Curbside Consultation

Female Genital Mutilation or Cutting

 

Am Fam Physician. 2018 Jan 1;97(1):49-52.

Case Scenario

A 25-year-old woman came to my office as a new patient. With the assistance of a phone interpreter, I learned that she and her four-year-old daughter recently arrived from Somalia, and she thinks she may be pregnant. During the encounter, I asked if she had undergone female genital mutilation or cutting (FGM/C). She did not understand the question at first, and the translator had to explain. Because the patient's answer was unclear, I did not press further. Her pregnancy test was positive. How could I have better formulated my question, and what do I say when she comes back for her first prenatal visit? How do I counsel her if she has undergone FGM/C, especially concerning how it may affect her delivery?

Commentary

FGM/C involves partial or total removal of the external genitalia or other injury to the female genital organs for nonmedical reasons. It is considered a human rights violation.1 It has no known health benefits, but many reported harmful consequences. According to the World Health Organization, more than 200 million women and girls around the world are affected by FGM/C.1 Each year, an estimated 3 million girls are at risk of undergoing FGM/C, generally before 15 years of age.1

FGM/C is practiced in about 30 countries, primarily in Africa, the Middle East, and Southeast Asia. It is a cultural practice strongly tied to ethnicity, and is performed for a variety of reasons, including to fulfill a rite of passage, confer a sense of ethnic identity, ensure social acceptance, safeguard virginity, and promote marriageability and fidelity, or beliefs about aesthetic ideals and cleanliness. Some groups believe that FGM/C is a religious requirement, but it is not mentioned in any major religious texts, including the Koran or the Bible.1 In some countries, the prevalence of FGM/C surpasses 80%.2

An estimated 513,000 women and girls have immigrated to the United States from FGM/C–practicing countries or have been born in the United States to mothers from these countries, which, according to the Centers for Disease Control and Prevention, puts many of them at risk of FGM/C and its consequences.3,4  Approximately 55% of these women and girls come from Egypt, Ethiopia, or Somalia (Table 1).4

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TABLE 1.

U.S. Women and Girls Potentially at Risk of Female Genital Mutilation or Cutting, 2013 Data

Countries of originEstimated number of U.S. women and girls at risk of FGM/C*

Egypt

109,205

Ethiopia

91,768

Somalia

75,537

Nigeria

40,932

Liberia

27,289

Sierra Leone

25,372

Sudan

20,455

Kenya

18,475

Eritrea

17,478

Guinea

10,302

Other countries of origin

69,981

All countries of origin

506,794


FGM/C = female genital mutilation or cutting.

*—Estimates are subject to both sampling and nonsampling error.

Adapted with permission from Mather M, Feldman-Jacobs C; Population Reference Bureau. Women and girls at risk of female genital mutilation/cutting in the United States. February 2016. http://www.prb.org/Publications/Articles/2015/us-fgmc.aspx. Accessed May 1, 2017.

TABLE 1.

U.S. Women and Girls Potentially at Risk of Female Genital Mutilation or Cutting, 2013 Data

Countries of originEstimated number of U.S. women and girls at risk of FGM/C*

Egypt

109,205

Ethiopia

91,768

Somalia

75,537

Nigeria

40,932

Liberia

27,289

Sierra Leone

25,372

Sudan

20,455

Kenya

18,475

Eritrea

17,478

Guinea

10,302

Other countries of origin

69,981

All countries of origin

506,794


FGM/C = female genital mutilation or cutting.

*—Estimates are subject to both sampling and nonsampling error.

Adapted with permission from Mather M, Feldman-Jacobs C; Population Reference Bureau. Women and girls at risk of female genital mutilation/cutting in the United States. February 2016. http://www.prb.org/Publications/Articles/2015/us-fgmc.aspx. Accessed May 1, 2017.

Although the distribution of women and girls affected by or at risk of FGM/C varies across the United States, certain urban areas (e.g., New York; Washington, DC; Minneapolis–St. Paul; Los Angeles; Seattle) have higher concentrations of women and girls living with or at risk of FGM/C.4

PATIENT EVALUATION

There are no studies evaluating the benefits of screening for FGM/C in women and girls from certain countries, nor are there currently any validated tools. Most experts recommend screening women from countries where the practice is prevalent to anticipate possible pregnancy-related issues, prepare for what might be encountered during pelvic examinations, and assess the risk of FGM/C in female offspring.58  Table 2 offers suggested screening questions for patients from these countries.

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TABLE 2.

Suggested Screening Questions and Language for Possible Female Genital Mutilation or Cutting

“Can you tell me what country you came from?”If the patient is from a country known to have FGM/C, proceed as follows:

“I have cared for women from your country and

Author disclosure: No relevant financial affiliations.

Address correspondence to Ranit Mishori, MD, MHS, FAAFP, at mishorir@georgetown.edu. Reprints are not available from the authors.

References

show all references

1. World Health Organization. WHO guidelines on the management of health complications from female genital mutilation. 2016. http://www.who.int/reproductivehealth/topics/fgm/management-health-complications-fgm/en/. Accessed April 13, 2017....

2. UNICEF data: monitoring the situation of children and women. https://data.unicef.org/topic/child-protection/female-genital-mutilation-and-cutting/. Accessed October 16, 2017.

