Female Genital Cutting Martin Donohoe

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

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

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)

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

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)

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

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

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

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

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

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

Female Genital Cutting Illegal to perform in U.S. under child abuse statutes before 1996 and by federal ban since then ?“cultural imperialism”? 2017: First federal charges brought against 2 doctors in MI 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

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

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

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

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