Epidemiological surveillance study of female genital mutilation in the UK.

OBJECTIVES: Describe cases of female genital mutilation (FGM) presenting to consultant paediatricians and sexual assault referral centres (SARCs), including demographics, medical symptoms, examination findings and outcome. DESIGN: The well-established epidemiological surveillance study performed through the British Paediatric Surveillance Unit included FGM on the monthly returns. SETTING: All consultant paediatricians and relevant SARC leads across the UK and Ireland. PATIENTS: Under 16 years old with FGM. INTERVENTIONS: Data on cases from November 2015 to November 2017 and 12 months later meeting the case definition of FGM. MAIN OUTCOME MEASURES: Returns included 146 cases, 103 (71%) had confirmed FGM and 43 (29%) did not meet the case definition. There were none from Northern Ireland. RESULTS: The mean reported age was 3 years. Using the WHO classification of FGM, 58% (n=60) had either type 1 or type 2, 8% (n=8) had type 3 and 21% (n=22) had type 4. 13% (n=13) of the cases were not classified and none had piercings or labiaplasty. The majority, 70% had FGM performed in Africa with others from Europe, Middle East and South-East Asia. There were few physical and mental health symptoms. Only one case resulted in a successful prosecution. CONCLUSIONS: There were low numbers of children presenting with FGM and in the 2 years there was only one prosecution. The findings may be consistent with attitude changes in FGM practising communities and those at risk should be protected and supported by culturally competent national policies.

Female genital mutilation (FGM): Is it still an existing problem in Egypt?

BACKGROUND: Female Genital Mutilation (FGM) is one of those traditional practices whose origin can be traced back to antiquity. The worst types of FGM are practiced in Sudan, Egypt and Nigeria. The international movement against FGM gained momentum in the past two decades, and attempts were made to increase public awareness of the procedure and its complications. In addition, laws were passed in Egypt to criminally charge practitioners who perform FGM. OBJECTIVES: The aim of this study was to describe frequency, prevalence, complications of FGM and awareness of the women at the clinic visit about the latest update (2016) of the Egyptian law that criminalizes it. METHODOLOGY: This was a cross sectional study of women in their childbearing years (18-45) who attended the Gynecology and Obstetrics outpatient clinics at Fayoum University hospitals between January 1st and December 31st, 2018. After giving their consent, one hundred women attending the clinic received a medical examination and structured interview related to their views and plans regarding FGM of female children. RESULTS: Sixty two percent of women participants reported that they had been circumcised. In 88% of cases, the participant's mother was the person who made the decision to have their daughter circumcised. The most common type of circumcision reported was type II, in 86% of cases. Regarding intent to have a female child circumcised, 32% reported that they would have their own daughter circumcised. CONCLUSION: Despite Egyptian law that criminalizes FGM, the know potential for serious complications of the procedure, including death, and the efforts of governmental, non-governmental, and international organizations to combat the use of FGM, one third of the women interviewed still planned to have their daughter circumcised.

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.

Programa de Educación para la Salud: sexualidad en mujeres víctimas de mutilación genital femenina / Health Education Program: Sexuality in female genital mutilation victims

Se presenta un programa de educación sexual orientado a la mujer que ha sufrido mutilación genital femenina (MGF), que se incluye en grupos preconstituidos que abordan temas relacionados con el cuidado y la salud. Este programa estará dirigido por matronas y mediadores culturales, y requiere una colaboración interdisciplinar. El objetivo del programa es promover la vivencia positiva de la sexualidad en la mujer mutilada. Se propone un programa de salud de seis sesiones con objetivos educativos y criterios de resultado. Se sugiere realizar la evaluación mediante un cuestionario que permitirá conocer los cambios en conocimientos, habilidades y actitudes producidos, junto a indicadores de cobertura, proceso y resultados y un cuestionario de satisfacción

We present a sexual education program targeted to women who have suffered female genital mutilation (FGM), to be included in pre-established groups addressing topics associated with care and health. This program will be led by midwives and cultural mediators, and requires interdisciplinary collaboration. The objective of this program is to promote a positive experience of sexuality in mutilated women. A six-session health program is put forward, with educational objective and outcome criteria. It is suggested to conduct the evaluation through a questionnaire that will allow to learn about the changes occurred in knowledge, skills and attitudes, together with indicators for coverage, process and outcomes, and a satisfaction questionnaire

Are obstetric outcomes affected by female genital mutilation?

