Female genital mutilation (FGM) is a practice in some cultures that cuts or otherwise alters the external female genitals. It is usually performed on young girls before puberty. FGM occurs in large parts of Africa and some of the Middle East and Asia. It has deep cultural meaning in the societies that practice it as a rite of passage and a means to ensure a woman’s suitability for marriage. However, many nations and international organizations condemn the practice as medically unnecessary and harmful and have outlawed it. This has resulted in controversy regarding outside organizations making decisions about practices that some populations view as socially and culturally acceptable.

Girls usually go through the procedure of genital mutilation before age 12. The external parts of the girl’s genitals are cut, usually removing the clitoris and sometimes cutting and joining the outer vaginal lips (labia majora) so they will fuse together. This reduces the opening to a small hole for urine and menstrual blood. The procedure is painful and frequently involves excessive bleeding. The lack of sanitary conditions means many girls are likely to contract infections as well.

After undergoing FGM, girls and women may experience problems with urination and menstruation. Sexual intercourse can be painful and uncomfortable for many months or even permanently. The procedure can also complicate pregnancy and childbirth.

As more of the women who have experienced genital mutilation have moved to areas where it is uncommon, physicians and other medical professionals have become more aware of the practice. Some women have chosen surgical procedures that remediate some of the damage and make pregnancy and childbirth easier.

FGM is most commonly practiced in 28 nations in Africa including Sudan, Chad, Sierra Leone and Djibouti. Female genital mutilation also takes place in some countries in the Middle East, such as Saudi Arabia, and among immigrant communities in the United States and Europe. The World Health Organization (WHO) estimates that between 100 million to 140 million girls and women have had FGM. Each year, three million girls and young women are at risk for the practice. Even the name of the practice contributes to the controversy. Western nations that oppose the practice have called it genital mutilation. In nations where FGM is part of the culture, it is generally not considered mutilation and is called female circumcision or female genital cutting. In 1996, the WHO adopted the term female genital mutilation. 

Female genital mutilation (FGM) is the practice of cutting or removing all or part of the external female genitals. These include the clitoris and its hood (prepuce), the labia minora and the labia majora. In some cases, the labia majora are sewn together or otherwise attached to each other, essentially blocking the opening to the vagina.

FGM is traditionally practiced in much of Africa and some parts of the Middle East and Asia. In these areas, it is generally considered an honored rite of passage for females, although some girls and women in these regions have in recent years begun resisting it. Of the 28 African nations that practice FGM, 14 countries have laws prohibiting it. However, the laws may not be enforced and the practice is still widespread. Only a few nations (Burkina Faso, Egypt, Ghana, Senegal and Sierra Leone) have arrested or charged people for practicing FGM.

In most Western countries the practice is discouraged or illegal and considered medically unnecessary and harmful. Although FGM is illegal in these countries, Western nations have experienced an influx of women with FGM as immigration from Africa and Asia has increased. It is sometimes performed in immigrant cultures in the United States, Canada, Europe and other developed regions.

The type of female genital mutilation varies by area and culture. In some places, it may be only a small, symbolic cut or scarring. Some groups in Kenya have succeeded in replacing the procedure with a rite of passage for girls that does not involve any cutting.

The World Health Organization (WHO) has divided female genital mutilation into four categories:

• Type I includes the removal of the hood of the clitoris (clitoridotomy) and may include the partial or total excision of the clitoris (clitoridectomy).
  
  
• Type II includes clitoridectomy and the partial or total excision of the labia minora. This is the most widely practiced form of FGM.
  
  
• Type III is called infibulation. It includes all procedures in Type II (clitoridectomy, partial or total excision of the labia minora) and cutting of the labia majora. The two sides of these labia are joined together with stitches, paste or thorns. The labia eventually fuse and cover most of the vaginal opening, with just a small opening remaining for urine and menstrual blood to pass.
  
  
• Type IV involves other methods not classified in the types above, such as pricking, burning, scarring or stretching the external genitalia.

FGM usually takes place before puberty, between the ages of 4 and 12 years. However, it may take place in infancy or shortly before a woman is married. The practice may be performed for one girl, but commonly includes a group of girls of a similar age. It is usually performed by a midwife or by another woman, most commonly someone with no medical training. A girl will be held and the genital area is cut with a knife, scissors or even a piece of broken glass. For infibulation, the labia may be sewn or held together with thorns or some sort of paste, leaving just a small opening for the passage of urine and menstrual blood. Some girls may have their legs bound together to promote healing and fusing of the labia.

The procedure is quite painful for a girl and may involve excessive bleeding. Anesthesia is not often used and the conditions are usually not sterile. In some cases, the procedure is performed by a physician or other medical professional. The WHO and other medical organizations have condemned this practice, indicating that the procedure is unnecessary and harmful and should not be legitimized by the medical establishment.

When a woman is ready to be married, the genital area can be opened, either by cutting, gradual dilation with instruments or more commonly through sexual intercourse with her husband. The previously performed FGM causes pain during the initial intercourse (dyspareunia), which may continue throughout a woman’s life.

