Female Genital Cutting

1. Female Genital Cutting Martin Donohoe

2. Female Genital Cutting • 200 million girls and women affected worldwide (3 million girls/year) • 30 countries • ½ in Egypt, Ethiopia, and Indonesia • Many in Africa (e.g. 98% of women in Somalia, 90% in Sudan, 27% in Kenya) • Outlawed in Egypt – 2007 (was 80%, still 70%) • 2016: 27 sub-Saharan countries have banned • Rare in Asia, Western hemisphere

4. Female Genital Cutting • All socioeconomic strata and all major religions • Reasons: gender/cultural identity, hygiene, fertility, child survival, maintain virginity, enhance male sexual pleasure • Formerly used in U.S. and U.K. as treatment for hysteria (“floating womb”), epilepsy, melancholy, lesbianism, and excessive masturbation

5. Female Genital Cutting • Has been called female genital mutilation • Not female circumcision • i.e., male equivalent would be penectomy • Ranges from clitoridectomy to total infibulation (removal of clitoris and labia minora, removing labia majora and stitching rough edges together, and leaving a small opening posterior for urine and menstral blood)

6. Female Genital Cutting • Represents cultural control of women’s sexual pleasure and reproductive capabilities • surgical “chastity belt” • c.f. virginity exams by physicians in Turkey

7. Female Genital Cutting • Type I - removal of clitoris • Type II - removal of clitoris and part of labia minora (80% of procedures) • Type III - modified infibulation - 2/3 of labia majora sewn together • Type IV - total infibulation – labia majora cut, rough edges sewn together (15% of procedures)

8. Female Genital Cutting • Procedures sometimes include: • Incisions/scarification of perineum and vaginal walls • Introduction of corrosives and herbs into vagina

11. Female Genital Cutting • Most commonly carried out between ages 4 and 10 • physicians perform about 12% of operations • Midwives, barbers, relatives • Often done under non-sterile conditions and without anesthesia

12. bleeding infection dyspareunia painful neuromas keloids dysmenorrhea infertility childbirth complications decreased sexual responsiveness shame fear depression Female Genital CuttingComplications/Sequelae

13. Female Genital Cutting • 500,000 women and girls in US affected/at-risk • Some women choose, for beauty’s sake, the “Barbie” (surgery to fuse the outer and inner labia, to create a clamshell-type effect) • Sensitivity/understand cultural identity issues • Immigration Issues

14. Management of Female Genital Cutting Deinfibulation Clitoral reconstructive surgery (breaking scar, pulling the remaining clitoris, the majority of which lies below the surface, back out) – associated with complications without conclusive evidence of benefit

15. Female Genital Cutting • UN, WHO, and FIGO have condemned • AAP initially supported “ritual clitoral nick,” then reversed position

16. Female Genital Cutting • Illegal to perform in U.S. under child abuse statutes before 1996 and by federal ban since then • ?“cultural imperialism”? • 2013: U.S. criminalizes transport of underage girls out of country for FGC (“vacation cutting”) • Fear of FGC can be the basis for an asylum claim

17. ?Cultural Imperialism? • Other outlawed “cultural practices”: • Slavery • Polygamy • Child labor • Denial of appropriate, life-saving medical care to sick children

18. References • Adams KE. What's Normal: Female Genital Mutilation, Psychology, and Body Image. JAMWA 2004;59(3):168-170. Available at http://jamwa.amwa-doc.org/index.cfm?objectid=2A3A132A-D567-0B25-5985AC5574B1C538

19. References • Donohoe MT. Individual and societal forms of violence against women in the United States and the developing world: an overview. Curr Women’s Hlth Reports 2002;2(5):313-319. • Donohoe MT. Violence and human rights abuses against women in the developing world. Medscape Ob/Gyn and Women’s Health 2003;8(2): posted 11/26/03. http://www.medscape.com/viewarticle/464255

20. Contact Information: Martin Donohoe, MD, FACP martindonohoe@phsj.org http://www.phsj.org