931 In the Trenches In Africa, an estimated 91.5 1 & GYNECOLOGY Although prevalence varies from an 2 MD The obstetrician explained the reasoning for midline repair tocontinuously the at the patient bedside. and Thethe obstetrician her also patient informed sister, that who thecian was began separated. As repairinginsisted the the obstetri- internal that lacerations, the(reinfibulation). the Although patient majora therisks of be obstetrician poor wound sewed explaineddevascularized healing back the and tissue infection together fromimportance plane, suturing of a infibulation the inhave sister their the culture circumcised emphasized and anatomy thesideration, the restored. need the After to obstetrician careful performed con- aated repair tissue, of including the a lacer- partial reinfibulation. estimated 97.9% of Somalian womenlow ages 18–49 of 0.6% to a populations of blur women the instatistics. Uganda, borders In growing of addition, the refugee national World prevalence Health Organization QUESTIONS FOR THE COMMENTATOR What is the prevalencecutting of worldwide? female genital Female genital cutting, alsomutilation, known circumcision, as or female ritualtional genital practice cutting, that is is near-universal athe in world certain tradi- and parts exceedingly of rarenomenclature in others. reflect The various thebate, charged and nature for of our“female genital the article, cutting.” we de- The havesial procedure in is selected both controver- the developing term nationsworld. and With the contemporary industrialized migrationobstetrician–gynecologists patterns, many inwill the care developed forcutting. world a Defining woman female genital whodures cutting involving has as partial or had “all total proce- removal femalefemale of the genitalia genital external or otherorgans injury for to non theOrganization medical female estimates genital reasons,” that the 100–140worldwide World million have Health women had somecutting version or of mutilation. female genital million womengenital and cutting. girls have undergone female , and Joanna F. Shulman, MD

Physical examination revealed the results of Type III VOL. 113, NO. 4, APRIL 2009 © 2009 by The Americanby College Lippincott of Williams Obstetricians & and Gynecologists. Wilkins. ISSN: Published 0029-7844/09 Financial Disclosure The authors did not report any potential conflicts of interest. From the Mount Sinai SchoolUtah of Hospitals and , Clinic, New Salt York, LakeGynecology New City, Utah; York; & and University Department Reproductive of ofYork, Science, Obstetrics, New The York. Mount SinaiMs. Medical Rosenberg Center, New isMedicine who a has a fourth-year strongyear medical interest resident in student biomedical in ethics.;interest at Obstetrics Dr. in Gibson this Mount and is subject a Gynecology Sinai beganis fourth Assistant as at School Professor a of the Peace of Obstetrics CorpsMedicine University and volunteer in Gynecology of in at New Mali.; The Utah York. Mount Dr.had Over Sinai whose Shulman undergone School the of female years she genitalNew has cutting York; encountered these in women a their have fewand sparked home patients patient many countries who passionate care before discussions issues of coming involved. the to ethical Address correspondence toNygaard, Consultant Editor MD, for MS,Obstetrics Clinical University and Case Gynecology, of 30 Series: NorthUT Utah 1900 Ingrid 84132; East, School e-mail: Room 2B200, of [email protected]. Salt Lake Medicine, City, Department of female circumcision, orlabia total minora, removal and of infibulation,labia the or majora. sewing The together, and completely prepuce absent. of and In the addition, body thewas of external not urethral the orifice visible clitoris dueinfibulation. were to The extensive tissue scarextended was tissue pale almost overlying gray, the the avascular,leaving and a entire relatively length smallued, opening. it of became As clear active the that the laborallow constricted labia contin- opening for would majora, not fetalsubsequently performed descent. a Theperineal body. midline A obstetrician healthy episiotomy male inthe neonate through postpartum was attendance examination, delivered. the During the obstetriciansive identified exten- lacerations as wellpreviously fused as labia an majora. almost total separation of the CASE: A 28-year-old primigravida atpreviously 41 weeks unregistered, of presented gestation, toand a Delivery tertiary unit care reportingminutes Labor painful apart. uterine contractions TheNortheastern 7 patient, African a country,extended family. was recent She accompanied promptly immigrant disclosedold by from that she as her underwent a a genital 10-year- cutting in her country of origin. Leah B. Rosenberg, Keri Gibson, Female Genital Cutting and U.S. Obstetric Practice When Cultures Collide

Downloaded from https://journals.lww.com/greenjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3XI41p+sDLxYw3vPuNMKGq76uXHrlJmVGxSxh7hJUR9SrZDVMFoPICQ== on 09/02/2020 Downloaded from https://journals.lww.com/greenjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3XI41p+sDLxYw3vPuNMKGq76uXHrlJmVGxSxh7hJUR9SrZDVMFoPICQ== on 09/02/2020 Fig. 1. Shaded areas represent the tissue removed in Type I female genital mutilation or circumcision (removal of prepuce and/or clitoris). Toubia N. Female circumcision as a public Fig. 2. An example of a repaired clitorodectomy. N Engl health issue. N Engl J Med 1994;331:712–6. Copyright © J Med 1994;331:712–6. Copyright © 1994 Massachusetts 1994 Massachusetts Medical Society. All rights reserved. Medical Society. All rights reserved. Rosenberg. Female Genital Cutting. Obstet Gynecol 2009. Rosenberg. Female Genital Cutting. Obstet Gynecol 2009.

