Type I: Partial or total removal of the clitorisa and/or the prepuce (clitoridectomy)
Type Ia: Removal of the clitoral hood or prepuce only
Type Ib: Removal of the clitorisa with the prepuce
Type II: Partial or total removal of the clitorisa and the labia minora, with or without excision of the labia majora (excision)
Type IIa: Removal of the labia minora only
Type IIb: Partial or total removal of the clitorisa and the labia minora
Type IIc: Partial or total removal of the clitoris,a the labia minora and the labia majora
Type III: Narrowing of the vaginal orifice with creation of a covering seal by cutting and apposition of the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)
Type IIIa: Removal and apposition of the labia minora
Type IIIb: Removal and apposition of the labia majora
Type IV: Unclassified All other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping and cauterization
An agreed-upon classification and a corresponding correct morphology for each type of female genital mutilation are important for clinical practice, management, recording and reporting, as well as for research on prevalence, trends and consequences of female genital mutilation. A visual reference and learning tool for healthcare professionals is now available. This tool can be consulted by caregivers when unsure on the type of FGM diagnosed, used for training and surveys for monitoring the prevalence of female genital mutilation types and subtypes and be used in legal disputes Figs.12.1, 12.2, and 12.3 .
Female genital mutilation type Ia: removal of the prepuce of the clitoris or clitoral hood (female circumcision). Courtesy of Jasmine Abdulcadir
Female genital mutilation type IIc: partial or total removal of the clitoris, the labia minora and the labia majora. Courtesy of Jasmine Abdulcadir
Female genital mutilation type IIIb without cutting of the clitoris before and after defibulation. Courtesy of Jasmine Abdulcadir
12.3 FGM, Religion and Social Factors
FGM is not prescribed by any religion even if it is often thought that they are a religious obligation. Women and children with FGM/C can have Islamic, Christian, Jewish or Animist religion depending on their ethnicity.
Factors used to justify and perpetuate FGM are multiple and diverse: social and peer acceptance, preparation for adulthood and marriage, removal of dirty, masculine and impure parts of the genitalia, reduce sexual impulses to ensure chastity and overall maintain cultural identity .
The young girls who come from these cultures have to go through this painful experience, painful both physically and psychologically, to become part of the female group, and to be worthy of becoming wives and mothers 1 day.
While FGM leaves the ability for procreation intact, FGM mutilates the female body in the most intimate and sensitive parts which have the only function, so far discovered, of giving sexual pleasure. Furthermore, in the majority of cases, the subjects who are subjected to FGM are not in a position to oppose. This practice is recognized as an abuse and violence against minors and a violation of human rights .
FGM is practiced at different ages depending on the country of origin. It may be performed from few days after birth to 15 years, usually before the first period . Among certain ethnic groups, it can be performed after the marriage or after giving birth. Most of girls examined for a study on FGM in a London safeguarding clinic were less than 10 years old when FGM was performed .
FGM can be responsible for heath complications, the severity of which depends on different factors such as quantity of removed tissue (types and subtypes of FGM), pre-existing health and nutritional condition of female baby/child, childhood feelings and emotions (often fear coexists with pride), hygienic and sanitary modalities and instruments used for the practice (unhealthy or sanitary tools, traditional practitioner or physician or nurse, etc.).
Although FGM is carried out during childhood, the available medical literature, often coming from countries of the diaspora, has mainly focused on the obstetric and gynaecological impact on adults. However, FGM is illegal and in many countries it is mandatory for health professionals to report to the police when a case of mutilation has been disclosed or when physical signs or symptoms of FGM are seen in a minor [9, 10].
FGM can be responsible for short- and long-term health complications .
The short-term effects of FGM afflict children/girls immediately after the procedure.
Haemorrhage, infection of the wound, pain, and shock are reported as common. Anaemia has been reported in 38% of girls after FGM . Because of the use of unsterile tools, cases of tetanus, transmission of blood-borne infections such as Hepatitis B and C and HIV have been described. The real number of children who died for the operation is not officially registered .
Long-term complications may afflict women with FGM for long life. Their care and treatment require specific medical attention and sensitivity as women can be unaware that their symptoms are caused by FGM or that they underwent the practice. The most frequent complications are well described in the medical literature. Some others of them are frequent and unknown. The most serious complications concern FGM type II and III, which has also been more investigated compared with type I and IV.
Recurrent vaginal-urinary tract infections and dysuria (including prolonged micturition, drop by drop urinary stream flow through the tiny orifice of the infibulation) have been reported in up to 22% of women following FGM [9, 13]. When in the scar of FGM type III there are several orifices, urination is rainy. With the stagnation of the urine behind the infibulation scar, small stones can be hidden behind it. A prolonged bladder outlet obstruction caused by the infibulation (urethral meatus is covered by the scar) can cause myogenic, morphological and neurogenic changes which lead to detrusor overactivity, urinary urgency, with incontinence, frequency and nocturia .
Cysts in the scar are frequent and sometimes may evolve in abscesses or grow very much .
Post-traumatic clitoral neuroma (benign tumour arising after a section or injury to a nerve caused by the regenerative disorganized proliferation of the lesioned nerves) can be a consequence of FGM. Sometimes neurinomas are asymptomatic or they cause chronic pain or severe pain during sexual activity. In that case, the treatment seems to be surgical excision. Considering the high frequency of clitoral cysts in case of infibulation, clitoral neuroma should be considered in the differential diagnosis when a cyst is painful .
Haematocolpos/haematometra has to be suspected in girls coming from countries with tradition of FGM when the absence of the menarche coexists with developed secondary sexual characteristics. The excessive tightness of the vaginal introits caused by an infibulation could be the cause. In that case, a defibulation can solve such complication.
Mental health problems such as anxiety, post-traumatic stress disorder and depression have been linked to FGM [17, 18].
The first sexual intercourses can be painful and sometimes remain so for life if not treated appropriately. In women with FGM type III, penetration is difficult or even impossible and a defibulation should be offered. When there is a sexological problem, it should not be assumed that the mutilation is the only cause responsible for it. Other factors may cause a sexual dysfunction, including other past traumatic events, and it is necessary to provide sexual education, information and proper treatment, involving the partner if necessary.
It is important to support adolescents with FGM because the social stigmatization and the negative messages from the media regarding FGM may provoke negative expectations on the possibility of experiencing sexual pleasure creating sexual dysfunction. They should have correct information on anatomy, sexual functioning, and appropriate treatment [1, 19, 20].
Negative impact on obstetric outcomes for the mother and baby has been described (increased risks of post-partum haemorrhage, C-section, perineal trauma and perinatal death) [1, 9, 21]. Risks were increased with more extensive FGM.