Public Health
Female genital mutilation
CMAJ 2000;162:1344
Epidemiology
The removal of external female genitalia has been part of a celebrated ritual in the lives of girls and women in some cultures and countries for centuries. Despite a growing international campaign to abolish female genital mutilation (FGM) that has been endorsed by both the World Medical Association1 and the World Health Organization,2 many still see this tradition as an effective and acceptable method of controlling women's attitudes toward sex and sexuality and of ensuring their virginity and suitability for marriage. An estimated 120 million girls and women have undergone FGM, and approximately 2 million procedures are performed annually on girls under the age of 11.3 Most commonly performed in Africa, FGM is also practised in parts of Southeast Asia, the Middle East and in Central and South America. In countries such as Somalia, an estimated 70% to 90% of women have undergone FGM.4 Civil unrest has brought several waves of refugees who have undergone FGM to Canada, where they seek health care.
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WHO adopted the term "female genital mutilation" in 1996 to describe any of 4 forms of the procedure.3 The least invasive is the clitoridectomy, also known by the Arabic term sunna, which involves excision of the prepuce and part or all of the clitoris. The second form, "excision," involves removal of the clitoris and part or all of the labia minor. "Infibulation," which means "to fasten with a clip or buckle," is the most invasive form and is most common in Somalia, Ethiopia, parts of Kenya and the Sudan. It involves removal of the clitoris, all of the labia minor and part or all of the labia majora, and the pinning or stitching of the two sides of the vulva closed. A narrow opening is left for urinary and menstrual outflow.
A fourth, unclassified type includes procedures such as pricking, piercing, stretching, scraping or cauterization.
Clinical management
Immediate complications include severe pain, urinary retention, hemorrhage and infection. Canadian physicians are more likely to encounter the chronic health effects, including urinary tract infections and painful menstruation. They must also manage prenatal care and vaginal deliveries involving infibulated women.3 The American College of Obstetricians and Gynecologists has developed a kit, available through its Web site, to help doctors handle delicate issues like requests for deinfibulation (reversal of the procedure) or reinfibulation (reclosure following vaginal delivery).5
Prevention
In Canada, FGM is considered child assault and prohibited under sections 267 (assault causing bodily harm) or 268 (aggravated assault, including wounding, maiming, disfiguring) of the Criminal Code.4 Some provincial colleges have issued statements advising physicians to refuse requests to perform FGM or reinfibulation.6,7
The National Organization of Immigrant and Visible Minority Women of Canada has prepared a workshop manual for health care workers and facilitators working with communities that have traditionally practised FGM.3 The aim is to educate participants about the health and legal consequences of FGM, to correct misperceptions and fallacies about the tradition and to support efforts to eradicate the practice.3 In 1994, the Federal Interdepartmental Working Group on Female Genital Mutilation was established. Its mandate is to identify and promote methods to prevent the continuation of FGM by families now living in Canada. This organization is establishing a national FGM network and preparing a Health Canada document for dissemination.4
Further information is available from the National Organization of Immigrant and Visible Minority Women of Canada (tel. 613 232-0689), the Federal Interdepartmental Working Group on Female Genital Mutilation, Health Canada (tel. 613 957-1944) and the Circumcision Information and Resource Pages (www.cirp.org/pages/female.html) — Erica Weir, CMAJ
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References
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Richards T. Female genital mutilation condemned by WMA. BMJ 1993;307:957.
World Health Organization. A traditional practice that threatens health — female circumcision. WHO Chronicle 1986;40:31-6. [MEDLINE]
National Organization of Immigrant and Visible Minority Women of Canada. Female genital mutilation: workshop manual. Ottawa: The Organization.
Federal Interdepartmental Working Group on Female Genital Mutilation. Female genital mutilation and health care — an exploration of the needs and roles of affected communities and health care providers in Canada. Ottawa: Health Canada; 1999.
www.acog.com
www.cpso.on.ca
www.cpsbc.bc.ca/policymanual/index.htm
© 2000 Canadian Medical Association or its licensors
