/111 J Gyttecol 0/nut. 1992,37:149 latemati001l Federatioa of OYJieCOIOJY and Obltetric:a Female Circumcision Female genital mutilation INTERNATIONAL FEDERATION OF WORLD HEALTH ORGANIZATION GYNECOLOGY AND OBSTETRICS (FIGO) Female circumcision in any of its three forms, is a community cannot afford to rebel against or even ques• painful fact of life for about 80 million girls and women tion this tradition which remains profoundly entrenched in over 30 countries of Africa, the Middle East and in powerful taboos and is protected by secrecy and South East Asia where its practice is widespread. moral codes. If she loses her community social accep­ Although a traditional practice, female circumcision tance and support, it may mean the difference between is also a health issue because it potentially affects the life and death. Hence the paradox - the victims of the physical and mental well being of every woman and girl practice are also its strongest proponents. who undergoes the surgical procedure. Because of the difficulty and delicacy of eradicating a In its mildest form, female circumcision involves only practice based on cultural and traditional patterns that the removal of the foreskin of the clitoris. But in the ma­ have been traced back for over 2000 years, the issue can jority of cases the clitoris itself is removed, together with only be addressed effectively by promoting awareness all or part of the labia minora and in the most severe through education of the public, of health workers and form the labia majora. of trained practitioners. It requires the active involve­ Initial circumcision is carried out bef!>re a girl reaches ment of local communities, thefr leaders, women groups puberty sometime between I week and 14 years, and in and organizations rather than emotional stalemcms by some societies where infibulation is practiced, women outsiders, however well intentioned they may be. Elper­ are commonly re-infibulated after each delivery, after ience shows that when the practice of female circumci­ divorce and on the death of their husband. sion has been condemned by outsiders or outlawed Because the operation is usually preformed by tradi­ by governments in isolation from the complex tional midwives, with unsterilizec:l knives, razors or psychosocial, cultural process of which it is but one part, pieces of glass and without any anesthesia, it carries it has led to the exacerbation of the problem. The prac­ many health risks. tice has simply been done with greater secrecy and those The immediate physical effects - acute infection, suffering from complications have been inhibited from tetanus, bleeding of adjacent organs, shock resulting seeking help. from violent pain, and hemorrhage - can even cause In any effort to change prevailing attitudes towards death. In fact, many such deaths have occurred and con­ this custom, the education of men is as critical as the tinue· to occur as a result of this tradional practice. wider efforts to improve the· status of women including The lifelong physical and psychological . debilities that of their reproductive health as a whole. In settings resulting from female genital mutilations, are manifold: where female circumcision represents one among many chronic pelvic infecti<ms, keloids (scar tissue), vulval other serious problems facing women, it is these women abscesses, sterility, incontinence, depressiop. anxiety themselves who must set their priorities and initiate the and even psychosis, sexual dysfunction lftld marital steps towards the abolition of this practice in line with disharmony, and obstetric complications, with risk to the religious and cultural sensitivities surrounding this both the infant or fetus and the mother. Female circum­ subject. National and local women's organizations, cision also carries with it the pouibility of AIDS infec­ governmental or not, have been distinctly identified as tion. FiDally, there is profound impairment of women's the most appropriate mechanism for influencing the potential for development as a-result of trauma and process of change in attitudes and practice of this age chronic suffering. old custom. Such national and local initiatives can be Female circumcision is significantly associated with greatly helped by outside support to accelerate this pace proverty, illiteracy and low status of women, with com­ of change. munities in which people face hunger, ill health over­ Together with UNICEF, UNFPA, WHO and FIGO work and lack of clean water. In these settings, the continue to support national efforts against female cir­ woman who is not circumcised is stigmatized, ostracized cumcision and to collaborate in research and in the dis­ and not sought in marriage. Regardless of her personal semination of information. WHO also collabonues with feelinp, a woman who wants to remain with her own the Inter-African Committee, a regional NGO which works through its affiliates in 22 African countries. •tuued by the joint WHO/FIGO Task Force. For further in­ WHO believes that integrating information on female forrllation contact FIGO Secretariat, 27 Suuex Place, RCFJ!ts circumcision in programs of primary health care and .Part,' London, NWI 4RG, UK. safe motherhood will have a far reaching effect. JOURNAL OF OBSTERICS AND GYNAECOLOGY OF INDIA - ADVERTISER The Journal of Obstetrics and Gynaecology of India The following statement about the ownership and other particulars relating to "The Journal of Obstetrics and Gynaecology of India" is published as required by Clause 19-D of the Press and Registration of Books Act of 1867 as modified in 1956 :- 1. Place of Publication Purandare Griha 31/C, Dr.N.APurandare Marg, Bombay 400 007. 