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A correction has been published: N Engl J Med 1995;332(3):188.
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Female circumcision is practiced today in 26 African countries, with prevalence rates ranging from 5 percent to 99 percent. It is rarely practiced in Asia. It is estimated that at least 100 million women are circumcised. The practice is known across socioeconomic classes and among different ethnic and cultural groups, including Christians, Muslims, Jews, and followers of indigenous African religions2. From the perspective of public health, female circumcision is much more damaging than male circumcision. The mildest form, clitoridectomy, is anatomically equivalent to amputation of the penis. Under the conditions in which most procedures take place, female circumcision constitutes a health hazard with short- and long-term physical complications and psychological effects. The influx of refugees and immigrants from different parts of Africa to North America, Europe, and Australia in the past decade requires that physicians and other health professionals familiarize themselves with the practice and its ramifications for their patients.
This article reviews the common types of circumcision, their complications, and the challenges in giving appropriate care to circumcised women. In counseling families who believe in the practice, it is important to understand the depth of cultural meaning it carries. Finally, a brief review of legal and ethical issues will include consideration of existing and expected pieces of legislation and what they mean to the medical profession.
The Procedures
Girls are commonly circumcised between the ages of 4 and 10 years, but in some communities the procedure may be performed on infants, or it may be postponed until just before marriage or even after the birth of the first child. The often quoted Shandall system of clinical classification adopted by Verzin in 19753 is not accurate and is of little clinical use. That system claims the existence of what is termed "circumcision proper," described as the circumferential excision of the clitoral prepuce in a manner analogous to male circumcision. In my extensive clinical experience as a physician in Sudan, and after a careful review of the literature of the past 15 years, I have not found a single case of female circumcision in which only the skin surrounding the clitoris is removed, without damage to the clitoris itself.
I have advanced a newer system of classification2 that groups the most common forms of female circumcision into two broad categories: clitoridectomies (type I and II procedures) and infibulations (type III and IV procedures).
Type I clitoridectomy (Figure 1) involves the removal of a part of the clitoris or the whole organ. This is what is commonly referred to as "Sunna circumcision"4.
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This anatomically precise and simplified system of classification is only a guide to help clinicians and researchers standardize their descriptions of a multitude of operations. In reality, the extent of cutting and stitching varies considerably, since the operator is usually a layperson with limited knowledge of anatomy and surgical technique. With local or no anesthesia, the girl may move, and the extent of cutting cannot be accurately controlled.
Physical Complications
Because the specialized sensory tissue of the clitoris is concentrated in a rich neurovascular area of a few centimeters, the removal of a small amount of tissue is dangerous and has serious and irreversible effects. Common early complications of all types of circumcision are hemorrhage and severe pain, which can lead to shock and death. Prolonged lesser bleeding may lead to severe anemia and can affect the growth of a poorly nourished child. Local and systemic infections are also common. Infection of the wound, abscesses, ulcers, delayed healing, septicemia, tetanus, and gangrene have all been reported.
Long-term complications are associated more often with infibulation than with clitoridectomy alone, because of interference with the drainage of urine and menstrual blood. Chronic pelvic infection causes pelvic and back pain, dysmenorrhea, and possibly infertility. Chronic urinary tract infections can lead to urinary stones and kidney damage.
The most common long-term complication is the formation of dermoid cysts in the line of the scar. These result from the embedding of keratinized epithelial cells and sebaceous glands in the stitched area. They can be as small as a pea or as large as a grapefruit. The formation of keloids is another disfiguring complication that, like dermoid cysts, causes anxiety, shame, and fear in women who think that their genitals are regrowing in monstrous shapes or who fear they have cancer. When painful stitch neuromas develop as a result of the entrapment of nerve endings in the scar, the result is severe dyspareunia and interference with sexual intercourse4. Recurrent stitch abscesses and the splitting of poorly healed scars, particularly when they occur over the clitoral artery, can plague women for many years.
Childbirth adds other risks for infibulated women, particularly where health services are limited. If deinfibulation is not performed, exit of the fetal head may be obstructed and strong contractions can lead to perineal tears. If contractions are weak and delivery of the head is delayed, fetal death can occur and necrosis of the septum between the vagina and bladder can cause vesicovaginal fistula, a distressing condition of urinary incontinence for which women are often ostracized by their communities5.
