Female circumcision is a culturally determined practice of ritually cutting a female’s external genitals that results in removal of part or all of the external genitalia including the labia majora, labia minora, and/or the clitoris. This activity is illegal in many locations. Female circumcision (female genital mutilation, inﬁbulation) is generally performed as a ritual process, often without beneﬁt of anesthesia and frequently under unsterile conditions, generally near the time of puberty or soon after. The resulting scarring may preclude intromission or normal vaginal delivery should pregnancy be achieved. In rare cases, scarring and deformity may be sufﬁcient to result in amenorrhea or dysmenorrhea. The ritual is often performed to reinforce a woman’s place in her society, to establish eligibility for marriage and entry into womanhood. It is sometimes also performed to safeguard virginity or to paradoxically improve fertility. Although the ritual can have devastating effects on the woman’s sexual pleasure, it is some- times performed to enhance the husband’s pleasure.
The amount and location of tissue removed determine the type of inﬁbulation:
Type I—excision of the prepuce, with or without excision of part of or the entire clitoris.
Type II—excision of the clitoris with partial or total excision of the labia minora. (This is the most common form.)
Type III—excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (inﬁbulation).
Type IV—pricking, piercing, or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue.
Other forms of female genital mutilation include the following:
Scraping of the tissue surrounding the vaginal oriﬁce (angurya cuts) or cutting of the vagina (gishiri cuts) or the introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing the vagina.
It has been estimated that more than 130 million women worldwide have undergone some form of female circumcision. Although uncommon in the United States (estimated to be 168,000 in the United States, with 48,000 younger than 18 years), more than 95% of women in some countries (e.g., Somalia) have had one of these procedures.
These patients may experience bleeding and infection (including tetanus), urinary retention, and pain at the time of the original procedure. Long term, the patient may experience sexual dysfunction, difﬁculty with menstrual hygiene, recurrent vaginal or urinary tract infections, retrograde menstruation, hematocolpos, or chronic pelvic inﬂammatory disease. Excessive scarring, including keloid formation, adhesions, and pelvic and back pain are all common. Initiation of sexual activity may also present medical complications for the inﬁbulated woman. For example, if her narrow introitus tears “naturally” (by penile penetration), local infections and laceration of adjacent tissues may occur, leading to possible further complications. Increasingly, women are consulting physicians prior to initiating sexual activity and requesting deinﬁbulation.
Surgical opening of fused or scarred genital tissue may be necessary to allow for menstrual hygiene and sexual function. An anterior episiotomy, with or without subsequent repair, may be required at the time of child-birth. (Subsequent repair of the episiotomy is illegal in some locations, such as the United Kingdom and others, because this amounts to reinﬁbulation.) Sexual sequelae are often lifelong despite surgical revision (especially when clitoridectomy has been performed). Care for these women must be provided in a nurturing, nonjudgmental way.