2. Periodicity of its Publication Bimonthly 3. Printer's Name Dr.Adi E.Dastur Nationality Indian Address 23, Nepean Sea Road, Bombay 400 036. 4. Publisher's Name Dr.Adi.E.Dastur Nationality Indian Address 23, Nepean Sea Road, Bombay 400 036. 5. Editors's Name Dr. V .N .Purandare Nationality Indian Address 3rd Floor, Purandare Griha, Dr.N.A.Purandare Marg, Chowpatty, Bombay 400 007. 6. Name and address of the Owner The Federation of Obstetrics and Gynaecological Societies of India, Purandare Griha, 31/C, Dr.N.A.Purandare Marg, Bombay 400 007. I, Dr.Adi E.Dastur, hereby declare that the particulars given above are true to the best of my knowledge and belief. Dr. Adi E.Dastur Secretary & MaQager r haematoma. within few days. Here it is very difficult to locate bleeding I bad some occasions to do timely total vessels. In sul·h type of l·ascs one has to abdominal hysterectomy on such patients, choose between total hystcredomy or bi­ who have survived subsequently. lateral ligations of internal iliac arteries, VI.Cornual rupture of ectopic gestation : with extensive repair operation, depend­ Sometimes in such patients severe intrap­ ing upon the prevailing circumstances eritoneal haemorrhage occurs alongwitb during opentlivc prO<:edure. shock. Nowadays on laparoscopy one can IIJ.Aionk Postpartum haemorrhage: Some­ diagnose such a condition. In such cases limes atonic postp:~rlum haemorrhage oc­ abdominal total hysterectomy maybe nec­ curs in patients with incoordinate uterine essary. al·tionetc., after vagina I delivcryorduring VII. Carcinoma of Cervix with pregnancy: If or aflcr C.tesarcan sel·tion. Inspite of ad­ carcinoma of cervix is detected in the first ministnttion ofOxytol"il·s and Prostaglan­ and second trimester of pregnancy, in dins, if the postpartum haemorrhage is not cases of stage 0, I, and II a, Radical controlled, one has to choose between Wertheim's Hysterectomy of such gravid hysterel"IOiny and bilateral ligation of in­ uterus could be carried out. If patients ternal iliac arteries. come during the third trimester of preg­ IV.Hydatidiform Mole : In elderly patients na ney, then pa ticnts with stage 0, I and II a, over the age of 35 years, prophyhtctic particularly between 26th and 28th week abdominal total hysterectomy in cases of of gestation, treatment may be delayed hydatidiform mole would save the patient until 34th and 36th week, so that the fetus from future possible development of may have a good chance for survival. At chorionepithelioma. about 34th and 36th week of gestation, a Sometimes one l·omcs across cases of classical caesarean section is carried out perfor.tting hydatidiform mole, which followed by Radical Wertheim's Hyster­ leads to severe intraperitoneal ectomy. Radical Wertheim's hysterectomy haemorrhage and shock. The l"Orrect diag­ during pregnancy is much easier, because nosis is made on laparotomy. In such of the plane of cleavage is much easier and patients abdominal total hysterectomy may better while dissecting the tissues. be necessary ;ts a life saving measure. Conclusion : In the developing countries Suda invasive moles leading to pcrfora­ there is necessity of doing Hysterectomy tionare diagnosed mul·h earlierthescdays, in gravid uterus. If the socioeconomic by repeated radioimmune assay ofBHCG conditions, literacy rate and antenatal, and ultrasonography. Timely treatment intranatal, and postnatal care facilities with l·hemotherapywith Methotrexate can improve, and if offered arc availed off by be administered. This will retain the fertil­ patients, the i ncidcncc ofobstructed Ia bour ity potential of the patient in the younger will come down considerably, thereby re­ age group. ducing the necessity of doing hysterec­ V. Septic Abortion : In some cases of illegal tomy. abortions done especially by quacks/un­ If investigation facilities like rddioimmune qualilied persons, uterus gets severely in­ assays of BHCG, ultrasonography are fected. Sudal·ases sometimes arc prone to made available, an early diagnosis can be get bacteraemic shock, which proves fatal obtained in case of placenta praevia Ac- cidcntal Haemorrhage, hydatidiform mole, dlictive function in the patient. However perforating hydatidiform mole etc. which there are some patients who do not re­ can further reduce the necessity of doing spond favourdbly even after bilateral liga­ hysterectomy. tion of internal iliac arteries, in whom one I would advocate doing the total abdomi­ might have to do total abdominal hyster­ nal hysterectomy whenever feasible in­ ectomy as a last resort.