Module VII

Lesson 1. Female genital mutilation

The World Health Organization (WHO) defines female genital mutilation (FGM) as “all
procedures that involve partial or total removal of the external female genitalia, or other injury
to the female genital organs for non-medical reasons”. (1)

FGM is performed in many countries in Africa, and in some parts of Asia and the Middle East.
The practice is deeply rooted in those cultures where it is widely performed. There is a
misconception that FGM reduces women’s sexual desire and thus promotes chastity and
fidelity: as such, the practice is encouraged by both women and men. FGM is usually performed
between the age of four years up to puberty. It has many harmful health effects including
recurrent urinary and vaginal infections, chronic pain, infertility, haemorrhage, epidermoid
cysts, and difficult labour. (2) It also has a psychological impact. FGM has been performed on
>200 million women and girls, the majority in Africa.

The practice of FGM continues despite efforts to eradicate it. WHO classifies FGM into four
types, varying in severity from partial removal of the clitoris to extensive mutilation of the
external genitalia. The type of FGM practiced varies within and between countries.

Type 1, partial or total removal of the clitoris and/or the prepuce (clitoridectomy). Variations
include:

• type 1a, removal of the clitoral hood or prepuce only; and

• type 1b, removal of the clitoris with the prepuce.

Type 2, partial or total removal of the clitoris and the labia minora, with or without excision of
the labia majora. Variations include:

• type 2a, removal of the labia minora only;

• type 2b, partial or total removal of the clitoris and the labia minora; and

• type 2c, partial or total removal of the clitoris, the labia minora and the labia majora.

Type 3, narrowing of the vaginal orifice and creation of a covering seal by cutting and
appositioning the labia minora and/or the labia majora, with or without excision of the clitoris
(infibulation). Variations include:

• type 3a, removal and apposition of the labia minora; and

• type 3b, removal and apposition of the labia majora.

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Type 4 includes all other procedures harmful to the female genitalia – pricking, piercing,
incising, scraping and cauterization – undertaken for non-medical reason.

Despite global efforts to eradicate FGM every year an estimated three million girls are at risk of
undergoing this harmful practice.

Complications
FGM is associated with potential localized infections, abscess formation, septicemia, tetanus,
haemorrhage, shock, acute retention of urine, contraction of hepatitis and/or HIV, especially
when performed in non-sterile settings, and death. (3) A multicentric study by WHO showed
increased relative risk (RR) for caesarean delivery (RR 1.31), postpartum haemorrhage (RR
1.69), extended maternal hospital stay (RR 1.98), infant resuscitation (RR 1.66), and stillbirth or
early neonatal death (RR 1.55).

In later life FGM may result in sexual dysfunction, dyspareunia, chronic pain, scar formation,
difficulty passing urine, and infertility, and during pregnancy there are increased maternal and
fetal risks.

Although the medicalization of FGM may reduce the incidence of acute complications, it has no
effect on later gynecological and obstetric complications.

Medicalization of FGM
Medicalization of FGM refers to situations in which FGM is performed by a health care provider,
whether in a public or a private clinic, at home or elsewhere. It also includes the procedure of
re-infibulation at any point in a woman’s life.

The definitions of FGM and medicalization were first adopted in 1997 in a joint WHO, United
Nations Children’s Fund and United Nations Population Fund statement published by WHO, and
reaffirmed in 2008 in an interagency statement by 10 United Nations agencies.

Medicalization of FGM is claimed by some health professionals to reduce the incidence of

complications. Yet complications, sometimes fatal, can still occur with medicalized FGM, and it
has no impact on long-term complications. The medicalization of FGM also represents a setback
in global efforts to eradicate the practice.

FGM has no health benefits and no medical indications: as such its performance violates codes
of medical ethics.

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A recent analysis of data from countries where it is available showed that more than 18% of
girls and women subjected to FGM had the procedure performed by a health care provider.
There were, however, large variations between countries, from less than 1% up to 74%.

Many experts believe that global efforts to eradicate the internationally condemned practice
are being undermined by a growing trend for health providers to carry out FGM. Fourteen
studies (4), conducted in countries where FGM is widely practiced or which host migrants from
regions where the practice is common, revealed the motives behind health care providers
performing FGM as:

• it being less harmful than when performed by a traditional practitioner (the so-called
harm reduction perspective);
• the practice is justified for cultural reasons;
• financial gain; and
• community pressure.

The main reasons given by health care providers for not performing FGM were:

• concerns about the health risks FGM poses;

• legal sanctions that might result from performing FGM;
• the fact FGM has no health benefits whatsoever; and
• that it violates the ethics of medical practice.

While the concept of harm reduction has been used to justify the medicalization of FGM, with
proponents arguing it mitigates acute complications and can be used to promote less radical
forms of FGM, opponents stress it does nothing to mitigate the long-lasting health and
psychosexual consequences of FGM, is incompatible with medical ethics, violates human rights
agreements and, rather than helping end the practice, only entrenches FGM, ultimately causing
more harm to women.

References:

1. World Health Organization. Female Genital Mutilation. Geneva: World Health

Organization; February 2013 (https://www.who.int/news-room/fact-
sheets/detail/female-genital-mutilation)
2. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, Ferguson D,
D'Agostino R Jr. The Female Sexual Function Index (FSFI): a multidimensional
self-report instrument for the assessment of female sexual function. J Sex
Marital Ther. 2000 Apr-Jun;26(2):191-208. doi: 10.1080/009262300278597.

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3. WHO study group on female genital mutilation and obstetric outcome, Banks E,
Meirik O, Farley T, Akande O, Bathija H, Ali M. Female genital mutilation and
obstetric outcome: WHO collaborative prospective study in six African
countries. Lancet. 2006 Jun 3;367(9525):1835-41. doi: 10.1016/S0140-
6736(06)68805-3.
4. Doucet MH, Pallitto C, Groleau D. Understanding the motivations of health-care
providers in performing female genital mutilation: an integrative review of the
literature. Reprod Health. 2017 Mar 23;14(1):46. doi: 10.1186/s12978-017-
0306-5.