INTRODUCTION AND HYPOTHESIS: Female genital mutilation (FGM) has been associated with adverse obstetric and neonatal outcomes, such as postpartum haemorrhage (PPH), perineal trauma, genital fistulae, obstructed labour and stillbirth. The prevalence of FGM has increased in the UK over the last decade. There are currently no studies available that have explored the obstetric impact of FGM in the UK. The aim of our study was to investigate the obstetric and neonatal outcomes of women with FGM when compared with the general population. METHODS: We conducted a retrospective case-control study of consecutive pregnant women with FGM over a 5-year period between 1 January 2009 and 31 December 2013. Each woman with FGM was matched for age, ethnicity, parity and gestation with subsequent patients without FGM (control cohort) over the same 5-year period. Outcomes assessed were mode of delivery, duration of labour, estimated blood loss, analgaesia, perineal trauma and foetal outcomes. RESULTS: A total of 242 eligible women (121 FGM, 121 control) were identified for the study. There was a significant increase in the use of episiotomy in the FGM group (p = 0.009) and a significant increase in minor PPH in the control group during caesarean sections (p = 0.0001). There were no differences in all other obstetric and neonatal parameters. CONCLUSIONS: In our unit, FGM was not associated with an increased incidence of adverse obstetric and foetal morbidity or mortality.

Gurya cutting and female genital fistulas in Niger: ten cases.

INTRODUCTION AND HYPOTHESIS: The objective was to determine the contribution of female genital cutting to genital fistula formation in Niger from the case records of a specialist fistula hospital. METHODS: A retrospective review was undertaken of the records of 360 patients seen at the Danja Fistula Center, Danja, Niger, between March 2014 and September 2016. Pertinent clinical and socio-demographic data were abstracted from the cases identified. RESULTS: A total of 10 fistulas resulting from gurya cutting was obtained: 9 cases of urethral loss and 1 rectovaginal fistula. In none of the cases was genital cutting performed for obstructed labor or as part of ritual coming-of-age ceremonies, but all cutting procedures were considered "therapeutic" within the local cultural context as treatment for dyspareunia, lack of interest in or unwillingness to engage in sexual intercourse, or female behavior that was deemed to be culturally inappropriate by the male spouse, parents, or in-laws. Clinical cure (fistula closed and the patient continent) was obtained in all 10 cases, although 3 women required more than one operation. CONCLUSIONS: Gurya cutting is an uncommon, but preventable, cause of genital fistulas in Niger. The socio-cultural context which gives rise to gurya cutting is explored in some detail.

Female Genital Mutilation as a Concern for Special Operations and Tactical Emergency Medical Support Medics.

Female genital mutilation (FGM), frequently called female genital cutting or female circumcision, is the intentional disfigurement of the external genitalia in young girls and women for the purpose of reducing libido and ensuring premarital virginity. This traditional, nontherapeutic procedure to suppress libido and prevent sexual intercourse before marriage has been pervasive in Northern Africa, the Middle East, and the Arabian peninsula for over 2,500 years. FGM permanently destroys the genital anatomy while frequently causing multiple and serious complications. The International Federation of Gynecology and Obstetrics proposed a classification system of FGM according to the specific genital anatomy removed and the extensiveness of genital disfigurement. Although it has been ruled illegal in most countries, FGM continues to be performed worldwide. With African, Asian, and Middle Eastern immigration to the United States and Europe, western countries are experiencing FGM in regions where these immigrants have concentrated. As deployments of Special Operations Forces (SOF) increase to regions in which FGM is pervasive, and as African, Asian, and Middle Eastern immigration to the United States increases, SOF and Tactical Emergency Medical Support (TEMS) medics will necessarily be called upon to evaluate and treat complications resulting from FGM. The purpose of this article is to educate SOF/TEMS medical personnel about the history, geographic regions, classification of procedures, complications, and medical treatment of patients with FGM.