sewing the . In Type III female genital estimates that approximately three million girls are at cutting, the clitoris may or may not be removed.4 Type risk for receiving the practice each year. IV female genital cutting encompasses all other non- Why is female genital cutting performed? medical procedures such as cutting, pricking, burn- ing, and other modification.5 In many cultures where female genital cutting is performed, it is viewed as a rite of passage to adult- What are the possible medical sequelae of hood as well as a source of esthetic beauty. The female genital cutting? practice is often believed to ensure a woman’s virgin- The main short-term medical complications of female ity and thus her suitability for marriage and subse- genital cutting are pain (both from lack of anesthesia quent child bearing–a matter of paramount impor- tance for many women in traditional societies. In certain cultures, the clitoris is considered unattractive and dirty and may be viewed as a cause of infection or . Furthermore, the narrowed introitus pro- duced by Type III female genital cutting is believed to increase men’s sexual pleasure – although in fact it may prevent vaginal penetration. Female genital cut- ting has erroneously come to be associated with Islam; however, the practice antedates the Qur’an and has its origins in a variety of tribal settings.3

What are the various presentations of female genital cutting? The World Health Organization classifies female genital cutting into four subtypes, roughly graded by invasive- ness of the procedure. Type I (Fig. 1) is confined to Fig. 3. Shaded areas represent the tissue potentially re- , or the surgical removal of the clitoris and moved in Type III female genital mutilation or circumci- sometimes the prepuce. Type II (Fig. 2) involves a more sion; dashed lines represent the skin sewn together in the extensive excision of both the clitoris and infibulation portion of the procedure. Toubia N. Female circumcision as a issue. Toubia N. Female and may involve removal of the labia majora as well. circumcision as a public health issue. N Engl J Med Type III (Fig. 3), the presentation of the case patient, is 1994;331:712–6. Copyright © 1994 Massachusetts Medi- characterized by the infibulation procedure, where the cal Society. All rights reserved. introitus is narrowed by cutting, repositioning, and Rosenberg. Female Genital Cutting. Obstet Gynecol 2009.

932 Rosenberg et al Female Genital Cutting OBSTETRICS & GYNECOLOGY and postoperatively), infection, and bleeding. The result of this event in their childhood, and a pelvic practice can spread infection when the procedure is examination can trigger posttraumatic stress disorder. performed using the same unsterilized instruments for It is important to initiate conversations with preg- many girls in the same village. A localized skin nant patients about these issues early in antenatal infection can quickly become septicemia in a rural care. The obstetrician should understand the type of setting without access to antibiotics. Profuse bleeding circumcision and the differences in gynecologic struc- can occur when the clitoral artery is severed during ture and function. The American College of Obstetri- clitoral excision. cians and Gynecologists (ACOG) guidelines for Long-term complications include dysuria, dyspa- healthcare recommend offering defibulation (taking reunia, , obstruction of labor, and psy- down the original infibulation) during the second chological trauma. Micturition can be impaired be- trimester under spinal anesthesia.6 In a recent study, cause the neointroitus (referring to the opening of the Nour et al4 found that antepartum defibulation greatly after the girl has undergone infibulation) pro- reduced the associated risks as well as exposed the vides only a small aperture for urinary flow. This can patient’s clitoris in 46% of cases. Taking this into lead to calculus formation and frequent urinary tract consideration, it is important to thoroughly discuss infections. is a common complaint of the patient’s expectations. The alteration (even if it is females who have undergone female genital cutting, restoration) of a woman’s genital anatomy from the and can be exacerbated by formation. Some way it has been since puberty may generate a strong women seek care for apareunia (the inability to emotional response. Furthermore, many women with achieve penetration) leading to infertility. After Type female genital cutting have limited knowledge regard- III female genital cutting (infibulation), dysmenorrhea ing the structure and function of their external geni- is common, related to the restricted menstrual flow. talia. A sensitive approach to patient education is an Women with clitoral neuromas and epithelial inclu- essential component of their care. Obstetricians sion cysts after female genital cutting may present should also counsel women who undergo defibulation with a painful vulvar mass. This experience also may that their menstrual flow and stream of urine will lead to psychological trauma, particularly posttrau- change after the procedure. While some women will matic stress disorder, which may be triggered when request restoration of their anatomy to the state before the girl reaches sexual maturity and tries to receive a female genital cutting, other women strongly desire , , or attempts intercourse. reinfibulation after delivery (discussed further below). In the developing world, women with a history of Documentation of the particular type of circumcision female genital cutting are at higher risk for a pro- (ie, Type II, etc) and a clear written communication of longed second stage of labor due to obstruction as the patient’s wishes is necessary in the context of a well as vesicovaginal and rectovaginal fistulae due to group practice. pressure of the fetal head on the vaginal wall. At delivery, such women are at risk for a larger volume What is the position of the American College of blood loss due to less predictable perineal tears. of Obstetricians and Gynecologists on female A prospective study by the World Health Orga- genital cutting and patient requests for nization of 28 obstetric centers in six African coun- reinfibulation? tries reported that Types II and III female genital American College of Obstetricians and Gynecologists cutting were associated with higher risks of cesarean Committee Opinion Number 151, published in Jan- delivery, postpartum hemorrhage, and infant resusci- uary of 1995, states that ACOG “joins many other tation, and all types of female genital cutting were organizations in opposing all forms of medically associated with extended hospital stay and stillbirth unnecessary surgical modification of the female gen- compared with those women who had not been italia.”7 The statement emphasizes the importance of circumcised.5 raising awareness about the issue and treating female genital cutting patients with sensitivity and culturally What are the relevant issues for the competent care. In addition, ACOG recommends obstetrician–gynecologist of a woman with a that practitioners caring for women with female gen- history of female genital cutting? ital cutting apprise themselves of alternative methods One of the primary objectives for the caring of obstetric and gynecologic procedures to accommo- for women who have had female genital cutting is to date the results of the procedure. With regard to provide a gentle and sensitive examination. Such “specialized care of the patient who has undergone women often have suffered psychological trauma as a female genital cutting,” ACOG specifically mentions