Cultures practice FGM for a variety of reasons. It is considered a rite of passage for girls and makes them accepted members of their community. This conveys higher status to the girl’s family and makes her eligible for a better marriage. Those who promote FGM believe that by reducing female sexual response, it will discourage sexual promiscuity and help maintain a girl’s virginity until marriage. Some societies consider the female genitals unattractive and potentially harmful if touched by a man’s genitals or by a baby during childbirth. Some people consider it a tenet of religion, particularly Islam. However, FGM is practiced in many faith communities in Africa (indigenous religions, Muslim, Jewish and Christian) and predates the arrival of Islam in these areas.

Women who have undergone FGM may consider it a normal part of life and may not think they have been mutilated. They may think it is necessary for a good marriage in their culture. Many continue to encourage the practice for their own daughters and granddaughters. Women in some of these cultures have little exposure to outside societal influences. When these women move to other locations, some may be shocked that other people and medical professionals consider them mutilated. However, other women may have had the procedure performed against their will and now can seek relief without being condemned by their culture.

Female genital mutilation (FGM) can have immediate and long-term complications. Although women who have had FGM face numerous health problems, it can be difficult to separate the consequences from the procedure from those caused by poor sanitary conditions and lack of access to medical care. The procedure is painful, especially since anesthesia is rarely used, and may cause excessive bleeding, which can lead to death.

Some of the immediate consequences of female genital mutilation include:

• Severe pain
• Severe bleeding (hemorrhage)
• Shock
• Infection

The number of women who experience long-term complications from FGM is difficult to determine. Women from cultures that practice FGM may be conditioned not to discuss pain, especially any pain associated with their genitals. They may also consider the complications normal. If they were very young when the procedure was performed, they may not remember ever feeling differently.

Longer-term consequences usually affect the urinary and reproductive systems. Some of these long-term complications can include:

• Painful urination and difficulty emptying the bladder (dysuria). This can increase the likelihood of urinary tract infections.
  
  
• Painful menstruation (dysmenorrhea).
  
  
• Blocked menstrual flow. This may lead to a condition called endometriosis. 
  
  
• Scarring at the incision sites. This may make a woman more susceptible to infection with sexually transmitted diseases, including the human immunodeficiency virus (HIV).
  
  
• Pelvic inflammatory disease.
  
  
• Chronic pain.
  
  
• Painful intercourse (dyspareunia).
  
  
• Psychological trauma. This may occur because girls are often taken by surprise and forcibly held down during the procedure.
  
  
• Infertility.
  
  
• Inability to use any intravaginal or intrauterine forms of birth control (e.g., IUDs, female condoms).
  
  
• Difficulty in receiving pelvic examinations.
  
  
• Complications during pregnancy and childbirth. Infibulation makes pregnancy examinations difficult and childbirth more complicated. Women may need their infibulation scar opened to give birth. Surgical opening of the scar (deinfibulation) using regional or general anesthesia is best performed before pregnancy, but can be performed during pregnancy. If deinfibulation is not carried out before labor begins, it can be done during labor to prevent severe tearing. Women with FGM also are more likely to require a Caesarean delivery (C-section).
  
  In addition, women with FGM are at greater risk of having their baby die before or soon after birth than those without the procedure, according to a recent study conducted by African and international researchers. The study, which is the first comprehensive study of the effects of FGM on maternal and child health, involved over 28,000 women giving birth in various African nations where FGM is commonly practiced. Besides increased risk of perinatal death, other complications associated with FGM include greater risk of C-section (as well as complications during such deliveries), maternal hemorrhage during childbirth and longer hospitalization of the mother. The degree of these complications also increases in relation to the extent and severity of the FGM. After delivery, the researchers also found an increased need to resuscitate the babies of mothers with FGM.

Women in areas where female genital mutilation (FGM) is practiced usually receive no special treatment for the condition. When they have received infibulation (the fusing of the labia), the scar is opened up for childbirth and may be resewn after giving birth. In recent years, more women with FGM have immigrated to areas where the procedure is uncommon or illegal. Physicians are able to perform remedial surgery in some cases. Infibulation scars can be reopened. Some surgery can restore external areas around the clitoris. However, clitoral removal cannot be reversed.

Cultural differences may aggravate communication problems with physicians unfamiliar with FGM practices. Women may be accustomed to more pain, not realizing it is associated with the condition. Physicians may not understand the cultural importance some people place on the procedure. Some women may request that FGM be performed on their daughters. In the United States, any medically unnecessary procedure on the genitals cannot be performed on girls under the age of 18. Any initial procedure cannot be performed on adult women. However, resewing an infibulation scar (reinfibulation) is permitted.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions about female genital mutilation (FGM):

1. Is FGM performed in the United States?
2. Is the type of FGM that I have harmful for my reproductive health?
3. What are my treatment options?
4. How will my condition affect my sexual satisfaction?
5. How can FGM affect my ability to become pregnant?
6. Will I be able to deliver a child vaginally with my condition?
7. How will my condition affect the delivery? Are there any risks involved for my baby or myself due to my FGM?
8. Is surgery an option to change the appearance of my genitalia?
9. Can you refer me to specialists that are familiar with FGM?
10. Am I at greater risk for sexually transmitted diseases due to my FGM?
11. Are there any emotional support groups for women with my condition?