Another problem related to labor and delivery is emerging among immigrants in Europe and North America, where physicians are not trained to deal with infibulated women. Unnecessary cesarean section can be avoided with a simple deinfibulation6 performed with the woman under local anesthesia (Figure 5).
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Psychological and Sexual Effects
In contrast to numerous studies and case reports on the physical complications of genital mutilation, little scientific research is available on the sexual and psychological effects of the practice. This dearth of research has left the subject to a great deal of lay speculation7,8,9. Among girls who live in communities where female circumcision carries high social value, the desire to gain social status, please parents, and comply with peer pressure is in conflict with the fear, trauma, and after-effects of the operation4,10,11. Physical complications add to the psychological trauma12. In my clinical experience in Sudan, many infibulated women have a syndrome of chronic anxiety and depression arising from worry over the state of their genitals, intractable dysmenorrhea, and the fear of infertility.
One major study by two Egyptian psychologists suggests that a woman's sexuality is affected according to the extent of the operation and the degree to which other social messages inhibiting sexual expression are internalized13. However, the assumption that all circumcised women have sexual problems or are unable to achieve orgasm is not substantiated by research or anecdotal evidence. The relation between the degree of anatomical damage and the ability of women to compensate for it through other sensory areas or emotions and fantasy is not well understood.
A few cases of psychopathologic disorders directly attributable to genital mutilation have been reported in Sudan4. Among the majority of girls and women, however, the psychological effects are often subtle and are buried in layers of denial and acceptance of social norms. Understanding the personal and community dynamics of accepting circumcision is important not only in uncovering psychopathologic disorders but also in comprehending why the practice continues. Such understanding is central to the design of efforts to stop the practice.
The psychological sequelae of female circumcision among immigrants differ from those where the practice is prevalent. Circumcised women living in societies where the procedure is not performed may have serious problems in developing their sexual identity. Sooner or later, health professionals will be called on to deal with these problems.
The Cultural Meaning of Female Circumcision
No ethical defense can be made for preserving a cultural practice that damages women's health and interferes with their sexuality. It is important, however, that those who are alien to the culture make themselves familiar with the causes and meanings of cultural practices and relate them to ideas of sex roles in their own societies.
Cultural identity is of paramount importance to everyone. Defending that identity becomes especially important when the group has faced colonialism (as in Africa), when immigrants are faced with a stronger majority culture, and when change does not favor those holding social power (that is, men). Female circumcision is part of the socialization of girls into acceptable womanhood.
In poorer societies, where the extended family is the principal source of social and economic security and has not been replaced by the modern state, women have very few options outside marriage. Female circumcision is the physical marking of the marriageability of women, because it symbolizes social control of their sexual pleasure (clitoridectomy) and their reproduction (infibulation). Cultural identity is often stronger than individual interest, and it may take some time and much new information for people to abandon traditional customs.
Clinical Management
Although clitoridectomies (type I and II procedures) have many short- and long-term complications, they usually do not create mechanical obstruction to first intercourse or to labor. Tightly infibulated women, on the other hand, may need deinfibulation (Figure 5) before their first sexual intercourse or first vaginal examination can take place. Most women with infibulation (type III and IV procedures) are at serious risk, as are their unborn babies, if deinfibulation is not performed. Multiparous women usually have heavily scarred and deformed perineums from repeated deinfibulation and reinfibulation and routine (usually unnecessary) posterior episiotomy.
After deinfibulation, the raw, bleeding edges must be secured in some fashion. Two options are available. The first, a circular stitching around the edges of the labia majora (Figure 6), leaves the vulval area open, allowing the free flow of urine and menstrual blood. This also facilitates intercourse and may relieve dyspareunia. The second option is the one traditionally performed and is considered a reinfibulation. The raw edges are sewn back together to restructure the hood of skin covering the urethra and vaginal introitus.
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The management of gynecologic complications of female circumcision does not differ from the handling of other surgical complications. However, physicians should exercise extreme caution in deciding to operate on an already damaged and scarred area. The decision to incise an abscess or remove a dermoid cyst or keloidal scar must be made conservatively, and care must be taken to perform only the most minimal surgical dissection.
