Female Genital Mutilation

Question 1

What is the definition of FGM?

Answer 1

• All procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons
• Mutilation is the removal of healthy tissue

Question 2

What are the 4 formal types of FGM procedures?

Answer 2

• Type 1 Clitoroidectomy: Excision of the clitoris prepuce (“Sunna-circumcision”) and of the clitoris or parts thereof - remove pleasure for the woman
• Type 2 Excision: of the clitoris prepuce, the clitoris and the inner lips or parts thereof
  
  • Partial or total removal of the clitoris and labia minora, with or without excision of the labia majora
• Type 3 Infibulation: Narrowing of the vaginal opening through the creation of a covering seal.
  
  • The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris. (“infibulation”, also referred to as “Pharaonic Circumcision”).
  • Excision of part of or all of the external genitals, The remaining parts of the outer lips are sewn together leaving a small hole for urine and menstrual flow.
  • The scar needs to be opened before intercourse or giving birth, which causes additional pain.
• Type 4 - All other harmful procedures to the female genitalia for non-medical purposes, for example pricking, piercing, incising, scraping and cauterising the genital area (Fig 1).

It is important to realise that wounds from small cuts and pricks will heal with minimal scarring and may be difficult to detect later.

Question 3

What are the immediate and short term complications of FGM?

Answer 3

• Haemorrhage
• Pain
• Injury to adjacent tissues
• Fractures from being held down
• Urinary retention
• Wound infection (herbs, ash added to the wound), Sepsis
• Tetanus
• Gangrene
• HIV / Hep (non-sterile instruments)
• Death

Question 4

What are the long term effects of FGM?

Answer 4

• Recurrent UTI
• Painful menstruation: de to a small vaginal orifice
• Keloid scarring and cysts
• Sexual difficulties
• Infertility (ascending infections, smears, difficulty with penetration)
• Complications in pregnancy*
• Psychological

Question 5

What are the psychological effects of FGM?

Answer 5

• Feelings of anxiety
• Fear
• Betrayal
• Loss of trust
• Feelings of incompleteness
• Loss of self-esteem, including difficulty with body image
• Panic disorder or post-traumatic stress disorder (PTSD)

Question 6

What are the complications in pregnancy/ delivery in women who have had FGM?

Answer 6

• Carrying out vaginal examinations
• Induction of labour IOL with prostaglandins
• Evacuation of uterus in miscarriage/RPOC,
• Interventions in labour - FSE/FBS, identifying cord prolapse
  
  • difficulty to get probes and monitoring devices in
• Prolonged labour
• Increase risk of severe tears and haemorrhage
• Increased risk of caesarean section – particularly if not disclosed prior to birth, no plan for management

Question 7

What is the management of FGM for children under 18?

Answer 7

• Ring police (101) - mandatory reporting
• contact child protective services/ safeguarding lead
• referral to social services if there is a suspicion that the child might be genitally mutilated

Question 8

What is the management of those who’ve had FGM - non-pregnant women?

Answer 8

• Identify the type of FGM
  
  • is de-infibulation indicated
  • are there associated cysts etc
• Referal to:
  
  • Women: FGM service (psychosexual, urogynae, infertility)
  • Offer psychological services
  • Testing HIV, Hep B+C, Sexual health screen
  • Consider any children at risk

Question 9

How is a de-infibulation procedure carried out?

Answer 9

• carried out and general or local anaesthetic
  
  • local anaesthetic should be just underneath the skin and not around any other surrounding structures
  • an anaesthetic with adrenalin cane help reduce haemorrhaging
• the incision is made in the midline of the scar
• the cut edges should be sutured with absorbable sutures to keep the reopened flap in place and to help reduce bleeding
• can be done gynaecological and can be done at the time of delivery if they want a vaginal delivery

Question 10

What is the management of women who have had FGM in pregnancy?

Answer 10

• Ask all women about FGM at booking irrespective of country of origin
  
  • Offer referral for psychological assessment if confirmed
  • All Trusts to have named lead obstetrician and midwife (safeguarding)
• Examine: Document the Type? Whether de-infibulation indicated and when it could be done
  
  • antenate/1st stage labour/ delivery / post CS
• Involve safeguarding / social services – think about risk to any female newborn
• manage labial teats as standard practice
• Re-infibulation is illegal