Female Genital Mutilation Flashcards
Definition of FGM
FGM refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.
FGM is practiced for a variety of complex reasons, usually in the belief that it is beneficial to the girl. FGM is a human rights violation and a form of child abuse. It is a severe form of violence against women and girls.
Prevalence of FGM worldwide and in the UK
- Worldwide over 125 million women and girls have undergone FGM (traditional cultural practice in 29 African countries (also occurs in Yemen, Iraq, parts of Indonesia, Malaysia)
- It has been estimated that 137000 women and girls in England and Wales have undergone FGM
Classification of FGM
- Type 1: Partial or total removal of the clitoris and/or prepuce (clitoridectomy)
- Type 2: Parial or total removal of the clitoris and the labia minora, with or without excision of the labia majora
- Type 3: Narrowing of the vaginal orifice with creation of a covering seal by cutting and apositioning the labia minora and/or labia majora, with or without excision of the clitoris
- Type 4: All other harmful procedures to the female genitalia for non-medical purposes
Short term complications of FGM
Haemorrhage (5-62%), urinary retention (8-53%) and genital swelling (2-27%) are common
Long term complcations of FGM
- Genital scarring- Keloid scarring has been reported in up to 3% of women (epidermoid inclusion cysts and sebaceous cysts may require surgical excision and drainage)
- Urinary tract complications- lower UTIs are more common in FGM (particularly types 2 or 3)- may result in obstruction, stasis and infection
- Dyspareunia, apareunia and impaired sexual function
- Psychological effects- PTSD, anxiety
- Menstrual difficulties- dysmenorrhoea has been reported though the underlying mechanisms are unclear
- Genital infection and PID- increased risk of bacterial vaginosis and HSV2
- Obstetric complications (no good studies)
Law on FGM (Female Genital Mutilation Act 2003)
- FMG is illegal unless it’s a surgical operation on a girl or woman irrespective of her age: Which is necessary for her physical or mental health OR She is any stage of labour, or has just given birth, for purposes connected with labour or birth
- It is illegal to arrange, or insist on arranging for a UK national or resident to be taken overseas for the purposes of FGM
- It is an offence for those with parental responsibility to fail to protect a girl from FGM
- If FGM is confirmed in a girl under 18 years of age (either on examination or because the patient or parent says it has been done), reporting to the police is mandatory and this must be within 1 month of confirmation.
- Female genital cosmetic surgery (FGCS) may be prohibited unless it is necessary for the patient’s physical or mental health. All surgeons who undertake FGCS must take appropriate measures to ensure compliance with the FGM Acts.
- Re-infibulation (resuturing of the incised scar in any woman with FGM type 2 or 3) is illegal; there is no clinical justification for re-infibulation and it should not be undertaken under any circumstances.
What is re-infibulation
Resuturing of the incised scar in any woman with FGM type 2 or 3
When should investigation for FGM be considered
o Pregnant women with FGM with a possible female child
o Siblings or daughters of women or girls affected by FGM
o Extended trips with infants or children to areas where FGM is practised
o Women that decline examination or cervical screening
o New patients from communities that practise FGM
General management of FGM (counselling, reporting etc.)
- Need to explain the UK law on FGM to patients
- Need to record any incidence of FGM according to the HSCIC FGM enhanced dataset (demographic, clinical and family information for all women with FGM and for these data to be submitted, without anonymisation, to the HSCIC. This should be explained to the woman)
Genital piercings should be included as type 4 FGM
Reporting means making a referral to the police or social services:
* FGM is child abuse and any child with confirmed or suspected FGM, or a child considered to be at risk of FGM, must be reported, if necessary without the consent of the parent
* There is no requirement to report a nonpregnant adult woman aged 18 or over to the police unless a related child is at risk
* It is alo not necessary to report every pregnant women with FGM to the police (needs risk assessment): If the unborn child, or any related child, is considered to be at risk of FGM, then a report must be made to children’s social care or the police
Gynaecological management of FGM
- Gynaecologists should ask all women from communities that traditionally practise FGM whether they have had the procedure.
- All women should be offered referral for psychological assessment and treatment, testing for HIV, hepatitis B and C and sexual health screening. Where appropriate, women should be referred to gynaecological subspecialties, e.g. psychosexual services, urogynaecology, infertility.
- Gynaecologists should be aware that narrowing of the vagina due to type 3 FGM can preclude vaginal examination for cervical smears and genital infection screens. De-infibulation may be required prior to gynaecological procedures such as surgical management of miscarriage (SMM) or termination of pregnancy (TOP).
- Women who are likely to benefit from de-infibulation should be counselled and offered the procedure before pregnancy, ideally before first sexual intercourse
- Clitoral reconstruction should not be offered due to current complication rates
Antenatal care of women with FGM
- All women, irrespective of country of origin, should be asked for a history of FGM at their booking antenatal visit so that FGM can be identified early in the pregnancy
- Referral for psychological assessment and treatment should be offered
- The vulva should be inspected to determine the type of FGM and whether de-infibulation is indicated.
- If the introitus is sufficiently open to permit vaginal examination and if the urethral meatus is visible, then de-infibulation is unlikely to be necessary
- De-infibulation may be performed antenatally (typically at around 20 weeks), in the first stage of labour or at the time of delivery and can usually be performed under local anaesthetic in a delivery suite room
- Women should be informed that re-infibulation will not be undertaken under any circumstances
Intrapartum management of FGM
- If de-infibulation planned for the time of delivery is not undertaken because of recourse to caesarean section, then the option of perioperative de-infibulation (i.e. just after caesarean section) should be considered and discussed with the woman
- Labial tears in women with FGM should be managed in the same manner as in women without FGM.
