Female Genital Mutilation/Female Circumcision Reference Card for Health Care Providers
What is female genital mutilation or female circumcision?
It is ritualistic cutting of female genitals for nonmedical reasons. This practice is more commonly known as "cutting" or Female Circumcision (FC). It is generally performed by traditional practitioners or family members, not medical professionals. The most severe form involves sealing the vagina, leaving only a small opening for urination and menstruation.
The World Health Organization (WHO) defines and classifies these procedures as follows:
- Type I Partial or total removal of the clitoris and/or its prepuce. Known as 'clitoridectomy'.
- Type II Partial or total removal of the clitoris and labia minora. May or may not include excision of the labia majora. Known as 'excision'.
- Type III The most severe form. Narrowing the vaginal orifice by cutting the labia minora and/or labia majora and placing them side by side. This creates a seal with a small opening for urine and menstrual blood to escape. May or may not involve removal of the clitoris. Known as an 'infibulation' or 'pharaonic type circumcision'.
- Type IV All other harm to female genitalia for nonmedical purposes. Consists of pricking, piercing, stretching, cutting or cauterization of the clitoris. Includes introducing corrosive substances into the vagina. Known as 'unclassified'.
Physicians are not obligated to perform circumcision or reinfibulation for women older than 18 years.
Communication Guidelines and Physician Obligations
The health care provider has the opportunity to successfully treat and educate women by providing accurate information and a positive health care experience. Also, in 1995, the American College of Obstetricians and Gynecologists (ACOG) stated that there is no scientific basis for the practice of female circumcision. ACOG, WHO, the American Medical Association and many other professional organizations oppose all forms of medically unnecessary surgical modification of the female genitalia. To accomplish this, an open dialogue must occur between health care provider and patient:
- It's more appropriate to use the term "cutting," or "Female Circumcision" as it is more commonly known, rather than "Female Genital Mutilation".
- Speak slowly and use simple, accurate terms.
- Use pictures and diagrams when possible.
- Allow time for the patient to answer your questions and to ask her own questions.
- Do not overwhelm the patient by giving her more information than she can understand during her initial visit. Start by giving her just the most important information.
- To clarify the patient's understanding, ask her to repeat information you give her. Also, be sure to clarify how well you understand what she says.
- If English is not the patient's primary language, access medically qualified interpreter services. Telephonic or live interpreter services are available throughout the state. An independent adult female is recommended. If possible, avoid using children or other relatives as interpreters.
- Be sensitive to the patient's cultural expectations regarding eye contact and personal space. If culturally appropriate, maintain eye contact with the patient, not her interpreter, and direct your speech toward her.
Why is female circumcision performed?
FC is performed for cultural, religious and social reasons that vary within families and communities. Although no religion's holy texts require FC, practitioners often believe FC is a religious requirement.
Some reasons given for performing FC:
- social acceptability is the most common reason. Families often feel pressure to have their daughter cut so she is accepted by their community,
- due to a belief that it is a religious duty,
- as a ritual or "rite of passage" into womanhood; girls are then considered to be women,
- to preserve virginity until marriage,
- in order for the female to be considered suitable for marriage,
- because external genitals are unclean,
- to prevent bad odor,
- due to a belief that it increases sexual pleasure for a man, and
- due to a belief that it makes a woman smart and calm.
FC is viewed internationally as a health and human rights issue, but because FC is deeply rooted into cultural traditions it is difficult to address. The World Health Organization (WHO) states that there aren't any hygiene or health reasons to support FC and states that it's a form of discrimination against women and an act of violence.
Circumcised women need clinicians familiar with these surgeries who will treat them with dignity and respect. Treating with respect does not mean acceptance of the practice.
Where is female circumcision practiced?
Female circumcision is practiced in 28 African countries as well as some countries in the Middle East and Asia – Egypt, Indonesia, India, Iraq and Pakistan. The custom is not specific to one religion. It is practiced by Christians, Muslims, followers of traditional religions, and the Falasha (Ethiopian Jews) now living in Israel.
Who is at risk and when?
It is estimated that more than 7,500 girls and women in New York State are at risk for FC either in the state or overseas. Girls living in communities that practice FC are most at risk. Communities of immigrants that practice FC are most often from African countries. Some are from the Middle East and Asian countries. Girls are more at risk if FC has been carried out on their mother, sister or member of their extended family.
An especially risky time is during school vacations. This is when families send girls out of state or to another country for circumcision, a practice called "vacation cutting". This practice has been illegal at the federal level since 2013. It is a crime to send, or attempt to send, a female from the U.S., younger than 18 years, to have FC performed in another country.
Most girls are circumcised when they are between five and eight years old, but it can happen at any age. Some females are babies when it is done but it can happen in adolescence, just before marriage or during pregnancy, too.
Thousands of females in New York State are at risk. Female circumcision is likely to cause lifelong physical and psychological damage.
There is an increasing number of U.S. females at risk for FC – especially girls younger than 18. This increase is due to an influx of immigrants from countries that practice female circumcision. In 2012, about 513,000 women and girls in the United States were at risk for FC or its consequences. Source: Female Genital Mutilation/Cutting in the United States: Updated Estimates of Women and Girls at Risk, 2012
What are the medical complications of female circumcision?
Along with emotional trauma, girls and women are at risk for severe pain and bleeding, infection, and even death. Women who have undergone FC experience long-term complications -- physical, sexual and psychological. Pain and complications can continue throughout a woman's life.
Long-term health problems include:
- Infections such as Tetanus and other infectious diseases, such as HIV, due to unsterilized cutting tools
- Infertility
- Problems having sex including painful intercourse
- Depression and anxiety, including post-traumatic stress disorder
- Urinary tract dysfunction and dysmenorrhea
- Fistula, a permanent abnormal passageway between two organs in the body or between an organ and the exterior of the body
- Problems during and after childbirth including severe pain, vaginal obstruction, scar tissue tears from childbirth and reinfibulation
- Sebaceous/Inclusion Cysts, Labial Ulcerations, Neuromas and Keloids
Do pregnant women need special care?
Possible problems during and after childbirth include being at risk for longer labor and cesarean section. Women who have undergone FC are also more at risk for excessive bleeding after childbirth.
No special care is necessary for women with uncomplicated and well-healed Type 1 or 2 circumcision. If a Type 3 circumcision (infibulation) is present, then reopening of the stitched or narrowed vaginal opening (defibulation) is necessary. The best time to do this may be during the second trimester according to Cambridge Medicine's Clinical Gynecology, Second Addition. If the woman presents while in labor, defibulation should be done during the second stage of labor, with a low-presenting part. A protocol for defibulation is described in Caring for Women with Circumcision: A Technical Manual for Health Care Providers by Nahid Toubia, M.D. If a woman requests restitching of the opening (re-infibulation) following childbirth, follow the counseling recommendations below, and explain why it is inadvisable to recreate the urethral/vaginal obstruction. Also, discuss the advantages of defibulation, including ease with sexual intercourse and future childbearing.
How do you counsel someone requesting circumcision?
It is illegal to perform circumcision or reinfibulation in New York State on any female younger than 18 years. Following a request for this procedure:
- Express your understanding and respect for cultural practices and customs.
- Explain the procedure and its potential medical complications.
- Discuss the emotional response to any changes in her genitals.
- Encourage a family consultation to review health risks.
- Allow patients 18 years and older time to think about the procedure.
For further information on counseling, cultural competence, legal issues, clinical management, or protocols for defibulation, refer to Caring for Women with Circumcision: A Technical Manual for Health Care Providers by Nahid Toubia, M.D.,
