puts pressure on the wall of the lower pelvic outlet, that pressure leads to the wall falling apart since its nerves and vascularity have been destroyed in FGM/C, and leads to a vesicovaginal fistula. It is basically an opening between the vagina and urinary bladder. This fistula is one of the worst things a woman can live with as the urine continuously falls through the vagina without end.

d. Menstruation is debilitating for these women, as the muscles are weakened, the blood causes pressure on the scarred tissue, and the disrupted flow leads to gathering of the blood in the pelvis. This is painful and difficult for them to function normally. Extended periods can keep her from prayer for a longer time

3. Keloids and Scars and Genital Infection.

All types of FGM/C interrupt the natural skin barrier. The body responds by making scar tissue that is weaker, thinner, has easily broken blood vessels.

a. STD’s: Women who have undergone FGM/C have higher rates of catching sexually transmitted infections including Trichomonas, Herpes, Syphillis, etc. Blood transmitted diseases such as Hepatitis C and HIV are also easily transmitted into the weakened and broken blood vessels. This is traumatic in the cases of sexual assault, and in cases where the partner has been unfaithful.  

b. Cancer Cervix: HPV is particularly dangerous because it is a sexually transmitted disease that leads to Cancer Cervix. Women who are victims of FGM/C have higher rates of Cancer Cervix.

c . Infertility: Repeated genital infections by bacteria can lead to Pelvic Inflammatory Disease, which can lead to infertility.

d. Skin cysts and keloids: exaggerated scarring response is common in women of African background. When this scarring occurs in the genital area it leads to large disfiguring and ugly scars.  Cysts made of degenerated skin layers get infected and cause abscesses.

4.    Difficulty of Preventive Care

The key prevention of cancer cervix is early detection by pap smears and molecular testing of samples, with or without biopsies, to treat the pre-invasive stage. Lack of screening for cancer cervix and other diseases: women who have undergone FGM/C are more hesitant to be assessed gynecologically, for fear of of pain.  The colposcopic examination is also challenging in FGM/C victims because of the narrowing of the vagina. Pre-invasive lesions are missed, and instead, victims of FGM/C present at later stages of Cancer Cervix. These are often complicated by other infections or conditions that are also missed without a thorough examination.

5. Birth Trauma and Harm to the Baby and Mother

When the cut of FGM/C is made, the body tries to heal by scarring and creating new smaller vessels. This scarring is thinner and weaker than the normal skin and connective tissue.

a. “Elasticity” or the capacity of the birthing canal to expand and allow the release of the baby is also destroyed by FGM/C.

b. Blood loss: Tearing of this area during childbirth leads to excessive blood loss.

c. Perineal tears: Up to 65% have extensive perineal tears due to the scarring. These tears can take months to heal.

d. Obstruction of Labour: The baby cannot get through the birth canal, leading to still birth, distressed or asphyxiated babies, and harm to the mother due to prolonged labor.

6. Psychological Trauma

Having their genitalia cut as children or young women leads to lifelong psychological effects. The extensive scarring and disfigurement is also a source of constant stress and a reminder of the trauma. The lack of sexual pleasure causes self esteem, guilt, and emotional distress. Did you know that up to 80% of women who are victims of FGM/C have anxiety disorders and up to 30% have post- traumatic stress disorder?

7. Death

Many girls bleed to death when they are cut.

Other women bleed to death during childbirth.

Some women fight infections all their life, and succumb to septicemia, which they die from, or complications of renal failure due to obstruction.

Female Cutting Versus Male Circumcision

There is a gross misunderstanding in that male circumcision is similar to female genital mutilation. I hope that this table will clarify the main differences.

Male Circumcision	Female Genital Cutting or Genital Mutilation
recommended in some religions	Not recommended in ANY religion
Excess skin removed	Organ removed or damaged
Most sensitive area responsible for sexual pleasure remains as is (dorsum of penis)	Most sensitive area responsible for sexual pleasure REMOVED or DAMAGED (clitoris/hood/labia).
Decreased rates of infections and transmission of STDs	Increased rates of infections and transmission of STDs
Decreased lifelong risk of penile cancer	Increased lifelong risk of Cervical Cancer

Seeking Treatment:

For women who have undergone FGM/C treatment defibulation can be a relief. The scars are removed, and the labia is reconstructed.  This leaves the vulva open permitting a free flow of urine and menstrual blood and allows for a more comfortable sexual intercourse. Pelvic Floor exercises and physiotherapy can help return the muscles and anatomy to normal function.  Almost all women who undergo defibulation describe relief of urinary and sexual functions and can even experience orgasm.

