Female Genital Cutting: An Evidence-based Review for the OBGYN of Long-term Sequelae and Management Options.

Female genital cutting (FGC) is a persisting global practice that increases patients' risk for experiencing long-term health sequelae. Existing meta-analysis evidence strongly supports an association between FGC and the development of long-term dyspareunia, urinary tract infections, and sexual dysfunction as well as increased risk obstetrically of prolonged labor, cesarean section, perineal lacerations, and episiotomy. Surgical defibulation is recommended in patients with type III FGC to decrease obstetric and gynecologic morbidity. Existing evidence does not seem to definitively support clitoral reconstructive surgery. More research is needed to study conservative treatment and management approaches to long-term sequelae of FGC.

Diagnosis, Management, and Treatment of Female Genital Mutilation or Cutting in Girls.

Female genital mutilation or cutting (FGM/C) involves medically unnecessary cutting of parts or all of the external female genitalia. It is outlawed in the United States and much of the world but is still known to occur in more than 30 countries. FGM/C most often is performed on children, from infancy to adolescence, and has significant morbidity and mortality. In 2018, an estimated 200 million girls and women alive at that time had undergone FGM/C worldwide. Some estimate that more than 500 000 girls and women in the United States have had or are at risk for having FGM/C. However, pediatric prevalence of FGM/C is only estimated given that most pediatric cases remain undiagnosed both in countries of origin and in the Western world, including in the United States. It is a cultural practice not directly tied to any specific religion, ethnicity, or race and has occurred in the United States. Although it is mostly a pediatric practice, currently there is no standard FGM/C teaching required for health care providers who care for children, including pediatricians, family physicians, child abuse pediatricians, pediatric urologists, and pediatric urogynecologists. This clinical report is the first comprehensive summary of FGM/C in children and includes education regarding a standard-of-care approach for examination of external female genitalia at all health supervision examinations, diagnosis, complications, management, treatment, culturally sensitive discussion and counseling approaches, and legal and ethical considerations.

Global women's health--a global perspective.

The burden of disease and public health issues affecting girls and women throughout their lives is significantly greater in resource-poor settings. These women and girls suffer from high rates of maternal mortality, obstetric fistulas, female genital cutting, HIV/AIDS, malaria in pregnancy, and cervical cancer. Although the Millennium Development Goals (MDGs) are being met in some nations, the majority of the goals will not be reached by 2015. In addition, insufficient attention is given to non-communicable and chronic diseases such as diabetes, hypertension, hypercholesterolemia, cardiovascular diseases, stroke, obesity, and chronic respiratory diseases. A life-course approach that includes improvements in earlier-life factors such as diet and exercise is necessary to improve women's long-term health outcomes. Innovative diagnostic tools and treatment strategies along with cost-effective health service delivery systems are needed to make a significant impact on women's and girls' health worldwide.

Child marriage: a silent health and human rights issue.

Marriages in which a child under the age of 18 years is involved occur worldwide, but are mainly seen in South Asia, Africa, and Latin America. A human rights violation, child marriage directly impacts girls' education, health, psychologic well-being, and the health of their offspring. It increases the risk for depression, sexually transmitted infection, cervical cancer, malaria, obstetric fistulas, and maternal mortality. Their offspring are at an increased risk for premature birth and, subsequently, neonatal or infant death. The tradition, driven by poverty, is perpetuated to ensure girls' financial futures and to reinforce social ties. One of the most effective methods of reducing child marriage and its health consequences is mandating that girls stay in school.

Cervical cancer: a preventable death.

Cervical cancer kills 260,000 women annually, and nearly 85% of these deaths occur in developing nations, where it is the leading cause of cancer deaths in women. Disparities of health and poverty play a large role in this high mortality rate. Whereas routine Papanicolaou and human papillomavirus (HPV) testing has dramatically reduced cervical cancer deaths in Western nations, without proper infrastructure, facilities, and medical training, the rates of cervical cancer in developing nations will remain high. Studies on HPV DNA testing and the low-technology method of "screen and treat" are promising. In addition, reducing the cost and increasing the availability of HPV vaccines in developing nations brings hope and promise to the next generation of women.

An Introduction to Global Women's Health.

Sex-based health disparities are evident throughout the world; however, nowhere are these disparities greater than in resource-poor countries. Women in developing nations lack basic health care and face life-debilitating and life-threatening health issues. Some health issues never existed in the West, whereas science eradicated others decades ago. Maternal mortality, female genital cutting, child marriage, human immunodeficiency virus (HIV)/AIDS, and cervical cancer are a few of the issues that plague developing nations. This article introduces some of these challenging health problems. In subsequent issues, they will be explored in more depth. Reviews in Obstetrics & Gynecology hopes that highlighting global women's health issues will increase awareness and establish a renewed commitment to improving women's lives.