[Complex vulvar reconstruction following female genital mutilation/cutting]. / Die komplexe Rekonstruktion der Vulva nach weiblicher Genitalverstümmelung/Genitalbeschneidung.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is a worldwide problem affecting millions of women and is especially common in Africa and Arabia. Women suffer from serious physical and psychological problems. Anatomic reconstruction, therefore, is an important and life-changing option for many affected women. OBJECTIVES: This work gives a short overview of specialized techniques invented by the author for functional and aesthetic vulvar reconstruction following FGM/C. This work does not intend to provide anatomic or surgical details. MATERIALS AND METHODS: The anterior obturator artery perforator flap (aOAP flap), the omega domed flap (OD flap), and a microsurgical procedure called neurotizing and molding of the clitoral stump (NMCS procedure) are described. RESULTS: The aOAP-flap for vulvar reconstruction, the OD-flap for clitoral prepuce reconstruction, and the NMCS-procedure for reconstruction of the clitoral tip provided natural, reliable, and long-lasting results, all of which normalize the anatomy of the mutilated outer female genitalia. CONCLUSIONS: The reconstructive options presented contribute to re-establish normal anatomy and, thus, support women's health and relieve the burden forced upon them by FGM/C.

Counselling for deinfibulation among women with type III female genital mutilation: A systematic review.

BACKGROUND: Counselling is a routine practice done before deinfibulation in women with type III female genital mutilation (FGM). However, cultural and social pressures, in addition to maladaptation to the changes in the body post deinfibulation, cause some women to choose to be reinfibulated after being deinfibulated. OBJECTIVE: To conduct a systematic review of the impact of counselling prior to deinfibulation on patient satisfaction, marital satisfaction, and rate of requests for reinfibulation among women living with type III FGM. The secondary aim was to assess the impact of male partner involvement in counselling on patient satisfaction, marital satisfaction, and rate of requests for reinfibulation. SEARCH STRATEGY: Major databases including Cochrane Central Register of Controlled Trials, Medline, SCOPUS, and ClinicalTrials.gov were searched until August 2015. SELECTION CRITERIA: Studies comparing women with type III FGM who received counselling before deinfibulation versus no counselling were included. DATA COLLECTION AND ANALYSIS: Two team members independently screened and collected data. RESULTS: No eligible studies were identified. CONCLUSION: There is no evidence to conclude that counselling before deinfibulation influences patients' satisfaction with overall quality of care or rates of request for reinfibulation. PROSPERO REGISTRATION: CRD42015024675.

Antepartum or intrapartum deinfibulation for childbirth in women with type III female genital mutilation: A systematic review and meta-analysis.

BACKGROUND: There remains no consensus on the best timing of deinfibulation in women with type III female genital mutilation (FGM). OBJECTIVES: To conduct a systematic review of the effects of antepartum or intrapartum deinfibulation on childbirth outcomes in women with type III FGM. SEARCH STRATEGY: The following major databases were searched: Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov, from inception until August 2015 without any language restrictions. SELECTION CRITERIA: Studies of pregnant women or girls with type III FGM who were deinfibulated antepartum or intrapartum were included. DATA COLLECTION AND ANALYSIS: Two team members independently screened and collected data. Quality of evidence was assessed using GRADE. Summary odds ratios and proportions were calculated when possible. RESULTS: There is no evidence of a significant difference between antepartum and intrapartum deinfibulation for obstetric outcomes such as duration of labor, perineal lacerations, episiotomies, postpartum hemorrhage, and cesarean deliveries. Outcomes in women living with type III FGM and those who have undergone deinfibulation were not statistically different; however, trends show a benefit for deinfibulation. All studies were underpowered to detect statistical differences. CONCLUSION: Larger studies are required to have full confidence in these findings. PROSPERO REGISTRATION: CRD42015024464.

Prioritizing and synthesizing evidence to improve the health care of girls and women living with female genital mutilation: An overview of the process.