3. Goldberg H, Stupp P, Okoroh E, Besera G, Goodman D, Danel I. Female genital mutilation/cutting in the United States: updated estimates of women and girls at risk, 2012. Public Health Rep. 2016;131(2):340–347.

4. Mather M, Feldman-Jacobs C; Population Reference Bureau. Women and girls at risk of female genital mutilation/cutting in the United States. February 2016. http://www.prb.org/Publications/Articles/2015/us-fgmc.aspx. Accessed May 1, 2017.

5. Nour NM. Female genital cutting: clinical and cultural guidelines. Obstet Gynecol Surv. 2004;59(4):272–279.

6. Royal College of Obstetricians and Gynaecologists. Female genital mutilation and its management. Green-top guideline no. 53. July 2015. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-53-fgm.pdf. Accessed April 27, 2017.

7. Resolution. Solicitors Family Law Association. Female genital mutilation screening toolkit. http://www.resolution.org.uk/site_content_files/files/fgm_toolkit.pdf. Accessed April 13, 2017.

8. Hearst AA, Molnar AM. Female genital cutting: an evidence-based approach to clinical management for the primary care physician. Mayo Clin Proc. 2013;88(6):618–629.

9. World Health Organization. Sexual and reproductive health. Classification of female genital mutilation. http://www.who.int/reproductivehealth/topics/fgm/overview/en/. Accessed May 1, 2017.

10. Abdulcadir J, Catania L, Hindin MJ, Say L, Petignat P, Abdulcadir O. Female genital mutilation: a visual reference and learning tool for health care professionals. Obstet Gynecol. 2016;128(5):958–963.

11. Perron L, Senikas V, Burnett M, Davis V; Social Sexual Issues Committee; Ethics Committee. Female genital cutting. J Obstet Gynaecol Can. 2013;35(11):1028–1045.

12. World Health Organization. Sexual and reproductive health. Health risks of female genital mutilation (FGM). http://www.who.int/reproductivehealth/topics/fgm/health_consequences_fgm/en/. Accessed October 10, 2017.

13. Abdulcadir J, Rodriguez MI, Petignat P, Say L. Clitoral reconstruction after female genital mutilation/cutting: case studies. J Sex Med. 2015;12(1):274–281.

14. Abdulcadir J, Botsikas D, Bolmont M, et al. Sexual anatomy and function in women with and without genital mutilation: a cross-sectional study. J Sex Med. 2016;13(2):226–237.

15. Banks E, Meirik O, Farley T, Akande O, Bathija H, Ali M. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet. 2006;367(9525):1835–1841.

16. Essén B, Bodker B, Sjoberg NO, Gudmundsson S, Östergren PO, Langhoff-Roos J. Is there an association between female circumcision and perinatal death? Bull World Health Organ. 2002;80(8):629–632.

17. Berggren V, Bergström S, Edberg AK. Being different and vulnerable: experiences of immigrant African women who have been circumcised and sought maternity care in Sweden. J Transcult Nurs. 2006;17(1):50–57.

18. Vloeberghs E, van der Kwaak A, Knipscheer J, van den Muijsenbergh M. Coping and chronic psychosocial consequences of female genital mutilation in the Netherlands. Ethn Health. 2012;17(6):677–695.

19. Nour NM, Michels KB, Bryant AE. Defibulation to treat female genital cutting: effect on symptoms and sexual function. Obstet Gynecol. 2006;108(1):55–60.

20. Victor D. Father imprisoned for genital cutting is deported to Ethiopia. The New York Times. March 14, 2017. https://www.nytimes.com/2017/03/14/us/father-imprisoned-for-genital-cutting-is-deported-to-ethiopia.html. Accessed May 1, 2017.

21. Gordon B. Mother in Georgia charged with female genital mutilation. Digital Journal. March 16, 2010. http://www.digitaljournal.com/article/289176. Accessed April 14, 2017.

22. U.S. Department of Justice. Detroit doctor and wife arrested and charged with conspiring to perform female genital mutilation. April 21, 2017. https://www.justice.gov/opa/pr/detroit-doctor-and-wife-arrested-and-charged-conspiring-perform-female-genital-mutilation. Accessed May 1, 2017.

23. U.S. Department of Justice. Detroit emergency room doctor arrested and charged with performing female genital mutilation. April 13, 2017. https://www.justice.gov/opa/pr/detroit-emergency-room-doctor-arrested-and-charged-performing-female-genital-mutilation. Accessed May 1, 2017.

24. Cornell Law School. Legal Information Institute. 18 U.S. code § 116. Female genital mutilation. https://www.law.cornell.edu/uscode/text/18/116. Accessed May 1, 2017.

25. Lee EY. ‘Vacation cutting’: the little known global health crisis affecting girls in the U.S. June 13, 2016. https://thinkprogress.org/vacation-cutting-the-little-known-global-health-crisis-affecting-girls-in-the-u-s-f7da557cdd1d. Accessed April 13, 2017.

This series is coordinated by Caroline Wellbery, MD, Associate Deputy Editor.

A collection of Curbside Consultation published in AFP is available at http://www.aafp.org/afp/curbside.

Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.

 

 

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