Legal and Ethical Considerations
The legal and ethical debate over female circumcision is not within the scope of this article. It is important, however, that medical practitioners be aware of the legislative and professional actions taken in various countries in recent years.
In Sweden, a law passed in 1982 makes all forms of female circumcision illegal14; a similar law was passed in the United Kingdom in 198515. No specific law has been passed in France, but several cases have been brought against parents for circumcising or intending to circumcise their French-born daughters16. The cases were tried under child-abuse laws and established a precedent for the illegality of female circumcision in France. The Netherlands and Belgium have also made it clear that the practice is illegal14,17. In the United States, a bill drafted by the Congressional Women's Caucus has been presented to Congress. It would make female circumcision illegal and recommend that the Department of Health and Human Services fund programs to assist immigrant communities in dealing with the practice18. Even without a specific law, circumcising a girl under the age of consent would most likely be considered illegal under child-abuse laws in the United States.
It is only a matter of time before all forms of female circumcision in children will be made illegal in Western countries and, eventually, in Africa. The Vienna Declaration of the World Conference on Human Rights held that traditional practices such as female circumcision were violations of human rights19,20. This position has been adopted by various United Nations health and human-rights organizations.
Another medicolegal question, recently discussed by Baker et al.,6 concerns the legality and ethics of reinfibulating a woman after vaginal delivery in the United States. Although physicians have an obligation to respond sensitively to a patient's request, reinfibulation is harmful and may be considered illegal. Citing the Prohibition of Female Circumcision Act of 1985, the Royal College of Obstetrics and Gynaecology made it clear in a June 1993 press release that reinfibulation is illegal in the United Kingdom. It stated that
The agreed definition of the word infibulation is that it is a stitching together of the labia. By definition, therefore, when an obstetrician is faced with the repair of the vulva of a woman who has delivered a baby vaginally following a previous infibulation it is illegal then to repair the labia intentionally in such a way that intercourse is difficult or impossible21.
Although debate about the interpretation of various laws will continue, the medical profession must develop its own rules of ethical conduct concerning the clinical aspects of this practice. How regulations governing reinfibulation fit with the regulations governing other plastic and genital surgeries must be part of the discussion. As such regulations are being developed, it is important to ensure that women who request reinfibulation do not suffer ethnic or cultural bias.
In 1992 the International Federation of Gynaecology and Obstetrics published a joint statement on female circumcision with the World Health Organization,22 and in 1993 the World Health Assembly, the highest authority of the World Health Organization, issued a similar statement23. Both statements condemn the practice of female circumcision as harmful and call for coalitions to abolish it. Greater efforts are needed by national and regional professional associations to promote awareness of the issue among their members and to articulate their own policy positions on the various aspects of the practice.
Conclusions
Female circumcision, or female genital mutilation, can no longer be seen as a traditional custom. It has become a problem of modern society in Africa as well as in Western countries. In recent years, concern has grown over how to stop the practice, rather than whether it is appropriate to intervene.
There are two main areas of concern for health practitioners. The first is the danger that a trained and licensed practitioner could be expected to assist in circumcising a girl, particularly a young child. Legislation against the practice will resolve this question. The second area of concern is how to deliver the most appropriate clinical care and psychological support to girls and women who have already suffered from this practice.
More research is needed to examine the full range of physical, sexual, and psychological consequences of the various procedures. Guidelines and training materials must be developed to inform providers about how to manage the health needs of circumcised women and about appropriate ways to counsel patients when they request circumcision or reinfibulation. Professional associations should publish guidelines that outline their members' obligations and responsibilities to their patients.
Source Information
From the School of Public Health, Columbia University, and the Research Action and Information Network for the Bodily Integrity of Women, both in New York.
Address reprint requests to Dr. Toubia at P.O. Box 1554, Cooper Sta., New York, NY 10276.
References
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Related Letters:
Female Circumcision
Horowitz C. R., Jackson J. C., Teklemariam M., Schoen E. J., Buff D. D., Weydert J.-M., Fleiss P. M., Gilson G. J., Toubia N.
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Full Text
N Engl J Med 1995;
332:188-190, Jan 19, 1995.
Correspondence
This article has been cited by other articles:
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