Female genital mutilation (FGM) constitutes a harmful traditional practice that can have a profound impact on the health and well-being of girls and women who undergo the procedure. In recent years, due to international migration, healthcare providers worldwide are increasingly confronted with the need to provide adequate health care to this population. Recognizing this situation the WHO recently developed the first evidence-based guidelines on the management of health complications from FGM. To inform the guideline recommendations, an expert-driven, two-step process was conducted. The first step consisted of developing and ranking a list of priority research questions for the evidence retrieval. The second step involved conducting a series of systematic reviews and qualitative data syntheses. In the present paper, we first provide the methodology used in the development and ranking of the research questions (step 1) and then detail the common methodology for each of the systematic reviews and qualitative evidence syntheses (step 2).

Surgical or medical interventions for female genital mutilation.

Deinfibulation can prevent or treat gynecological and obstetric complications in women living with type III female genital mutilation (FGM), and subsequently improve childbirth outcomes. Recently published WHO guidelines recommend use of deinfibulation in both circumstances. However, to really impact practice, evidence-based guidance needs to be matched with evidence-based implementation strategies. This qualitative evidence synthesis provides information on the factors that facilitate or act as barriers to use of deinfibulation, and the context and conditions that are necessary for implementing the procedure, including healthcare providers' knowledge and experience, the service delivery environment, as well as broader health system contexts. This information is of great value for policy makers and others considering this as an option for better clinical care of women living with FGM.

Deinfibulation for treating urologic complications of type III female genital mutilation: A systematic review.

BACKGROUND: Women and girls who have undergone type III female genital mutilation (FGM) may suffer urologic complications such as recurrent urinary tract infections, obstruction, stones, and incontinence. OBJECTIVE: To assess the effectiveness of deinfibulation for preventing and treating urologic complications in women and girls living with FGM. SEARCH STRATEGY: The following major databases were searched from inception to August 2015: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, SCOPUS, Web of Science, and ClinicalTrials.gov without language restrictions. SELECTION CRITERIA: Randomized controlled studies (RCTs) or observational studies with controls were considered. DATA COLLECTION AND ANALYSIS: We screened the results of the search independently for potentially relevant studies and applied inclusion and exclusion criteria for the full texts of the relevant studies. RESULTS: No RCTs were found. We found three case reports and a retrospective case review, all of which were excluded. CONCLUSION: There is no evidence on the use of deinfibulation to improve urologic complications among women with type III FGM. Current clinical practice may be informed by anecdotal evidence from case reports. Appropriate RCTs and observational studies with comparison groups in countries where FGM is common are needed. PROSPERO registration: CRD42015024901.

Deinfibulation for preventing or treating complications in women living with type III female genital mutilation: A systematic review and meta-analysis.

BACKGROUND: Deinfibulation is a surgical procedure carried out to re-open the vaginal introitus of women living with type III female genital mutilation (FGM). OBJECTIVES: To assess the impact of deinfibulation on gynecologic or obstetric outcomes by comparing women who were deinfibulated with women with type III FGM or women without FGM. SEARCH STRATEGY: Major databases including CENTRAL, MEDLINE, and Scopus were searched until August 2015. SELECTION CRITERIA: We included nonrandomized studies that compared obstetric outcomes of women with deinfibulation, type III FGM (not deinfibulated during labor), and no FGM. DATA COLLECTION AND ANALYSIS: Quality of evidence was determined following the GRADE methodology. Summary measures were calculated using odds ratios at 95% confidence intervals. RESULTS: We found no randomized controlled trials. We included four case-control studies. The quality of evidence was very low. Compared with women with type III FGM at delivery, deinfibulated women had a significant reduction in the risk of having a cesarean delivery or postpartum hemorrhage. Compared with women without FGM, deinfibulated women had a similar risk of episiotomy, cesarean delivery, vaginal lacerations, postpartum hemorrhage, and blood loss at vaginal delivery. The length of second stage of labor, mean maternal hospital stay, and Apgar scores less than 7 were also comparable. CONCLUSIONS: Low-quality evidence suggests deinfibulation improves birth outcomes for women with type III FGM. PROSPERO REGISTRATION: CRD42015024466.

