Female Genital Mutilation Flashcards
Define
Any procedure involving partial or total removal of external genitalia and/or injury to the female genital organs, whether for cultural, religious or other non-therapeutic reasons.
4 main types:
o Type 1 – clitoridectomy – removing part or all of the clitoris
o Type 2 – excision – removing part or all of the clitoris, labia minora ± labia majora
o Type 3 – infibulation – narrowing vaginal opening by creating a seal by cutting and repositioning the labia
o Other harmful procedures to genitals including pricking, piercing, cutting, scraping, burning
IMPORTANT: It is ILLEGAL for FGM to be carried out in the UK. There is a LEGAL obligation to document ALL cases in the medical notes and REPORT ALL cases through the safeguarding team in NHS Trusts to reduce the incidence of this practice in young girls and women in the UK. It is considered child sexual abuse.
It is a GMC Requirement for doctors to inform ALL cases in girls < 18 years to the Police.
Epidemiology
Epidemiology
Occurs in Africa, in particular:
- Somalia
- Egypt
- Sudan
- Ethiopia
- Middle East
- Asia
Occurs in young girls’ infancy – age 15, commonly before puberty
o 2% women in London
o Over 100 000 women and girls in England and wales
Symptoms and Signs
Presenting Symptoms
This has physical, psychological and psychosexual implications
- Menorrhagia
- Dysuria
- Constant pain
- Dyspareunia
- Repeated infections which can lead to infertility
- Reduced libido, reduced frequency of orgasms, aorgasmia, reduced lubrication
- Poorer sexual satisfaction
- Bleeding
- Cysts and abscesses
- Urinary incontinence
- Urinary retention
- Depression, flashbacks, self harm
Signs O/E
- Self-harm
- Vulvovaginal lacerations from sexual intercourse
- Genital scarring
- NOTE: never do speculum, bimanual, or vaginal USS
Investigation
Should include inspection of the vulva to determine type of FGM and whether de-infibulation is indicated
Identify any other FGM comorbidities
Note: Type 3 may preclude from vaginal examination for cervical smears and genital infection screens
Management
De-infibulation
- Surgery to open up the vagina
- The incision should be made along the vulval incision scar and the urethra identified before surgery commences to reduce damage
- This is performed under LA- adequate analgesia should be used
- Should be urinary infection screened prior to surgery and consider prophylactic antibiotics
- Women should be identified and referred to specialist gynaecology/ FGM clinic
Offered to those unable to have sex comfortably, pass urine, or pregnant women at risk during delivery
Obstetric care
- All women at booking should be asked for a history of FGM
- Should be assigned to a designated obstetrician ideally someone who specialises in caring for women with FGM
- De-infibulation can occur antenatally. It may need to occur intrapartum
- If de-infibulation was not carried out antenatally/ intrapartum (i.e. due to C-section), then this should be offered postnatally
- It is illegal in the UK to close back (reinfibulate) the area after childbirth.
o If <18yo à record in notes (name, DoB, address), report to police and social services
o If >18yo à record in notes, no obligatory duty to report though à may offer deinfibulation
Reporting to police and/or social services
- Children < 18 years- ALL suspected/ at risk or confirmed cases must be reported
- There is NO requirement to report in non-pregnant women with FGM unless a related child is at risk
- Pregnant women must undergo a safeguarding risk assessment, and if the unborn child or any other child in the family is at risk- report to social services or the police
- Document maternal history of FGM in ‘Red book’
- If delivery of a baby girl, notify the designated child protection midwife
Complications
Immediate complications
- Haemorrhage
- Urinary retention
- Genital swelling
Long term complications
- Renal failure from urinary obstruction and infection
- Labour may be obstructed in a Type 3 and a midline episiotomy may be needed for safe delivery
- Genital scarring
- Keyloid scarring
- Epidermoid inclusion cysts
- Sebaceous cysts
- Urinary tract complications
- LUTS occur more in Type 2 or Type 3 FGM
- Poor urinary flow beneath the infibulation scar may result in symptoms of urinary obstruction and stasis of urine may result in recurrent UTIs or urinary/ vaginal calcui
- Urethral damage can lead to strictures or fistulae
- Dyspareunia
- Due to vaginal narrowing and painful scar tissue
- Apareunia and vulvovaginal lacerations during sexual intercourse can occur
- Removal of sexually sensitive tissue may reduce sexual sensation
- Scarring over the clitoris may be painful
- Psychological
- Flashbacks and PTSD
- Domestic violence
- Menstrual difficulties
- Haematocolpos
- Dysmenorrhoea
- Genital tract and PID
- Increased risk of bacterial vaginosis and HSV2
- Infertility
- HIV and Hepatitis B infection
- Risk of obstetric complications is much higher with greater tissue damage
- Higher incidence of stillbirth and neonatal death
PACES
If you are worried that you may be pressured by your family or community to have FGM, or if you
are concerned about any girl who may be at risk of FGM, tell a healthcare professional or contact
the National Society for the Prevention of Cruelty to Children (NSPCC) helpline or childline
