Female Genital Cutting

Female genital cutting (FGC), also called female genital mutilation or circumcision, is the partial or complete removal of a girl’s external genitals. This cultural practice is based on various traditions and beliefs (e.g prepares a girl for adulthood, preserves virginity before marriage, facilitates cleanliness) and has no known medical benefits.

FGC is typically performed before the age of 15, but in some countries, it is often practised on girls <5 years of age. FGC is a criminal offence in Canada and has been banned by the United Nations. It is mainly practised in Africa and in the Middle East (see Map), as well as in Indonesia.

Physicians seeing refugees from countries where FGC is practiced should be aware of the potential associated complications/symptoms and be able to identify FGC on physical examination.

 

CHRONIC COMPLICATIONS

FGC is associated with multiple chronic complications including the following: anorgasmia, dyspareunia, vaginal dryness, bacterial vaginosis, lower abdominal, vaginal and vulvar pain, dysmenorrhea, vaginal stenosis, chronic UTI.

FGC is also associated with obstetrical complications, and can have long-term psychological impacts.

 

FGC CLASSIFICATION

FGC can be easily missed on physical exam. The World Health Organization (WHO) has classified FGC into 4 types:


Female Genital Cutting

Female genital cutting: an evidence-based approach to clinical management for the primary care physician (Hearst et Molnar, 2013). Illustration by Jessica Stanton, MD. With permission.

 

SCREENING

While there is currently no evidence supporting routine screening for FGC in asymptomatic patients, screening should be considered for the following patients:​

  • Prenatal or antenatal patients (in preparation for delivery)
  • Patients who will undergo a gynecological procedure (such as a Pap test)
  • Any female patient who is from a country where FGC is performed and who has one of the complications/symptoms listed above

​​Screening for FGC should be done in a respectful and culturally sensitive manner. The word “circumcision” is preferred to “mutilation” when asking patients about FGC. The patient should be asked about her circumcision history (where, when, how) and about her beliefs regarding FGC. The physician should also inquire about potential physical and psychological symptoms related to the circumcision.

An external genital exam should be offered to patients with a history of female circumcision in order to classify the type of FGC and guide further management.

Once a trusting therapeutic relationship has been established, physicians should also consider raising this topic with parents of young girls coming from countries with a high prevalence of FGC. These patients should be educated about the Canadian laws relating to FGC. They should know that sending their daughter away to be circumcised in another country is also a criminal offence.

 

MANAGEMENT

Patients with FGC who have any associated complication/symptom or who are potentially interested in a defibulation (surgical opening of the labia) should be offered a Gynecology referral. This is especially important if the patient is pregnant or planning a pregnancy (defibulation can be done ante or intrapartum). Children and teenagers should be referred to Pediatric Gynecology.

 

>> For additional information on the assessment and screening of FGC, refer to the Caring for Kids New to Canada website.