Pediatric surgeons and obstetric uro-gynecologists can provide this treatment.

Seeking psychological help to resolve issues of PTSD, anxiety and to help navigate the healing process is available. Couples therapy for spouses can provide support and healing.

The earlier treatment is sought the better the outcome with regards to marital relationships, childbirth, and urinary function.

A Few Last Words:

…If you are a woman who was a victim of FGM/C, you can get treatment and support your sisters to seek treatment, and you can stand up against FGM/C for your daughters. You do not have to stay the way you are, or accept the cultural norms that destroy not build.

…If you are a man, your role is valuable. Many women agree to FGM/C because you ask them to. You will be happier, and your marriage relationship and sexual relationship improved.  Stand up against this harmful practice and protect your daughters and future wife from FGM/C. Encourage the women in your family to seek treatment.

We can all work as a community to protect our young girls from this vicious practice, and help our community heal.

I wish - A Poem About FGM, For The Girl Generation By Sahra Ahmed Koshin, Garowe, Puntland, Somalia.

“I wish to overcome.This emptiness of fear.

The incompleteness of life.

The lingering search for my innocence.

The memories of the painful cut.

The fierce grip and my tremble under your gaze.

The masking of my face and my soul.

The mishandling of my body.

The pains never expressed and the scars forever inflicted.

I wish to overcome this feeling of brokenness, of incompleteness...”

"I want to tell the parent that mutilation is very harmful to your daughter, you didn’t protect her by it  [instead] you destroyed her marriage relationship" Victim of FGM, Cairo, Egypt

Thank you,

Dr. Hoda Amer, MD, FCAP

Previous Project Leader, Muslims Against FGM/C, an initiative by MyProject USA

Treasurer, American Board Certified Doctors for Egypt

Sign the Petition Against FGM Here

References and Useful Resources:

1.       Vella, M. & Argo, Antonina & Costanzo, Angela & Tarantino, Lucia & Milone, Livio & Pavone, Carlo. (2015). Female genital mutilations: genito-urinary complications and ethical-legal aspects. Urologia. 10.5301/uro.5000115. Link here.

2.       Behrendt A, Moritz S. Posttraumatic stress disorder and memory problems after female genital mutilation. Am J Psychiatry. 2005;162(5):1000-1002. doi:10.1176/appi.ajp.162.5.1000.

3.       A.R. Sharfi, M.A. Elmegboul, A.A. Abdella. The continuing challenge of female genital mutilation in Sudan. African Journal of Urology, Volume 19, Issue 3, 2013, Pages 136-140,ISSN 1110-5704, https://doi.org/10.1016/j.afju.2013.06.002.

4.       Khayat MH. Health as a Human Right in Islam. WHO Regional Office for Eastern Mediterranean. Cairo, Egypt. 2004. https://applications.emro.who.int/dsaf/dsa217.pdf

5.       Varol N, Turkmani S, Black K, Hall J, Dawson A. The role of men in abandonment of female genital mutilation: a systematic review. BMC Public Health. 2015;15:1034. Published 2015 Oct 8. doi:10.1186/s12889-015-2373-2

6.       Esho, T., Kimani, S., Nyamongo, I. et al. The ‘heat’ goes away: sexual disorders of married women with female genital mutilation/cutting in Kenya. Reprod Health 14, 164 (2017). https://doi.org/10.1186/s12978-017-0433-z 

7.       Osterman, A.L., Winer, R.L., Gottlieb, G.S., Sy, M.‐P., Ba, S., Dembele, B., Toure, P., Dem, A., Seydi, M., Sall, F., Sow, P.S., Kiviat, N.B. and Hawes, S.E. (2019), Female genital mutilation and noninvasive cervical abnormalities and invasive cervical cancer in Senegal, West Africa: A retrospective study. Int. J. Cancer, 144: 1302-1312. doi:10.1002/ijc.31829

8.       Ogah J, Kolawole O, Awelimobor D. High risk human papilloma virus (HPV) common among a cohort of women with female genital mutilation. Afr Health Sci. 2019;19(4):2985-2992. doi:10.4314/ahs.v19i4.19

9.       Sara Johnsdotter, Birgitta Essén. Cultural change after migration: Circumcision of girls in Western migrant communities. Best Practice & Research Clinical Obstetrics & Gynaecology,Volume 32, 2016, Pages 15-25, ISSN 1521-6934, https://doi.org/10.1016/j.bpobgyn.2015.10.012