VOL. 113, NO. 4, APRIL 2009 Rosenberg et al Female Genital Cutting 933 the need for scarring revision and defibulation among providers to perform the procedure in a community other potentially relevant surgical procedures but setting without the benefit of antiseptic technique. does not remark upon cases where reinfibulation is However, physician performance of reinfibulation requested. seems to run counter to national and international guidelines on the primary procedure of female genital Should an obstetrician–gynecologist cutting. There is a need for an expanded discussion participate in the primary procedure or among American obstetrician–gynecologists as well postpartum repair of female genital cutting? as their regulatory bodies on the establishment of a According to federal criminal law,8 it is illegal for any consensus regarding postpartum reinfibulation. physician or person in the United States to perform female genital cutting on a girl aged younger than 18 REFERENCES years. In addition, a 2002 decision by the Federal 1. World Health Organization. Eliminating female genital muti- Court of Appeals for the 7th Circuit classified female lation: an interagency statement. Geneva (Switzerland): WHO genital cutting/mutilation as a form of torture suffi- Press; 2008. cient to grant asylum status.9 This law allows a degree 2. Yoder PS, Khan S. Numbers of women circumcised in Africa: of ambiguity surrounding the reinfibulation of women the production of a total. Calverton, Macro International Inc. MEASURE DHS, 2008 Mar. 19 p. (DHS Working Papers No. aged older than 18 years. For this reason, 39USAID Contract No. GPO-C-00-03-00002-00). must find a culturally appropriate solution that satis- 3. American College of Obstetricians and Gynecologists. Female fies the demands of professional ethics. The ethical genital cutting: clinical management of circumcised women. tension in the case concerns the competing principles 2nd ed. Washington (DC): ACOG; 2007. p. 10. of beneficence and respect for patient autonomy. 4. Nour NM, Michels KB, Bryant AE. Defibulation to treat female genital cutting: effect on symptoms and sexual function. While physicians are rightfully committed to “doing Obstet Gynecol 2006;108:55–60. good” for patients, this case involves a complex 5. World Health Organization. Fact Sheet Number 241. May request originating in the intimate matrix of culture 2008. Female genital mutilation. Available at: http://www. and sexuality. who.int/mediacentre/factsheets/fs241/en. Retrieved August If postpartum reinfibulation of an adult patient 24, 2008. 6. American College of Obstetrics and Gynecology. Guidelines can be viewed as a cosmetic procedure analogous to for women’s health care. 3rd ed. Washington (DC): ACOG; a or clitoral/labial tattoo, it might seem 2007. p. 243–7. inconsistent to forbid physician participation. In ad- 7. ACOG committee opinion. Female genital mutilation. Num- dition, some critics of U.S. and Canadian anti–female ber 151–January 1995. Committee on Gynecologic Practice. genital cutting legislation have argued that criminal- Committee on International Affairs. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1995; izing female genital cutting as a “special case” proce- 49:209. dure can be viewed as a type of cultural imperialism. 8. 18 U.S.C. § 116 [Federal Criminal Code]. Pragmatically speaking, it is possible that physician 9. Nwaokolo v. Immigration and Nationalization Service, 314 F. nonparticipation will lead to women seeking out 3d 303 (7th Cir. 2002).

934 Rosenberg et al Female Genital Cutting OBSTETRICS & GYNECOLOGY