Defibulation to treat female genital cutting: effect on symptoms and sexual function.

OBJECTIVE: Women who have undergone type III female genital cutting may suffer long-term complications. Defibulation (reconstructive surgery of the infibulated scar) can alleviate some of these complications. We studied the physical and sexual outcomes after defibulation and evaluated both patient and husband satisfaction. METHODS: The medical records of 40 consecutive women with a history of type III female genital cutting who underwent defibulation between 1995 and 2003 were reviewed. Data collected included demographics, indications for the procedure, closure type, intraoperative and postoperative complications. Telephone surveys were conducted between 6 months and 2 years postprocedure to evaluate the long-term health and sexual satisfaction outcomes. RESULTS: Of 40 women identified as having undergone defibulation, 95% were Somali, 65% were married, and 73% were between the ages of 19 and 30. Primary indications for defibulation were being pregnant (30%), dysmenorrhea (30%), apareunia (20%), and dyspareunia (15%). Secondary indications were apareunia (20%), difficulty urinating (12.5%), and dyspareunia (10%). Sixty-five percent had a subcuticular repair. Forty-eight percent had an intact clitoris buried beneath the scar. None had intraoperative or postoperative complications. Of the 32 patients reached by telephone, 94% stated they would highly recommend it to others. One hundred percent of patients and their husbands were satisfied with the results, felt their appearance had improved, and were sexually satisfied. CONCLUSION: Defibulation is recommended for all infibulated women who suffer long-term complications. The complication rates are minimal, with high satisfaction rates among patients and their husbands. LEVEL OF EVIDENCE: II-3.

Health consequences of child marriage in Africa.

Despite international agreements and national laws, marriage of girls <18 years of age is common worldwide and affects millions. Child marriage is a human rights violation that prevents girls from obtaining an education, enjoying optimal health, bonding with others their own age, maturing, and ultimately choosing their own life partners. Child marriage is driven by poverty and has many effects on girls' health: increased risk for sexually transmitted diseases, cervical cancer, malaria, death during childbirth, and obstetric fistulas. Girls' offspring are at increased risk for premature birth and death as neonates, infants, or children. To stop child marriage, policies and programs must educate communities, raise awareness, engage local and religious leaders, involve parents, and empower girls through education and employment.

Benign vaginal villi noted at time of defibulation of female genital cutting.

BACKGROUND: Female genital cutting is a cultural practice in Africa and the Middle East. As more patients who have undergone this procedure are seen in the United States and undergo surgical revision of the scarred labia, new clinical findings will arise. CASE: At the time of surgical revision of female genital cutting, small clusters of villi were noted on the vaginal and labial mucosa of 3 patients. Pathological examination revealed benign-appearing papillary structures. These villi completely resolved by the 6-week postoperative visit. CONCLUSION: Female genital cutting may lead to a vaginal environment that predisposes women to benign changes in the vaginal mucosa that resolve after the closed (infibulated) labia are surgically revised.

Female genital cutting: clinical and cultural guidelines.

Clinical guidelines for managing women who have undergone female genital cutting are essential in providing appropriate and culturally competent care. The objectives of this study were to review the literature, describe the types of female genital cutting, evaluate its immediate and long-term complications, and provide clinical guidelines for managing women who have undergone this procedure. We conducted an extensive literature search on the MEDLINE database (1966-2003) for articles pertaining to female circumcision/genital mutilation/cutting. The search was extended further by citations in these journals not identified in MEDLINE. National and international nongovernmental organizations provided articles not available in American libraries. The author has developed guidelines based on personal experience and recommendations from the literature. The major inclusion criteria limited the search to: 1) English language, 2) medical journals, 3) WHO publications, 4) medical society publications, 5) case studies and statistical data on medical complications, 6) infertility and sexual issues, 7) U.S. legal practice, and 8) deinfibulation. The exclusion criteria pertained to articles: 1) reviewing the literature, 2) lacking epidemiologic data, 3) addressing political and ethical issues, and 4) discussing international concerns. Immediate complications include hemorrhage, infection, urinary dysfunction, shock, or death. Long-term complications include urinary complications, scarring, pain, infection, and infertility. Obstetric complications include lacerations, wound infections, postpartum hemorrhage, and sepsis. Fetal complications are rarely seen in Western countries. Women who have undergone female genital cutting can experience complications. Practitioners must recognize the type of circumcision, ensure cultural competency, and provide appropriate clinical care.