Sexual counselling for treating or preventing sexual dysfunction in women living with female genital mutilation: A systematic review.

BACKGROUND: Female sexual dysfunction is the persistent or recurring decrease in sexual desire or arousal, the difficulty or inability to achieve an orgasm, and/or the feeling of pain during sexual intercourse. Impaired sexual function can occur with all types of female genital mutilation (FGM) owing to the structural changes, pain, or traumatic memories associated with the procedure. OBJECTIVES: To conduct a systematic review of randomized and nonrandomized studies into the effects of sexual counseling with or without genital lubricants on the sexual function of women living with FGM. SEARCH STRATEGY: Cochrane Central Register of Controlled Trials, MEDLINE, African Index Medicus, SCOPUS, LILACS, CINAHL, ClinicalTrials.gov, Pan African Clinical Trials Registry, and other databases were searched to August 2015. The reference lists of retrieved studies were checked for reports of additional studies, and lead authors contacted for additional data. SELECTION CRITERIA: Studies of girls and women living with any type of FGM who received counselling interventions for sexual dysfunction were included. DATA COLLECTION AND ANALYSIS: No relevant studies that addressed the objective of the review were identified. CONCLUSIONS: Despite a comprehensive search, the authors could not find evidence of the effects of sexual counseling on the sexual function of women living with FGM. Studies assessing this intervention are needed. PROSPERO REGISTRATION: CRD42015024593.

Female genital mutilation and cutting: An anatomical review and alternative rites.

The World Health Organization reports that more than 200 million women currently alive have been subjected to female genital mutilation/cutting (FGM/C) worldwide, and three million girls continue to be at risk each year. FGM/C today is women's business. The vulva is formed by the labia majora and the vestibule, with its erectile apparatus. These structures are located under the urogenital diaphragm, behind the pubic symphysis in the anterior perineal region. The clitoris is entirely an external genital organ: the glans and body covered by the prepuce are visible/free while the roots are hidden. FGM/C procedures are classified into four types. Infibulation is the narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning of the labia minora and/or the labia majora, with or without removal of the clitoris. Deinfibulation is necessary to improve health and well-being and to allow intercourse or facilitate childbirth. Clitoral reconstruction is feasible for genitally mutilated patients. Female genital cosmetic surgery should be classed as FGM/C type IV. Both immediate and long-term complications are associated with FGM/C. It remains primarily a cultural rather than a religious practice. Different interventions have been used to persuade communities to abandon it. Alternative rites of passage are seen as an important strategy for eliminating this harmful practice. Such alternative rituals avoid genital cutting and involve educating girls about family life and women's roles, exchange of gifts, celebration, and a public declaration for community recognition. FGM/C is a violation of human rights and must be abandoned. Clin. Anat. 30:81-88, 2017. © 2016 Wiley Periodicals, Inc.

Intermittent self-catheterisation for urolgical problems caused by FGM.

This is the fourth and final article in a series on female genital mutilation (FGM). It describes the complications of FGM, with a focus on the urinary ones. FGM refers to all procedures that involve partial or total removal of the external female genitalia and/or damage to other female genital organs for non-medical reasons. The World Health Organization (WHO) has classified FGM into four types (1-4). Women who have type 3 commonly experience long-term complications of their urological tract. The first-line treatment for type 3 FGM involves surgical defibulation, but this is not always successful and women can be left with neurogenic bladder dysfunction and urethral stricture disease. Intermittent self-catheterisation (ISC) enables these women to have control of their bladder function.

Female genital mutilation: a urology focus.

Female genital mutilation (FGM) is a collective term for the deliberate alteration, removal and cutting of the female genitalia. It has no known health benefits and can have negative physical and psychological consequences. The number of women and girls in the UK that are affected by FGM is unknown. Recent NHS data suggested that FGM has been evident (declared or observed) in women who have accessed health care; however, there are gaps in knowledge and a limited evidence base on the health consequences of FGM. This article explores the urological complications experienced by women who have undergone this practice, and the effects this can have on their health and wellbeing.